Nuancing Drug Harms: Exploring the Context of Substance Use Among Street-Involved Women in Uyo,Nigeria

Abstract

Recent studies on women’s substance use have emphasized the role of structural and environmental contexts in shaping substance use patterns and harms, but the dynamics constitutive of specific substance use contexts are seldom unpacked. This study works with Cameron Duff’s elaboration of context as an assemblage of space, embodiment and practice to explore the contextual dynamics that mediate substance use practices among socially marginalized women. In-depth interviews were used to gather data from a purposive sample of street-involved women who use drugs (n = 16) in Uyo, Nigeria. Data revealed that substance use was mediated by actors, social norms and processes within social networks developed in street environments. The women used substances to achieve particular affective states such as pleasure, stress relief and coping with trauma. Social network dynamics combined with the use of drugs to manage trauma and social stress, within a wider context of social and material deprivations, to foster substance use practices that created risk for harm. Drug harms were not inherent to the substance use experience or incidental to benefits and pleasures. Instead, they were unintended, but inevitable, outcomes of the embodied practices of beneficial substance use. On the other hand, corporeal techniques of controlled drug use served to minimize drug harms. Findings indicate a need to address the contextual dynamics that influence harmful patterns of substance use, and to leverage the harm reducing potentials of controlled use practices.

Keywords

embodiment harms street-involved women social networks substance use

The research literature on women’s substance use is notable for its emphasis on drug-related problems. The older literature emphasized deviance, psychological disorders and effects on pregnancy and childrearing (Ettore, 1992; Gossop, 1986; Inciardi et al., 1993; Pagliaro & Pagliaro, 1999; Rosenbaum, 1979, 1981). In analyzing women’s substance use in terms of the associated social and health problems, these studies tended to ignore the complexity of women’s substance use and how they negotiate drug harms (Anderson, 2005). Further, the emphasis on harms goes beyond the research literature on women’s substance use. In many ways, it reflects a totalizing logic that conflates substance use with harms (Duff, 2015; Race, 2008). This logic, which is seen as the principal rationale underlying modern drug policies (Duff, 2015), support approaches to drug control that are at odds with the experiences and needs of people who use drugs (PWUD).

Recent studies have contributed to a better understanding of women’s substance use by explicating how structural and environmental factors shape substance use patterns and harms (Bourgois et al., 2004; Bungay et al., 2010; Collins et al., 2018; Epele, 2002; Fairbairn et al., 2008; McNeil et al., 2014; Saleem et al., 2021; Shannon et al., 2008). Studies have shown how initiation of substance use among women is influenced by social networks, which also mediate drug supply (Martin, 2010; Mburu et al., 2019; Meyers et al., 2020; Nelson, 2021). Women consume drugs in response to complex personal needs or problems such as the desire for intimacy, health improvement or for pleasure (Martin, 2010; Nelson, 2021; Payne, 2007). Studies have also shown that most substance dependent women have had traumatic experiences, including sexual abuse, inter-personal violence and homelessness (Bungay et al., 2010; Epele, 2002; Gilbert et al., 2001; Haritavorn, 2014; Maher, 1997; Romero-Daza et al., 2003; Shannon et al., 2008). Also, women become dependent on drugs faster than men, and experience higher levels of mental health problems, stigma and stressors in their lives (Fraser et al., 2019; Howard, 2015).

In addition to risks related to drug consumption, women also experience disadvantages and disproportionate risks in the illegal drug economy. Illegal drug dealing is often regarded as a male-dominated occupation (Maher, 1997). In earlier studies on this topic, female dealers were often portrayed as “unsuitable” as drug dealers (Adler, 1993). They were also seen as occupying marginal and subordinated positions both in male-dominated drug markets (Dunlap et al., 1997; Rosenbaum, 1981), and in drug use spaces, where they were vulnerable to violence and sexual exploitation (Bourgois et al., 1997; McNeil et al., 2014). Similar to pathways into drug use, women may be “compelled” into drug dealing by victimization, economic marginalization, survival needs and drug dependence (Maher & Daly, 1996; Morgan & Joe, 1996; Stefensmeier & Allan, 1996).

More recent studies have challenged the view of female drug dealers as dependent and powerless, offering critical perspectives that emphasize their agency and resourcefulness in navigating a male-dominated drug economy. Anderson (2005), for example, has shown that female dealers are powerful and competent, and their “supportive roles” (e.g., cookers, sex workers) are central to the organization of the illegal drug economy. Other studies (Denton & O’Malley, 1999; Dunlap et al., 1994; Fleetwood, 2014; Grundetjern, 2015; Hutton, 2005; Ludwick et al., 2015; Murphy & Aroyo, 2000) show how women leverage diverse socio-cultural and gendered repertoires to negotiate violence and male dominance, and to achieve relative levels of success in the illegal drug economy. These findings speak to women’s agency and capacity to negotiate drug harms more generally.

