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'I guess my own fancy screwed me over': transitions in drug use and the context of choice among young… Fast, Danya; Small, Will; Krüsi, Andrea; Wood, Evan; Kerr, Thomas Mar 12, 2010

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RESEARCH ARTICLE Open Access‘I guess my own fancy screwed me over’:transitions in drug use and the context of choiceamong young people entrenched in an opendrug sceneDanya Fast1, Will Small1, Andrea Krüsi1, Evan Wood1,2, Thomas Kerr1,2*AbstractBackground: There is growing interest in describing the broader risk trajectories experienced by young peoplewho use drugs - that is, in describing the sequences of drug use transitions experienced by youth in relation toevolving understandings of risk and harm. This study sought to examine young people’s perspectives regardingthe evolution of their drug use in the context of a local drug scene in Vancouver, Canada.Methods: Semi-structured qualitative interviews with 38 individuals recruited from a cohort of young drug usersknown as the At-risk Youth Study (ARYS) were supplemented by ongoing ethnographic fieldwork (e.g.,observations and informal conversations with youth) conducted within the same cohort population. Interviewswere transcribed verbatim and a thematic analysis was conducted.Results: The majority of youth characterized past transition events as non-exceptional, largely ‘spur-of-the-moment’decisions motivated by evolving feelings of curiosity. At the same time, participants’ reflections indicated that thesocial, structural and material contexts of drug scene entrenchment play a powerful role in shaping these decisionsand transition experiences.Conclusions: Importantly, as young people become increasingly entrenched in the local drug scene, drug usetransitions seem to constitute increasingly relevant (and even ‘inevitable’) choices congruent with everyday livedexperience. The implications of these findings for the development of meaningful interventions for youth arediscussed.BackgroundTransitions into more harmful forms of illicit drug useamong young drug users have been identified as animportant focus for research and intervention [1,2]. Inparticular, given alarming rates of HIV and hepatitis Cincidence among young drug users in several urban set-tings [3-5], a number of studies have focused on thetransition into injection drug use among youth [6-9].There is growing interest, however, in characterizingand understanding the broader risk trajectories experi-enced by young drug users, which include but are notlimited to experiences with injection drug use [10-13].A risk trajectories perspective emphasizes the sequencesof transitions experienced by young people in relation todrug use and risk over time; furthermore, it recognizesthat transitions are oftentimes shaped by particular criti-cal moments (e.g., becoming homeless), as well asbroader contexts (e.g., exclusion from mainstreamopportunity structures) that can greatly influence long-term patterns of risk and harm.While it is acknowledged that individual agency isintimately associated with drug-related risk taking [14],a growing body of research emphasizes the intersectionof social, structural and physical environmental factorsin powerfully shaping drug use practices among youth[9,11,15]. Attention to the social situations, structuresand places in which risk is produced has illuminated* Correspondence: uhritk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital,Vancouver, CanadaFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126© 2010 Fast et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.some of the processes operating within drug-using con-texts that push young people towards more harmfulpractices, until it becomes difficult or impossible forthem to avoid ‘risking risk’ - that is, to avoid transition-ing into increasingly harmful drug using behaviors[9,14,16]. From a risk environment perspective [17],social, structural and physical environmental factors areunderstood to be operating at three levels: the micro- orinterpersonal level; the meso-level of social and groupinteractions (including institutional and organizationalaction or in-action); and the macro-level of core or dis-tal causes that intersect with micro- and meso-level fac-tors to produce risk. The risk environment is thus aproduct of interplay between different factors operatingon multiple levels [18]. For example, intimate negotia-tions between drug users in particular places regardingspecific drug use practices (micro-level factors) intersectwith institutional responses - such as a lack of access tohousing among the urban poor, and aggressive policingwithin public drug use settings that encourages theunsafe administration of drugs and equipment sharingamong people who have no where else to be but in thosesettings - to shape patterns of risk and harm [19-21].Social inequalities and wider cultural beliefs connectedto racism, sexism, stigma and discrimination (macro-level factors) powerfully inform experience and practiceat both the institutional level - where they are repro-duced through policy (or the policy climate more gener-ally) - and the interpersonal level - where they areoftentimes internalized and experienced as everyday fea-tures of lived experience in particular neighborhoods[22-24].Increasing interest in risk environments has directedattention to the role played by drug scenes in shapingthe evolution of risk and harm among specific drugusing populations [25]. Broadly defined as distinctiveinner-city areas characterized by high concentrations ofdrug users and drug dealing, drug scenes anchor elabo-rate social and spatial networks, practices associatedwith the day-to-day realities of securing basic necessitiesthat go beyond drug procurement, and wider patterns ofincome generation activities. Drug scenes vary consider-ably according to a number of factors, including thetypes of drugs available, who controls the sale of illicitsubstances, the specific locales in which drugs are soldand used, as well as the history of particular drug-usesettings [26,27]. ‘Open’ drug scenes are those in whichdrug procurement and use is highly