Open Collections

UBC Faculty Research and Publications

‘It’s more about the heroin’ : Injection drug users’ response to an overdose warning campaign in a Canadian… Kerr, Thomas; Small, Will; Hyshka, Elaine; Maher, Lisa; Shannon, Kate Jul 31, 2013

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-Kerr_T_et_al_Its_more_about_the_heroin.pdf [ 611.93kB ]
JSON: 52383-1.0320822.json
JSON-LD: 52383-1.0320822-ld.json
RDF/XML (Pretty): 52383-1.0320822-rdf.xml
RDF/JSON: 52383-1.0320822-rdf.json
Turtle: 52383-1.0320822-turtle.txt
N-Triples: 52383-1.0320822-rdf-ntriples.txt
Original Record: 52383-1.0320822-source.json
Full Text

Full Text

‘It’s more about the heroin’: Injection drug users’ response to anoverdose warning campaign in a Canadian settingThomas Kerr1,2, Will Small1,3, Elaine Hyshka1,4, Lisa Maher5, and Kate Shannon1,21British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada2Department of Medicine, University of British Columbia, Vancouver, BC, Canada3Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada4Addiction and Mental Health Research Lab, School of Public Health, University of Alberta,Edmonton, AB, Canada5The Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical Research),University of New South Wales, Sydney, NSW, AustraliaAbstractAims—To assess heroin injectors’ perceptions of and responses to a warning issued by publichealth officials regarding high-potency heroin and increases in fatal overdoses.Design—Semi-structured qualitative interviewsSetting—Vancouver, Canada.Participants—Eighteen active heroin injectorsMeasurements—Semi-structured interview guide focussing on heroin injectors’ perceptions ofand responses to the overdose warning, including reasons for failing to adhere to risk reductionrecommendations.Findings—Although nearly all participants were aware of the warning, their recollections of themessage and the timing of its release were obscured by on-going social interactions within thedrug scene focussed on heroin quality. Many injection drug users reported seeking the highpotency heroin and nearly all reported no change in overdose risk behaviours. Responses to thewarning were shaped by various social, economic and structural forces that interacted withindividual behaviour and undermined efforts to promote behavioural change, including salestactics employed by dealers, poverty, the high cost and shifting quality of available heroin, andrisks associated with income-generating activities. Individual-level factors, including emotionalsuffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire forintense intoxication also undermined risk reduction messages.Conclusions—Among heroin injectors in British Columbia, a 2011 overdose warning campaignappeared to be of limited effectiveness and also produced unintended negative consequences thatexacerbated overdose risk.Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608 – 1081 Burrard Street, Vancouver,BC V6Z 1Y6, Canada, uhri-tk@cfenet.ubc.caDeclarations of interestNone.NIH Public AccessAuthor ManuscriptAddiction. Author manuscript; available in PMC 2014 July 01.Published in final edited form as:Addiction. 2013 July ; 108(7): 1270–1276. doi:10.1111/add.12151.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptKeywordsheroin; injection drug use; overdose; public health warningIntroductionThe health sequelae of heroin use are severe, and include fatal and non-fatal overdose [1]. Inmost settings, the primary public health response to heroin overdose has been individually-focussed interventions that seek to educate drug users about risks for overdose and promotechanges in behaviour [2]. This over-reliance on individually-focussed interventions persistsdespite the known limitations of these approaches and growing awareness that drug-relatedharm is shaped by an array of physical, social and structural forces operating within thebroader risk environment surrounding drug use [3, 4].One commonly applied, but understudied, overdose prevention intervention involves issuingwarnings to drug users about adulterated or potent heroin, or increases in fatal overdose [5–7]. Although many municipalities issue overdose warnings, we know of only one in-depthqualitative evaluation of this form of intervention. Miller studied injection drug user (IDU)responses to media stories about increases in heroin overdoses in Geelong, Australia [8]. Hefound that none of the 60 IDU interviewed had communicated messages contained in thestories to their peers, and that none had changed their injecting practices or reduced theamount of heroin they were injecting. Importantly, a small minority of IDU reported activelyseeking out the strong heroin described in the stories, leading Miller to conclude that ‘mediareporting of killer batches of heroin has little value as a public health strategy’. This latterfinding is also consistent with a quantitative study by Freeman et al. [6], which found that21% of drug users in New Jersey, USA, had sought out fentanyl despite warnings of a spikein overdoses associated with use of the drug.Vancouver, Canada, has long been home to dual epidemics of heroin injection and heroin-related overdose [9]. In May 2011, local health authorities issued a warning that there hadbeen a recent increase in heroin-related overdoses in Vancouver associated with ‘higherpotency heroin’ circulating within the province of British Columbia [10, 11]. As indicated inFig. 