Injecting Alone. The Importance of Perceived Safety,Stigma and Pleasure for Solitary Injecting

Introduction

The burden of disease caused by drug use has continued to increase during the past decade (UNODC, 2021). In Europe, drug overdose is the main cause of death among high-risk drug users (EMCDDA, 2018, UNODC, 2021), of which drug injection is one of the leading risk factors (Degenhardt et al., 2011; Mathers et al., 2013). Norway is one of the countries in Europe with a high and stable overdose-related mortality rate (EMCDDA, 2020, EMCDDA, 2021; Gjersing, 2021). This is partly due to a persistent culture of injecting poly-drug use (Gjersing & Bretteville-Jensen, 2014, 2018), and the fact that many people inject drugs alone (Gjersing, 2017; Gjersing & Helle, 2021), which eliminates the opportunity to intervene in a timely manner (Papamihali et al., 2020).

The number of people who inject drugs (PWID) in Norway is estimated to be between 7400 and 10 500 (Burdzovic & Amundsen, 2018). In order to reduce the drug-related mortality, the Norwegian Government introduced a national overdose strategy in 2014. Several preventive measures were implemented as part of the strategy, such as the “Switch”-campaign, which encouraged PWID to switch from injecting to safer intake methods (e.g. smoking). PWID were also encouraged to avoid poly-drug use, and to be aware of reduced tolerance after periods of abstinence (Helsedirektoratet, 2019, Helsenorge, 2021). The use of harm reduction services was also expanded, such as the take-home naloxone program, drug consumption rooms (DCR), which now exist in two cities in Norway: Oslo and Bergen, and the establishment of heroin-assisted treatment in 2022 (Edland-Gryt, 2018; Helsedirektoratet, 2019). Additionally, encouraging PWID to inject together with peers has become a widespread overdose-prevention strategy aimed at individual behavioural change (Helsedirektoratet, 2019; Winiker et al., 2020). However, minimal research has been conducted to understand the reasons why PWID inject alone, despite the elevated risks (Bardwell et al., 2019; Winiker et al., 2020). While harm-reduction strategies have focused on individual-level behaviours, some studies show that the choice of drug-use environments is shaped by factors such as perceptions of unsafety, shame or avoidance of legal prosecution (Rhodes et al., 2007; Small, Moore, et al., 2012; Winiker et al., 2020). This may help explain the limited effectiveness of interventions that aim to prevent solitary injections among PWID (Winiker et al., 2020). To determine effective harm-reduction interventions, there is a need to understand factors that influence the setting in which injections are performed and why many PWID prefer to inject alone.

In this paper, we explore the complex practices of solitary injecting as expressed by a large group of PWID. Based on qualitative data from interviews with 80 Norwegian PWID, the aim is to study the meanings, perceptions and possible rationales associated with such a drug-using practice. The qualitative approach is sensitive towards the lived experiences of those under study and helps provide new understandings of solitary injecting drug use. This insight should help inform future harm-reduction interventions.

Injecting Drug Use Environments

The setting where drugs are injected represents an important dimension in the production of drug-related harms (Small, Moore, et al., 2012). Injecting in public places is associated with elevated risks (Carlson, 2000), deriving from hasty injections due to fear of interruption or arrest. The public exposure involved in such settings may also cause feelings of shame, leading PWID to prefer private settings for their drug use (Hagan et al., 2007; Small et al., 2007). Public injections are therefore described as a situational necessity, resulting from homelessness or withdrawal, rather than an active choice among PWID (Rhodes et al., 2007).

Injecting alone may entail lower rates of risk behaviour by avoiding multiple use of drug paraphernalia and thus preventing cross-contamination (Hagan et al., 2007). However, those who inject alone experience elevated risks of mortality and morbidity (McCrae et al., 2020). For example, naloxone programmes require another person present for administration. As such, the majority of overdose-related deaths occur within residential environments (e.g. private residences, supportive housing or shelters) and among those using alone (Bardwell et al., 2019; Papamihali et al., 2020; Tsang et al., 2019).