Studies have also highlighted an overlap between female substance-using and sex-working populations (Romero-Daza et al., 2003; Shannon et al., 2008). Female street-based sex workers experience disproportionate health and social harms (e.g., violence, stigma and HIV infection) (Nelson, 2020; Saleem et al., 2021; Syvertsen et al., 2019). They use substances for social, coping and work-related reasons (Needle et al., 2008; Wechsberg et al., 2006). Associated social and health problems elevate their vulnerability to high-risk substance use and harms (Shannon et al., 2008; Wechsberg et al., 2006). These findings suggest that the harms experienced by women on account of drug use are not only linked to drug effects. They also indicate a need for a better understanding of the contextual dynamics that mediate women’s drug use and experiences of harm.

Theoretical Approach

Informed by Zinberg’s (1984) seminal work on drug settings, most studies on women’s substance use have emphasized the broad structural forces (e.g., poverty, homelessness) that mediate substance use patterns. While these factors are of importance, in as much as they serve as an enduring and relatively stable background of social life, they reveal very little about specific substance use contexts and their constituent dynamics. Theoretical developments such as Moore’s (1993) processural view of setting and, more recently, Duff’s (2007) conceptualization of drug use contexts as an assemblage of space, embodiment and practice, offer potential for a more grounded explication of diverse local contexts. Drawing on the ideas of writers such as Gilles Deleuze, Michel Foucault, Michel de Certeau, and Nigel Thrift, Duff has characterized context as “an assemblage of relations drawing together diverse experiences of space and spatialization; embodiment and becoming; conduct and social practices” (Duff, 2007, p. 504).

In this view, space is not absolute, natural and given, but is constantly being constructed and reconstructed through “the agency of things encountering each other in more or less organized circulations” (Thrift, 2003, p. 96). Describing space in relation to substance use involves an emphasis on “spatial relations” (Osborne & Rose, 2004), or “the various ways relations between individuals and other actors are structured in and through distinct spatial networks” (Duff, 2007, p. 509). Conversely, embodiment describes how social and cultural processes actively produce the body as a distinct category (e.g., as a woman drug user). The body is seen as open and malleable; the social world is continually folded into the body so that embodiment becomes the outcome of flows, intensities, encounters and transitions. Practice, in turn, refer not only to intentional actions by which people transform themselves (“technologies of the self,” in Foucault’s parlance), but also to more fluid, elusive activities of resistance and meaning-making. Following from this theoretical elaboration, substance use becomes a “practice of the body in space” (Duff, 2007, p. 507).

Study Context and Aims

Different iterations of this theoretical perspective have inspired recent substance use research (Bohling, 2015; Dilkes-Frayne, 2014; Sultan & Duff, 2021), but few, if any, studies have applied it to women’s substance use. This approach could facilitate understanding of drug harms among women in Africa, especially when used to unpack the effects of macro-structural factors. Used in this way, it would respond to the call for dialogue between qualitative social science drug research and epidemiology in order to overcome dogmatic methodological and theoretical blinders and foster understandings of the social patterning and nuances of drug-related harms in structurally vulnerable populations (Bourgois, 2002).

The focus on Africa is informed by emerging drug markets linked to illegal drug trafficking through the continent enroute to more lucrative drug markets in the industrialized west (Akyeampong, 2005; Cockayne & Williams, 2009), contributing to increased consumption of drugs in these transit countries. High-risk substance use practices have been reported among street-involved women in Africa (Lancaster et al., 2016; Leddy et al., 2018; Nelson, 2020; Syvertsen et al., 2019; Wechsberg et al., 2006). In Nigeria, the setting of the current study, an estimated 22% of high-risk drug users (i.e., those who used opioids, cocaine, or amphetamines in the past 12 months, and on at least 5 occasions in the past 5 months) were women, and most had exchanged sex for money, drugs and shelter (United Nations Office on Drugs and Crime, 2018).

In Nigeria, poor economic growth, endemic corruption and rapid population increase have yielded dramatic increase in poverty, diseases and human suffering (Lewis, 2006). In 2019, prior to the coronavirus pandemic and related socio-economic impacts, an estimated 82.9 million Nigerians lived in extreme poverty (World Bank Group, 2022). Twice as many women as men live below the poverty line, and most possess little or no formal education or capital to earn income and extricate themselves from the grip of poverty (Enfield, 2019). Women are, therefore, disproportionately affected by current economic conditions. Many make a living from street sex work, which has brought them into the proximity of drug dealing and use (Izugbara, 2007; Nelson, 2020). Women’s substance use has been shown to be woven into multiple and overlapping dynamics of social and economic marginalization, including poverty, homelessness, and criminalization and stigmatization of sex work and drug use, which shape substance use practices (Nelson, 2020, 2021; Nelson & Bridget, 2022).