1, local IDU were encouraged not to use drugs alone, to call 911 (emergency responseservices) in the event of an overdose and to use local services, including the supervisedinjection site.We undertook a qualitative evaluation of this overdose warning initiative to examine IDU’sawareness of the warning, their reactions to it and the impact of contextual factors onoverdose prevention behaviours. In doing so, we have endeavoured to complement and buildupon past work on this topic by exploring the reasons why some IDU ignore such warningsand fail to modify their drug use behaviour, as well as why many seek out potent heroindespite the risks this may pose.MethodsIn May 2011, 2 weeks after the overdose warning was issued, we conducted 18 in-depthqualitative interviews over a 10-day period with regular heroin injectors recruited fromVancouver’s Downtown Eastside—a neighbourhood characterised by a large open drug andsex-work scene, a network of single-room occupancy hotels, and longstanding epidemics ofHIV infection and fatal overdose [9]. A research assistant, who was a member of theVancouver Area Network of Drug Users, approached IDU known to be regular heroininjectors. Efforts were made to ensure adequate representation of women, and, in order toKerr et al. Page 2Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptassess potential changes in established behaviours, we sought to recruit experienced, ratherthan novice, heroin injectors.Potential participants were invited to visit the study office, where the project was explainedto them and where they provided written informed consent to participate in the study.Details concerning the age, gender and length of injecting were self-reported by participantsand are presented in the following. A semi-structured interview guide was used to facilitatediscussion of the overdose warning, including behavioural responses and the impact ofcontextual factors on overdose prevention behaviours. The guide was adapted from previousqualitative work on overdose among IDU in Vancouver [12], and was modified to include anumber of questions and related prompts specific to the objectives of our study. After thefirst two interviews, the interview team met to discuss ways of improving upon the existingguide, although no changes were deemed necessary. After 16 interviews, no newinformation was forthcoming. Therefore, two more interviews were conducted to confirmthat data saturation had been reached. Interviews lasted 30–80 minutes, were audio-recordedand transcribed verbatim. There were no refusals to participate and no dropouts during theinterview process. All participants received a CA$20 honorarium. The study receivedinstitutional ethical approval from the Providence Health Care/University of BritishColumbia Research Ethics Board.Our analysis was informed by Rhodes’ Risk Environment framework [4, 13, 14], whichposits that drug-related harm is shaped by forces operating within the physical, social,political and economic environments. Analysis began early in the data collection processand continued as interviews were completed. Emergent thematic analyses of earlyinterviews were discussed among the three interviewers (TK, WS and EH) and served toinform the focus of subsequent interviews, as well as ongoing analyses. The codingframework employed a priori codes derived from the topics used to structure the interviewguide, as well as emergent codes based upon the content of the transcripts. All interviewdata were reviewed, and text segments related to each individual code were categorised/classified. Subsequent coding passes (i.e. continued efforts to apply our coding framework)were used to refine and expand code categories, and to identify instances of negativeevidence.ResultsQualitative intervieweesThe 18 individuals participating in qualitative interviews included 8 female and 10 maleIDU. The median age of participants was 45 years (range: 26–60 years), the median lengthof injecting career was 21 years, and all participants confirmed that they were regular heroininjectors upon recruitment.Awareness and timingAlthough many of participants were aware of the overdose warning that had been issued 