Over the last 6-7 years, in my role as a university-based researcher, I have been given privileged access to a number of Needle and Syringe Programmes (NSP) throughout England. Throughout this time, a large number of organisations and individuals have assisted me in carrying out research concerning injecting drug use that takes place in public settings (such as toilets, car parks, green areas, derelict property etc). This assistance has permitted me to carry out observational research within NSP, to make contact with injecting drug users regarding their experiences of public injecting drug use and to identify harms associated with this practice. From this work I have been able to make a number of harm reduction recommendations regarding the harm production effect of public injecting drug use.
During observational work, I have noted that there is often a correlation between ‘the type of equipment request and where drug users inject’. For example, requests for 1ml insulin syringes typically related to injections in superficial veins located in the forearm; requests for shorter needles infer hand/foot injections, whereas requests for 2ml barrels with longer needle attachments typically related to deeper injections into deeper veins (such as the femoral vein in the groin area). This is information is probably well established within NSP-workers on a global scale and will probably come as no great surprise to many readers of this website.
However, from a research perspective, requests for certain paraphernalia not only prove to be an indicator of where injectors inject, but also provides an indicator of where they inject (sic)! More simply, and less ambiguously, I have noted that requests for wider gauge, longer needles, higher volume syringes, in addition to water ampoules often correlates to injecting episodes that take place in outdoor settings. As such, when I note service user making requests for this type of equipment I am particularly interested in learning more of the locations/environments where they may subsequently go to inject.
But, here’s the tricky part! How does a complete stranger introduce this interest to another person who may be reluctant to disclose any details of their injecting drug use in public places? It is now well established in the research literature that public injecting is associated with shame, stigma and negative self-worth. As such, why would somebody volunteer participation in something that they perceive as ‘shameful’ and possibly reinforce a negative self-identity in doing so? The challenge I have faced in all my attachments to NSP sites is how to raise this issue with service users in a manner that is sensitive, non-offensive and ‘relevant’ (as it is entirely possible that requests for 2ml barrels, longer needles and water may be for ‘domestic’ use too).
My initial experiences of this challenge (during a pilot study in 2007) proved useful in ensuring contact with those people that have experience of public injecting. That was because the way in which I raised the topic of public injecting was completely inappropriate and totally the wrong way of asking people about sensitive (almost taboo) topics!!
During the pilot study, after service users made their request for injecting equipment, I would approach the individual, introduce myself (as a researcher based within the NSP) with the question: ‘could I ask you if you have ever injected in a public place?’ After failing to get any positive answers in the first few days – I decided that my question was inappropriate and too ‘in your face’. In research terms, this is called ‘question threat’ and it inadvertently seeks to provide a negative response amongst those asked. After a slight tweak, I amended my question to:
In the last month, have you injected outside at all? Have you used in a toilet, a car park or somewhere similar?
This rephrased question is much more sensitive in its approach and has proved very successful in recruiting research participants to studies that require experience of particular injecting experiences. This is because it omits the ‘taboo’ word of ‘public’. In using a more relevant alternative (‘outside’), that is more neutral and value-free, any judgements, assumptions and associations attached to the word ‘public’ are minimised – if not removed altogether. In addition, this is a question that can be asked that purposely and sensitively excludes those who would not qualify for a particular study – as if they do not have experience of an issue, they can’t talk about it!
When talking to service users about their injecting experiences, there is a great deal of common ground between NSP workers and health researchers. This is especially so when attempting to unpack experiences (and inform intervention, advice and information) regarding the physical spaces and environments in which service users are injecting drugs. Places such as public toilets and the cubicles covered in urine. Places such as ‘safe houses’. Or the kitchen in a squat. The back alley behind the shopping centre.
I would encourage all NSP workers to raise the issue of ‘place’ with all service users during visits for new injecting equipment and during any conversations when doing physical inspections of service users’ veins, injuries, dressings etc. My research (and that of others) demonstrates that a number of already established drug-related harms and hazards are reproduced and made worse in public settings. This may relate to the physical and social environment (causing rushing, sharing, inappropriate technique, recycling discarded equipment, lack of washing facilities, no water, dirty hits, overdose etc etc). If NSP workers can identify the type of setting where service users are actually injecting, they may be able to provide more informed advice and intervention (including any additional paraphernalia to assist safer injecting). But this will largely depend on asking the right questions – and how they are asked.
In short, choose your words carefully and good luck.
Stephen is a Research Fellow at the National Addiction Centre at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. His most notable ethnographic work relates to a multi-site study of street-based injecting drug, drug-related litter and associated harm and hazard from the perspectives of people who inject drugs and frontline staff who encounter such issues in their daily employment. The views expressed in this article are those of the author and do not necessarily reflect those of his employer.