Women’s substance use has attracted significant publicity in the local media in recent times owing to concerns about health risks (Babafemi, 2021), buttressing popular views about drug harms and bolstering support for criminalization of personal drug use. Criminalization of drug use is premised on a lack of recognition that drug harms are highly contextualized phenomena. This unrecognition is mostly due to the neglect of critical perspectives from qualitative social science research in academic and policy discourse on drugs, which is currently dominated by quantitative epidemiology (Bourgois, 2018). In this context, a need exists for critical qualitative scholarship to enable a better understanding of drug use contexts in order to inform appropriate policies. In this study, I explore the contextual dynamics that shape substance use practices and harms among street-involved women. The study was originally designed to explore chronic pain and substance misuse, but probes elicited data on high-risk substance use and harms. This study explores how drug use and harms are mediated by an assemblage of space, embodiment and practice (Duff, 2007).

Methods

Study Setting and Participants

This study was conducted in Uyo, the administrative capital of Akwa Ibom State in Nigeria. The city has an estimated population of 1,143,689 people (World Bank, 2020). A large proportion (51%) live in absolute poverty, defined as living on less than one dollar per day (National Bureau of Statistics, 2010). This translates to inability to meet basic needs (e.g., food, healthcare, housing) for many individuals and households. Most earn a precarious living from the urban informal sector (Idemudia, 2009), where the boundary between what is legal and illegal is blurred. Commerce, services and a variety of low-level office, administrative and salaried positions mostly in the civil service are the mainstay of the city’s economy. Oil extraction in the state has encouraged massive in-migration, resulting in a rapidly growing ethnically diverse population (Okeibunor et al., 2011). Population growth has outstripped infrastructural development and provision of basic social amenities such as healthcare services, housing, electricity and safe drinking water. Women bear a disproportionate burden of poverty, and some have turned to sex work to earn income to meet personal needs and those of their dependents (Nelson, 2020). Sex work overlaps with street drug markets, creating a risk environment for drug use and dealing (Nelson, 2020). The participants were recruited through purposive sampling from two Drop-in Centers (DICs) for PWUD in the city. Information on the research was communicated to women attending the centers by the staff, and interested persons contacted the researcher on phone, and were screened to confirm eligibility. In addition to suffering a chronic pain condition (the key eligibility criterion for the study), eligible participants were women (aged 21 to 34) who had used illegal drugs (e.g., heroin, cocaine) at least once in the past thirty days and were street-involved, which means being absolutely, periodically or temporarily without stable and safe housing, and those who may be housed but who are heavily involved in the street economy (Kerr et al., 2009). Altogether, 16 women were recruited for interviews. The highest level of schooling attained by any participant was secondary education. Many were unstably housed (e.g., living with a friend). Most were sex workers, and some combined it with other income generating activities (e.g., trading). Nearly all had regular sexual partners.

Data Gathering and Analysis

Data was collected through in-depth interviews conducted between September 2019 and January 2020. Interviews relied on a topic guide designed to elicit information on chronic pain and substance misuse. However, in the course of the interviews, insights emerged on consumption practices and patterns, harms and controlled use. These themes were probed to elicit more information. Examples of probing questions are: “does your drug use cause you problems?”; “describe to me the kind of use that have caused you problems”; “what kinds of problem have your drug use caused you?”; “tell me about the ways you use so they don’t cause you much problems?” During interview sessions, participants were provided information on the study and they all gave verbal consent to participate. Interviews were conducted at the DICs, cafeteria, and bars, and they lasted between 45 and 90 minutes. Responses were digitally recorded with the consent of each participant.

All participants were gifted five hundred naira (US$1.3) in appreciation. Interviews were transcribed verbatim and checked for accuracy. The transcripts were then read repeatedly for immersion. A manual inductive coding was undertaken based on both deductive and inductive codes (e.g., supply, high-risk use, benefits, harms). The coding framework was independently assessed by two experts to improve analytic rigor (Syed & Nelson, 2015). This informed dropping or merging unsuitable codes, and clarifying the meanings of codes. The framework was then applied to code the remaining transcripts, before themes were identified and developed, and the patterns of meaning were recorded (Braun & Clarke, 2019). Pseudonyms are used in this article to protect participants’ identity. The study was approved by the Health Research Ethics Committee of the Ministry of Health, Akwa Ibom State, Nigeria.

Results

Initiation of Substance Use

Initiation of substance use was mediated by contextual factors, including social networks, availability of drugs in sex work environments, and health system factors (e.g., barriers to pain management). Most women were introduced to substances within social networks, particularly by sexual partners. For some, accounts captured a trajectory from homelessness and/or street-involvement through co-habitation with a male partner to substance use. This indicates that the women’s social networks were characterized by dynamism and ever-changing relationships (Moore, 1993, p. 420). Florence’s (aged 34) story illustrates this trajectory:
I started like taking these drugs when I was staying with my boyfriend. I was staying with him at that time because I didn’t have a place. We met out there (i.e., on the streets) and like hook up. He used to take drugs, so we will like do it together when we were living together…Now, I am with someone else.

