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Injection settings and drug-related harm in Vancouver, Canada Small, William 2010-12-31

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INJECTION SETTINGS AND DRUG-RELATED HARMIN VANCOUVER, CANADAbyWILLIAM SMALLBA, University of Victoria, Canada, 1996MA, University of Victoria, Canada, 2000A THESIS SUBMITTED IN PARTIAL FULFILMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF PHILOSOPHYinTHE FACULTY OF GRADUATE STUDIES(Interdisciplinary Studies)The University of British Columbia(Vancouver)April, 2010© William Small, 2010ABSTRACTEcological approaches to addressing injection-related risk seek to reduce drug-related harm by identifying and removing environmental barriers to risk-reduction.While the settings where drugs are injected represent a key location for these efforts,further knowledge regarding the role of injection settings is required to understand andaddress context-specific barriers to risk-reduction. This thesis sought to employ the riskenvironment framework and use ethnographic methods to examine two key types ofinjection settings, public injection venues and a local supervised injection facility (SIF),in the Downtown Eastside (DTES) of Vancouver, Canada.Ethnographic fieldwork, including naturalistic observation of activity withindrug use settings and 50 in-depth interviews with local injection drug users (IDUs),generated information regarding local public injection settings and the SIF.Generatingdetailed descriptions of the settings investigated, and the use of analytical approachesdrawing on the risk environment framework, permitted identification ofthe influenceof various ecological forces upon risk production/reduction in relationto these settings.In Vancouver, public injecting often occurs in spaces characterizedby unsanitaryconditions and a lack of adequate amenities for hygienic injecting,where the threat ofstreet violence or arrest impedes individual abilityto employ safer injecting practices.While the SIF fosters risk-reduction by addressingmany of these contextual featureswhich pose barriers to safer injecting, the perspectivesof IDUs emphasise that theyinject at the facility because it addresses multiplesalient risk priorities, including healthconcerns as well as “everyday risks” associatedwith injecting. A contextualisedunderstanding of the operation of Insite highlights how theinteractions betweenmacro-level forces (e.g., regulatory mechanisms),operational features of the facility,and the local drug using context shape utilisation ofthe SIF by local IDUs.11This work highlights the importance of developing contextualizedunderstandings of injection settings in order to identify barriers to risk-reduction, andinform the development of safer injecting environments. While initiatives fosteringinjection safety within existing injection settings must be pursued, these should becomplemented by efforts to remove barriers to accessing SIFs.111TABLE OF CONTENTSABSTRACT.iiTABLE OF CONTENTS ivLIST OF TABLES viiLIST OF FIGURES viiiACKNOWLEDGEMENTS ixDEDICATION xCO-AUTHORSHIP STATEMENT xiCHAPTER 1: BACKGROUND, RESEARCH JUSTIFICATION, AND OBJECTIVES..11.1 Introduction 11.2 Injection Drug Use, HIV and Drug-related Harm 11.3 Public Health Interventions and Injection Drug Use 21.4 Injection Settings and Drug-related Harm 41.5 Contemporary Research on Injection Drug Use 61.6 Safer Injecting Environment Interventions 71.7 Injection Drug Use in Canada and Vancouver’s Downtown Eastside81.8 Supervised Injecting in Vancouver 131.9 The Need for Ethno-epidemiological Approaches 151.10 Research Objectives 171.11 Organization of Dissertation 191.12 References 20CHAPTER 2: PUBLIC INJECTION SETTINGS IN VANCOUVER: PHYSICALENVIRONMENT, SOCIAL CONTEXT AND RISK272.1 Introduction272.1.1 Background 292.2 Methods 312.2.1 Environmental survey312.2.2 Qualitative interviews332.2.3 Ethics342.3 Findings342.3.1 Public injection settings: The physical environment342.3.2 Risk and the physical injecting environment362.3.3 Risk and the social context of injecting environments372.4 Discussion412.4.1 Risk environment and situated risk reality412.4.2 Public injecting and safer injecting facilities432.4.3 The limits of individualism in harm reduction442.4.4 The need for further ethnographic research on injectionsettings 452.5 References50CHAPTER 3: RISK AND SAFETY WITHIN INJECTIONSETTINGS: INJECTIONDRUG USERS’ REASONS FOR ATTENDING ASUPERVISED INJECTINGFACILITY553.1 Introduction553.1.1 IDU perceptions of risk and safety within injection settings56iv3.1.2 Environmental interventions and Supervised Injection Facilities (SIFs) 583.1.3 Injection