Sociodemographic characteristics of sample
Twenty-four people who inject drugs were recruited and participated in the study. One participant had to be excluded due to an error in the audio recording process. Of the 23 participants included in analysis, the median length of the interviews was 82 min (interquartile range (IQR) = 46) including break times. Fourteen (61%) men and nine (39%) women participated, with a median age of 50 years (IQR = 7.5). The median length of time participants had been injecting was 29 years (IQR = 19.5). Participants had lived in Ottawa for a median of 30 years (IQR = 34). At the time of their interviews, 15Footnote 4 (75%) participants lived in the Centretown, Downtown or Lowertown areas of the city, which are nearest to the majority of health and social services for people who use drugs. Furthermore, 13 (62%) participants lived in an apartment or house, and 14 (67%) considered their housing to be stable. A majority of participants reported using multiple types of drugs (e.g. opioids, crack/cocaine, benzodiazepines) in multiple forms (e.g. injecting, smoking, ingesting).
Themes arising from the data
Several themes emerged from the data. Most notably, PWID described how their harm reduction strategies expanded beyond health and social service use; how their reasons for using harm reduction strategies were multi-dimensional; and the ways that structural factors inhibited or promoted their use of harm reduction strategies. While understanding how people with lived experiences conceptualize harm reduction strategies was the main objective, the other themes are informative in highlighting why such strategies are used and how micro and macro contexts influence their use. For each of the three main themes, only the most common or unique sub-themes are described in detail and highlighted with quotations, while other sub-themes are listed briefly.
Harm reduction strategies expand beyond using health and social services
Participants described how they used specific strategies to incorporate harm reduction into their daily lives, and these strategies were grouped into two overarching themes: (1) accessing community health and social services and (2) employing personal practices.
Accessing community health and social services
Most participants mentioned that their harm reduction regimen included using services and supports in at least one of three community health centres located in the downtown core of Ottawa. The most common reasons for using these services included access to drop-in rooms, mobile vans, obtaining sterile equipment for substance use, moral support or positive social interaction with staff, information, a comfortable space or sense of connection with the community, and counselling. Although many of these reasons correspond to the primary intended purposes of the services, others are benefits incurred as a result of the health or social service delivery model. For instance, several participants made statements reflecting their appreciation for having a space in which they felt a sense of belonging to the community. As JasonFootnote 5 explained:
I go there you know just to sit and have a coffee. I go to the back and I know everybody back there.
Likewise, participants often spoke about the importance of having moral support or positive social interaction with staff members at these centres. Kimberly described her experience in this way:
When I’m down sometimes I feel like using and stuff. I just come here and say ‘hi’ to whoever’s here. I just come and I feel better. […] Or I see this one and she makes me laugh. You know it doesn’t have to be talking about [using] or something.
On the whole, participants made it clear that frequenting community health centres had multiple purposes, including the convenience of having many health and social services offered in one location. Most importantly, however, it seemed that frequenting these centres often helped participants break social isolation.
In addition, all participants mentioned accessing services and supports at community-based health and social services other than those offered at the community health centres. In discussing their use of these services, it was common for participants to highlight particular individuals who had made a crucial difference in facilitating their access to such aid. For instance, Angela described the impact of housing support on her stability in the following way:
I have a little more stability going on, and if it wasn’t for [name of a service provider] putting me on the list for the [supportive] ‘housing thing’ when it first came out, I don’t know where I’d be today. I could probably still be out there on the street. Thank God for [her]!
Overall community-based health and social services are a crucial component of the harm reduction toolkit for PWID, especially when these services involve interactions with helpful and non-judgemental service providers.
Finally, opioid replacement therapy was a prominent harm reduction strategy that participants discussed at length in their interviews. Participants described opioid replacement therapy in both positive and negative ways, almost always in reference to methadone programs. Although methadone is clearly an important strategy for helping PWID to manage their daily lives, the mixed feelings about such programs appear to stem from several key issues, which we will address later in the results.