A key highlight of Florence’s account is how sexual relationships developed within street environments mediated substance use initiation. The women were not compelled to use substances. Instead, many decided to use the substances introduced to them by their partners for reasons such as stress relief and pleasure. Substance use practices, therefore, served to constitute particular affects and modes of embodiments, and this encouraged the participants to continue using. Angela (aged 24) described how she started using cannabis for stress relief:
I was going through a lot of things at that time. So, my boyfriend told me “you should try this (cannabis), it will help you to feel better.” He used to use weed and alcohol, but I didn’t use to take anything. But there was this day I couldn’t bear the problems again so I decided to try the weed, and truly it was great. So, I started to use it.

Here, Angela describes an affective experience (which she termed “great”) brought about by the consumption of cannabis. Expectancies of such an experience and its actualization in the event of consumption influenced her initiation and continuation of cannabis use. This brings to the fore the affective dimension of the women’s substance use contexts. Grace’s (aged 27) decision to try heroin was similarly influenced by expectancies of embodied experience of pleasure stoked by her male partner’s laudation of the drug’s effects:
It is my boyfriend that made me to take Thai (heroin). You know, when someone is telling you all the time that this thing is nice, cool and all of that. So, you will try it. He was always telling me that it gives him a good feeling, makes him relax and enjoy himself. I took it to have that same feeling.

While some (like Angela and Grace above) started using substances in the context of affective relationships, others (like Mary) had started using substances before establishing sexual relationships. For most of such women, drug use initiation took place within the context of sex work and was mediated by availability of drugs within sex work environments (e.g., bars, clubs, motels). These cases show how substance use, as an embodied practice, is mediated by physical spaces and social network actors that mediate the supply of drugs (“spatial relations,” according to Osborne & Rose, 2004). Mary (aged 21) commented:
Personally, I started using when I used to work as a call girl. You know those things, like going to a bar and drinking and all those things. Sometimes, you go out with someone who takes drugs. That is how you will also take drugs. You do these things so you will not look like you don’t know anything and so that your customers will be relaxed and enjoy being with you.

Mary’s comment highlights an understanding of how normative expectation to consume drugs interacts with availability of drugs in sex work environments to shape substance use. Imelda (aged 28), on the other hand, started using crack cocaine while retailing the drug on the streets, an income generating activity she combined with sex work. Her account further show how substance use is mediated by relations that are constituted in and through distinct spaces (Duff, 2007; Osborne & Rose, 2004):
One of the guys I met introduced me to selling block (crack cocaine). He said that I can make a lot of money doing the business. So, I started selling it and it was easy because I used to meet like a lot of people on the streets who were taking it. Me, too I started taking it. You know, if you’re selling something, you will also use it.

Sex work spaces played a major role in drug use initiation for women who solicit clients at bars and clubs. Drugs were said to be pervasive and commonly used in these spaces (“Drugs are everywhere here where I work, and many people take it,” Rhoda 24). Women usually consume alcohol, with a labile network of co-sex workers, while waiting for clients (“If you are waiting for a customer, you will be drinking something,” Imelda 28). They also consume other substances with clients in hotels and chalets to be able to satisfy their clients. The normativity of drug use within sex work environments was seen as a major contributor to drug use among the women. Ruth (aged 28) narrated:
I think I started using when I became like a street girl (street-based sex worker), because there is no how you work in the streets and you won’t use hard drugs. Most girls who are doing it also take drugs, because this work is not easy. They also like encouraged me to use. I use it to be able to do what customers want.

In this comment, physical spaces (“streets”) and social relations (in this case, the co-workers who encouraged her to take drugs and the clients she wishes to please) interact to shape drug consumption. The participants’ drug use is not the product of either factor operating alone, but of the two inter-acting. Ruth’s comment is corroborated by Sarah (aged 23), who highlights how substances and their consumption are integral to the social and spatial dynamics of street sex work:
These drugs we’re talking about is all here on the streets because those of us who are on the streets need it. Most of the girls I know take drugs. They have to do that to be able to survive as street girls. Like, to be able to be with a customer, you have to like be high on something.

As seen in Sarah’s comment, drugs are not only widely available on the streets, their use is critical to women’s survival in street environments. In the parlance of assemblage theory of drugs, street spaces are not a passive background or “context,” in the traditional sense; they play an active and constitutive role in these women’s drug use.

Accounts emphasized the role of co-sex workers in the women’s introduction to substance use. Some described how their co-workers offered them substances to use so they would be able to cope with the embodied effects of sex work. This may be seen in Angela’s (aged 24) account of her reliance on friends for drug supply to cope with the effects of sex work:
My friends that I was staying with gave me the drug (cocaine). They told me, “girl you have to take this thing so you will not chicken out, so you will survive the stress.” That was when I just started this work. They used to buy the stuff, and give me some because I didn’t know anything.