drug use settings within Vancouver’s Downtown Eastside 583.1.4 Study purpose 603.2 Methods 603.2.1 Ethics 623.3 Findings 623.3.1 Interview participants 623.3.2 The injection setting provided by the SIF 633.3.3 An alternative to injecting in public and private venues 633.3.4 Reducing injection-related health risks 643.3.5 Sanctioned injecting environment 663.3.6 Regulated environment 673.3.7 A “safer” environment: mediating the risks associated with other injectionsettings 693.3.8 A contextualised view of risks and safety: constraints on ability to utilize theSIF 703.4 Discussion 713.4.1 Protecting health and keeping safe 723.4.2 Social and spatial relations 743.4.3 On being ‘responsible’ 753.4.4 Limitations 773.5 Conclusion 773.6 References 80CHAPTER 4: INJECTION DRUG USERS’ ACCESS TO A SUPERVISEDINJECTION FACILITY IN VANCOUVER, CANADA: THE INFLUENCE OFOPERATING POLICIES AND LOCAL DRUG CULTURE844.1 Introduction 844.2 Study Context 874.2.1 Policies and legislation: the regulatory framework governing supervisedinjection in Canada 874.3 Features of the Local Drug Scene in the Downtown Eastside of Vancouver874.3.1 Operational context within Insite884.3.2 Statement of study purpose894.4 Methods894.4.1 Naturalistic observationS904.4.2 In-depth interviews with local IDUs whouse the SIF 904.4.3 Document ana1ysis914.4.4 Ethics924.5 Results924.5.1 Site utilisation924.5.2 Site regulations and code of conduct934.5.3 Waiting to access the injection room954.5.4 Time spent within the injecting room964.5.5 Regulations prohibiting sharing or splitting drugs974.5.6 Regulations prohibiting assisted injection98v4.5.7 Frequent visits by cocaine injectors and the impact of synchronised welfarepayments994.5.8 Ensuring compliance1004.6 Discussion 1014.6.1 Capacity versus demand for the service 1024.6.2 Governing access and use1034.6.3 Implementing the ‘rules’ 1054.6.4 Structural forces shaping SIF operation in Canada1064.6.5 Potential complementary interventions 1084.7 Conclusion1104.8 References 111CHAPTER 5: DISCUSSION AND SYNTHESIS OF DISSERTATION FINDINGS .1165.1 Overview1165.2 Interpretation of Findings and Reflexivity1175.3 Ethno-epidemiological Approaches to Complex Research Problems1205.4 Study Limitations and Strengths1245.5 Promising Policy and Practice Actions1255.6 Future Research1275.7 Knowledge Translation: From Research to Action1285.8 References130APPENDIX A: HUMAN ETHICS APPROVAL CERTIFICATE132viLIST OF TABLESTable 3.1 Characteristics of interview participants compared to members of the SEOSIcohort (a representative sample of SIF clients) 79viiLIST OF FIGURESFigure 2.1: Diagram depicting the spatial distribution of public injecting ‘niches’ in theDowntown Eastside 46Figure 2.2: Police presence in public injecting venues 47Figure 2.3: A typical injection niche 48Figure 2.4: A formerly hidden injection niche 49viiiACKNOWLEDGEMENTSI would like to thank the members of my supervisory committee, includingmyco-supervisors, Drs. Mark Tyndall and Jean Shoveller, as well as Dr. David Moore,forall of their support and guidance during the course of my PhD program. I would alsolike to extend my gratitude to Drs. Thomas Kerr and Evan Wood, for their enthusiasticsupport of this ethnographic research, and their ongoing mentorship. Thanksare due tothe staff of the SEOSI study, past and present, as wellas the reseaich and administrativestaff at the British Columbia Centre for Excellence inHIV/AIDS.I acknowledge the support of the Canadian Institutesof Health Research and theMichael Smith Foundation for Health Research for my DoctoralResearch funding,which enabled the conduct of this work. I would alsolike to acknowledge the generousassistance of all Insite staff and coordinators, inparticular Jeff West, Sarah Evans, RussMaynard, Bev Lighftoot, and Doug Ferris. I thankmy fellow students at the BritishColumbia Centre for Excellence in HIV/AIDSfor their support, and would liketoacknowledge M-J Milloy in particular. I would liketo express my appreciation for theendless support of my friends and family, andparticularly my partner.Most importantly I would like to acknowledgeall of the individuals who tookthe time to talk with me and sharetheir experiences over the course of my fieldwork.This research would not have been possible withoutthe benefit of their perspective.ixDEDICATIONTo my parents.xCO-AUTHORSHIP STATEMENTThis statement is to certify that the work presented in this thesis was conceived,written and disseminated by the PhD candidate. The co-authors of the manuscriptsthatpartially constitute this thesis made contributions only as was consistent withcommittee or collegial duties. The co-authors