Employing personal practices
The second major theme of harm reduction strategies include personal practices that participants described using to manage their drug use and reduce the harmful impact it had in their daily lives. The most common practices included (1) using in moderation, including replacing one drug with another drug or adhering to prescription instructions, (2) engagement in the community, and (3) cognitive and behavioural strategies.
Employing moderation in using substances was described by participants as both a strategy used to reduce harm in their daily lives and as a lifestyle goal which they hoped to achieve. Participants talked about moderation through a multitude of terminology, including: “cutting down”, “keeping it down to a dull roar”, “dabbling”, “using very carefully with a lot less”, considering drug use to be “a treat”, “not using as much or as often”, or simply using “[j]ust very moderately”. Importantly, participants discussed the progress they had made toward improved control over their substance use and reduction of harms in their daily lives due to using tactics of moderation. As Patricia outlined:
[H]aving that three months behind me of moderation and trying to be aware of my decisions, it’s been easier since to keep things down a bit. Balanced.
Working toward increased moderation was the most common personal harm reduction practice that emerged from the data. Abstinence-based treatment models were not well appreciated by the participants, although a few participants considered such models to be helpful in some ways.
Participants also used moderation specifically in the way they tended to replace what they saw as more problematic substance use with the use of drugs that had less of an impact on their daily functioning. Steven described the importance of this practice for how he incorporated harm reduction into his life:
[I]n the last year what harm reduction means for me […] now it means trying to stay on softer drugs instead of harder drugs.
Marijuana was the most commonly mentioned drug participants used as a replacement for other substances that they felt caused them more problems. As Heather noted:
I can stay clean for a whole week. Like I mean I have no problems staying clean for a whole week. If he doesn’t get money from work, we’re good. We stay home, as long as we have that gram of weed. He comes home, he’s tired from work. We smoke a joint.
The next most common substitution drugs that participants mentioned were alcohol or cigarettes. Participants also noted the use of prescription medications for this purpose (whether obtained legally or illegally), including methadone, methylphenidate (Ritalin), hydromorphone (Dilaudid), aripiprazole (Abilify), venlafaxine (Wellbutrin), and Tylenol 3s. Furthermore, it is noteworthy that several participants indicated their use of replacement substances was with the intention to avoid using crack. Overall, participants’ replacement of their own most difficult-to-manage substances with other substances they felt they could regulate more easily was an important way they implemented moderation as a harm reduction strategy.
Participants also employed moderation through attempting to follow medication instructions as prescribed, despite enduring negative side effects. Participants noted efforts to minimize the use of other drugs that might interfere with their prescribed treatments. Heather mentioned that taking medication to manage her mental health symptoms was one of her key harm reduction practices:
[M]y harm reduction […] I’m bipolar so I’m on Abilify which is for depression, bipolar so […] that’s a fairly new one actually, so that kind of saves me every day. I don’t drink very much…
However, some participants also made changes to their medication intake to suit their everyday needs. For instance, sometimes participants ingested their prescription medications in non-specified ways (e.g. injecting or snorting), or they adjusted the procedures slightly (e.g. reducing or increasing dosages) in ways that they felt improved their ability for self-care. As Michael explained:
I take four of these a day. But I take one during the day and I take three at night. This works better for me. Because I find when I take two, it just makes me too dragged out. So when I take the three at night, I sleep like a baby…
PWID also described engagement in community activities as another essential harm reduction practice in their lives. Our participants mostly referred to being involved in community initiatives that served other people who use drugs or other marginalized populations in some manner, such as sharing their personal experiences relating to drug use, promoting services and identifying or requesting services that were needed, receiving overdose prevention training, or “needle hunting”,Footnote 6 and these were also identified as ways to give back to the larger community. Some participants noted a desire to have more opportunities to participate in this type of work, in part, because helping others provided benefits to themselves.
Patricia described the powerful impact on her own well-being due to being able to help her peers:
I took the Naloxone training, the peer overdose prevention program […] and I’ve had […] successful resuscitations from respiratory arrest since then. That’s sort of given me a little bit of confidence and good feeling, to be able to help the people around me who are using. And to sort of, I guess remind myself of why I’m not wanting to do that anymore.