visible and few bar-riers to access exist, while ‘closed’ drug scenes are thosein which daily exchanges between various social actorsare more clandestine, and individuals seeking drugsmust know or be introduced to a dealer [28,29].In Vancouver, Canada, the local street-based drugscene includes two distinctive neighborhoods known asthe Downtown Eastside and the Downtown South.Although these areas are geographically adjacent (andwithin walking distance of each other), they are consis-tently differentiated according to their history and anumber of aspects of place. Among the general public,the boundary that exists between them is largely aes-thetic; while the Downtown Eastside is widely recog-nized as North America’s poorest urban drug- andcrime-ridden postal code [30,31], the Downtown Southis a residential and entertainment district characterizedby both high- and (limited) low-income housing andnumerous thriving businesses. The drug-using popula-tions in these two neighborhoods are also distinctive(although overlap exists); while the Downtown South ischaracterized by high rates of crystal methamphetaminesales and use primarily among youth [32], the Down-town Eastside is characterized by a trade in crackcocaine, cocaine and heroin involving primarily adultdrug users, including many who inject drugs [33].Furthermore, the Downtown Eastside is a long-standingand well-established drug market that has been inoperation for decades, while the Downtown South drugmarket is a relatively recent development. Although theDowntown Eastside can accurately be characterized as amore ‘open’ drug scene in comparison to that of theDowntown South, in reality a wide range of illicit sub-stances are easily available on the streets of both locales.Furthermore, both neighborhoods are characterized bythriving ‘shadow economies’ largely propelled by sexwork activities, drug dealing and the exchange of stolengoods. The Downtown Eastside in particular has beensubjected to intensive enforcement initiatives in recentyears [34], although police activities are also ongoing inthe Downtown South [35]. In spite of their differences,our ongoing ethnographic research in both neighbor-hoods indicates that a large number of young drug usersmove frequently between them.In order to reflect an emerging focus on risk environ-ments and the broader risk trajectories experienced byyouth, this study sought to examine young people’sunderstandings of how their drug use evolved over timein the context of the downtown Vancouver drug scene.We were particularly interested in how youth describedtheir initiation into self-identified problematic drug use,as well as their subsequent progression towards whatthey viewed as increasingly harmful drug use practices.Thus, although the cessation of drug use is an importantdrug use transition in and of itself (and was featured inthe narratives of a small number of participants), it doesnot form a part of the present discussion.In the context of the present study, a ‘transition’ wasdefined as a self-identified, significant change in druguse practices (including initiation into drug use, and anysubsequent changes in patterns of drug use includingFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 2 of 10changes in substances used, modes of use, or intensityof use). From our previous ethnographic work in down-town Vancouver, we noted that young people oftentransition very quickly from one pattern of drug usepractices to another and then back again (often over aperiod of just a few months). Thus, we were more inter-ested in how young people articulated any meaningfultransition in their drug use practices, than in whetherthese transitions led to ‘regular’ or ‘robust’ patterns ofuse according to etic definitions of the concept [1].MethodsWe drew upon data from 38 in-depth individual inter-views as well as ongoing ethnographic fieldwork (e.g.,observations and informal conversations with youth)conducted in both the Downtown South and DowntownEastside neighborhoods. Interviewees were recruitedfrom the existing At-Risk Youth Study (ARYS) cohort, aprospective cohort of drug-using and street-involvedyouth that has been described in detail elsewhere [32].Eligibility criteria for this larger cohort study includesbeing between the ages of 14 and 26 years and self-reported use of illicit drugs other than or in addition tomarijuana in the past thirty days. Previous epidemiologi-cal research among this population indicates that theyare vulnerable to intensive drug use - including the useof crystal methamphetamine, heroin, cocaine and crackcocaine [8,36,37] - homelessness [38], and alarmingrates of HIV and hepatitis C infection [5].A subgroup of the ARYS cohort was selected to com-plete qualitative interviews. A first wave of interviews wasconducted during April and May of 2008, followed by asecond wave of interviews in September and October ofthat year. Sampling was largely opportunistic; approxi-mately half of the selected participants were well knownto the research team as a result of our ethnographicactivities, and an additional 20 participants were selectedto ensure variation in gender, ethnicity, age, currenthousing and ‘employment’ situation, as well as length oftime having lived within the downtown Vancouver drugscene comparable to that observed in the wider ARYScohort. In addition to considerations of representative-ness, the sample size was determined appropriate when itseemed that no dramatically new perspectives were emer-ging from the interviews or our ethnographic activities(although undoubtedly such views exist, and we do notpurport to present a complete account of all youth per-spectives regarding transitions in drug use in our setting).In other words, upon completing 38 interviews (sup-ported by observational work and informal conversationswith youth), we felt that a reasonably appropriate level of‘data saturation’ had been achieved.Interviews were undertaken by three trained inter-viewers (one male and two females) and facilitatedthrough the use of a topic guide encouraging broad dis-cussion of transitions in drug use within the downtowndrug scene. More specifically, we asked youth to tell usabout their first