Quantitative studies exploring solitary drug use (not exclusively injections) highlight factors such as convenience, stigma, peer pressure to share injection equipment and the avoidance of legal consequences or violence, as common denominators (Hagan et al., 2007; Papamihali et al., 2020). In one such study, Winiker et al. (2020) found competing priorities in PWID’s choice of drug-using environment, such as withdrawal, stigma, lack of trusted friends, fear of legal responsibility if present during another person’s overdose, as well as a desire not to share drugs with other PWID. Other studies have found similar results (Bardwell et al., 2018; Kirst, 2009), and highlight how social constructs of masculinity may affect overdose risk and solitary drug use (Bardwell et al., 2019). Such factors may help explain the limited effectiveness of interventions aimed at individual-level change (Winiker et al., 2020). Without undermining the importance of these strategies, critiques have suggested that individual behaviour is de-contextualized from the environments in which it occurs, and may fail to account for the greater socio-cultural factors involved in solitary injections (Rhodes et al., 2007). This invites further discussion of social and environmental factors, and how they may help inform an analysis of the complex reasons for injecting alone.

Risk, Stigma and Pleasure

Alongside a focus on the individualization of risk, scholars emphasize the importance of socio-structural factors influencing decision-making regarding where and with whom injecting occurs (Winiker et al., 2020). In contrast to behaviourist models of research, such studies highlight how perceptions of safety and risk are influenced by social relations (Bourgois, 1998; Rhodes et al., 2004). As such, Rhodes’ (2002) concept of ‘risk environment’ emphasizes social and environmental factors, and how they may shape individual, community and policy responses to risk and the reduction thereof. Thus, the various ways risk is experienced and lived by the PWID in their everyday lives may shape their practices as well as their choice of environment for injecting drugs (Rhodes et al., 2007).

Research suggests that PWID are heavily stigmatized both by the public and by health professionals (Luoma et al., 2007; Simmonds & Coomber, 2009). This may be related to perceptions of injection as an undesirable mode of use and due to its associations with HIV (Rivera et al., 2014). Enacted drug use stigma entails be treated negatively as a reaction injecting drug use, such as dismissive attitudes or language with a judgmental demeanor. This may contribute to felt stigma and reduced self- worth (Muncan et al., 2020; Paquette et al., 2018). Goffman (1963) relates stigma to an attribute that is discrediting and how those stigmatized tend to internalize aspects of a ‘spoiled identity’ (Goffman, 1963; Simmonds & Coomber, 2009). This form of stigma may lead to riskier injections, by which PWID take measures to hide their drug use (Latkin et al., 2010; Rivera et al., 2014).

Additionally, the concept of pleasure is important for understanding the varying practices of illicit drug use (O’Malley & Valverde, 2004; Zajdow, 2010). While there has been an absence of discourses of pleasure in the drugs field, Moore (2008) argues that this is an essential part of understanding the subjective motives for drug use. This may include ‘a desirable bodily experience arising from the interaction of pharmacology, subjectivity, culture and history’ (Moore, 2008, p. 354), as well as the specific activities related to the drug use itself (Tsang et al., 2019). Importantly, the concept of pleasure also extends beyond purely physiological experiences and includes a focus on contextual elements (Duff, 2008). Zajdow (2010) argues that there is rationality not only in the drug use, but also in the techniques used for preparing drugs and how they impact on the experience of pleasure. Thus, pleasure needs to be considered as more than a product of intoxication, because ‘the pleasures that emerge in consumption events extend beyond the (…) pharmacological effect of the drug’ (Duncan et al., 2017, p. 6), to include the various ‘contexts, practices, bodies and performances that inhabit and transform each consumption event’ (Duncan et al., 2017, p. 8).

The aim of this study is to explore the various accounts of injecting alone as well as possible meanings and explanations for why such behaviours are preferred, despite the elevated risks. We rely on the concepts of risk environment, stigma and pleasure, and study the various meanings and rationales associated with solitary injecting.