David went further to describe how his early involvement had led to increasing engagement due to being able to make a lasting change in the community:
It started, too, I guess the first time I started trying to do community stuff was when I was doing needle hunting […] And then I moved in this area, and I got involved with [another community organization]. But the needle hunting was neat. I remember the last year I was there, the government was thinking of closing it down. But we kept track of everything. And that summer I think we found something like 8000 needles […] So we had the proof and the numbers. Yeah. So then they kept it going.
The third crucial harm reduction practice that PWID identified involves the use of cognitive and behavioural strategies. With respect to cognitive strategies, almost all participants mentioned at least some instances of using increased awareness or self-reflection to help manage their substance use. Many of these mentions included the following types of thinking: explicitly trying to have more awareness, trying to make sense of things, reflecting on difficult or traumatic events (e.g. death, jail or prison, abuse), reflecting on drug use, addiction and harm reduction, and recognizing their progress over time. David noted that having more awareness was a helpful harm reduction practice:
Harm reduction. […] you’re trying to control the triggers and because addiction is so tricky, you’ll actually subconsciously do stuff and go some places […] I guess to me, it’s trying to be aware.
Similarly, Matthew outlined how reflecting on and learning to work through his emotions had contributed to gaining more control in his life:
I’ve come to a theory that I’m the only one who controls my emotions, not nobody and nothing around me can control how I feel. […] and if I allow myself to be depressed it means that I need to feel something so, I allow myself to feel it. […] it took awhile to get my brain to think like that.
Some participants also noted the benefits of maintaining a positive attitude or sense of humour in order to cope with harms arising from their drug use. Furthermore, participants who talked more about using cognitive strategies tended to be more hopeful about making progress in managing their drug use and lives overall.
Participants also considered certain behavioural practices among their harm reduction tools. They often described these practices in general terms, such as staying active or leaving the house, having a structure or routine, or simply keeping busy. Specific actions were also mentioned, including the following: athletics, working, traveling, volunteering, and participating in community activities. For Matthew, moving around meant challenging habits and thus reducing the possibility of developing harmful ones:
Well I just realized in the survey here that hitchhiking across the country was sort of a harm reduction; get away from one city, one type of drug, and then go to a different city to a different type of drug.
Several participants also mentioned that having a distraction of some sort helped them to better manage their drug use, and they suggested that community-based harm reduction services should incorporate more opportunities for people who use drugs to participate in activities or environments in which they are likely to be distracted.
Other harm reduction strategies that were mentioned included safe injecting/drug use practices (e.g. using sterile needles, disposal in biohazard containers), alternative drug use practices (e.g. re-using own needles only, disposal in garbage), not keeping cash readily available (e.g. direct payment of bills, giving cash away to others), and basic self-care (e.g. hygiene, sleep). On the whole, participants made it apparent that while making use of conventional harm reduction strategies, such as frequenting community-based health and social services, was an important component of their harm reduction arsenal, their personal harm reduction tactics were similarly critical to making progress in managing their drug use.
PWID have multi-dimensional reasons for using harm reduction strategies
Participants described multiple motivations for why they incorporated harm reduction strategies into their daily lives. One of the most common reasons cited was to improve their health. That is, many participants mentioned they were trying to better control their drug use because they wished to prevent or manage an illness such as an infectious disease, another physical health issue, an aging-related issue, or a mental health concern. As an example, Patricia noted her efforts to adjust her drug use habits in order to enhance the effectiveness of her treatment for hepatitis C:
So I’ve made an effort to not [inject drugs]. And if I’m using then it’s done in a different way. Part of that was driven by seeking treatment, medical treatment, for hepatitis last year.
In addition, for some participants, health was increasingly a reason to use harm reduction strategies (such as reducing the frequency of injecting) due to advancing age:
Peer Research Coordinator: Okay now, what’s more important to you now?
