The experience of injecting drugs in public spaces was characterised by urgency, a need for privacy, hygienic concerns, and a sense of shame
Correspondence to: Dr T Rhodes, London School of Hygiene and Tropical Medicine, London, UK;
What is the lived experience of injecting drugs in public places and the social and structural factors that affect access to syringe distribution services?
A purposive sample of 49 people (age range 18–47 y, 69% men) who were current injecting drug users (had injected drugs in the past 4 wks; mean duration 7.2 y).
49 individual semi-structured interviews were held, each lasting 30–90 minutes. Topics included injecting equipment use, access, and availability; injecting locations; and health and service needs and experiences. Interviews were tape recorded, transcribed verbatim, and analysed from a perspective of interpretive critical realism.
Public injecting. Participants described public injecting as a situational need rather than a choice. Injecting was viewed as a private behaviour, preferably done in non-public environments, which were also associated with cleanliness. Situational factors leading to public injecting were opportunity (“If I’m out, and they say ‘Oh do you want a sort out’, yeah, you do it on the stairs or something”), immediacy (“We couldn’t wait to take it”), and craving or withdrawal (“Toilets, if I’m clucking [withdrawing]. If I’m really ill, then I don’t care, I go behind a wall or in a car park”). Public injecting spaces included “anywhere and everywhere” (eg, buses, toilets, telephone boxes, and back gardens). Findings highlighted the interplay between public injecting and urgency, privacy, and hygiene. Urgency was borne from the constant fear of being interrupted while injecting in public. Participants spoke of balancing the need for privacy, and the lack of it, in public injecting spaces. The need for privacy related not only to fear of interruptions, but also of public exposure. Concerns about hygiene related to the physical injecting environment, which was filled with debris and had contaminated surfaces and a lack of running water. Participants distanced themselves from public injecting places they perceived to be dirty or degrading (“it’s absolutely stinking… but I’ve never injected there”). They also distinguished themselves as hygienic in terms of sharing and safer disposal of syringes. Shame and fear of being publicly exposed as an injector featured in descriptions of public injecting spaces. Experiences of shaming were described in interactions with police (“They like embarrassing us. The police make us out to be really horrible people and we’re not”), drug dealers (“… the dealers, the people that actually sell it, they are the ones doing all the shunning, dissing and cussing, […]”), passers-by (“When you are walking down the street and people have seen you begging […] they just go ‘Ugh, you dirty Gippo, you dirty Smackhead’”), and healthcare and drug-related helping service providers, such as pharmacists (“They’re afraid to touch you, which puts up a barrier straight away,” “They are pretty rude to us users […] It’s quite embarrassing”). Accessing syringe exchange services at pharmacies was also noted in terms of the potential for public disclosure as an injecting drug user (“You have to queue up with other people getting normal prescriptions, and they hear what you’re asking for. There’s no privacy at all, so it does make you feel dirty.”)
The experience of injecting drugs in public places was described in terms of a sense of urgency, lack of privacy, and hygiene concerns. These were related to fears of being publicly exposed as drug injectors and feelings of shame.
Rhodes T, Watts L, Davies S, et al. Risk, shame and the public injector: a qualitative study of drug injecting in South Wales. Soc Sci Med 2007;65:572–85.
Rhodes et al provide an in-depth description of the lived experience of injection drug use in public places. This important work gives voice to injection drug users, traditionally a marginalised group of people. The account of injection drug use offered in this paper reframes the discussion of “risk” from an individualistic-behavioural perspective and focuses on the social and physical contexts that shape behaviour.
Of public health importance is that while 74% of participants reported pharmacy and non-pharmacy needle exchanges as their main source of needles and syringes, 22% reported injecting with a needle or syringe previously used by someone else. It has long been recognised that needle-exchange programmes are effective in reducing the transmission of infection from injection drug use.1 However, the findings of Rhodes et al suggest that needle exchanges and education about safer injection behaviours must be part of a comprehensive strategy that also addresses the social and physical contexts of drug use. Participants discussed issues of urgency and fear of interruption when injecting, with these immediate concerns drawing attention away from safer injection practices and fostering increased risk. Similar findings have been described elsewhere.2
Participants’ negative experiences with healthcare and drug-related helping agencies, and their insights into the complexities surrounding injection drug use, highlight the importance of working with injection drug users to develop future policies and programmes aimed at decreasing the risks associated with injection drug use. By working with this population, healthcare providers can help to decrease further marginalisation of this population and provide client-centred care.