2weeks prior to the interviews, some reported first hearing about it in the last 2 days, whileothers reported hearing about it weeks or months earlier.The disparity in responses regarding the timing of the warning appeared to reflect ongoingdiscussions among IDU regarding the quality of drugs within an unregulated market. In acontext of variable heroin quality, a warning concerning strong heroin appeared to get lost inon-going social interactions focussed on the quality of the heroin:[What were people saying?] That there was some strong heroin. But there’s always,there’s always messages going around.Kerr et al. Page 3Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript(Respondent #7: male, age 46, injecting forapproximately 20 years)When asked to describe the warning, many participants noted that discussions on the streetamong IDU were focussed first and foremost on heroin quality and not the recent rise inoverdose deaths:I mean, there’s not really a lot to discuss, you know. Whether if it’s good [heroin]or not, you know? … It’s more about the heroin.(Respondent #2: male, age 44, injecting for over 20years)Other participants pointed out that dealers were constantly telling IDU that the heroin theywere selling was particularly strong. This ‘selling tactic’ was said to be so pervasive thatmost IDU simply ignored it:[P]eople say “That’s really good stuff, be careful.” So many people say that soyou’ll buy it. That, that’s bullshit. Nobody even listens to that any more.(Respondent #9: female, age 43, injecting forapproximately 20 years)The Reaction: People don’t go “warning, warning”. They go “good dope!”(Respondent #11: male, age 48, injecting forapproximately 30 years)Given the variable quality of heroin and the need to avoid opiate withdrawal on a daily basisin the context of long-term dependency, some participants welcomed the news that strongheroin was available. These factors appeared to contribute to IDU’s desire to seek the potentheroin described in the warning:It would probably make me think … I do a point [a tenth of a gram, 0.1μg] now,and I barely feel it so yeah … maybe I will look for this stuff … maybe it will bebetter … you know, better high …(Respondent #14: male, age 46, injecting for 32 years)The positive response in relation to the arrival of stronger heroin also appeared to begrounded in the cultural logics of street-based heroin injectors. Within a context wherescarce resources, engagement in high-risk income-generating activities and violence are partof daily life, the purchase of low-quality heroin may precipitate opiate withdrawal:They’re glad that there’s something out there worth buying. Yeah, you know howdisappointed someone is when they’re sick [experiencing opiate withdrawal], theygo out there, they spend their hard-earned money on dope and they’re sick afterthat?(Respondent #11: male, age 48, injecting forapproximately 30 years)Nearly all participants noted that information about strong heroin travelled very quicklyamong local IDU, and suggested that many heroin users would actively and repeatedly seekthe strong heroin once aware of it:I know a lot people that would turn around and go from here to the … far reachesof the earth to try and find it … the better it is the less that they do, but the better itis the more they want it.(Respondent #4: male, age 39, injecting for 23 years)Injecting Routines: “I just pretty much do like I do every day”Kerr et al. Page 4Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript(Respondent 12: female, age 43, injecting for 20 years)Although the warning contained specific messages about various strategies to minimise risks(e.g. don’t inject alone, etc.), nearly all participants reported that they injected heroinaccording to established routines. Many also offered the view that this was the case forothers as well:A lot of times they just, they just fix like it’s their usual, you know what I mean,like as if it was the usual hit they did. A lot of people they don’t … takeprecautions.(Respondent #14: male, age 46, injecting for 32 years)Some noted that these routines have been established for years and are not particularlyamenable to change:[O]nce they get into a routine and they get used to the routine that they do, they doit every day for years and years on end. They won’t, it won’t change the way theydo it.(Respondent #4: male, age 39, injecting for 23 years)Invincibility: “Yeah, there’s no nervousness … it does not bother me.”(Respondent #2: male, age 44, injecting for over 20years)As indicated above, several individuals reported that while they actively sought the potentheroin, they did not alter their injecting behaviour in accordance with overdose riskreduction messages. Within the accounts of these participants was a narrative about a lack offear and a sense of invincibility:[People are a little bit sceptical about the warning?] Yeah. [And why do you thinkthat is?] I don’t know, they think they’re invincible I guess … they think they canhandle it.