Caroline: It’s my health. […] I’ll always be a user if I don’t stop and what’s going to happen is, I’m [in my fifties] and I’m going to have a heart attack. I’m not stupid.
Aside from health-related motivations, another fundamental reason for using harm reduction strategies was to improve one’s social relationships. This mainly centred on attempts to re-kindle or maintain positive relations with one’s children, but also sometimes included references to relations with other family members, romantic partners, friends, and even pets. Steven discussed practicing harm reduction strategies because he was thinking more about his children:
I try and wear clean clothes, I try and eat three meals a day and I try in doing a little more self-care, and within the last week I haven’t used any hard drugs, and I think the guilt is coming in more for me maybe when I’m getting a little older now and that I am thinking more about my kids when I use hard drugs.
At the end of his interview, Steven explicitly linked his family to his use of harm reduction strategies:
And I think now, I think now I realize that my mom would be proud of myself that I have my addiction in check. And I’m sure my kids will come around, and the more I keep in the harm reduction, it’s a better chance I have of getting my kids back.
After moving into his daughter’s home, Michael also expressed the powerful impact of being given another chance by his loved ones:
I would not smoke in the house, like cigarettes, and I wouldn’t even bring it home. I wouldn’t even do it around the friggin’ house, you know? Like, she told me, she says: ‘The first time [Michael], I catch you or mom using, you’re gone and no questions asked’. So like, what’s more important, family, blood or a fuckin’ toke, right?
Some participants also noted that they were motivated to take care of themselves because of worries that their children might experience similar addiction-related challenges and they wanted to be available to support them.
A further key reason participants incorporated harm reduction strategies into their lives was because they were goal-oriented. Participants often projected themselves into the future by describing their projects or plans, and they indicated that reducing their drug use was connected to achieving other goals in their lives:
PRA: And I remember you saying that you work out, and you –
Donald: Yeah, I want to get back into that too. I was supposed to do back in Christmas. That was my goal. Quit smoking crack, and start working out and possibly go back to work. See if I could get a job.
Many participants also talked about how they were trying to return to normal or find balance. Jason described his progress in this regard:
But yeah and then now that 2015 came around it’s great, I’m doing volunteer, I’ve got a job, I cleaned right up. […] I ain’t smoking no more, my mom and dad big time, my family is back in my life, my son, everything is back to normal again.
Moreover, when participants discussed such improvements they often exhibited feelings of pride in their use of harm reduction strategies:
But that’s why I’m proud of myself […] well I mean, I have some sort of harm reduction. I’ve been clean for a week, I’m just [using] pot. (Steven)
Several participants mentioned additional reasons for using harm reduction strategies, including facing mortality (either of oneself or of another person), not wanting to do sex work, experiencing pregnancy, or avoiding contact with law enforcement. Overall, the majority of reasons participants discussed for employing harm reduction strategies in their lives centred on their relationships to others and themselves, which constitute part of their social environment .
Structural facilitators and barriers for using harm reduction strategies
In order for the harm reduction strategies described above to be effective at reducing harm in the lives of PWID, many socio-structural aspects of their environments must be considered. First, our findings indicate that PWID face immense obstacles to implementing harm reduction strategies into their lives, including but not limited to rigid eligibility criteria or procedures, lack of accessible information or misinformation, societal discrimination and stigmatization, and negative affect. In addition, although the following list of barriers will not be discussed here because they have been described in other studies, we found that PWID face extensive issues with housing stability (an important part of the physical environment), financial stability (central to the economic environment), criminalization (largely a result of the policy environment), relationship problems and peer pressure (key to the social environment), as well as challenges related to physical or mental health issues .