experiences with drug use which inhindsight they viewed as problematic, and then askedthem how things progressed from there up until theirpresent drug use practices (or lack thereof). We aimedto elicit broad narratives regarding the evolution ofpractices over time, when necessary probing for howspecific drug use experiences were shaped by social,structural and physical environmental contexts (by ask-ing for example, ‘Who were you spending time withthen?,’ ‘What was your living situation at that time?,’‘How were you getting money at that time?,’ ‘Can youdescribe the place where that happened?, ’ etc.).Interviews lasted between 30 and 120 minutes, weretape-recorded, transcribed verbatim and checked foraccuracy. Shorter interviews (i.e. those less than onehour) were rare and usually due to the participant’s abil-ity (i.e., alertness, wakefulness) or willingness to partici-pate in an interview lasting one hour or longer.Although such brief interactions cannot be considered‘in-depth interviews,’ they oftentimes yielded importantdata and were therefore not removed from the data set.All participants provided informed consent, and thestudy was undertaken with ethical approval granted bythe Providence Healthcare/University of British Colum-bia Research Ethics Board. Participants received atwenty-dollar honorarium. There were no refusals of theinvitation to participate in the interview, and no drop-outs (i.e. the participant chooses to decline participationin the study) occurred during the interview process.Data collection and analyses occurred concurrentlyand via ongoing engagement with participants, in orderto continually re-evaluate the validity of research find-ings. While remaining cognizant of confidentiality issues(many of the participants of this study knew each otherand it was therefore important to emphasize that whatone person said in an interview would under no circum-stances be repeated to another participant), evolvinginterpretations of the data were discussed with partici-pants, both informally with those who had already beeninterviewed, and more formally in subsequent inter-views. This process was used to inform the focus anddirection of subsequent interviews (for example, throughthe addition of new questions and probes). In addition,the research team discussed the content of the inter-views throughout the data collection and analysis pro-cesses, informing the development and refinement of acoding scheme for partitioning the data categorically.ATLAS.TI software was used to manage the codeddata. Interview data was initially coded based on broadthemes, including ‘transition in substance used,’ ‘transi-tion in intensity of use’ and ‘transition in mode of use.’Fast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 3 of 10In other words, we originally separated out different‘kinds’ of transitions. However, from these broad cate-gories emerged several more specific narrative themesthat cut across the broader classifications. Furthermore,it was frequently the case that these ‘types’ of transitionsoccurred simultaneously in the lives of young peoplewith whom we spoke and could not be meaningfullyseparated out, reinforcing the value of a broaderapproach to understanding drug use transitions amongyouth in our setting. We therefore revised our codingscheme to reflect the overarching narrative themes,which apply to a wide range of transitions experiences.All names appearing below have been changed, andsome youth narratives have been condensed in the inter-est word length.ResultsParticipants ranged from 16 to 26 years of age andincluded 18 women, 18 men and 2 transgender indivi-duals. Sixty-seven percent of study participants wereCaucasian, 28 percent self-identified as being of Aborigi-nal descent, and 5 percent were African Canadian. Halfof interview participants reported being homeless at thetime of the study, and the majority had experiencedhomelessness at some time over the course of theirinvolvement with the local scene. All but two partici-pants were currently engaged in drug use practices thatthey defined as problematic (including the use of crystalmethamphetamine, crack cocaine, cocaine and heroin),and over half of these participants had been involved inself-identified problematic drug use for at least threeyears. Participants were involved in numerous incomegeneration activities (oftentimes simultaneously) includ-ing street-level drug dealing, sex work, theft and theexchange of stolen goods. To a lesser extent, someyouth also engaged in recycling activities (referred to as‘binning’), panhandling, and street performing (referredto as ‘busking’). In sum, the majority of the young peo-ple with whom we spoke were significantly ‘entrenched’in the downtown drug scene; as characteristic of thewider ARYS cohort, they were largely consumed by thedaily project of survival ‘on the streets’ in the context ofhomelessness, chronic poverty, involvement in harmfulforms of drug use and/or dangerous income generationactivities.Evolving curiosity and ‘nonchalant’ choicesYouth narratives regarding the evolution of their druguse emphasized several key themes. Perhaps most perva-sive of these was the generalized assertion that transi-tions in drug use practices (including initiation intodrug use) represent decision points over which indivi-duals have total control. Young people articulated thissense of autonomy both when they were referring totheir own transition experiences (‘it was my choicetotally - my friends had nothing to do with it’) andwhen referring to the experiences of drug users in gen-eral (‘they always have the choice - I hate it when peopleblame others for their mistakes’). Darren ran away fromhis foster home and became involved in the local drugscene at age 13 - before which time he described himselfas being ‘totally clueless’ when it came to ‘hard’ drug use(unanimously defined by participants as the use of crys-tal methamphetamine, heroin, cocaine and/or crackcocaine). Upon arriving in Vancouver’s Downtown East-side neighborhood, Darren was homeless and immedi-ately recruited as a street-level drug dealer - perhaps, hereflected, because of his age and relative immunity frompolice harassment. He attributed his initiation into crackcocaine use three weeks after arriving to growing curios-ity about ‘what the hell he was selling people.’ Similarly,he described his transition from crack cocaine to crystalmethamphetamine several years later as resulting from‘his own fancy’ and a largely spur-of-the-moment deci-sion:It was three years of using crack everyday until I justdecided that I was going to do jib [crystal metham-phetamine] one day. So it was my choice totally.Then I liked it, and that’s the bad thing. That’salways the bad thing - same as with the crack ... Iguess my own fancy screwed me over big time in theend. (Darren, age 23)The majority of participants attributed transitions intheir drug use practices to evolving curiosity and aresulting choice that at the time seemed relativelyinconsequential; it was only in hindsight that thesechoices were sensationalized and recognized as havinggrave consequences.A small number of youth, however, emphasized theirlimited autonomy in becoming involved with increas-ingly harmful forms of drug use, and the inevitability ofprogressing to ‘the worst kind of drug use out there’(unanimously defined as intravenous heroin use). Mariedescribed growing up ‘on the streets’ of the DowntownEastside - a phrase that implies involvement withnumerous outdoor and indoor locales with relevance todrug scene activities. During this time her parents were‘off doing heroin,’ and she spent most of her time in theDowntown Eastside with the other Lost Boys (from thepopular film title, i.e. other youth who grew up on thestreets with parents who were heavily involved in thelocal scene). She reflected that she had ‘been arounddrug use her whole life’ whether via peers or her par-ents, and was 13 years old when she started smokingcrystal methamphetamine in the Downtown South. Initi-ally, she recalled avoiding injection drug use because sheFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 4 of 10had ‘seen what it had done to her parents.’ Nevertheless,Marie described the circumstances that surrounded hertransition to intravenous heroin use at age 15 - againemphasizing the role played by a growing sense of curi-osity. However - in contrast to Darren’s story - shedescribed being fully aware of the long-term impact ofher decision at the time; furthermore, she recalled asense of resignation to the fact that ‘kids like her’ (i.e.youth who grew up on the streets) inevitably ended upas ‘heroin addicts’ and ‘junkies’:I finally got curious ... My friends were doing it and Iwas like, ‘Well, my mom used to be a heroin addicttoo, so I want to try it’ ... I thought, I don’t know, Iwas probably always going to do it, because, like, Iguess I was born addicted to it because of my parentsand stuff.’ (Marie, age 16)All participants made a direct connection betweenevolving curiosity in relation to a particular drug usepractice and having repeatedly watched other socialactors engaging in that practice. Even among youngpeople who did not grow up on the streets, prolongedproximity to open drug use (which is particularly ubi-quitous in Vancouver’s Downtown Eastside neighbor-hood) was associated with the redefinition of previouslyestablished risk boundaries [14] and eventual engage-ment in forms of drug use that were previously viewednegatively. Carla started smoking crystal methampheta-mine intensively with her boyfriend at age 16. Uponrelocating to the Downtown Eastside at age 20 in orderto ‘find a cheap place to live,’ she and her boyfriendtransitioned to crack cocaine use because it was ‘easy toget and it was everywhere.’ Although heroin use is alsoubiquitous in the Downtown Eastside, it remained ‘offlimits’ for the pair during their first year downtown; asCarla recalled, she had always associated it with shame-ful and public ‘junkie’ behavior (as she put it, ‘I didn’twant to become one of those people in the park, nod-ding off with a needle hanging out of my arm’). How-ever, when the couple lost their single-room occupancyhotel in the Downtown Eastside due to falling behind inrent, and her boyfriend ended up in jail, Carla describedthe growing sense of curiosity that led her to contem-plate (and then go through with) snorting heroin for thefirst time:We always said we would NEVER do that [heroin].Like never. But about four months ago, I don’t know,I just started seeing people doing heroin and I justwanted to try it ... I mean, I had always been aroundit [in the Downtown Eastside] but I guess I juststarted to notice it more. I tried it, and I gotaddicted. (Carla, age 22)Furthermore, youth indicated that a range of socialactors - including peers, romantic partners, dealers and‘clients’ vis-à-vis drug dealing activities - could play anactive role in the definition and re-definition of accepta-ble risk and ‘normal’ patterns of drug use. Anka becameinvolved in the downtown drug scene when she was 13,at which time she was already using ecstasy. Like Marie,Anka had grown up around hard drug use (althoughnot in downtown Vancouver) and initially avoided it asa result of negative childhood experiences. She recalledthe circumstances under which she and a friend transi-tioned from ecstasy to crystal methamphetamine only afew months after she relocated to the streets of theDowntown Eastside:It used to be like me and my friend would gettogether, and we’d get some caps of E [ecstasy]... Andthen, after a while she was like ‘Do you think maybewe could get jib [crystal methamphetamine]instead ofE?’ Just kind of nonchalant about it. At first I waslike, ‘Why do you want to get jib?’, right? But thenafter a while I was kind of like, ‘Oooh, yeah, I thinkthat’s a good idea.’ (Anka, age 19)Although the transition from ecstasy to crystalmethamphetamine could be interpreted as an escalationof stimulant use, it is important to note that participantsrarely articulated these types of transitions as such.Rather, as noted above, the vast majority of participantsstressed the (as Anka put it) ‘nonchalant’ circumstancesunder which they made the decision to transition fromone substance to another. The exception was youngpeople who ‘grew up on the streets’; these youth tendedto view their progression from marijuana to crackcocaine and/or crystal methamphetamine, and thenfinally to heroin, as an inevitable escalation towards ‘theworst drug out there.’ For the majority of participants,however, the notion of escalating drug use applied totransitions in mode of use - that is, transitions fromsmoking (understood as the least harmful) to snortingand then finally to injecting (understood as the mostharmful). Youth consistently emphasized that these tran-sitions in mode of use were almost always accompaniedby transitions in intensity of use - and by association, anescalation of the harms associated with that particularsubstance.Contextualizing choice: the social-spatial and materialcircumstances of drug scene entrenchmentWhile curiosity and ‘on-the-spot,’ non-exceptionalchoices were associated with the moment of initiation ortransition, participants’ reflections in hindsight alsopointed to the role played by social-spatial and material(i.e. economic) contexts in shaping these choices andFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 5 of 10prompting transitions to increasingly harmful forms ofdrug use. The role played by these wider contexts wasunderscored by those youth who had at one timeattempted to exit downtown Vancouver and the localdrug scene - oftentimes with the express purpose oftransitioning away from harmful forms of drug use -and found that upon returning (whether by choice ormaterial necessity or both), familiar social-spatial net-works of drug users and dealers facilitated an immediatetransition back into harmful drug use practices. Forexample, Anka lamented her rapid transition back intocrystal methamphetamine use after a period of absencefrom downtown Vancouver when she was 16, indicatingthat upon her return she knew exactly who to find andwhere to go in order to get crystal meth:My mom sent me away to Armenia to live with mystep-dad’s family ‘cause she wanted to get me offdrugs ... When I got back from Armenia I just reallyneeded to get high ... So I went over to this guy’shouse, because I knew that he always had jib [crystalmethamphetamine] there. So that very first fuckingday that I came back, I got really high on jib ... Ihave this little calendar that I kept up. I wrote down,like, the drugs that I did just cause I wanted to keeptrack ... the day that I came back [from Armenia] itsays ‘jib,’ and then since that day, every single dayit’s full. (Anka, age 19)The relationship between the social-spatial and mate-rial contexts of drug scene entrenchment and transitionsto increasingly harmful forms of drug use was perhapsmost powerfully articulated by those participants whogrew up within these contexts, and without the meansto enact or even envision an exit from them (whether inthe sense of exiting the physical, geographical bound-aries of the drug scene, or the social structural circum-stances embedded in these neighborhoods). Amongthese youth, initiation into drug use occurred at a veryyoung age, and subsequent transitions to increasinglyharmful forms of drug use were particularly accelerated.Both initiation and transition experiences were com-monly facilitated by an older family member or long-time acquaintance who was themselves drug sceneentrenched, and occurred in familiar places (e.g., con-cealed camps of people who are homeless in downtownVancouver’s Stanley Park, which is adjacent to theDowntown South). As noted previously, youth likeMarie and Sara viewed their eventual transition to intra-venous heroin use as a ‘natural’ - albeit deadly - pro-gression:I was like eight. First time I ever smoked a joint.[DF: And how did things progress from there?]Well, smoked pot, drink a bit of alcohol at age 9-10,then I started getting into mushrooms, acid, youknow, all the hallucinogens (and eventually withdrugs as well). They were all around me down here,right? Then you get into the crystal methampheta-mines by 12-13 [years of age], and then you get tothe crack cocaine and then you get into the heroin,and then you’re done. You’re dead ... I started shoot-ing [injecting]heroin when I was 15. We [herself andthe other Lost Boys] were all at our camp in StanleyPark ... It just seemed like the thing to do - I mean, Igrew up down here. And heroin’s what I’m on rightnow. (Sara, age 18)Young people’s immersion (or rapid re-immersion) inthe social-spatial contexts of the local scene - combinedwith their exclusion from those places populated byupper and middle class citizens (contexts which mightindeed offer a refuge from open drug use) - create a sce-nario in which youth increasingly viewed drug use as arelevant, mundane and even inevitable choice congruentwith everyday lived experience. Within these social-spa-tial realities, drugs are both highly visible and highlyavailable, while alternative contexts for escape and plea-sure (e.g., involvement in recreational sport or arts pro-grams) are completely out of sight - in both the literaland figurative sense.Participants made a direct connection between druguse transitions and a material reality characterized by,on the one hand, chronic poverty and homelessness,and on the other, a heightened need to accrue incomein order to remedy ‘dopesickness’ (i.e. withdrawal symp-toms caused by escalating drug use). In our setting,these material conditions frequently intersect with theubiquity of drug use and the availability of drugs (aswell as the absence of opportunities to gain even low-level formal employment) to facilitate involvement indrug dealing activities, particularly when youth are rela-tively young and new to the scene. Drug dealing activ-ities among youth in downtown Vancouver are mostoften informal and range from street-level dealing forrelatively higher ranking ‘workers,’ to ‘scoring’ (i.e. buy-ing) and re-selling small quantities of drugs for a modestprofit. Importantly, these activities facilitate constantproximity to drugs and a range of drug use practices -including those not previously engaged in. Youth fre-quently hang out with or in the vicinity of their ‘clients’(who are perhaps more accurately characterized aspeers, friends, or casual acquaintances) while the latterget high, and may use drugs with them (whether theyare engaged in the same drug use practices or