reviewed each manuscriptprior tosubmission for publication and offered critical evaluations; however,the student wasresponsible for overseeing and conducting data analyses, preparingthe initial drafts ofall manuscripts. In addition, the candidate was responsible forrevising the manuscriptsbased on the suggestions of the co-authors, submitting manuscriptsfor publication andpreparing final revisions based on the commentsof the journal editors and externalpeer reviewers.xiCHAPTER 1:BACKGROUND, RESEARCH JUSTIFICATION, AND OBJECTIVES1.1 IntroductionThe settings where illicit drugs are injected represent a crucial dimension in thesocial-structural production of drug-related harm. Accordingly, therehas been growinginterest in the development of interventions that aim to create safer injectionenvironments. However, existing research on injection settings and associatedinterventions has primarily been epidemiological in nature and focused onindividualbehaviour that is de-contextualised from the broader social-structuralenvironment inwhich injection drug use occurs. Using an ecological perspective, in particularthe ‘riskenvironment’ framework, as well as ethnographic researchmethods, this body of workseeks to build upon past research on injectionsettings by: providing a detailedcontextualised understanding of public injectionsettings in Vancouver, exploringinjection drug users’ motivations for injecting withina sanctioned supervised injectionfacility, and examining the influence ofregulatory forces and the operationalcharacteristics of Vancouver’s supervised injectionfacility on access to its program.Contextualised understandings of injectionsettings in relation to local riskenvironments will serve to inform the developmentof appropriate strategies to reduceinjection-related risk in unregulated settings,as well as help to identify barriers to saferinjecting environments that enable risk reduction.1.2 Injection Drug Use, HIV and Drug-relatedHarmCurrent estimates indicate that over 15million individuals worldwide injectdrugs (Aceijas et al., 2004; Mathers et al., 2008),and that a third of new HIV infectionsoutside of Africa result from injection druguse (UNAIDS, 2006). These trends indicatethat the injection of illicit drugs continuesto play a major role in driving the global HIV1epidemic, as well as the elevated prevalence of HIV in Canadian cities, most notablyVancouver and Montreal (Mclnnes et al., 2009; Bourgois & Bruneau, 2000). There isgreat variation between the character of drug ‘scenes’ across different settings in termsof the drugs consumed, common injecting behaviours, and availability of preventativeand harm reduction interventions (Rhodes, 2002; Institute of Medicine, 2007; Aceijas etal., 2004). However, regardless of differences across these environments, significanthealth consequences stemming from injection drug use include infectionwith theblood-borne viruses HIV and hepatitis C, fatal and non-fatal drug-related overdose, aswell as bacterial and viral infections related to unhygienic injection practices (Matherset al., 2008; Aceijas & Rhodes, 2007; Warner-Smith, Darke & Day, 2002).1.3 Public Health Interventions and Injection Drug UseA range of public health programs target IDUs and seek to address negativehealth outcomes related to injection drug use. These include initiativesproviding:targeted primary health care through community clinics,health outreach in streetsettings, voluntary HIV/HCV testing and counselling, safer injectioneducation, accessto sterile syringes, methadone maintenance therapy andbuprenorphine substitutiontherapy, overdose prevention education, and the prescriptionand distribution ofnaloxone to drug users (Institute of Medicine, 2007).While some of these programs aimto increase access to and uptake of health servicesamong IDUs, minimising variousforms of injection-related harm, includingblood-borne virus transmission, viral andbacterial infections, and morbidity and mortalitystemming from drug-related overdose,represent primary objectives for public health interventionsseeking to promote riskreduction.The dominant public health response to theharms associated with injection druguse has involved delivering educational interventionsintended to modify individual2behaviour (Rhodes, 1997; Rhodes, Singer, Bourgois, Friedman & Strathdee, 2005). Thelimitations of such approaches have been increasingly recognized, and estimatesindicate that individual-focused interventions can at best reduce HIV risk behavioursby 25 to 40% (Heimer, Bray, Burns, Khoshnood & Blankenship, 2002). Recognitionthatinjection-related risks are partially shaped by social, structural