Four superordinate themes were identified. From these stem several subordinate themes. The first superordinate theme discusses elements that could hinder outreach accessibility in a disaster, including infrastructure and equipment costs. The second superordinate theme identifies the importance of peers, and includes social capital, practical support and key contact networks. The third superordinate covers social stigma, including fear of stigma from managers at emergency centres. The last superordinate theme explores the most frequently mentioned solutions to NEP service disruptions during disasters. These solutions are hypothetical and additional to current services (such as the online NEP store, courier delivery and a key contact system). All superordinate themes and their subthemes are substantiated by excerpts taken from participant narratives.
Infrastructure and equipment costs
Distance and road vulnerability challenges
Participants in this study were aware of the risks associated with disasters. KyleFootnote 3, for instance, recognises that he might not be able to access the mobile outreach service due to critical infrastructure failures, specifically blocked road networks. Kyle attributed this to living remotely:
We’re so remote on the West Coast […]. We’re cut off in the event of a disaster. Just a couple of roads could block, and nothing (injecting products/OST) could come in. If we had a big earthquake […], the only supplies (that would go in) are essential medical supplies, food, and water.
In his wider narrative, Kyle mentions that Westport is surrounded by water, and roads vulnerable to erosion could easily prevent access to the NEP mobile outreach service. Kyle discusses how essential health gear (like NEP products or OST medications) will likely not be prioritised for PWID in emergencies, unlike other medical supplies. David is also aware of accessibility issues people in smaller towns face. He compares accessibility in remote areas and cities:
Here in the small town, you can’t access what you want readily as in the city. You know, you have lots of options in the city, but here people just sort of bite the bullet. Oh, they do the rounds, see what they can do, but it’s a small cliquey little town.
As David suggests, remote areas do not have static NEP exchanges and limited local options to source equipment (e.g. NEP-based pharmacies, key contacts), which expose people to harm if they need to reuse or share injecting equipment. Participants’ discussions around infrastructure vulnerabilities from natural hazards led them to identify other disaster preparedness actions, such as storing NEP products in advance, as Kyle’s quote demonstrates:
I have enough [NEP products] for the month plus another two weeks in case something happens […]. I do it consciously because I live remotely, and there’s always something that could happen.
Kyle’s foresight in preparing for a “happening” outside of the everyday was an approach based on living remotely. He was one of the few in this study who had prepared for an emergency by storing general disaster survival essentials (water, food, blankets) as suggested by the New Zealand National Emergency Management Agency (NEMA) . However, lower overall preparedness rates were not unexpected, given that, on average, only 24% of the Aotearoa New Zealand population have fully prepared for an emergency . Overall, these findings highlight how critical infrastructure vulnerabilities, such as roading blockages, are recognised by the PWID in this study as potential barriers to accessing safe injecting equipment. These accessibility problems emphasise the importance of local emergency planning that caters to all community needs.
Cost of products
As other scholars argue [43, 44, 45, 46, 47, 48, 49, 50, 51], disasters can exacerbate existing vulnerabilities for minoritised people. This includes financial hardships, which, in turn, perpetuates and reinforces poor health outcomes. Harriet spoke about the cost of drug-injecting equipment as a barrier in everyday life because she and her partner are unable to afford to purchase items and, at times, had to reuse their needles and syringes:
When the [NEP mobile outreach service] comes, all we get is four butterflies and four barrels, and I have to reuse them until [the staff member] is here next cos that’s all we can afford to do.
We can presume from Harriet’s excerpt that she has reused the same equipment numerous times as it is approximately one month between mobile outreach visits to the West Coast. Her action is concerning as reusing drug-injecting equipment carries risk. For example, butterflies are needles that are used when people have trouble finding veins or when there are larger amounts of liquid being injected. Reusing butterflies (or any needle) can cause bacteria to enter the body and cause other harm . We can also presume that cost will be a problem following a disaster.