Angela’s comment positions substance use as a practice of and for the body. By this I mean that drug use is an embodied practice which helps the women to cope with the embodied effects of sex work. This is further revealed in the accounts of women whose pathway to substance use was through healthcare. For example, Kate (aged 34) was prescribed opioid analgesics for lower back pain. She later developed dependence on these medications and went on to use illegal substances such as heroin. For Idara (aged 31), health system barriers (e.g., restrictions on opioid prescribing) made her resort to diverted opioid analgesics, which led to habitual substance use (“When I started getting [Tramadol] from streets, I never stopped again”). All these shows how embodied substance use serve affective purposes.

High-Risk Substance Use

Accounts revealed patterns of high-risk substance use among the women, which were mediated by the drug use context or “setting,” in Zinberg’s terminology. One of these was heavy substance use, which meant consuming large quantities of drugs. Some participants described a pattern of heavy substance use involving increase in the quantity of substances consumed, usually occurring within a relatively short period after initiation. For example, Mercy (aged 21) expressed concern about her heavy heroin use, which developed barely a year after she started using it:
It has not been long since I started to be using the thing (heroin). I would say about nine months ago? But I can take up to six bags at one time now. That is why I am saying that I am using too much. I am worried about the way I am taking it these days.

Rose (aged 27), similarly, consumed alcohol heavily. Her account captured a pattern of heavy alcohol use involving consumption of upwards of nine bottles of beer in a single drinking episode (“I usually drink too much; like say nine bottles of beer”). Also, Angela, who had been using heroin for a little over a year, was consuming over six bags at once. She was not only concerned about her substance, but also expressed a need for treatment:
I think that I am using a lot…Like, I use over six bags if I sit down to use it. That is too much. Yes, I know it is too much, especially because I started using it like last year. So, I think I need to get rehab. I should go for rehab.

For other women, high-risk substance use involved a transition from smoking to injecting. Such transitions were influenced by social network actors (e.g., sexual partners, co-sex workers), and helped to minimize the risk of withdrawal pains within the context of drug dependence and material deprivation. Besides increasing the range of drug consumption practices available to the women, injecting also helped them to cope with the embodied effects of drug withdrawal amidst lack of funds to procure drugs sufficient for their need. This may be seen in Florence’s comment below:
I used to only like smoke it (crack cocaine), but then I learned how to inject. So, sometimes I do inject it…Actually, what happened was that I couldn’t buy like enough for my needs because I was using so much. Then the guy I was staying with at that time, he encouraged me to try injecting. He said it will last and I will not be suffering cold turkey.

In this case, transition to a riskier mode of drug administration resulted from an attempt to navigate withdrawal risk in the context of income precarity. The availability of substances within street sex work environments also encouraged heavy use. The roles of this street-based social networks in drug supply and use is captured in Glory’s (aged 26) response:
Interviewer:
How do you get the drugs to use so much?
Glory:
It is through my friends that we do (sex work) together that I get it. We usually share it among us. Something like Thai or Tramadol, we always share like that so I always get drugs. Sometimes I could get it from the people I am going out with, like customers.

This suggests that drugs are among the “things” that, to paraphrase Thrift (2003), circulate and are encountered in sex work spaces. Accounts also indicated that the participants used substances as self-medication for the embodied effects of violence, and this fostered heavy consumption. Street sex work and drug market spaces are characterized by violence, and participation in these scenes exposes women to diverse forms of violence in the hands of clients and male drug dealers (McNeil et al., 2014; Nelson, 2020). For some of the women, violent victimization in street sex work contexts combined with histories of child abuse to exacerbate trauma and suffering. In their accounts, these women described how drug use helps them to cope with such experiences. Substance use, therefore, represent attempts by the women to make sense of the world or “bring meanings to the vicissitudes of bare life” (Duff, 2007, p. 513). It also offered a means of self transformation, which may be seen in the affective benefit of drug use in offering a temporary escape from distress and suffering. This dynamic often resulted in heavy consumption:
Interviewer:
Could you tell me more about why you take these drugs?
Idara:
It is because it helps me to forget all the terrible things that I face everyday in life. Women like me go through a lot, like problem with your man, police harassing you or getting into a fight with customer. It is because of these things that we use drugs. For me, I use a lot so I can get high and forget all the bad things.

Idara’s comment frames substance use practices as “technologies of the self,” situating them within the wider context of structural and everyday violence. As this example shows, drug harms are foregrounded in the structural and affective dynamics that mediate heavy use.

