Harm reduction interventions often fail to engage people who inject drugs because they over-emphasise infection and risk, Magdalena Harris of the London School of Hygiene and Tropical Medicine told the recent HIT Hot Topics conference in Liverpool. Her interviewees frequently adopted safer injecting practices, but were more motivated by a desire to have a quick, pleasurable hit than by concerns about blood-borne viruses.
“Harm reduction needs to pay more attention to the pleasures and pragmatics of using drugs,” she said.
The language and messaging of existing harm reduction programmes are essentially negative, focusing on the risk of infections and the things that people should not do. But, on its own, awareness of the potential of infection doesn’t seem to be enough to change people’s behaviour. While harm reduction programmes in the UK have succeeded in keeping the incidence of new HIV infections low, this is not the case for hepatitis C, which is both more prevalent and easier to transmit. More than 40% of people who inject drugs (and 60% in London) have or have had hepatitis C.
Research also tends to dwell on the negative, identifying gaps in the knowledge and awareness of people who inject drugs. Harris’ qualitative study took a different approach, making particular efforts to speak to people who were still injecting drugs, had done so for many years (average 19 years of injecting) and who had managed to avoid hepatitis C.
Interviews were structured around taking an in-depth life history which did not initially focus on public health concerns. Only in a second interview did Harris ask her respondents to talk about protective practices and strategies.
She interviewed 35 people who inject drugs in London. Nine were women; most were in unstable housing and unemployed; and most were currently in an opioid substitution therapy programme. The drugs currently injected were either heroin or snowball (a crack and heroin mix). Whereas 15 participants had hepatitis C, 20 did not.
“We wanted to learn from the experts,” said Harris. “We wanted to learn from people who inject drugs who’ve managed to avoid hepatitis C.”
In common with other qualitative research, most respondents saw the virus as ubiquitous and an ‘occupational hazard’. Moreover, it wasn’t considered to be likely to affect a person’s health for many years or be life-threatening, as this respondent explained:
“My mate said: ‘you’re bound to get it. Everyone who injects has got hep C’... And I thought, you can’t die from it, can you. It didn’t really bother me.”
While respondents tended to be fatalistic (“if you’re going to get something, you’re going to get it”) they did report numerous practices which protected them against infection. The motivation not to re-use needles was not blood-borne viruses, but that a blunt needle would be painful and take a long time to use.
“I’m not going to use a pin [needle] more than once, once it's punctured my skin twice that pin is dead now because it’s blunt, therefore I can’t share anyone else’s because it’s blunt already, that was one of the reasons. That was the main reason.”
Re-used needles could also give a person scars and track marks that would risk publicly identifying them as a drug user. Moreover, blunt needles would damage their veins and make it harder to inject in the future.
“If you always use fresh needles you minimise any vein damage ... [I do it] to look after my veins to try and get more usage out of them.”
Respondents generally preferred to use drugs alone at home – not so as to avoid sharing, but in order to be able to relax and enjoy the experience. Others insisted on preparing their own drugs, rather than allowing a friend to do it. This reduced the risk of shared equipment but was mostly motivated by a desire to avoid badly prepared mixtures.
“I’ll add a bit [citric acid] if I need to, but ain’t gonna put too much in ‘cos it burns ... That’s why I used to cook up my own hit, I never trusted anyone to do it.”
“I’d had a dirty hit once before ... you get a great big pounding headache and you go all shivery and oh, it’s horrible, really horrible, so it was just from that I knew to keep my shit clean.”
Harm reduction programmes may be more effective if they focus on the issues that matter to people who inject drugs, Magdalena Harris argued. People’s concerns tend to be focused on short-term priorities, rather than the distant prospect of liver damage. Having a quick and easy hit, as well as maintaining usable veins, are concerns which harm reduction could engage with.
She contrasted the language used in HIV prevention materials for gay men with that used in materials for people who inject drugs. Many gay men’s organisations acknowledge the pleasure of sex and its importance to people. She highlighted a campaign that urged gay men to ‘have fun safely’ but said that she’d never seen messaging for drug users that encouraged them to ‘have fun’.
But the motivations for safer practices that have been identified could be reflected in harm reduction messaging. She said that slogans could be along the lines of ‘Don’t use used works, it hurts’ or ‘New kit – better hit’.
Harris M An elephant in the room? The role of pragmatics and pleasure in effective harm reduction. HIT Hot Topics conference, Liverpool, November 14 2014.