Commentary
Young people and injection drug use: Is there a need to expand harm reduction services and support?

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Abstract

A complex array of intersecting social contextual factors are known to influence safer and/or unsafe practices among people who inject drugs. However, less is known about the social contextual factors that may specifically influence injection practices for young people who inject drugs. In this qualitative study, we explored with young people, ages 18–29, living in an urban centre in Nova Scotia, Canada, their perceptions and experiences of the social contextual factors that influence their safer and/or unsafe injection practices. We found that many of the social contextual factors the young people reported as influencing unsafe practices are at the micro-environmental level, and a number of these factors also affect adults (as per the literature). Methadone maintenance treatment was identified by a number of the participants as an important factor influencing safer practices. An expansion of harm reduction services and supports may help to address many of the social contextual factors identified by young people who inject drugs and should be considered given their important role in reducing the harms associated with injection drug use.

Introduction

Research conducted within Canada suggests that although drug use among young people is fairly common, injection drug use is not (Adlaf et al., 2003, Asbridge and Langille, 2013, Boak et al., 2013). However, injection drug use is prevalent among young people who are marginalized within Canada, and more specifically those who are street-involved (with ‘young’ being defined variably in different studies, but as young as 12 and as old as 29) (Brands et al., 2005, Kerr et al., 2009). Research also indicates that many young people who inject drugs (YPWID) are at high risk of contracting HIV and the Hepatitis C virus (HCV) because of the sharing of needles and other drug paraphernalia (Lloyd-Smith et al., 2008, Patten, 2006, PHAC, 2007). Within Canada, rates of HIV and HCV among YPWID living in Vancouver, British Columbia were reported at 16 and 57 percent respectively (Miller, Kerr, Strathdee, Li, & Wood, 2007), suggesting that in this centre, sharing of needles and drug paraphernalia may be a significant problem. Studies of needle sharing among young people in Vancouver report varied rates of needle sharing (Lloyd-Smith et al., 2008, Miller et al., 2002), with one study reporting that among young people (ages 14–26) who had injected in the previous 6 months, 29% had shared a needle (Lloyd-Smith et al., 2008), suggesting that sharing is a significant problem among young people. Rates of paraphernalia sharing (e.g., sharing drug cookers, cotton/filters, rinse) also vary from study to study in Canada and the United States (Brands et al., 2005, Kipke et al., 1996PHAC, 2006, Thiede et al., 2007), with one multi-site United States-based study indicating that paraphernalia sharing may be as high as 96% among young people (ages 15–30) who also report needle sharing (Thiede et al., 2007).

Sharing needles and other drug paraphernalia is shaped by a variety of social contextual forces (Rhodes, 2002, Rhodes, 2009, Rhodes et al., 2005). Such forces include macro-environment level structural factors such as stigma and discrimination and various national policies (Rhodes, 2009, Simmonds and Coomber, 2009). At a micro-environment level, there are also various factors that play a role in unsafe practices, such as local policing practices and crackdowns (Rhodes, 2009). This is well illustrated by a study of adults who inject drugs (PWID) in New York City where sharing was associated with a neighbourhood police crackdown on illicit drug use because fears of arrest made it difficult for PWID to access clean supplies (Cooper, Moore, Gruskin, & Krieger, 2005). At a micro-environment level, social and peer group influences also shape unsafe practices (Rhodes, 2009). For example, sharing has been reported among injection drug users who are in an intimate sexual relationship (Evans et al., 2003, Unger et al., 2006). A qualitative study of PWID suggests that such sharing may be due to the belief that one can trust one's partner to be ‘clean’ from infectious diseases (Jackson et al., 2002).

Although there are many factors at both macro- and micro-environment levels that can shape unsafe practices, there are also factors that shape safer practices. For example, at a macro level, political support for drug consumption rooms can support safer practices (Houborg & Frank, 2014). At a micro level, community needle exchange programmes that are tailored specifically to the needs of PWID in the community can also support safer practices; for example, in one study, an increase in the number of sites for needles distribution resulted in reduced sharing (Kerr et al., 2010). Peers educating one another about the risks of sharing and/or “peer helpers” who informally distribute clean needles can also help to ensure safer practices (Jackson et al., 2009, Parker et al., 2012).