A prominent barrier faced by the majority of participants was rigidity in eligibility criteria or procedures of many health or social services. The most commonly discussed area in which PWID felt they were expected to meet excessive criteria was in regard to the prescribing practices of physicians. As noted earlier, such inflexibility was most evident in opioid replacement programs. Other types of medications were also mentioned as being particularly restrictive to access, such as those for the purpose of treating mental illnesses, as well as those classified as painkillers or medical marijuana. Patricia mentioned that although she had maintained relative stability on pain medication for many years following a car accident, her prescription was taken away due to a blood test indicating that she had other drugs in her system:
[I]t was all pretty consistent until (a recent date). I got my meds pulled. Yeah, so after 14 years of being on [the medication]…
Likewise, Kimberly explained how rigid dosage procedures, in her case experienced when dosing during a prolonged hospital admission differed from those prescribed by her community physician, contributed to her relapse upon hospital discharge:
In the hospital I was getting […] Four and a half months, needles every four hours. […] You know so like I relapsed when I got out because he only put me back on 15 mg of methadone. I know maybe it sounds like an excuse, but […] while I was on methadone, I was successful for four years.
In regard to opioid replacement programs, for those participants who were on methadone maintenance therapy, problematic aspects of service design or delivery seemed to be a primary concern in their lives, regardless of whether they wanted to stay on the methadone or not. The issues participants experienced included difficulty receiving or maintaining carriesFootnote 7 (i.e. take-home dosages), restrictions in trying to change dosages, and the negative side effects (including more difficult withdrawal compared to other drugs). Some participants mentioned that they really wanted carries, yet their previous carries had been taken away too easily or they had never been given the chance to try one. This rigidity in permitting carries is detailed in Caroline’s discontented description of the program:
[T]he only reason I get up is to go and get that fucking methadone that I hate to go and do. Every day because I’m always dirty [drug test results show other drugs in system], you know? […] I’ve been on it for about 17 years and I’ve never had a fucking carry in my life. It’s like, just give it to me (laughter), I’m so sick of being on the program. […] Yeah right, like I really want to look at your face every day, to get a drink. Like there’s times when I don’t even go for 2 days, and not because I have anything to use, it’s because I don’t want to go.
Participants also often discussed the rigidity of methadone programs with respect to adjusting their dosages. Some participants mentioned being able to wean down to a lower dosage (when requested by their physicians or through their own self-regulation), whereas others mentioned that being given a lower dosage interfered with the stability they had achieved. Others indicated that their physicians tried to get them to change their dosage or to wean off of the methadone altogether despite their desire to maintain their current regimen. David described his experience, making it clear he wanted his needs and preferences to be taken into consideration:
[My methadone physician] actually wanted me to stop – work down to stop methadone. I’m going ‘No, I’m doing this shit until the day I die.’ Like, I’m not stopping. […] They don’t get it! […] And I’m going ‘Look it, if you’re gonna try to fucking cut me off like this, I’m gonna go somewhere else’. […]Well the thing is, too, I don’t get is, look, it’s fucking working, I’m not using. Why do you want to fucking cut me off now? It’s working! […] When I don’t have this, this is why I wanna use again. You know, right now it’s taking that craving away.
Furthermore, participants who were not on a methadone program described not wanting to take it or feeling lucky that they never had to, because either they had tried it and did not like it, had seen what it did to others, or even considered it a form of governmental social control. Other health or social services that were singled out for placing undue restrictions on drug users included mental health services (e.g. difficulty obtaining treatment unless abstinent), needle and syringe program practices (e.g. difficulty obtaining an adequate number of needles and syringes, or other equipment such as pipes), and accommodation services (e.g. difficulty following rules at shelters).
A further barrier that almost all participants mentioned was a perception of difficulty in obtaining harm reduction information in the community. Specifically, this mainly included instances in which participants indicated they were unaware of the existence of certain harm reduction services. This was evident in references to having a lack of awareness of services beyond the distribution of sterile equipment for substance use. A number of participants noted that while they initially started frequenting community health and social services for this purpose, it took longer than they felt it should have before they became aware of the additional services offered by these organizations (e.g. housing support, counselling). As Patricia described:
I became aware of the [mobile] van being available through media about needle exchange at a place downtown. Yeah, but it took a while to become familiar with some of the services.