During the Level 4 COVID-19 lockdown period, temporary Income Relief Payments by Work and Income  and other forms of social support increased, including food parcels  and the provision of ‘safe’ housing . An online NEP store enabled people to make confidential orders that were delivered by courier to minimise human contact during the 2020 COVID-19 Level 4 lockdown . However, it is not uncommon for people living with socioeconomic hardship or in remote areas to not own a smartphone or be computer literate . Any absence of being online negates the utility of online options for purchasing goods or any other internet-based emergency management solutions . All participants reported underutilising the online NEP service due to limited cell phone coverage or minimal internet use, for instance, Christy declares, “I don’t do online […] I would have to be able to ring up and order”. For Christy, a phone order was best. Additionally, the online courier delivery incurs a fee, which some PWID are unable to cover due to their limited budget. As a way to counteract this, according to the mobile outreach staff, “donation money” (spare money donated by other PWID) was used during that time to cover the costs of sterile drug-injecting equipment for those who needed help, likely reducing any financial strain:
Key contacts were stocked up massively with all the free and spare non-free stock I could find…. During COVID-19, I’ve made sure that the Needle Exchange donations were used up, plus a couple of other NEP staff also donated equipment and cash. (NEP staff)
Providing additional financial and social incentives during a disaster goes some way towards improving resiliency for communities that have material disadvantages. It also demonstrates the importance of peer-based support.
Social capital and practical support
Peer-based services, like NEPs, represent a form of social capital in action where the networks and relationships between people and communities can enhance wellbeing during and following disasters. Being peer-based meant that the mobile outreach staff could take either an active role (e.g. offering PWID the opportunity of a courier order) or a passive role (e.g. stocking up key contacts with additional free stock to distribute) in anticipation of a disaster. Ultimately, this foresight was instrumental in preventing product shortages on the West Coast throughout the 2020 lockdown period. The following quote also reflects the importance of committed and adaptable service providers that ensure product accessibility for PWIDS, no matter what:
I’m really okay with anything that goes down there (on the West Coast). I have to be open to any situation […] I’ve never not been able to manage to get somebody sorted out within a 24- hour period on the West Coast […]. We’ll just make sure that we’ve got plenty of safety processes in place […] we’ll take orders before I go, we’ll pack them in boxes, and leave them at the backdoors, and money will get handed out in windows […]. (NEP staff)
Being able to “sort someone out” attests to the competencies of peers and the importance of the lived experience workforce. With insider knowledge safe injecting equipment can be provided to PWID in disasters as soon as possible to minimise health risks. Thus, several participants describe having had no problems accessing drug-injecting equipment during the lockdown. For example, Kyle spoke about simply accessing products via the courier service, as arranged by the mobile outreach staff:
It (COVID-19) didn’t affect me at all, systems were in place, and I just used the courier programme via [the outreach staff].
Beyond the practical arrangements provided by the outreach staff, the social and emotional support as part of the peer-based approach to NEPs offers additional resilience for PWID whose lives can be chaotic and changeable. With this extra support being intentional, the mobile outreach staff speaks about providing psychosocial support at every opportunity:
It’s like […] there’s nothing else really solid in their lives a lot of times, but the needle exchange van comes every month, it’s so reliable, and they know I will be there to answer any questions or give whatever support I can. That is the way I’ve worked with this group I’ve given that extra layer of support, every opportunity I can.