Methods

This paper is based on qualitative interviews with 80 Norwegian PWID, aged 23–63 years (mean age 45), of whom 77% were males. The sample reflects the overall population of PWID in Norway (Gjersing & Bretteville-Jensen, 2018). Almost all participants received financial support such as work assessment allowance or regular social benefits provided by the Norwegian welfare system. In Norway, a person is considered homeless if he or she has no privately owned or rented accommodation, or has unstable positions in the housing market such as shelter for homeless people (Dyb, 2017). In this study, 6 participants owned their own apartment, almost 1 out of 3 had an unstable housing situation such as living in a shelter, half of the participants was provided a municipal rental apartment, and the remaining had other living arrangements such as living with a partner or provided unclear information. Although some described unstable housing, all participants described various private spaces for solitary injections. The information about income and housing-status does, however, have limitations because the information provided was specified in most, but not all interviews due to unclear answers. Yet, the sample in a large degree reflects the overall socio-demographic background of the PWID population in Norway (Gjersing, 2017). The majority injected drugs on a daily basis, and 71% of the interviewees used multiple substances (mainly combinations of heroin, amphetamines and benzodiazepines), 19% mainly used amphetamines, and 10% mainly used heroin.

The interviews were conducted face-to-face during October 2019 in five Norwegian cities. To ensure both breadth and variety, interviewees were recruited at low-threshold services such as health services, needle exchange programmes, shelters, food delivery and drug consumption rooms. The services received information about the project in advance and informed their clients verbally or in writing. Participants were recruited by the service staff at the services, through snowballing or by the researchers on site. The authors and two trained research assistants conducted the interviews. In order to create an atmosphere where the interviewees could talk freely and undisturbed, the interviews were conducted in separate rooms at the low-threshold services. Before the interviews started, the participants were informed about the aim of the study, issues of anonymity and voluntary participation, as well as the possibility to discontinue the interview at any time.

The interviews were semi-structured and guided by a list of topics covering questions about the interviewees’ thoughts on injecting and other intake methods, positive and negative experiences of injecting, risks and risk-prevention strategies, as well as narratives about their participation in street- based drug scenes. As the interviews were carried out with persons under the influence of drugs, level of intoxication, type of drug, and the physical and mental health of the interviewees all affected their capacity to engage in the interviews. This may entail limitations due to ethics as well as the participant’s well-being and concentration to be interviewed. Thus, it was a priority for the researchers to assess the participant’s level of intoxication and physical and mental health prior to gain consent, as well as continuously evaluating the participant’s state during the interview. Exclusions included those who were overly heavy intoxicated, or where there was doubt related to mental health (as assessed by the staff). Two interviews were discontinued by the researcher, as it was considered unethical to continue due to the participant’s heavy intoxication or poor mental health. This involved situations where one participant had challenges to stay awake, and one situation where the researcher assessed that the interview affected the participant’s well-being and capacity to take part due to mental health challenges.

The interviews lasted an average of 45 min, ranging from 25 to 60 min, were audiotaped and transcribed verbatim. Transcripts from the interviews were thematically coded in HyperRESEARCH. The use of thematic analysis focus on the flexible and reflexive nature of such a research method, independent of theoretical approaches (Braun & Clarke, 2006). Thus, rather than predefined concepts or theoretical lenses, the narratives presented by the participants were our initial starting point. The thematic coding was based on the interview guide and included a broad range of codes: reflections and narratives on injection initiation, risk and risk-prevention strategies as well as descriptions of their day-to-day lives as PWID. Topics that were introduced by the participants during the interviews or emerged from the fine reading of the interviews were added to the code list. The further analysis focused on the stories that were relevant to understanding participants’ injecting environment, including the time and setting of injection, descriptions and perceptions of their social environment and injecting drug use, attendance at low-threshold services, as well as detailed descriptions of how and where they preferred to prepare and inject drugs. The next analytical step consisted of fine reading of the selected transcriptions, and identifications of patterns and common themes that led to the classification into the three main categories presented in the results: risk environment and safety, stigma and privacy, and pleasure and context.

All interviewees were reimbursed NOK 200 (approximately 20 €) for their time. The project was approved by the Regional Committee for Medical and Health Research Ethics in Norway (REK), ref.nr.1,206,091. Any potentially identifiable information has been removed or anonymized, and the interviewees are referred to by pseudonyms. The sample consists of persons who use the low-threshold services. We have thus missed out on the views and experiences of people without established contact with these services, which may have affected the results. Although the study is based on a considerable number of interviews with PWID, it reflects findings from Norwegian settings and may therefore not be generalizable to other contexts.