and environmentalinfluences beyond the control of individuals (Moore& Dietze, 2005; Galea & Vlahov,2002) has led to calls for structural interventions that alter “the context in whichhealthis produced or reproduced” (Blankenship, Bray & Merson, 2000). Interventionsthattarget the social, economic and political forces that “shape and constrain,individual,community, and societal health outcomes” (Blankenship etal., 2000) recognize theimportance of concomitantly altering the risk environment (whilecomplementingongoing individual-focused education) and that this broaderapproach may “enable”individuals to adopt risk-reduction strategies (Rhodeset al., 2005; Moore & Dietze,2005).Providing sterile syringes to IDUs is a publichealth strategy that targets bothsocial relations (e.g., syringe sharing between individuals)and structural issues (e.g.,limited access to essential prevention materials)to reduce infectious disease risks(Blankenship et Al., 2000). State-sanctionedand “underground” needle exchangeprograms (NEPs) are an important mechanismthrough which sterile syringes aresupplied to IDUs. However, these initiatives havenot been implemented as widely aseducational prevention efforts (Institute ofMedicine, 2007). The availability of NEPsvaries widely across settings, and their implementationdepends heavily on nationaldrug policy and relevant regional legislation(e.g., the legality of syringe possession)(Bluthenthal, Kral, Lorvick & Watters, 1997; Burnset al., 2004). However, even whereneedle exchange is state-sanctioned,social-structural contexts heavily influencethecapacity to provide IDUs with sterile syringes,as law enforcement initiatives may3discourage injectors from carrying syringes (Koester, 1994; Burns et al., 2004) and themarginalization of IDUs creates further barriers to engagement with public healthprograms (Rhodes, 2002; Rhodes et al., 2005).1.4 Injection Settings and Drug-related HarmA reliance on technical, objective assessments of individual risk thatdecontextualise behaviours from the environments in whichthey occur impedes thedevelopment of effective and comprehensive interventionstrategies (Rhodes, Stimson& Quirk, 1996; Duff, 2003; Rhodes, 2009). Rhodes’ (2002) “risk environment”frameworkrepresents an explicitly ecological model of injection-relatedrisk, and its adoptionwithin the field of substance use research has brought increased recognitionof howsocial, structural, economic and political conditions shape boththe potential for drug-related harm, as well as opportunities to attenuate risk (Rhodeset al., 2005). As aheuristic tool, the risk environment framework emphasizeshow environmentalconditions in specific locales shape the character of local druguse, as well as responsesto injection drug use, and the impact of the interventions thatare implemented. Risk inthis framework is defined as the product of complex and dynamicinteractions betweenindividuals and micro-, meso-, and macro-level featuresof the social, economic,physical and political environment(s) in whichdrug use occurs (Rhodes, 2002; Rhodeset al., 2005). The interactions amongst differingenvironmental levels and types ofinfluence have been shown to exert a great influenceupon the course of blood-bornevirus epidemics, the distribution of diseasewithin drug user populations, and theimpact of public health interventions(Rhodes et al., 2005).The risk environment framework represents anexplicit attempt to correct theover-emphasis on individual level behaviourcharacterizing public health perspectiveson drug use, and was formulatedas a tool for guiding the developmentof effective4responses. Considering local drug scenes as particular risk environments permits theidentification of factors that function to “produce” drug-related harms and underminethe impact of existing protective or harm-reduction interventions, while enhancing thedevelopment of non-individually focused interventions (Rhodes et al., 2005). In druguse research, risk is increasingly conceptualized as being socially constructed andsocially mediated (Rhodes, 2009). Modifying contextual features to target social-structural factors implicated in the production of drug-related harm isa growingpriority for interventional efforts.Although macro-level structural forces, including legal frameworkswhichcriminalize drug use, represent important determinants of health among IDUs (Burnsetal., 2004; Rhodes et al., 2005), the role of contextual influencesthat operate at moremicro-levels within the settings where drugs are injected also arebeing recognized asimportant research and intervention foci (Kerr, Kimber & Rhodes,2007). The micro-environments