Having security or some sense that the world is reliable and stable is important when lives are mostly insecure and uncertain. In the same way, unconditional social and emotional relationality from key support people is important to the wellbeing of minoritised communities. The leadership and camaraderie demonstrated by empathetic NEP staff are valued immensely by the PWID in this study, as reflected in the following quote:
Everyone over here loves and respects the [outreach staff]. He does so much for us over here. Yeah, you’ve just got no idea. (Harriet)
The assertion of “no idea” marks a line in the sand—the intricacies of living as a PWID can only be understood by peers. It also draws attention to the importance of social capital and establishing relationships of trust, whereby PWID can open up to share their needs. Hay and colleagues  report that access to peer support at peer-based NEPs is associated with positive indices on anxiety and depression measures, greater satisfaction with life, and increased health-related information exchange with the exchange staff. The strength of these relationships will likely carry over into disasters. This was demonstrated by Kyle when asked how prepared he was for a disaster, he responded that, for him, preparedness included simply having open communication with the outreach staff:
You just gotta have communication about telling [the outreach staff] what’s happening in your life, yeah having communication channels [open], just being prepared.
In Kyle’s narrative, “having communication channels open” shows that reciprocity between PWID clients and NEP staff can lead to information sharing. These findings are like previous studies that suggest the strength of social networks is founded on collaboration, social cohesion and empowerment of people, which can generate resilience during emergencies [76, 77, 78, 79]. Our study also found that more informal peer-based networks, the "key contact" system, within the PWID community was usually an important resource for products and programme accessibility.
The PWID community on the West Coast distribute products among themselves, a method used predominantly in remote areas where alternative access options are scarce . It also provides a way of reaching people that might not use the mobile outreach service [24, 10]. The key contact system works by stocking designated PWID members with new injecting equipment to distribute as necessary or during emergencies. Ben explains how the key contacts he knows would have lots of needles if he needed them:
Lots of [key contact distributors] have heaps of needle ends and at the end of the day, if you're worried about it (not having access to needles), say an accident did happen, and the bridge did go down, most would always have a shitload of ends.
Knowing sterile needles were available was reassuring for people like Ben. Due to the uncertainty of the worldwide pandemic, extra precautions were taken to ensure PWID had access to health-sustaining equipment for “two–three months” when it was unsure how the COVID-19 pandemic would unfold and whether NEPs would be classified as essential services. It is important to note that the key contacts were utilised during the 2020 Level 4 lockdown period, and PWID accessed products from them during that time.
The key contacts are reliant on the mobile outreach staff to stock them up, which is a potential limitation. For instance, should road access to Westport be blocked for an extended period of time, access to stock could be difficult. The key contact system is also dependent on amicable interpersonal relationships between members of the PWID community, so some participants expressed concern that conflicts or drug-related dynamics could cause greed, intergroup conflict, and jealousy, limiting the willingness of key contacts to distribute to all members of the community. Ben had experienced gatekeeping by a key contact who appeared selective about whom he shared equipment with. Ben stated: “They say we are a [key] contact, but if we don't like you, we don't want you at our house.”
The potential for gatekeeping, as described by Ben, shows the limitations of the key contact system which, in a sense, mirrors ecological systems where social and material capital enables better response and recovery from a disaster [80, 81]. The mobile outreach staff reported that potential interpersonal conflict between peers could be managed by making PWID on the edge of townships key contacts, or those who are well-liked (have good connections with most). Relational issues more broadly, in the form of stigma, were also seen to interfere with access to NEP products. We now turn to discuss stigma and how that might impact in a disaster.
Our analysis supported that participants' experiences of stigma played a prominent role in their everyday lives. For the participants, stigma occurred when “respectable citizens” positioned them as inferior, criminals, or immoral, representing a deeply ingrained social mistrust. Some participants described experiences of being ostracised from local sports teams, having limited job opportunities, and even being disowned by family members after they found out about their drug use. The following excerpt represents how stigma remains the greatest struggle in the lives of PWID:
Stigma is our biggest battle by a long way […] we see it happen regularly in small communities. I guess rural New Zealand is a wee bit more judgemental than some of the larger cities. And for a good reason, too, in rural locations, [non-drug users] perceive they have a lot more to lose from the PWID they judge as thieves, unemployable, or always in the courts. (NEP staff)
Stigma is described as a “battle” conjuring warlike imagery, which attests to its deeply traumatising effects. Life is difficult enough for people living in precarity, especially when layered with drug use. Despite that, the participant above demonstrates compassion towards the people who judge them, especially as they might experience some form of harm from the consequences of drug use that is not well understood or supported. These consequences are discussed in more depth in the next section.