Frequent use was also a common substance use practice, with most accounts pointing toward daily or nearly daily use (“I take it [heroin] like all the time,” Idara; “I use like three days a week,” Mary; “I think it is like everyday,” Florence, aged 34). In addition to trauma management, frequent use was motivated by the need to prevent withdrawal sickness. Ama (aged 27) noted:
Interviewer:
Tell me why you use drugs so many times in a day?
Ama:
I use like so many times every day because of the sickness (withdrawal symptoms). You know, me I have been using drugs for a long time now. So, I am like addicted to it. So, I have to use it like from time to time. Even when I don’t like to use, I must still use it so that I will not get sick.

Concerns about preventing withdrawal symptoms made some to resort to prescription opioids (e.g., Tramadol) in the absence of heroin. This underlines the impact of embodied drug effects on substance use practices. Again, heavy use was the dominant pattern. Idara, for example, reported consuming a full card of 500 milligram Tramadol at once:
The thing is that women who take drugs will use it a lot, especially drugs like Tram (i.e., Tramadol). That is one thing that I have seen. Like, me I use to use a lot. I use like a full card each time I am taking it.

In the above quote, Idara points out that heavy consumption is common practice among women. As the accounts canvassed throughout this paper shows, this is mostly due to the affective and structural dynamics that mediate their drug use. Similarly, social networks developed within street environments also mediated drug use practices. Grace described how substance use was normalized within her social network, and how these norms (e.g., expected acceptance of the offer of free drugs) influenced her substance use behavior:
I think that the reason I use many times is because of the people I have around me now. Like I hang out with girls and guys who use drugs a lot. It is part of the lifestyle, you get it. So, you have to use too. If like your personal person (i.e., an associate) give you drug, you cannot say no. It will not look nice to turn it down.

Grace’s account indicates that pro-drug norms within social networks mediate substance use practices through an on-going process of negotiation where the participants in the drug exchange event co-create the outcome (Dilkes-Frayne, 2014; Moore, 1993). The outcome, or resultant substance use practice, is as a much a product of reflex encounters as they are conscious and deliberate (de Certeau, 1984; Duff, 2007).

Benefits, Harms and Controlled Use

Interviews probed participants’ perceptions of harms from their substance use practices (e.g., “what do you think about the way you are using these drugs”; “what about the effects they could have on you?”). In their responses, most participants contested notions of drug harms that are de-linked from the contexts of use, which, as shown earlier, were described in terms of the assemblage of space, embodiment and practice. Erroneous notions of harms were said to be expressed by persons who do not have embodied experiences of substance use. Naomi (aged 25) explained:
Most people who talk about how drugs can cause problem have never taken drugs before. So, they just sit down and look at people who take drugs and say that they have problems because of drugs. But you can never know how drugs affect people when you have never used it.

This comment indicates that valid knowledge of the effects of drugs can only derive from embodied experience of their use. In another account, Naomi admitted that substance use does have negative effects, but these effects were often exaggerated by non-users (“Like I know that drugs have problems but not as some people [non-users] talk about it”). Naomi’s view was shared by other participants, including Felicia (aged 26), who corroborated the view that drug effects are known bodily, and are substantially different from how they are often portrayed by non-users:
If you want to know how drugs can affect people, you have to use it to know. You can’t just stay there on your own and say that drug does this or that. When you take drugs, not that it won’t affect you, but you will know that the effect is not the way people say it is.

Participants considered drug harms along-side its embodied benefits, which motivated them to use these drugs in the first place. Many related how they started consuming substances (or some types of substances such as prescription opioids) in response to a range of health and social problems. They described other (extra-medical) benefits of drugs such as offering relief from distress or enhancing daily functioning. Viewed in this context, drugs use, though potentially harmful, are beneficial to street-involved women suffering material deprivations and unmet health needs (see Nelson, 2020). Such perspectives stand in contrast to views about drugs held by those who occupy more privileged social positions.
Interviewer:
So, what do you think about the problems that drugs cause?
Ruth:
Yes, drugs can affect you. But we that are using drugs use it for a purpose, which is to deal with the things that we are going through. Women who are on the streets go through a lot and that is why we take hard drugs. So, yes drugs have problems, but it also helps us. Those whose lives are better will not understand, that is why they will be talking nonsense about what drugs do.

Ruth’s comment, corroborated by many others, makes the point that the embodied benefits of drugs are what shapes substance use practices (including, as indicated earlier, high-risk use practices). Drug harms were seen as unintended outcomes of substance use practices intended to maximize health and social benefits within a context of structural vulnerability. Those who operate outside this context cannot make sense of drug use practices, hence they talk “non-sense.” One of the benefits of the women’s drug use practices was coping with the embodied effects of breaking-up with a sexual partner, which often resulted in homelessness. Angela’s case is illustrative of this dynamic:
These drugs have helped me a lot. I won’t lie. Like when my boyfriend left me, I was feeling so sad because like I didn’t have where to stay. So, I used drugs a lot. It was the drugs that helped me throughout the period I was going through all that.