where drugs are injected (i.e., injectionsettings) play a unique role in thesocial-structural production of injection-related risk(Rhodes et al., 2005) and represent astrategic location for interventions seeking to reduce drug-relatedharm (Rhodes et al.,2006; Weeks et al., 2001). Injection settings consist of theimmediate physicalenvironment and social context in whichconsumption occurs, but are also influencedsignificantly by the wider socio-cultural context(Moore, 1993). Research examiningsettings where drug users customarily inject revealsthat the social context and physicalenvironment shape potential for harm by eitherfacilitating risk reduction practices, orlimiting individual ability to adopt such strategies(Rhodes, 2002; Ouellet, Jimenez,Johnson & Wiebel, 1991; Page, 1990). Potential forharm in these venues is heavilyinfluenced by the availability of sterile syringesat both the neighbourhood level (Singeret al., 2000) and within the settings where drugsare actually injected (Page, 1990;Ouellet et al., 1991). In addition, the abilityto enact safer injecting routines without5disruption is impacted by the character of the location where the injection occurs;heightened potential for interruption in the midst of the injection process also mayreduce individual ability to enact risk-reduction measures (Rhodes et al., 2006).Ethnographic research examining the contexts where drugs are consumed suggest thatinjection settings represent an important site where IDUs navigate multiple andsometimes competing forms of drug-related harms (Dovey, Fitzgerald & Choi, 2001;Rhodes et al. 2006).While the influence of the physical environment and social context of injectionsettings upon risk is recognized, there is a lack of detailed description andcontextualized understandings of such settings within the international literature(Rhodes et al., 2006). Although “shooting galleries” and prison environments have beenextensively examined (Carlson, 2000; Ouellet, Jiminez, Johnson, & Wiebel, 1991; Saranget al., 2006; Small et al., 2005), other types of injection settings, including the publicinjecting venues that exist in many cities, have not been adequatelydocumented andanalysed (Carlson, 2000; Rhodes et al., 2006).1.5 Contemporary Research on Injection Drug UseResearch, especially conventional epidemiological research, examininginjectiondrug use has predominantly used quantitative methodsto examine the correlationsbetween demographic characteristics, patterns of drug use behaviours,and drugrelated harms (e.g., HIV and hepatitis C infection; overdose)(Rhodes, 1997; Rhodes etal., 2005). However, these approaches have not provided in-depthunderstanding of theimpact of social, structural and environmental forceson the production of drug-userelated health risks and harms. Ecological perspectives informthe current study, whichaims to investigate how cultural (e.g., situated risk perceptionsamong injectors),structural (e.g., legislation and policy shaping thedelivery of harm reduction6programs), and spatial (e.g., physical context of particular injecting environments)aspects shape injection drug use and drug-related harms (e.g., HIV).Within the fields of public health and drug research, there is a significantmovetowards exploiting ethnography’s capacities to provide essential informationregardingthe lived experience of drug injectors, as well as the social processes and structuresthatshape these experiences and the potential for drug-related harms.Emerging“environmental perspectives” have yielded important insightsregarding the social-structural production of risk (Moore & Dietze, 2005; Rhodes, 2002), andthe potential forundertaking structural interventions toreduce drug-related harm — particularlyinjection-related harms. While some research has documentedassociations betweenspecific forms of drug-related harm and particularinjecting environments, thecomparative impact and mediating characteristicsof all injection settings, especiallywithin the Canadian context, have yetto be fully investigated (Rhodes et al, 2005;Celantano et al., 1991; Latkin et al., 1996).1.6 Safer Injecting Environment InterventionsRecognition of the significantrole played by injection settings in the productionof drug-related harm has led to a focuson interventions targeting drug consumptionvenues. While a range of structuralinterventions may influence the character of localinjection settings, “safer injectionenvironment interventions” represent explicitattempts to alter contextual featuresto reduce risk in venues wheredrugs are injected(Rhodes et al., 2006). Some safer injectionenvironment interventions target existingvenues