Accordingly, some participants explicitly requested these organizations should make information about their services more accessible to the community:
Steven: Well I had support from them but I didn’t, I didn’t know about these programs.
PRA: But you wish that they had made it more, the information clearer.
Steven: More accessible.
The most prominent barriers not specific to health and social services were the pervasive anti-drug discrimination and stigmatization in society at large. The majority of participants mentioned experiencing discrimination or stigmatization because of their drug use, as well as for other reasons such as having an infectious disease, having a mental illness, being homeless, aging, being a woman, race/ethnicity, sex work, or having a criminal record. Such discrimination came from many different people they had contact with, including service providers, family or friends, and the general public. Angela’s experience depicts a poignant example of the effect of such widespread discrimination:
[T]hey were all saying ‘She’s nothing but a junkie’ […] you know ‘Look at her arms’. I remember the conversation, I could hear the conversation being said, like when I was in the hospital, like outside my room […] and it’s just […] I didn’t feel like I was worth much anyway.
Participants indicated that these types of experiences interfered with their use of harm reduction strategies by making them less likely to seek help from services, more likely to feel the need to lie to service providers, and more likely to hide their drug use from other people in their lives.
Finally, an important barrier emerged in regard to the influence of negative affect in participants’ lives. Despite attempts to incorporate harm reduction strategies into their daily lives, participants felt they were often treated with disrespect and condescension, including being judged or rejected.
Some of this negative affect occurred when participants had contact with service providers who they felt treated them in a condescending manner. Participants often indicated that they did not like it when service providers had no lived experiences with drug use or marginalization. They frequently described being disrespected, as if their opinions or feelings were not valuable. As Matthew noted:
I can’t deal with counselors because they’re friggin’ college educated with no experience and I hate how, them telling me how I’m supposed to feel. ‘Well, you should feel this.’ ‘Well, you know what? I don’t want to feel, and so please stop trying to make me feel that way.’
Other participants noted that negative affect stemmed from the judgement of their families:
PRA: Okay and are there people or circumstances that get in the way of you protecting or you practicing your harm reduction?
Steven: […] I had to throw the negative people out of my life. And part of those negative people was my family. My own family would bash me and throw me down so hard that I had to throw a lot of them out of my life…
In addition, participants reported a great deal of negative affect due to traumatic circumstances they had experienced (or were experiencing), including abuse and violence of various types or difficulty coping with the death of loved ones, which interfered with their use of harm reduction strategies. Note that a deeper exploration of these traumatic experiences was outside the scope of this study; hence, the methods were designed to retain focus on harm reduction experiences. As the interviews were research rather than therapy, and because of the potential to trigger trauma among our PRA team members, we purposely avoided exploring trauma during the interviews.
Overall, the magnitude and emphasis given to barriers in the interviews is a telling indication of the need to address the many socio-structural issues PWID face in order for ongoing harm reduction interventions to be as effective as possible.
Although facilitators were discussed much less often than barriers, there were still a few central aspects of participants’ lives which supported harm reduction strategies to thrive. In addition to finding strong evidence for several well-established facilitators that will not be detailed here, such as having support from loved ones (i.e. the social environment), stable housing (i.e. the physical environment), and steady income (i.e. the economic environment) , we also found that developing one’s self-esteem or self-efficacy, having continuity of care in health or social services, and having support from people with lived experiences, were all important facilitators for PWID.
One commonly mentioned facilitator was the development of one’s self-esteem or self-efficacy. Participants discussed many activities through which they increased their self-esteem or self-efficacy, including reconnecting with family, working or getting on the Ontario Disability Support Program (ODSP),Footnote 8 gaining education or skills, improving their appearance, helping to make positive change in their community, obtaining recognition of the value of their lived experiences, and making progress in controlling drug use. For instance, Steven’s statement conveys the valuable impact of improving one’s physical appearance:
Steven: Yeah, I’m so, like as soon as I got my teeth, my confidence went out the roof!
Peer Research Coordinator: Yeah it’s funny how that happens.