Accounts routinely contested the notion that substance use is always harmful, stressing the benefits instead. Idara, for example, described how drugs helped her to deal with trauma, which she saw as one of the embodied effects of street sex work:
Interviewer:
Tell me more about how using drugs have helped you.
Idara:
Drugs have helped me so much in all the things I have gone through in my work. Like all the violence and negative things, it helps me to be able to survive and not become “psycho” (i.e., develop mental health problems).

Mercy (aged 21) was similarly convinced about the affective benefits of substance use. Her accounts highlighted how drug effects provides her relief from psychological distress:
For me, I take drugs to feel high and enjoy myself. That is like the only way I can forget all the things I am going through. Someone like me, I am always having one bad mood or another because so many things are not going well in life. It is drugs that helps me to make it with all the stress and bad experiences.

The embodied benefits of substance use explained participants rejection of the notion that substance use is always harmful. Their accounts offered nuanced views that emphasized the health promoting benefits of substance use. Idara, for example, stated:
Something that makes you to go through difficult times in life is helping you because if you are not worrying so much about your problems you will feel fine and you will not have depression. That is why I said that drugs have helped poor girls like me.

The embodied benefits of substance use also accounted for its normalization within the participants’ social networks, particularly in the context of structural vulnerability. This view of the benefits of substance use corroborates Moore’s (1993) concept of “drug use style” because they circulated mostly within the quasi-group, and did not carry over to other social scenes in which the women participated. Grace stated:
Most of my friends that I work together are into drug use. Like, it is a normal thing and it helps them. It is not that drugs are all good. They know it can be bad, but they take it because it helps them in what they are going through. People outside don’t see it like that, but only those of us who use it know.

Drug harms were seen as normal, particularly when used heavily (“It [psychotic features] is normal if you have been taking weed too much,” Ama). The normalization of harms in the context heavy drug consumption foregrounds a harm reducing approach to drug problems. The participants sought to reduce drug harms by developing corporeal techniques for coping with drug effects. An example is relaxing after consuming drugs:
The thing is that you have to find a way to handle the problems that drugs bring. I say so because you have to know that anything that is good can also be bad sometimes. So, just find a way to handle it. Like, after you have taken it, don’t just go out like that. Chill (i.e., relax), so that the effects will reduce.

Given the social and embodied benefits of substance use, cessation was unforeseeable for most of the women (“you are not going to stop using because it also has the good side too,” Ruth). In this context, controlled use provided a means of minimizing drug harms. Reducing the frequency of use, admittedly an uphill task, was strategy of controlled drug use:
Interviewer:
So, how can you use in a way that will not give you much problem?
Rhoda:
For me, I try to reduce the times that I take it. Like I don’t take it many times because that will make you have problem…But it is not easy to reduce, if you have been using a lot before.

Others adopted safer methods of drug administration. For example, Idara smokes cocaine, instead of injecting, to minimize harms (“Like I smoke it cos it is safe”). The techniques used by the women to control drug use were not invented by them, but adapted from existing methods of safe substance use that, in Foucault’s words, more profoundly individualized the experience of subjectivity (Foucault, 1988).

Discussion

Discussions on the contexts of substance use and related harms have tended to emphasize broader structural factors such as class, gender and race, without adequate attention to the dynamic interactions between elements that constitute specific substance use contexts and how they influence drug use practices (Duff, 2007). This lacuna is particularly significant in relation to women’s substance use, given the preoccupation with harms in this strand of the substance use literature. This study presents data that begins to show dynamics within local contexts that shape women’s substance use practices and experiences of harms. Leveraging Duff’s (2007) view of context as an assemblage of space, embodiment and practices, the study shows how social norms and processes operating within social networks developed by the women in sex work environments mediated their drug use practices and the embodied effects of drugs. The findings also make clear that these dynamics are not delinked from macro-structural forces such as poverty and gender inequality, but reveal the ways these structural forces materialize in embodied practices of substance use in specific social and spatial contexts.

For the participants, drug supply and consumption were mediated by spatially-situated social networks developed by the women in the context of street sex work. In the main, social network actors such as sexual partners, clients, co-sex workers and drug suppliers played central roles in initiation and continuation of substance use. Studies have indicated an overlap between substance use and street-based sex work scenes, highlighting how they contribute to patterns of high-risk substance use among sex-working women (Cusick, 1998; Romero-Daza et al., 2003; Shannon et al., 2008). This study elaborates earlier findings by unraveling the specific actors within social networks that influenced substance use practices among street-involved women. Arising from this insight is the need to tailor interventions to address the influence of social network actors and processes on women’s substance use, as an adjunct to standard structural interventions to reduce drug harms among socially marginalized women (Bungay et al., 2010; Shannon et al., 2008).