where IDUs inject, whileanother approach involves the creationof purposebuilt drug consumption venues. Bothapproaches seek to minimize “the likelihoodofpolice or public interference, the disruptionof injecting safety and hygiene routinesandthe need for hurried or hasty injection”(Rhodes et al., 2006). They also maximize7opportunities for reducing injection-related risk by enhancing the availabilityof sterileinjecting equipment, sterile water, adequate lighting, cleanworking surfaces, andsyringe disposal. Interventions directed at modifying conditions within existinginjection settings have attempted to enhance accessto sterile syringes, encouragesyringe decontamination with bleach, or provide an element of monitoringwithin thesevenues (Weeks et al., 2001; Fitzgerald, Dovey, Dietze& Rumbold, 2004; Rhodes et al.,2006).Purpose-built venues where IDUs can inject are commonly referredto assupervised injection facilities (SIFs) (Broadhead et al., 2002), which providea sanctionedspace for the hygienic consumption of pre-obtained drugsin a non-judgmentalenvironment under professional supervision (Hedrich,2004; Kimber, Dolan, van Beek,Hedrich & Zurhold, 2003). The earliest SIFs wereestablished in Switzerland, Germanyand the Netherlands during the 1980s, and during the past decadeSIFs have also beenestablished in Spain, Australia, and Canada (Hedrich,2004).1.7 Injection Drug Use in Canada andVancouver’s Downtown EastsideAn estimated 120,000 Canadians inject drugs (Federal, Provincial,and TerritorialAdvisory Committee, 2001). As in other settings,injection drug use within Canada isassociated with various adverse outcomes includinginfectious disease, overdose, loss ofeconomic and social functioning, criminal activity,engagement with the criminal justicesystem and incarceration (Tyndall et al, 2001; Fischeret al., 2004; Wood, Kerr, Spittal,O’Shaughnessy & Schechter, 2003a). Elevatedrates of infection with HIV and thehepatitis C virus (HCV) have been identified amongIDUs in Vancouver and Montreal(Wood et al., 2001; De, Jolly, Cox & Boivin, 2006).Fatal drug-related overdose is a majorcause of mortality among Canadian IDUs (Tyndallet al., 2001), and high rates of nonfatal overdose have been identifiedamong IDUs in a number of Canadian cities (Kerret8al., 2007a; Fischer et al., 2004). Cutaneous infections, including cellulitis and abscessesmay result from unhygienic injection practices (Lloyd-Smith et al., 2005) and represent aleading cause of hospitalization and emergency room visits among IDUs (Palepu et al.,2001; Kerr et a!., 2004).Approximately 15,000 individuals who inject drugs live in the Vancouver area,representing between 11% and 18% of the total number of IDUs in Canada (Mclnnes etal., 2009). Vancouver’s Downtown Eastside (DTES) is a low-income neighbourhoodwhere a range of health and social problems exist, many of which are linkedto injectiondrug use (Wood & Kerr, 2006). The current health and social problems in theDTES havebeen shaped by the public policies of previous decades which greatly reduced theavailability of social housing and concentrated a large populationof highlymarginalized individuals within a small geographic area (Wood & Kerr,2006). Aunique risk environment emerged in the DTES which featured a largeopen drugmarket and outdoor injecting scene, an active sex trade,as well as large numbers ofdrug users living within sub-standard housing in single room occupancy(SRO) hotels(O’Shaughnessy, 2009; Wood & Kerr, 2006). In combination withincreasing levels ofcocaine injection and inadequate levels of syringe access among localinjectors (Wood etal., 2007a), these environmental conditions providedopportunities for rapid HIV spreadamong IDUs in the DTES (O’Shaughnessy, 2009;Wood & Kerr, 2006).In 1997, elevated levels of HIV infection emerged inthe DTES and an annual HIVincidence rate of 18% was identified amongIDUs (Strathdee et al., 1997).Approximately 17% of the IDU population in the DTESare HIV positive (Tyndall et al.,2006a), and over 80% are infected with HCV(Wood and Kerr, 2006). In addition, largenumbers of local injectors have died of drug-relatedoverdoses (Wood et al., 2001;Tyndall et al., 2001). Cocaine injection has beenidentified as playing a particularlyimportant role in the local HIV epidemic as epidemiological analyseshave found that9individuals who frequently inject cocaine are more likely to become HIV positive, andintense cocaine injection is a strong predictor of HIV infection among local injectors(Tyndall et al., 2003).A NEP began operating in Vancouver in 1988, and epidemiological researchconducted as HJV was first emerging among local injectors documented