(Respondent #1: female, age 44, injecting for 15 years)Some participants reported that continued survival and the relative infrequency of severeoverdose events in the face of ongoing injecting rendered fatal overdose an unlikely andremote risk to many IDU:A lot of these people have been doing this for years and if one day they say “well,now the heroin is supposed to be strong … You do a point [a tenth of a gram] andyou might just drop to your knees and that’ll be the end of it”. A lot of the timesthat never happens … [I]n five years I’ve been injecting, I think it happened oncethat I did a little bit too much and not that I was dying but I was kind of on a nod …You figure well, if it’s gonna happen, then what are my chances, right? … So thesepeople are probably thinking, “Well you know, I’ve been shooting this long for thismany years and I’m still here today …”(Respondent #12: female, age 43, injecting for 20 years)“Everyone wants to get high”: the desire for intense intoxicationAnother prominent narrative in participants’ accounts was the desire for intense heroinintoxication. This desire was offered as an explanation for both the eagerness to acquirestrong heroin and the avoidance of recommended overdose prevention strategies:Sometimes they’re just pigs and they like to get that nod. I know a fistful of peoplethat that’s what their goal is.Kerr et al. Page 5Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript(Respondent #15: female, age 42, injecting for 15 years)I hear from kids every day, right … they’re always asking if it’s really strong andso you know that tells you that … they’re looking for the ultimate high.(Respondent #12: female, age 43, injecting for 20 years)Some individuals linked the desire for intense intoxication to the emotional sufferingexperienced by many heroin users. For these individuals, accessing strong heroin was ameans to escaping painful memories and the everyday suffering experienced by IDU withinthe local drug scene, and overdose risks are likely to be a secondary consideration whenseeking to get ‘out of it’:[E]veryone wants to get high and they want to get out of it. Like they want to get,as much as they can, out of their life. You know everybody’s here to escape reality.(Respondent #9: female, age 51, injecting for 35 years)Other barriers to the adoption of overdose prevention strategies included the pervasivepoverty experienced by many IDU and the high cost of illegal drugs. Although nearly allparticipants expressed awareness that it was safer to inject with someone else, most said thattheir heavy dependence and limited financial resources meant they were unable to adhere tocultural norms dictating that one should share their drugs when with others:… People aren’t gonna sit there and watch you do a hit without you sharing, ok?It’s really difficult to watch someone get high and not use.(Respondent #9: female, age 51, injecting for 35 years)Opiate withdrawal was also said to serve as a barrier to adopting overdose preventionstrategies, including recommendations to inject in smaller amounts:When you’re sick, though, you just want to get it in you.(Respondent #15: female, age 42, injecting for 15 years)Regular dealers as overdose preventionFinally, a few participants stated that they did not need to engage in any overdose preventionbehaviours as they did not perceive themselves to be at risk because they always purchasedheroin from the same source:I only deal with two people for heroin, right, and I’ve been dealing with them for solong I don’t deal with anybody else. And that’s because they don’t … screw aroundwith their heroin the way everybody else does.(Respondent #4: male, age 39, injecting for 23 years)DiscussionThis examination of an overdose warning initiative revealed that although authorities wereable to reach many local IDU with messages about potent heroin, this warning had limitedimpact in terms of mitigating overdose risks, as well as some unintended negative effects.Consistent with the risk environment framework [14], a diverse set of social, economic andstructural forces appeared to interact with individual perceptions and behaviours tooverwhelm the messages advocating risk reduction contained in the warning.Previous research has generated mixed results concerning how quickly overdose warningspenetrate IDU networks [6, 8]. In the present study, while the overdose warning reachednearly all of the participants interviewed, perceptions of the warning and its content wereobscured by ongoing social interactions within the drug scene that focussed on heroinKerr et al. Page 6Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptquality. A growing body of literature has highlighted how social relations and norms withindrug scenes shape understandings of risk and associated practices among IDU [4, 15, 16].Although many IDU in this study were talking about the warning, these discussionsfocussed primarily on the quality of the heroin that was available and where it could bepurchased, rather than the elevated risk of overdose it presented. Further, common salestactics of dealers promoting purportedly potent heroin were reported to have led at least asmall number of IDU to ignore messages about overdose risks.Consistent with the work of Miller and Freeman et al. [6, 8], many heroin injectorsinterviewed viewed the arrival of potent heroin on the local scene as a positive development,and many reported seeking and finding it. However, unique to this study are findings thatshed light on why individual IDU seek potent heroin when they are encouraged to avoid it,and why they do not employ risk reduction recommendations promoted by public healthofficials. Considered within the broader criminalised risk environment and alongside thesituated risk perceptions of IDU, the opportunity to obtain potent heroin appeared tooutweigh concerns regarding overdose risks. Ethnographic research suggests that IDU’s riskperceptions are based upon socially and culturally situated knowledge [15, 17]. Health risks,such as overdose, are understood in relation to other ‘everyday risks’ that characterise thedaily lives of injectors, including the potential for arrest or incarceration, losing drugs topolice, opiate withdrawal and interpersonal violence [15, 17]. The opportunity to acquirehigher quality heroin could, therefore, be construed as advantageous, as it mediates theseother competing forms of risk [18]. The data presented herein also suggest that efforts toacquire higher potency heroin can also be understood as active responses to variations inheroin availability, quality and price, which are determined largely by macro-level structuralforces (e.g. policies and laws) aimed at reducing the supply of illicit drugs [19, 20].Also unique to our study is the identification of a number of individual-level factors thatappear to shape responses to overdose warnings. For example, the warning recommendedreducing the risk of overdose by altering individual behaviour, including avoiding injectingalone. However, consistent with the work of Miller [8], while some participants reportedreductions in overdose risk behaviour, upon further questioning about specific practices itbecame apparent that nearly all respondents continued to inject heroin in the same way asthey had for years. As in the present study, previous research has emphasised the importanceof drug-using routines and the meanings ascribed to such routines [21, 22], although this hasnot been studied widely in relation to overdose risks. Efforts to alter risk behaviour througheducation efforts appear to reflect a fundamental misunderstanding of the drug user as‘capable of rational decision-making and self-regulation in keeping with risk-avoidancecampaigns’ [15].Consistent with the work of Moore [15], we found that many individuals sought the potentheroin out of a desire for intense intoxication. This desire was linked frequently to emotionalsuffering and the desire to ‘escape reality’. These findings further underscore a flawedassumption underlying conventional overdose interventions [15], which assume that IDUwill minimise risk at the expense of a stronger ‘high’. While previous research hashighlighted the relationship between overdose risk-taking and ambivalence towards death[15], unique to our study was the finding that, because of a perceived sense of invincibility,some participants viewed fatal overdose as something that would not happen to them.It should be noted that a small number of participants reported efforts to manage their risk ofoverdose. Among the strategies most commonly cited by this group was buying drugs fromthe same dealer. It is important to understand drug users’ everyday practices as ‘productive’[14, 23] and active responses to real contextual constraints [14]. Although accessing heroinvia the same dealer was viewed by our participants as a way of managing overdose risk, theKerr et al. Page 7Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripteffectiveness of this strategy is unknown, and it is unlikely that street-level dealers provide aconsistent, unadulterated product, given the complexity of supply chains and the unregulatednature of illicit drug markets [24].Our findings have implications for public health policy and interventions. Dietze et al. haveurged caution when implementing strategies focussed on individual overdose riskbehaviours [25], as these