not). Thisis especially the case if drug dealing activities are takingplace at larger scale, ‘multi-purpose’ drug using localessuch as ‘crack shacks’ (private residences where one canFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 6 of 10go to obtain and use drugs) or particular outdoor orsemi-outdoor locales. When Lucas ran away to down-town Vancouver at age 14 he had no prior drug useinvolvement. On his first night in town he was intro-duced to crystal methamphetamine by ‘some guy’ he‘met on the street,’ who took him to a park in theDowntown South that is also a major center of activityamong young crystal methamphetamine users. A fewmonths later he was homeless and began scoring andre-selling heroin to support his crystal methampheta-mine use - an income generation strategy that eventuallyled to a transition in drug use practices:I was buying someone else’s heroin and eventually Isaid, ‘For once, you’re going to let me try doing whatyou’re doing, so at least I know what I’m buying ya!’... Before that my friend would use heroin and Iwould use meth at this apartment where we wouldgo. She didn’t want me to try heroin, partly because,like, I didn’t know much about drugs then. But Ihave a very strong curiosity in me, right? ... So Ithink that she saw at that moment I was going to tryit no matter what. (Lucas, age 25)Alternatively, Shawna moved to the Downtown Eastsidewhen she was 15, and soon after began selling drugs viaher older sister’s pre-existing connections to a well-estab-lished network of higher level dealers. These connectionsalso provider her with a place to stay initially - she spenther first year downtown sleeping in the apartments of dif-ferent men for whom she sold drugs (some of whom shebecame romantically involved with). She had no priorexperience with drug use; however, once involved in drugdealing it was not long before she began ‘doing her ownproduct’ (a scenario also described by Darren):I started selling drugs and when I’d finish, I’d go drink-ing in the bar ... [People in the bar started]offering melines of cocaine, so I started with that, and then Iopened what I was selling - the crack. And, you know, Isaid, ‘How do you do it?’ and some chick showed mehow, and I never went back. (Shawna, age 19)Shawna’s experience - in which she was selling drugsfor older men who were also providing her with a placeto stay (and eventually with drugs as well) - points toyet another context that can greatly influence transitionsin drug use, particularly among young women. In gen-eral, youth frequently reflected that in the context of thelocal scene, the distinction between a ‘friend’ and a‘drug dealer’ is often unclear, and that these ‘friend-deal-ers’ could play a critical role in the transition from onekind of drug use to another. For example, Darren’s ‘spurof the moment’ initiation into crack cocaine was largelyfacilitated by this type of social actor:Three weeks after I had gotten into town a friend ofmine, well, my dealer, he turned around and went,‘Try this!’ Hands me a pebble bowl of rock [crackcocaine]and, okay, I stuck it in the pipe, started smok-ing it and, oh my god. It was a dream come true ... Istarted a grand-a-day habit. (Darren, age 23)However, it seems that ‘boyfriend-dealer’ relationshipsare particularly prevalent in our setting for several rea-sons. Firstly, the material conditions experienced byyoung people in general can have especially adverse andoftentimes violent consequences for women - again, par-ticularly when they are relatively young and new to thescene. In the context of unstable or non-existent hous-ing (as was the case for Shawna), it is both protectiveand economically advantageous for young women toalign themselves with men who are ‘well connected’ onthe streets - and this almost always translates as wellconnected to drug dealing and drug procurement net-works. Secondly, these boyfriend-dealer relationships arefacilitated by the destabilized social networks frequentlyexperienced by young women as a result of everydayincidents of arrest among young men entrenched in thelocal scene. The frequent incarceration of young menmeans that the young women who were formerlyromantically attached to them must often seek out alter-native social relationships during periods of the latter’sincarceration, whether in order to secure greater safety,companionship and/or material resources (includingdrugs). These shifts in social networks - in which youngwomen realign themselves with a new male partner whois also involved in drug dealing - frequently result in acorresponding shift in drug use patterns. As mentionedpreviously, Carla transitioned to heroin use shortly afterher boyfriend was incarcerated. However, she transi-tioned to more intensive, injection heroin use after‘hooking up’ with a new partner who was also a dealer:I met this other guy while my boyfriend was in jail ...he was a drug dealer and he gave me heroin everyday, up to like four times a day ... That was when Ireally got into it. I started doing it more than everand now I am wired to it [physically dependent onit]. (Carla, age 22)Discussion and conclusionsYoung people emphasized their autonomy in choosing totransition into particular drug use practices, whether outof curiosity or as a result of ‘their own fancy.’ Further-more, they described the relatively non-exceptional cir-cumstances of these choices at the moment when theyFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 7 of 10were being made (‘I just decided I was going to do it,’ ‘Ijust wanted to try it’). It was only in hindsight thatyoung people sensationalized these moments as criticaldecision points (‘I wish I had know then what I was get-ting into’), which greatly influenced longer-term patternsof risk and harm.Undoubtedly, choice narratives were to a certain extentinfluenced by public health campaigns that assign respon-sibility for risky behavior on the individual actor andespouse an abstinence-based approach to avoiding transi-tions to more harmful forms of drug use (certainly, theyouth with whom we spoke represent a highly researchedand ‘socially worked’ population and are adept reiteratingthese public health messages in such a way that is pleasingto health workers and researchers). However, they also -somewhat paradoxically - reflect both assertions of control(‘it was my choice totally’), as well as young people’sincreasing powerlessness in the context of broader socialstructural forces related to poverty and social inequality.Farmer, Connors and Simmons [39] define structural vio-lence as ‘large scale forces - ranging from gender inequalityto racism to poverty - which structure unequal access togood and services,’ resulting in the social, emotional andphysical conditions that produce risk. While not discount-ing young people’s agency in shaping their drug use andthe nature of their drug scene involvement, it is alsorecognized that forces of marginalization, stigmatizationand other forms of structural violence can be internalizedas everyday features of lived experience, and expressed atthe individual level in the form of self-blame (‘I guess myown fancy screwed me over big time’) and fatalism (‘Ithink that I was probably always going to do it’) [11,18]. Inthis way, the structural violence of poverty and socialinequality is produced and reproduced [39], while theways in which power relations within societies hierarchiesshape ‘choice’ and risk are obscured (including fromyoung people themselves).Furthermore, although youth emphasized a connectionbetween evolving curiosity as a result of observing druguse behaviors and drug use transitions, our data contra-dicts the notion that harmful drug use among street-entrenched youth is attributable to a simple causal rela-tionship between observation and imitation [40]. If thiswere the case, then any youth who walked though theDowntown Eastside or saw drug use in a graphic filmlike Pulp Fiction would be vulnerable. Rather, partici-pant narratives illustrated the role played by intersectingsocial, spatial and material contexts in shaping the veryexperience of ‘choice’ over time. In the context ofchronic poverty and ongoing social-spatial exclusion,young people come to ‘notice’ drug use differently (asCarla aptly described it). Not only are drugs highly visi-ble within the physical landscape of the local drugscene, but drug scene entrenchment also provides thesocial-spatial and material contexts in which transition-ing into drug use and into increasingly harmful practicesbecomes, over time, an obvious, ‘nonchalant’ or eveninevitable choice, particularly in the context of exclu-sion from alternatives to this choice (e.g., exiting thelocal drug scene), which remain difficult to enact orsometimes even envision.Consistent with previous work [12], our findings illus-trate that within ‘high risk’ environments such as thedrug scene described herein, risk assessments and drug-related decision making focus not on whether or not totake drugs, but rather on acceptable versus unacceptableforms of drug use - the definitions of which are continu-ally being made and re-made through various social-spatial practices including interactions with other drugusers, dealers, ‘clients’ and lovers ‘on the streets.’Furthermore, as involvement in the local scene intensi-fies, these risk assessments and decisions are increas-ingly made in the context of escalating drug use and acorresponding need to accrue additional income via illi-cit income generation activities that ‘push’ youthtowards more harmful drug use practices [41,42]. Eachof these factors exacerbates the social suffering [43]experienced by young people, which likely further‘pushes’ vulnerable youth towards harm. It is importantto recognize that in the context of ongoing drug sceneentrenchment, the risks inherent in transitions toincreasingly harmful forms of drug use are only onepart of the story, which itself needs to be contextualizedwithin the myriad of risks inherent in experiences ofchronic homelessness and poverty, marginalization andeveryday violence among young people in our setting.A risk environment perspective [17], points to severalinterconnected contextual factors (as well as genderdynamics) operating on different levels to powerfullyshape transitions into increasingly harmful forms ofdrug use among local youth. At the micro-level, street-entrenchment and everyday interaction with the peopleand places that facilitate constant proximity to drug useand procurement activities, as well as the widespreadavailability of drugs, play a role in the re-definition ofpreviously established ‘risk boundaries’ [14] around par-ticular practices, and in the normalization of the mostharmful forms of drug use [9]. Particularly amongyoung women, unstable or non-existent housing, as wellas the destabilization of social networks via aggressivepolice action that targets their male partners, can alsoeach play a role in prompting transitions in drug use, asyoung women often find themselves quickly involved innew romantic relationships that include new patterns ofdrug use [11]. At the same time, macro-level factorssuch as entrenched poverty and social exclusion frommainstream opportunity structures encourage involve-ment in drug dealing and/or ‘scoring’ activities as one ofFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 8 of 10the only means to daily survival within this setting, facil-itating exposure to a range of drug use practices andtransitions to more harmful forms of drug use. Further-more, our results also indicate that childhood and earlyadolescent exposure to addiction (which is shaped bymacro-level forces of entrenched poverty and social suf-fering in particular households and neighborhoods)often results in an accelerated risk trajectory, evidencedby transitions into the most harmful forms of drug useat an extremely early age. At the meso-level, the lack ofsocial housing combined with drug treatment facilities -as well as a lack of recreation and education programsthat might facilitate the construction of alternate subjec-tivities and new identities among youth apart from ‘druguser,’ ‘homeless,’ or ‘junkie’ - mean that young peopleremain entrenched in the local scene without a viableexit strategy, and therefore highly vulnerable to transi-tioning into increasingly harmful forms of drug use.Our findings illustrate that, in order to be effectiveinterventions