that frequentuse of this NEP was associated with increased odds of HIV infection (Strathdee et al.,1997). While that particular study ignited a debate regarding the effectiveness of NEPsin preventing HIV, the study findings can be explained by the fact that individuals whoutilized the exchange on a daily basis were more likely to be cocaine injectors anddisplay other markers associated with elevated HIV risk, including being homeless orresiding in an SRO, as well as participation in sex trade activities (Wood et al., 2007a).Subsequent analyses determined that when models are adjusted to control forconfounding factors including cocaine injection and other risk factors, the associationbetween daily NEP use and HIV infection does not reach conventional statisticalsignificance (Wood et a!., 2007a).While methodological refinement has untangled the association betweenfrequent NEP use and HIV infection (Wood et al., 2007), increased considerationof theinfluence of the local context and features of the local needle exchange havealso helpedclarify why HIV spread so rapidly in the DTES despite the operationof the NEP.Operational and programmatic features of the local NEP reduced itsability to providelocal injectors with adequate access to syringes(Wood et a!., 2002a; Wood et at, 2002b;Spittal, Small, Wood, Johnston & Schechter, 2003). The programwas governed by astrict unitary exchange policy (which provided 1 new syringe for eachused syringereturned), had limited operation during night-time hours,and covered only a restrictedgeographical area (Spittal et al., 2003; Wood & Kerr, 2006) at the timethe VancouverHIV epidemic emerged. These programmaticfeatures resulted in difficulty in accessing10syringes for many local IDUs, particularly cocaine injectors, and a number ofepidemiological analyses have identified difficulty in accessing syringes as a primaryfactor driving syringe sharing locally (Wood et al., 2002a; Wood et al., 2002b).Additionally, large numbers of injections were taking place within SRO hotels, wheresyringe availability was low, and $10 re-entry fees for residents and guest fees forvisitors discouraged individuals from leaving hotels to obtain sterile syringes duringevening and night time hours (O’Shaughnessy, 2009; Wood & Kerr, 2006). In responseto the public health issues related to inadequate syringe access in Vancouver, policiesand programs were modified in 2002 to expand access to syringes through a needs-based “distribution” model (Small et al., 2008), which no longer supplied new syringesbased upon the number returned but rather provided syringes as requestedby drugusers (exchange of used syringes for new ones was no longer required).Additionally,more needle exchange outlets were established and local health clinicsalso began todistribute syringes. These efforts have largely addressed the previouslyidentifiedbarriers to acquiring syringes, and appear to have contributed to reductionsin syringesharing and HIV incidence among IDUs in Vancouver (Kerret al, In Press).It is clear that a broad range of social, structural, and environmentalfactorsinteracted to influence the ability of the Vancouver NEPto provide local injectors withaccess to sterile syringes. While NEPs vary widely in their design,operation, andprogram delivery (Small, 2005), important variationsbetween programs as well as thecontexts in which they operate have not been adequately consideredin the discussion ofneedle exchange as an HIV prevention measure(Bourgois & Bruneau, 2000; Kral &Bluthenthal, 2003; Rhodes et al., 2005). The emergenceof the Vancouver HIV epidemichas been cited as an important example of howthe potential for drug-related harm isshaped by local environments, and as wellas how interventions are impacted by thecontext in which they are deployed (Rhodes, 2002).The lessons learned regarding the11Vancouver needle exchange exemplify how features of the local environment can limitthe impact of public health interventions (Rhodes et al., 2002), highlighting theimportance of understanding contextual and programmatic factors shaping programcoverage, barriers to accessing services, and the limitations of particular aspects ofinterventions.Within the DTES, injecting behaviour occurs within three primary typesofinjection setting: public injection settings (located in streets, alleyways and parks), SROhotels, and Insite (the local SIF). A large volume of public injectinghas historicallyoccurred in the DTES, and outdoor venues where drugs are injected representa keylocal injection setting (Wood & Kerr, 2006). Among a community-recruitedsample ofIDUs in Vancouver, approximately 22% reported