may produce unintended negative effects. Indeed, they suggest thatstrategies should focus on informing drug users about responses that reduce the likelihood offatal overdose. The findings of the present study resonate with these suggestions. Otherauthors working in our setting have called for the implementation of elaborate overdosewarning strategies that include use of peer networks to disseminate such warnings [7].However, given the findings presented here and by others, the true value of such a system isunclear, and, if implemented, it should be subjected to rigorous evaluation. Also potentiallyproblematic is the focus on potent and adulterated heroin contained in such warnings, as pastevidence suggests that these factors may not contribute greatly to heroin-related overdose [1,26].Our findings also point to the need to address the social, structural, economic and physicaldimensions of the broader risk environment that produce overdose risk. Supervised injectionfacilities have been shown to be effective in reducing overdose fatalities [12, 27]. However,these interventions tend to be limited by low coverage resulting from limited opening hours,political constraints, and restrictive operating policies [28, 29]. Other approaches includecreating low-threshold employment opportunities as a means of addressing poverty and thereliance on high-risk income-generating activities, such as drug dealing and sex for drugsexchanges [30, 31] among IDU. Evidence concerning the positive impacts of take-homenaloxone for the reversal of opiate overdose is increasing [32, 33], and the potential of thisapproach merits further implementation and evaluation. Lastly, there is growing consensusthat the criminalisation of drug use has produced an array of unintended negativeconsequences, including dramatically inflating the price of drugs [34]. A growing number ofcountries are experimenting with alternative models of decriminalisation and regulation [34,35], and our data suggest that these models should be further explored and evaluated in theNorth American context and elsewhere.This study identifies important limitations and significant unintended consequences of apublic health warning regarding high potency heroin and increases in overdose, anddocuments how a diverse set of individual, social, structural and economic factorsundermined the impact of this public health intervention. While additional research isneeded to inform the development of novel overdose interventions, efforts to move beyondindividually-focussed strategies towards interventions that address the contextual drivers ofoverdose risk are urgently needed.References1. Darke S, Hall W. Heroin overdose: research and evidence-based intervention. J Urban Health. 2003;80:189–200. [PubMed: 12791795]2. Dietze P, Jolley D, Fry C, Bammer G, Moore D. When is a little knowledge dangerous?Circumstances of recent heroin overdose and links to knowledge of overdose risk factors. DrugAlcohol Depend. 2006; 84:223–30. [PubMed: 16542798]3. Rhodes T, Mikhailova L, Sarang A, Lowndes CM, Rylkov A, Khutorskoy M, Renton A. Situationalfactors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, RussianFederation: a qualitative study of micro-risk environment. Soc Sci Med. 2003; 57:39–54. [PubMed:12753815]4. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee S. The social structural production of HIVrisk among injecting drug users. Soc Sci Med. 2005; 61:1026–44. [PubMed: 15955404]Kerr et al. Page 8Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript5. Sorensen JL, London J, Tusel D, Wolfe R, Washburn A. Mass media as drug users’ key informationsource on overdoses. Am J Public Health. 1992; 82:1294–5. [PubMed: 1503176]6. Freeman RC, French JF. What is the addicts’ grapevine when there’s ‘bad dope’? An investigationin New Jersey. Public Health Rep. 1995; 110:621–4. [PubMed: 7480618]7. Fielden SJ, Marsh DC. It’s time for Canadian community early-warning systems for illicit drugoverdoses. Harm Reduct J. 2007; 4:10. [PubMed: 17391529]8. Miller PG. Media reports of heroin overdose spates: public health messages, moral panics or riskadvertisements? Crit Public Health. 2007; 17:113–21.9. Wood E, Kerr T. What do you do when you hit rock bottom: responding to drugs in the City ofVancouver. Int J Drug Policy. 2006; 17:55–60.10. CBC. [accessed 8 January 2012] Killer heroin doubles B.C. overdose fatalities. 2011. Available at: at on 6 March 2013)11. BC Coroners Service. [accessed 8 January 2012] BC Coroners Service warns of rise in heroin-related deaths. 2011. Available at: at on 6 March 2013)12. Kerr T, Small D, Moore D, Wood E. A micro-environmental intervention to reduce the harmsassociated with drug- related overdose: evidence from the evaluation of Vancouver’s saferinjection facility. Int J Drug Policy. 