Steven: And then I got off welfare, well I’m on ODSP now and I’m thinking ‘Okay, I’m on ODSP, I got my teeth, now I gotta get my glasses and I gotta get my motorcycle next year’.
For Michael, receiving positive feedback from his loved one was a powerful facilitator for using harm reduction strategies and making the most of the “last chance” he was being given, as expressed in the following conversation:
Michael: …I moved into my daughter’s house […] and […] my granddaughter, and it just gave me motivation to be just me.
PRA: It’s like a chance to be whatever…
Michael: Yeah, you know ‘last ticket to catch it’ sort of thing. I was thinking you know. And I was honoured by her asking me to give her away [at her wedding], that was awesome. With her own birth father, she says ‘[Michael], as long as I’m concerned you’re more of a father than my birth father’, and I said ‘Ah you shouldn’t be saying that’, you know what I mean. Wow!
Another facilitator for participants’ use of harm reduction strategies was to have continuity of care in health or social services. Participants often referred to the benefits of having consistent visits with a doctor or other service provider over time:
I got a counsellor once a week for an hour, and like I see my counsellor last week and I’m like ‘Hey, I’ve got a problem today’, and she goes ‘What?’, I’m like ‘I’ve gotta, I’ve gotta tell you about three hours of junk in one hour […] I’ll try my best but we only have an hour, let’s get going.’ (Everybody laughs) You know what I mean like, so it’s great that I have that every week because now I got somewhere to throw my shit right? (Steven)
The benefits of having continuity of services also sometimes involved frequenting one organization in preference to others. Furthermore, participants often discussed such continuity with reference to maintaining a positive relationship with a particular service provider:
Heather: I started getting introduced to Nurse [name of the nurse] in these years. […] and she’s been my God saviour. She was the only one that I can ever confide in and she’s the first one that I ever…
PRA 1: Nice.
Heather: Yeah she saved my life. She’s the one that got me diagnosed with bipolar.
PRA 2: Tell her that, it’s nice to hear that.
Heather: I do, I tell her all the time. I hug and kiss her all the time and she kisses me back. Oh yeah!
Finally, having support from people with lived experiences was another important facilitator. For example, there was evidence that secondary distribution of drug using equipment through peer networks was an important harm reduction practice. As Matthew described:
Yeah because you call the [mobile] van or the [other mobile] van out down where I live, because sometimes it takes a half hour for someone to get over there. So I make sure that I have enough that my friends can come knock on my door and ask for supplies.
Because waiting for sterile equipment can contribute to sharing drug using equipment and the subsequent risk of infection, secondary distribution as a back-up method may reduce such risk. In discussing the receipt of equipment directly from peers in his apartment building, Jason noted that the close proximity made this practice most convenient: “You didn’t even have to leave”.
In addition, the benefit of peer support was evident from participants’ reactions to being interviewed by their peers in the present study. As an example, Kimberly said the following in reference to the PRAs: “I’m grateful like you know, like for people like you guys…”
Accordingly, participants often indicated that they learned the most about harm reduction from their fellow peers:
Matthew: I think [my best friend] was the biggest harm reduction in my life because he introduced me to Ritalin. By the time I met him […] I’d let myself get a really bad cocaine addiction.
Participants also commonly discussed their desire for more avenues in which peer-to-peer support could occur among people who use drugs. Angela suggested this type of support would be a substantial improvement to the services available for this community:
[T]o have a little more people who are off the street now, maybe a little more community, like, meetings and stuff like that, not so much AA/NA but just meetings for us. […] ‘much’ (emphasized) more peer support, where we can sit down and talk about things that are going on in our lives and try and work it out as ‘a community’ (emphasized), like ourselves without inviting anybody from the outside in. […] Because those people don’t, like as far as I’m concerned, they don’t have a clue.
In sum, there are many facilitators that highlight not only the importance of reducing risks for PWID but also the need to foster growth of positive social relationships and self-progress over time. Taken together, the barriers and facilitators highlight the complex interplay of policy, social, economic, and physical risk environments that PWID face at both micro and macro levels .