must provide accessible and attractivealternatives to what the street has to offer. It is onlythrough access to alternative contexts and opportunitiesthat young people entrenched in drug use settings willbegin to re-envision and re-imagine the choices availableto them. Furthermore, consistent with the findings ofprevious studies [27,44], our results indicate that inter-ventions should aim to enable ‘exit strategies’ during theearly stages of drug scene involvement, before the dailypriorities associated with a lifestyle of addiction and sur-vival make it increasingly likely that young people willtransition into harmful forms of drug use, and increas-ingly difficult or impossible for them to envision orenact exits from this environment. In the short term,enabling environments [45] could include programssituated outside of the geographical boundaries of thelocal drug scene (such as recreation activities accompa-nied by accessible transportation to and from youngpeople’s places of primary residence), while in the longterm, providing enhanced support in finding safe hous-ing, income support and meaningful education andwork training placements for young people is crucial. Amore nuanced identification of the factors and widerenvironments that deter transitions into more harmfulforms of drug use and/or enable youth to exit the drugscene during the early stages of street involvement is acrucial area for future research [45].This study has several limitations that warrant acknowl-edgement. Our findings are based upon interviews withlocal youth participating in the current study. While aneffort was made to ensure that the study sample reflectsthe demographics of the local youth drug using popula-tion, it became clear over the course of the research pro-cess that our sample is more representative of the highestrisk youth in downtown Vancouver. It is notable that evenour youngest participants (age 16) had relatively extensiveexperience with drug use at the time of interview. Furtherresearch is needed to examine the spectrum of risk experi-enced by local youth, and to understand why some youngpeople abstain from harmful forms of drug use despiteprolonged involvement in the local drug scene, whileothers feel virtually powerless to avoid transitioning intoincreasingly harmful practices. Finally, perhaps because ofthe social and economic marginalization experienced byall of our participants, potentially salient factors such asethnicity and sexuality did not emerge as significant in ourfindings, although previous research within this populationhas demonstrated that these characteristics can intersectwith other contextual factors to produce unique patternsof risk and harm [46-48].In sum, youth described evolving curiosity and theeveryday circumstances under which they chose to initi-ate drug use or transition into increasingly harmful druguse practices. However, for the participants of the pre-sent study, these ‘everyday circumstances’ included earlyand ongoing experiences of economic marginalizationand social exclusion, unstable or non-existent housing,involvement in illicit income generation activities (mostnotably drug dealing), and immersion in shifting andoften highly unstable social networks ‘on the streets.’Importantly, they excluded access to the more main-stream opportunities for work, rest and recreation froma very early age. Our finding stress the need for a rangeof interventions that, on the one hand, enable youth innavigating drug-related harms within the local scene(including avoiding transitions to increasingly harmfulforms of drug use), and on the other hand, enable themin exiting this setting altogether.AcknowledgementsWe would particularly like to thank the ARYS participants for theirwillingness to be included in the study, as well as current and past ARYSinvestigators and staff. We would specifically like to thank Deborah Graham,Tricia Collingham, Caitlin Johnston, Steve Kain, and Calvin Lai for theirresearch and administrative assistance. This study was made possiblethrough financial contributions from the Canadian Institutes of HealthResearch (HHP-67262, MOP-81171, RAA-79918) and the National Institutes ofHealth Research (R01 DA011591).Danya Fast is supported by a Vanier Canada Graduate Scholarship and aMichael Smith Foundation for Health Research Trainee Award. Will Small issupported a Michael Smith Foundation for Health Research Senior GraduateStudentship and a Canadian Institutes of Health Research Doctoral ResearchAward. Thomas Kerr is supported by a Michael Smith Foundation for HealthResearch Scholar Award and a Canadian Institutes of Health Research NewInvestigator Award.Author details1British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital,Vancouver, Canada. 2Department of Medicine, Faculty of Medicine, Universityof British Columbia, Vancouver, Canada.Authors’ contributionsDF, TK and WS designed the study. DF, TK and WS conducted the analysisof the data. DF prepared the first draft of the article. All authors contributedFast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 9 of 10to the revision of the manuscript. All authors read and approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Received: 26 January 2009 Accepted: 12 March 2010Published: 12 March 2010References1. Strang J, et al: The study of transitions in the route of drug use: theroute from one route to another. 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Strathdee SA, et al: Social determinants predict needle-sharing behaviouramong injection drug users in Vancouver, Canada. Addiction 1997,92(10):1339-47.48. Wood E, et al: Burden of HIV Infection Among Aboriginal Injection DrugUsers in Vancouver, British Columbia. Am J Public Health 2008,98(3):515-519.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/126/prepubdoi:10.1186/1471-2458-10-126Cite this article as: Fast et al.: ‘I guess my own fancy screwed me over’:transitions in drug use and the context of choice among young peopleentrenched in an open drug scene. BMC Public Health 2010 10:126.Fast et al. BMC Public Health 2010, 10:126http://www.biomedcentral.com/1471-2458/10/126Page 10 of 10

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