In addition to the influence of social network actors, data shows that the women started using substances as a means of achieving particular affective benefits (e.g., pain and stress relief, pleasure). This corroborates findings from previous studies which show that women initiate substance use in the context of social relationships and to meet different social and health needs (Martin, 2010; Payne, 2007). I argue that drug use, as an embodied practice, was also shaped by embodied needs. This is seen in how the women used substances to manage trauma and emotional distress in a context of poverty, material deprivation and unmet health needs (Nelson, 2020). Previous studies had shown how psychological distress linked to exposure to traumatic experiences and inter-personal violence contributes to high-risk drug use among street-involved women (Romero-Daza et al., 2003; Shannon et al., 2008). This study shows how the context of poverty and material deprivation in Nigeria mediated a risk for using substances to manage symptoms of social stress and how this contributes to harmful patterns of drug use. This show how using drugs as a means of self-transformation and coping (see de Certeau, 1984; Foucault, 1988), materialize as a context of risk for harms through the drug consumption practices they mediate. It follows that to address drug harms among socially marginalized women, policies need to address the affective and embodied dynamics that mediate how they use drugs.

Following Duff (2007), social network actors and process, and the drug use practices they mediate, constitute the specific context of the women’s drug use. These aspects of the drug use context unfolded on the canvass of the wider macro-structural environment which, though less discernible, played a decisive role in shaping drug use patterns. Intimations of structural factors are evident in references to poverty, homelessness, and structural and everyday violence that motivated the women to use drugs and to do so in potentially risky ways. These structural factors are known on the basis of good evidence to contribute to elevated patterns of substance use among women, heightening their vulnerability to harm (Bungay et al., 2010; Epele, 2002; Haritavorn, 2014; Shannon et al., 2008). The accounts analyzed in this study show that the effects of these factors on everyday substance use practices are mediated by actors and processes within the social networks of the women, especially in sex work spaces, and how they influence the women’s drug use practices.

The women offered nuanced accounts that trouble popular views of drug-related harms. First, they maintained that drug effects and harms are embodied experiences understood only by people who use these substances. Notions of drug effects that are not grounded in embodied experiences are shown to distort understanding of harm. The implication of this finding is that interventions to address drug harms should incorporate the experiences and perspectives of PWUD, not focus only on expert discourses (Duff, 2003). Secondly, they contested the idea that all substance use is harmful, emphasizing the complex relationship between benefits and harms and how substance use practices that produce benefits (e.g., heavy use to relief stress or manage trauma) also produce harm. This suggests that harms are not inherent to substance use, but are unintended outcomes of consumption practices that are intended to produce benefits. This insight indicates a need to rethink how drug-related harms are conceptualized in harm reduction programs. Instead of seeing harms as discrete and routine outcomes of substance use, the findings suggest a contingent and relational understanding of harm as a product of the embodied practices of beneficial use. This calls for approaches to harm reduction that, recognizing the benefits of use, address the contextual dynamics that mediate drug harms (e.g., normalization of heavy use).

In his work on the governance of drug problems, Duff (2015) has rightly observed that the normalization of substance use in developed countries is indicative of a growing resistance among substance-using populations to discourses that automatically conflate substance use and harm. He further contended that this does not mean that these groups are indifferent to the problems that are sometimes associated with substance use. Instead, many maintain controlled patterns of substance use by developing techniques for managing drug problems (see also Zinberg, 1984). The women in this study similarly contested views that portray all substance use as harmful. They highlighted how drug harms are inevitable, but unintended, outcomes of substance use practices that are mediated by unmet affective and material needs. Similar to Duff’s (2015) study, the women sought to reduce harms through different techniques of controlled substance use, which offer a basis for alternative approaches to drug policy that emphasize harm reduction through self-care.

Conclusion

This study explores the contextual elements that mediate substance use practices among street-involved Nigerian women in terms of the assemblage of space, embodiment and practice. Drug supply and use were shaped by social network actors and norms operating within street sex work environments. The women substance use patterns were shaped by embodied and affective needs such as pleasure, stress relief and coping with trauma. These needs mediated drug use practices that created risk for harm. Drug harms are, therefore, not inherent to the drug use experience. Instead, they are inevitable, but unintended, outcomes of drug use practices that produce benefits. By unraveling the dynamic context of drug use, the study highlights entry points for policy and interventions. For example, harm reduction programs need to address the social networks and affective needs that shape drug use practices. It should also build on situated techniques for reducing drug harms to promote self-care in substance-using networks. Furthermore, structural interventions such as safe housing, poverty reduction and access to health services could create an enabling environment for socially marginalized women to adopt harm reducing drug consumption practices. In terms of limitations, the study is based on self-reported data which is subject to social desirability bias, although effort was made to improve data quality through rapport with participants. Also, the small sample size used in this study implies that the study’s findings may only be cautiously applied to other groups of women who use drugs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ediomo-Ubong E. Nelson

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