Our study identifies key barriers affecting PWID who are looking to safely inject or treat their drug dependency and provides PWID-generated recommendations addressing the barriers, namely sterile syringe access, treatment access, perceived discrimination by health care practitioners and the insufficiency in their training in relation to drug use, and lack of follow-up services. During one-to-one interviews, eight participants responded to questions about the services they typically access or have accessed in the past, the extent to which they can, and wish to, access sterile syringes, their experiences with various treatment services and health care practitioners (e.g. the province's treatment facility and interactions with medical staff, respectively), impediments to receiving treatment, and recommendations for improved sterile syringe access and service provision. The frameworks of Galea et al. and Rhodes, with their focus on environmental factors, guided the data interpretation. Challenges obtaining sterile syringes and access to treatment highlight the need for economic and policy changes to the service provision in PEI, while PWID who perceived discrimination, in relation to their receipt of medical care, denotes the presence of social barriers.
When questioned about where they accessed their sterile syringes, most participants reported buying sterile syringes at pharmacies instead of using one of the province's four syringe exchange centres. Due to the syringe exchange centres' limited hours of operation, pharmacies offered significantly greater opportunity to obtain sterile syringes during the later parts of the evening. It should be mentioned, however, that participants cited the hours of both the syringe exchange centres and pharmacies as being their biggest challenge when trying to access sterile syringes. Given that syringe exchange centres have limited hours (e.g. only 2.5 h per week for some participants) and pharmacies do not offer 24 h per day services as they do in large cities, a structural barrier such as this may be particularly problematic for PWID in rural or smaller urban centres.
Due in part to the inaccessibility of sterile syringes late at night, all participants reported re-using their own syringes, with six of the eight reporting having shared syringes with other PWID. Although participants were aware of the risks associated with the latter practice, they were less aware of the risks inherent in sharing drug injection paraphernalia such as spoons, water, and filters. This finding is consistent with the research suggesting that, despite having considerable knowledge on safe-injecting behaviour, many PWID continue to engage in risky injection practices. Indeed, four of the participants indicated that, at the time, they did not care about the consequences of either practice (i.e. re-using syringes or sharing them with other PWID).
Participants offered a number of recommendations to improve access to sterile syringes, which included extending the hours of operation at the syringe exchange centres (i.e. ensuring that the centres are operational outside of regular business hours), purchasing vending machines for the distribution of sterile syringes, and organising PWID to serve as secondary distributors. Several of these suggestions for improving syringe access are supported by the literature[28–30]. For example, Islam and Conigrave found that syringe-dispensing machines are effective means for distributing syringes to those who are unable, or unwilling, to frequent syringe exchange centres or pharmacies, and they can be incorporated into the existing distribution tactics of syringe exchange programmes. Although population density is relatively low in PEI, syringe-dispensing machines could be erected in the downtown regions of the most urban areas of the province, Charlottetown and Summerside, where it is likely that PWID are concentrated. Researchers also found that secondary distribution by other PWID or drug dealers could increase the use of sterile syringes among PWID who do not procure sterile equipment through formal distribution services[19, 32]. Syringe exchange programmes also can facilitate secondary distribution by furnishing providers with biohazard containers for used syringes and not limiting the number of syringes provided. According to Klein, PWID may prefer dispensing machines or secondary distribution as means of maintaining their anonymity. Further, these methods may be of particular importance for PWID in smaller communities who cannot purchase sterile syringes from pharmacies without suspicion from community members[31, 33].
In a federal study examining drug dependency programmes and policies, the Canadian Mental Health Association reported that ‘about half of the adult population who need services [including treatment designed to treat or manage drug dependence] must wait for eight weeks or more’ (, p. 161). Based on this estimate, it appears that PWID in PEI are facing comparatively longer wait times prior to starting a provincially funded treatment programme (i.e. periods of time in excess of 2 years) than PWID situated in other provinces. Indeed, seven of the eight participants who had received treatment from the Provincial Addictions Treatment Facility at some point in the past, indicated that the long waitlists was the biggest challenge to starting treatment, and a majority reported that their drug use typically intensified when treatment was inaccessible. Although some participants were able to access private clinics that had physicians who would prescribe methadone, most of our participants indicated that there are too few physicians in PEI (i.e. four in total) who can write methadone prescriptions, and at the time of our interviews, these physicians were not taking new patients. Based on these barriers, participants recommended that the provincial government increase funding for treatment services for PWID, a recommendation that may not be easily implemented. For instance, Gustafson et al. caution that small regions may not have the economic resources to increase funding, and therefore, initiatives such as these may not be feasible.