Stigma as a barrier to other distribution methods
NEP products are also distributed through participating pharmacies; these pharmacies are often community-based and provide a venue for PWID to access NEP products locally, especially as the mobile outreach service only visits the West Coast once per month. The participants in this study were concerned pharmacies might report the purchase of drug-injecting equipment to the local Alcohol and Other Drug Services if they were on managed treatment. This fear acts as a barrier that prevents PWID from using pharmacy-based NEP outlets. Moreover, in less populated areas there can be limited numbers of pharmacies so they dispense both NEP gear and other harm-reduction treatments. The mobile outreach staff believes this is problematic:
[Our area] only has one pharmacy, it does NEP, and it does OST, so there's a real dilemma for some PWID asking for injecting equipment from the people that are distributing their methadone, who take a personal view on this and say, "You shouldn't be injecting your methadone", when, once it goes out to the shop, it's down to the PWID what they do with it.
The experience of discrimination described in this excerpt comes from the misconception that injecting methadone is illegal and other moral discourses that say some mood-altering substances (like alcohol) are socially acceptable when others are not. It is also founded on substance gestation; it is tolerable to consume methadone orally, but not inject it:
It's not actually illegal to inject, and that's what a lot of confusion is about for a lot of people that don't know a lot about our world. […] we've had phone calls from people saying, "I've just come out of the pharmacy to pick up some injecting equipment, and they just looked at me like a piece of dirt". That doesn't help any process in any way, shape or form, you know? […] ‘cos to keep 'em (PWID) safe, they need that new equipment. You stigmatise, they might not come back for a week and go home and (re-)use that same pre-used syringe and needle.
While health services might have a duty of care, as the mobile outreach staff suggests above, healthcare services should prioritise the health and wellbeing of PWID. The goal of harm-reduction is to prevent harms associated with injecting and the aim of opioid treatment is to mitigate the chronic and relapsing pattern of problematic illicit opioid use, making it necessary to not promote abstinence to the exclusion of substance-using harm reduction methods . The mobile outreach staff point to the irony of stigmatising PWID for trying to keep themselves safe. Participants also note the role of stigma in broader emergency management practices, which we now turn to discuss.
Fear of mistreatment from emergency managers
When a large-scale disaster strikes, emergency management personnel respond to community needs which can include setting up community welfare centres for evacuations or providing support (e.g. information, food, psychosocial care) . As noted, the participants in this study express fear that they would be deprioritised by emergency management staff in such a setting. In the following excerpt, Finn reflected on how his “drug-using status” could impact the way he would be treated:
[Emergency responders] will be saying, “look, you're getting so many drugs that you could knock out a horse, you’re the last people we should take care of, you put yourself in that situation” […]. I just think out of everything they'd think of; no one would even think about all these guys are going without their meds. It's more like, oh well, the druggies are going to have to sit back for three days and handle it.
Alongside Finn, other participants also felt that they would not be supported, and instead be considered undeserving. This anticipated stigma is borne from the way in which they have been treated in other areas of their lives. The mobile outreach staff described experiences of inequitable treatment and general social scorn:
[PWID] know they're not getting treated the same as others are getting treated. Especially around the prescribing of their drugs […]. I was listening to the radio the second week of lockdown, and I heard one guy come on, and he said,” I know how to sort all the junkies through this period! You just get rid of drugs, and you put them all in lockdown - you put them all in prison. You've got to put all the addicts in prison”. What? Why would anyone ever think something like that! […] Sometimes, we prove them right, but often we prove them completely wrong.