Results

The interviewees recounted that they preferred to inject alone, and they offered several contributory reasons. First, the risk environment they inhabited caused distress and fear, and solitary injecting contributed to an increased sense of safety and protection from peers they did not trust. Second, stigma and shame were clearly described by the interviewees and, by injecting alone, they were able to hide their drug-using practices. Finally, the pleasure associated with injecting was a key component. Performing injecting rituals in private settings helped maximize the positive sensations associated with their drug use. The study illustrates important social and environmental factors that influence settings for injecting drug use.

Discussion

We have explored accounts of injecting alone from the perspective of PWID. Based on an extensive number of interviews, the analyses revealed that the participants constructed several rational and positive meanings of injecting alone. First, this involved a perceived notion of safety from an unpredictable risk environment and peers they did not trust. Second, feelings of stigma were described as causing additional harms, producing a wish to hide their drug-using practices from the outside world. Finally, the interviewees highlighted the need for peace and quiet in order to enjoy the pleasures associated with injecting. The study thereby illustrates how the risk environment caused additional harms, by which solitary injections was rationalized, despite its increased mortality risks.

These findings stand in contrast to most overdose prevention and harm-reduction strategies, which largely focus on individual-level behavioural change, and the relationship between knowledge and avoidance of risks (Small, Moore, et al., 2012a; Winiker et al., 2020), such as encouraging PWID to switch to safer intake methods (e.g. smoking), to carry naloxone, avoid mixing drugs and injecting alone (Edland-Gryt, 2018; Helsedirektoratet, 2019, Helsenorge, 2021). Although these strategies form an important part of overdose prevention work, it has been suggested that such individual behaviour is detached from environmental contexts that contribute to influencing drug-using behaviours (Small, Moore, et al., 2012). The participants in this study expressed awareness of the risks associated with their injecting practices. However, solitary injecting was perceived to be beneficial as it alleviated the contextual risks stemming from the street-based drug scenes, thus highlighting tensions between the risks and benefits of solitary injections. Other studies have also demonstrated how PWID weigh the adverse outcomes that may arise from using drugs in the company of others, against the risks of injecting alone (Moore, 2004; Papamihali et al., 2020; Winiker et al., 2020). As such, solitary injections may entail both protection and risk (Small et al., 2009). However, injection-related behaviour should be understood in context with the everyday risks that characterize the lives of PWID, in which solitary injecting is perceived to facilitate greater personal control and feelings of safety (Bourgois, 1998; Connors, 1992; Hagan et al., 2007).

The interviewees in this study also described experiences of shame and stigma, and therefore made efforts to hide the injecting drug use, even when around friends. Their discrediting attributes thus led to an internalization of these feelings, as well as a negative self-evaluation that arose from identification with a stigmatized group (Rivera et al., 2014). The embarrassment and stigma associated with injecting drug use may thus lead to riskier injection behaviours (Luoma et al., 2007; Rivera et al., 2014; Winiker et al., 2020), and further contribute to reducing the effectiveness of prevention measures and harm-reduction strategies aimed at PWID (Simmonds & Coomber, 2009; Strathdee et al., 2012).

Additionally, the interviewees described the importance of contextual pleasures associated with injecting alone, stressing factors such as calmness, temperature, perceptions of cleanliness and being able to ‘chill out’. The ability to control one’s injecting environment is tied with having a home or a personal space. Participants occasionally injected outdoors mainly for practical reasons such as stress due to withdrawal or after opening hours of the DCRs. Although they could be able to find personal spaces outdoors, this was perceived as stressful due to a fear of public exposure or to be disturbed by the police or security guards. Several interviewees occasionally attended the DCRs, emphasizing the benefits of safety and presence of health care personnel. Yet, they experienced barriers such as noise, theft and crowded environments. Instead, although several participants had unstable housing, they described private spaces for solitary injections, such as shelters or temporary rented apartments which the interviewees mainly referred to as their “home”, or “my room”. Solitary injecting was accordingly deemed beneficial as it allowed for peace and concentration, in which they could enjoy both the drug- induced sensations and the ritual act involved in the drug-using process. These environments allowed autonomy, comfort and feelings of pleasure both before, during and after injecting (Tsang et al., 2019). Similarly, Duff (2008) argues that the pleasures associated with drug use extend the physiological intoxication, to include the contextual elements involved. Pleasure emerges through particular social and emotional transformations enabled through specific consumption routines (Duncan et al., 2017). It is therefore key to understanding the dynamics of space, embodiment and practice, and how they interact with the contextual experiences of drug-related pleasures (Duff, 2008).