The nature of the medical care received by participants also was cited as a problem. Participants reported that doctors and nurses did not know enough about drug dependency and either dispensed narcotic drugs too liberally or did not supply enough narcotics for pain relief when a patient was identified as a PWID. Several participants in the present study reported that they were the recipients of verbal (e.g. name-calling) and non-verbal discriminatory behaviour (e.g. receiving no service) from health care practitioners and pharmacists. In their examination of incidents of discrimination encountered by PWID in Australia, Day et al. found that 37% of these events occurred in health care settings and more than half resulted in refusals of service.
Limitations and future directions
The present study advances understanding of the current atmosphere for PWID in PEI and offers PWID-generated recommendations as to what can be done to improve services for this population. Our interviews suggest that the current services for PWID do not meet the demand for treatment; this is valuable information given that no studies of this kind have been conducted in the province of PEI to date. However, since only eight PWID were interviewed, further research is warranted. Despite assurances of confidentiality and anonymity, most PWID were unwilling to participate in the present study because of their apprehension when asked to discuss their injection behaviour with someone associated with a service provision organisation due to fear of negative reprisals (e.g. loss of social assistance or child custody). Researchers should ensure that every effort is made to provide reassurance to PWID that their participation will not result in these deleterious consequences. One method to encourage increased participation among PWID may be the formation of an interdisciplinary team. For instance, the addition of a social worker may have assuaged the fears of those PWID who were apprehensive about repercussions related to their social assistance status or their parental rights, or the inclusion of a lawyer could have offered legal protection to those who were concerned about reporting on their illegal behaviour. Also, research teams that are unaffiliated with organisations providing services to PWID could potentially increase willingness to participate due to a greater level of perceived anonymity. Service providers in Atlantic Canada indicate that the preservation of PWID's anonymity may be particularly important for those in less populated regions, making the need to provide additional assurances of confidentiality and security critical when recruiting this population.
The number of PWID who agreed to participate also may have been low given that only Canadian 5$ was provided to those who were interviewed. By providing a greater monetary incentive, it is possible that more individuals would be willing to participate. Further, incentives such as free syringes, assistance with travel to and from the interview, and other gift-related alternatives (grocery cards, gift cards, products, and so forth) could be offered. Incorporating appropriate incentives into the research protocol could promote greater interest in participating. Additionally, the sampling procedures may have affected the themes that were generated. Since participants were recruited primarily through harm reduction and treatment organisations, this may be why only one participant reported currently injecting drugs (and all other participants reported some length of sobriety). Future research concentrating on PWID who are not utilising treatment or harm reduction services could provide additional information about the needs of PWID in PEI.
It also should be acknowledged that the primary researcher, who conducted the interviews, is not a current or former PWID and may not have been as readily accepted into the community or as trusted as an insider may have been. In an effort to recruit and build rapport with PWID, researchers might consider a team approach wherein a current or former PWID actively participates during interview sessions. Not only would this strategy likely improve participants' general comfort, but it also may assist the elucidation of themes that are not as easily arrived at when PWID are engaged in discussion with an outsider. However, an interviewer who may be less familiar with the minutia of injection drug use is more likely to probe for details that are presumed known by the insider. Some researchers suggest that a research team including both an insider and outsider is ideal[37, 38].
Participants also may have been selective with the information that they provided in order to correspond to the perceived expectations of the researcher. Male participants, in particular, may have tailored their answers in response to being interviewed by a woman. Therefore, if researchers choose to use the team approach in future studies, it may be useful to have interviewers of different genders or to match the gender of the participant with the interviewer. This approach also may highlight any gender differences that exist between the needs and lifestyles of male and female PWID. For instance, research has found that female PWID tend to participate in more syringe sharing, likely due to their larger social networks; however, they also engage in more protective behaviours such as carrying clean syringes and frequenting syringe exchange centres[39, 40]. While not a focus of the present study, our interviews revealed differences between men and women insofar as their initiation to injection drugs, the methods they use to obtain drugs, how they secure treatment services, and their fears related to speaking to service providers. Gender-related differences such as these should be explored in small urban centres in greater detail.
Finally, ongoing research is needed on PWID in PEI due to the continuous changes in service provision. The present study was conducted in 2010, prior to the establishment of the syringe exchange centre on the western side of the province. Additional research could determine how this new centre may affect sterile syringe access in PEI and how trends in injection drug use and PWID's service needs change over time.