In his narrative, the staff member also states,”everybody is lax around our people”, meaning the care and attention that PWID need to manage their problems are ignored. Knowing social systems produce a bias towards them and encountering stigmatising attitudes can be distressing for PWID. Stigma can prevent them from seeking help or acting defensively when engaging with the general public. Interviewing people on OST in Aotearoa New Zealand , similarly found participants anticipated they would be disregarded in disaster situations by emergency management personnel.
Solutions for accessibility
Given the health risks when NEP products are unavailable, the participants in this study offered a range of solutions for equipment distribution during an emergency. These included collaborating with local emergency personnel, storing injecting equipment for emergencies in community spaces, providing free drug-injecting equipment, and installing electronic dispensers.
The mobile outreach staff was optimistic about collaborating with emergency managers or key people in the community to store sterile drug-injecting products in various locations along the West Coast of the South Island:
Wouldn't it be great if we get some injecting products stored away in [Westport, Hokitika and Greymouth], maybe in community halls? We have all these community halls right around New Zealand in the smallest of areas, like where there are only two-three hundred people, there is a community hall!
This participant had spoken to a civil defence representative with “a fantastic attitude towards PWID”, who had suggested community halls as a space to store sterile drug-injecting equipment. This kind of alliance is imperative to the welfare of those who use drugs in rural communities, especially in small towns, because it could overcome travel barriers; however, storing injecting equipment in public venues would need careful planning and community buy-in.
Another participant, David, thought that using community halls would still be challenging in a disaster, given the long distance between townships:
There is 111 kilometres between [Hokitika and Greymouth], so even in a weather event, we can't get to Westport to get needles […]. We should only have [emergency NEP equipment] on this side of the bridge.
In this excerpt, David suggests alongside travel issues, critical infrastructure vulnerabilities like bridge collapses due to floodwaters present additional risks. This is a real concern for people living on the West Coast, as evidenced by a 2019 flood that washed away part of a bridge . Others added that travelling too far also presents financial barriers, Alice highlights "there is no way" people would drive to the neighbouring towns to pick up products because of the cost of transport or petrol. Along with earlier indications of user-pay products costing too much, this strengthens the idea that solutions should be local and free to maximise accessibility for PWID. David suggested free equipment as a solution during an emergency:
I think if there was an emergency, [equipment] would have to be free, ‘cos you wouldn't have the money […] it's just that money machines would be out, and electricity could be gone. You know anything could happen.
Contrary to free equipment and travel costs, a second popular solution identified by participants was electronic dispensers. Electronic dispensers (vending machines) already exist in all static NEP services in Aotearoa New Zealand. Vending machines are stocked with user-pays products (for instance: one syringe, one needle, one filter) and cost between 2 and 5 dollars (NZD). There are no vending machines on the West Coast or any other remote areas in Aotearoa New Zealand. Participants argued that installing one in the main West Coast towns (e.g. Westport, Hokitika, Greymouth) would provide a backup service for accessing NEP products in situations where the mobile outreach service cannot travel into the respective areas. However, it is important to note that they do also require restocking which could be problematic during a disaster. It further dissipates any potential barriers associated with interpersonal issues, including jealousy or favouritism with key contact distribution. No one can be a gatekeeper with a vending machine, as indicated by Alice:
No one is in control with that, even though behind the scenes [someone] might be filling them.
Vending machines, unlike the NEP-based pharmacies, would lessen the possibility of being stigmatised by non-drug users or the public. However, vending machines still pose serious confidentiality risk in small areas where everyone knows everyone, and “gossip” is common:
Just the fear of being [seen] going to that machine could jeopardise a lot of people's employment... big gossip town, mate. (Max)
Despite the risk to people's anonymity, both storing equipment in community venues and installing vending machines were favoured local solutions that could overcome critical infrastructure disruptions in disaster situations. Overall, these findings suggest that maximising accessibility to equipment involves locally accessible equipment as vital to emergency management planning, ideally delivered in a way that protects the identity of PWID to avoid stigma and minimise the potential consequences of being recognised as a PWID.