The findings in this study illustrate the competing priorities among PWID. Although some may prioritize health or safety by injecting with others (Winiker et al., 2020), solitary injections should also be understood as an adaptive strategy employed by marginalized individuals to manage various and often competing considerations (Moore, 2004; Small, Moore, et al., 2012). These priorities are socially and culturally intertwined (Rhodes et al., 1996), and further illustrate how overdose prevention strategies focusing on individual behaviour change may fail to account for the situated knowledge developed through the lived experiences of PWID (Moore, 2004; Rhodes et al., 2007; Small, Moore, et al., 2012). This invites further discussion of how solitary injecting is influenced by social and environmental factors, and how it may contribute to an improved understanding of such drug-using behaviours. The everyday experiences of PWID are shaped by multiple individual, social and environmental factors, which in turn shape the plethora of drug-using practices (Bardwell et al., 2018). Additionally, the restrictive focus on risks and harm may overlook the pleasurable aspects of illicit drug use (Duncan et al., 2017; Keane, 2003), as well as the complex needs of PWID (Moore, 2004). Scholars argue that such a narrow focus may be a barrier to responding to drug use in more effective ways, and stress the importance of increased sensitivity to the lived experiences of PWID, their subjective understandings of risks and the imminent pleasures of drug use (Duncan et al., 2017; Moore, 2004). The findings in this study suggest that, although some PWID prefer to inject around others, a significant number are likely to inject alone. Therefore, to address the needs of PWID, harm-reduction strategies would benefit from acknowledging how social and environmental factors influence drug-using behaviours. This involves emphasizing the structural and contextual risk environments of street-based drug scenes, the levels of felt stigma imposed on PWID based on enacted stigma such as hurtful comments or dismissive attitudes, as well as the often-neglected perspective of the pleasures involved in illicit drug use. These perspectives allow for a greater sensitivity towards the differing practices of injecting drug use and how the contextual spaces of drug scenes interact with such behaviours.

In this study, DCRs were perceived as a valuable intervention by the participants, which indicate that DCRs should be made available in more cities. Yet, negative experiences such as theft and crowded environments created barriers to access these services. Small, Moore, et al. (2012) suggest that this may exemplify a discrepancy between public health and PWID’s views of risks related to the drug use settings. The physical environment is thus not only a physical space, but also exemplifies how these settings communicate a wider social stigmatization of PWID, and contribute to feelings of shame and otherness (Rhodes et al., 2007). This suggests novel ways of optimising DCRs which are able to reflect the diverse needs of PWID, including the possibility to enact more pleasurable and positive relations to themselves and their drug use (Duncan et al., 2017; Small, Wood, et al., 2012). While the practice of injecting alone may seem irrational, the findings in this study illustrate the opposite, in which solitary injecting rather became an adaptive strategy for coping with the structural harms experienced by the participants. Eliminating stigma associated with injecting drug use thus remains imperative in in order to allow PWID to feel safe (Muncan et al., 2020; Papamihali et al., 2020). In Norway, there has been an evolvement in the drug policy, moving from a punitive to a more supportive approach. A drug reform was established in 2004, intended to ensure patient rights for people who use drugs. This entailed treatment for their drug use, and the need for specialized health services in order to reduce mental and somatic challenges (Gjersing & Amundsen, 2018). A shift in the society’s way of understanding drug use may also be reflected in the establishment of heroin-assisted treatment. The aim is to help people with opioid addiction to achieve a better quality of life, enhanced individual support, and to reduce the health risks associated with non-medical use of opioids (Oslo University Hospital, 2022). Although drug use is still prohibited, a strengthened health and social care approach may contribute to a direction towards less stigma and a more unified healthcare. Yet, this study illustrates that stigma is still important to address in order to facilitate safer drug use for PWID.