2007; 18:37–45. [PubMed: 17689342]13. Rhodes T. The ‘risk environment’: a framework for under- standing and reducing drug-relatedharm. Int J Drug Policy. 2002; 13:85–94.14. Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. Int JDrug Policy. 2009; 20:193–201. [PubMed: 19147339]15. Moore D. Governing street-based injecting drug users: a critique of heroin overdose prevention inAustralia. Soc Sci Med. 2004; 59:1547–57. [PubMed: 15246182]16. Fairbairn N, Small W, Van Borek N, Wood E, Kerr T. Social structural factors that shape assistedinjecting practices among injection drug users in Vancouver, Canada: a qualitative study. HarmReduct J. 2010; 7:20. [PubMed: 20807442]17. Bourgois P. The moral economies of homeless heroin addicts: confronting ethnography, HIV risk,and everyday violence in San Francisco shooting encampments. Subst Use Misuse. 1998;33:2323–51. [PubMed: 9758016]18. DeBeck K, Shannon K, Wood E, Li K, Montaner J, Kerr T. Income generating activities of peoplewho inject drugs. Drug Alcohol Depend. 2007; 91:50–6. [PubMed: 17561355]19. Dietze P, Fitzgerald J. Interpreting changes in heroin supply in Melbourne: droughts, gluts orcycles? Drug Alcohol Rev. 2002; 21:295–303. [PubMed: 12270082]20. Wood E, Stoltz J, Li K, Montaner JS, Kerr T. Changes in Canadian heroin supply coinciding withthe Australian heroin shortage. Addiction. 2006; 101:689–95. [PubMed: 16669902]21. Grund JP, Friedman SR, Stern LS, Jose B, Neaigus A, Curtis R, et al. Syringe-mediated drugsharing among injecting drug users: patterns, social context and implications for transmission ofblood-borne pathogens. Soc Sci Med. 1996; 42:691–703. [PubMed: 8685737]22. Peretti-Watel P, Moatti J. Understanding risk behaviours: how the sociology of deviance maycontribute? The case of drug-taking. Soc Sci Med. 2006; 63:675–9. [PubMed: 16533551]23. Fitzgerald JL. Mapping the experience of drug dealing risk environments: an ethnographic casestudy. Int J Drug Policy. 2009; 20:261–9. [PubMed: 19171472]24. Kerr T, Small W, Johnston C, Li K, Montaner JS, Wood E. Characteristics of injection drug userswho participate in drug dealing: implications for drug policy. J Psychoactive Drugs. 2008; 20:147–52. [PubMed: 18720663]25. Dietze P, Jolley D, Fry CL, Bammer G, Moore D. When is a little knowledge dangerous?:circumstances of recent heroin overdose and links to knowledge of overdose risk factors. DrugAlcohol Depend. 2006; 84:223–30. [PubMed: 16542798]26. Darke S, Hall W, Weatherburn D, Lind B. Fluctuations in heroin purity and the incidence of fatalheroin overdose. Drug Alcohol Depend. 1999; 54:155–61. [PubMed: 10217555]Kerr et al. Page 9Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript27. Marshall BD, Milloy MJ, Wood E, Montaner JS, Kerr T. Reduction in overdose mortality after theopening of North America’s first medically supervised safer injecting facility: a retrospectivepopulation-based study. Lancet. 2011; 377:1429–37. [PubMed: 21497898]28. Small W, Shoveller J, Moore D, Tyndall M, Wood E, Kerr T. Injection drug users’ access to asupervised injection facility in Vancouver, Canada: the influence of operating policies and localdrug culture. Qual Health Res. 2011; 21:743–56. [PubMed: 21378259]29. Maher L, Salmon A. Supervised injecting facilities: how much evidence is enough? Drug AlcoholRev. 2007; 26:351–3. [PubMed: 17564869]30. Debeck K, Wood E, Qi J, Fu E, McArthur D, Montaner J, et al. Interest in low-thresholdemployment among people who inject illicit drugs: implications for street disorder. Int J DrugPolicy. 2011; 22:376–84. [PubMed: 21684142]31. Richardson L, Sherman SG, Kerr T. Employment amongst people who use drugs: a new arena forresearch and intervention? Int J Drug Policy. 2012; 23:3–5. [PubMed: 21996164]32. Piper TM, Stancliff S, Rudenstine S, Sherman S, Nandi V, Clear A, et al. Evaluation of a naloxonedistribution and administration program in New York City. Subst Use Misuse. 2008; 43:858–70.[PubMed: 18570021]33. Sporer KA, Kral AH. Prescription naloxone: a novel approach to heroin overdose prevention. AnnEmerg Med. 2007; 49:172–7. [PubMed: 17141138]34. Wood E, Werb D, Kazatchkine M, Kerr T, Hankins C, Gorna R, et al. Vienna Declaration: a callfor evidence-based drug policies. Lancet. 2010; 376:310–2. [PubMed: 20650517]35. Griffiths P, Mounteney J, Lopez D, Zobel F, Gotz W. Monitoring the European drug situation: theongoing challenge for the European Monitoring Centre for Drugs and Drug Addiction(EMCDDA). Addiction. 2012; 107:254–8. [PubMed: 21539630]Kerr et al. Page 10Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 1.The overdose warning flyer circulated by the British Columbia Coroners Service in May2011Kerr et al. Page 11Addiction. Author manuscript; available in PMC 2014 July 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items