The body of literature documenting various social contextual forces that can influence both safer and/or unsafe practices is largely based on research with adults who use injection drugs (Dolan and Niven, 2005, Kipke et al., 1996). Some of these same social contextual forces may also shape the practices of YPWID. However, given that young people are at a different development stage than adults, and may be relatively new to the use of injection drugs, there may also be factors specific to young people that shape unsafe and safer practices. Indeed, a qualitative study of young people (ages 16–24) involved with problematic drugs use (e.g., crack cocaine, crystal methamphetamine, and/or heroin), found that participants avoided a particular area of the city (the Downtown Eastside of Vancouver, British Columbia), as they believed that being in the space would accelerate “addictions, sexual exploitation, disease and extreme violence” (Fast, Shoveller, Shannon, & Kerr, 2010, p. 55). As the authors note, the participants indicated that they preferred to stay in the Downtown South area where the vast majority of services for young people are located, and where they are known. This suggests that there may be particular social contextual factors specific to young people that shape their unsafe and safer drug using practices, as where young drug users go or live may be different from adult drug users. Understanding such contextual factors specific to young drug users is needed to ensure appropriate services and supports for young people. If, for example, services are in an area where young people do not go, or an area that is avoided by young people, then the uptake by young people will be limited. In order to help fill this gap in our knowledge about potentially contextual forces specific to young people who inject drugs, we spoke with YPWID to gain their perspective on key social-contextual factors that they perceive as influencing their safer and/or unsafe injection drug use practices. We wanted to give ‘voice’ to YPWID given that there is relatively little research specifically focused on young people and as such, a small-scale exploratory study was conducted with 10 YPWID in Halifax, Nova Scotia to understand their unique perspectives.

The research study was conducted in Halifax, which is the largest urban area in Nova Scotia, Canada with an estimated population of 390,328 (Statistics Canada, 2011). Nova Scotia is one of four Atlantic Provinces on the eastern coast of Canada, and is an economically depressed province within Canada (Statistics Canada, 2013a). High rates of chronic diseases (e.g., diabetes, cancer) characterize this province relative to many other provinces in the country (Statistics Canada, 2013b), and Nova Scotia has the worst overall health profile and the highest rates of disability of the Atlantic provinces (Hayward & Colman, 2003). In addition, in 2004, Nova Scotia had the highest number of PWID in Atlantic Canada, with an estimated minimum number of 1064 (Patten, 2006). In New Brunswick, the minimum estimate was 827 PWID, the minimum estimate in Newfoundland and Labrador was 140, and no data were available for Prince Edward Island (Patten, 2006). In a small 2005 community-based study of 35 street-involved young people (ages 16–25) in Halifax, over half reported that they had injected at least one drug (Loiselle, MacKenzie, Patterson, Tota, & Koeller, 2006), pointing to the prevalence of injection drug use among street-involved young people in Halifax.

Section snippets

Population, recruitment and interview guide

Young people 16–29 years of age who were living in Halifax were invited to participate in this study. Research with young people varies significantly in the age ranges used, with many reporting the upper age as 29 (Cronquist et al., 2001, Evans et al., 2009, Miller et al., 2007, Nova Scotia Advisory Commission on AIDS, 2003, PHAC, 2014, Roy et al., 2007), hence this study used 29 as the upper age limit. Sixteen was used as the lower age limit given that Health Canada defines this as the lowest

Socio-demographic background and drug use history of participants

All participants reported that they had injected opioids in the 30 days prior to their interview. Nine of the ten participants indicated that they were homeless or marginally housed at the time of interview; seven participants had as their main source of income some type of social assistance program (e.g., income assistance, disability) and two cited no income. Five participants self-identified as female and five self-identified as male; six participants were between 18 and 24 years of age, and

Needle exchange program

The young people indicated that the needle exchange program (NEP) is an important place that provides services (including information) to support the use of safer practices. For all participants, the NEP was their primary place for access to clean needles and other injection-related paraphernalia, and all felt most comfortable going to the NEP as compared to other places such as a pharmacy. Indeed, participants spoke of the NEP as key to safer use, as indicated by the following participant:

[The

Discussion

This study explored young people's understandings of the key social contextual factors that they perceive as influencing their safer and/or unsafe injection drug use. Results from this study point to several key factors that influence such practices. Not surprisingly, key micro-environment level contexts are the places and times at which one can (and cannot) gain access to clean needles and drug paraphernalia. Participants highlighted the fact that the times when the NEP is open, and the

Acknowledgements

This study was completed as a Masters Thesis project (for KA). Funding for the MA was provided by the Nova Scotia Health Research Foundation (NSHRF) Scotia Support Award; the Population Health Intervention Research Network (Canadian Institute for Health Research (CIHR) Training Grant) Masters Award; and the Faculty of Graduate Studies (FGS), Dalhousie University. Thank you to all of the participants who generously gave of their time. Thank you also to Dr. Jeff Karabanow (Dalhousie University)

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