frequently injectingin public venues(DeBeck et al., 2008). Public injection settings are often utilizedbecause drug users lackaccess to private space to inject drugs, due to homelessness or an inabilityto performinjections within their living quarters (Rhodes et al.,2006; Ouellet et al., 1991). IDUsoften expedite injection processes in order to reduce exposureto police or street-predators within public injection settings (Maher& Dixon, 1999; Small et al., 2006).Existing research from other settings indicatesthat public injecting often occurs inhidden locations, which reduces the potentialthat individuals will be discovered andassisted when overdoses occur, due to a lack ofwitnesses who can call for emergencyassistance (Dovey, Fitzgerald, & Choi, 2001). Thesefeatures of public injection settingspartially explain why public injecting, ina range of countries, is associated withincreased risk for abscesses, injection-relatedvascular damage, syringe sharing, andHCV infection (Klee & Morris, 1995; Suh,Mandell, Latkin & Kim, 1997; Latkin et al.,1994), as well as greater potential fornon-fatal overdose (Klee & Morris, 1995; Darke,Kaye & Ross, 2001).12While mobile needle exchange services and health outreach programs regularlyvisit public injection settings in Vancouver, a number of law enforcement effortshaveintermittently increased police presence within public injection venues overthe pastdecade (Wood et al., 2004a; Wood et al., 2003b). These initiatives haveresulted inunintended public health impacts among street-based injectors, includingdecreasedaccess to health services and sterile syringes, as well as the adoptionof high-riskinjecting practices within public injection settings during periodsof increased policepresence (Small et a!., 2006). In addition, increases in police presencehave resulted indisplacement of outdoor injecting behaviour, with injectorstemporarily re-locating todifferent venues within the DTES (Wood et al., 2004a),as well as geographic locationsoutside the neighbourhood (Small et a!., 2006).In cities throughout the world, a large proportion of localIDUs regularly injectwithin public settings (Bless et al., 1995; Rhodeset al., 2006), but there is a lack ofdetailed information describing the extent andcharacter of public injection settings inthe DTES. While the majority of research examiningpublic injecting has focused uponhealth risks, fewer studies have examinedthe lived experience of public injectorsbyexploring drug user narratives regarding injectionin public venues, or the socialmeaning of injecting in public places(Rhodes et al., 2006; Rhodes et al., 2007).1.8 Supervised Injecting in VancouverIn response to the public health crisisamong local IDUs, a government-sanctioned SIF was opened in Vancouver inSeptember 2003 (Wood et a!, 2004). Thefacility operates legally underan exemption under Section56 of the CanadianControlled Drugs and Substances Act, andwas established as a pilot projecttoscientifically evaluate the impact of supervisedinjection (Wood et al, 2006). Thestatedobjectives of the facility are to reduce overdoseand infectious disease risks, facilitate13increased uptake of health services among injectors, and address publicinjection druguse and unsafe disposal of used syringes in public spaces (Wood et al., 2006). TheVancouver SIF, known as Insite, is a three-stage clinical-model SIF consistingof areception area and waiting room, an injecting room, and a “chill-out” lounge whereclients can spend time prior to exiting to the street (Broadhead et al, 2002;Wood et al.,2006). The injecting room has 12 individual booths where IDUs inject pre-obtainedillicitdrugs under the supervision of nursing staff who respond to onsite overdosesandprovide other nursing care to SIF clients (e.g., wound care). Thefacility providesaddiction counselling onsite as well as referrals to health and social servicesandmultiple forms of addiction treatment (Tyndall et al., 2006b).Evaluation research has documented a range of impacts relatedto the VancouverSIF. These include reduced levels of public injecting inthe immediate vicinity of thefacility (Wood et al., 2004b), reductions in syringe sharingamong IDUs who utilize theSIF (Kerr et al., 2005), and reduced levels ofparticipation in public injecting amongInsite clients (Petrar et al., 2007). Use of the facility has resultedin increased uptake ofdetoxification services and addiction treatment among SIFclients (Wood et al., 200Th).It appears that the service model addresses barriers toservice commonly experience byIDUs (Small et al., 2009); and, large numbers of IDUsare referred to health and socialservices by Insite staff (Tyndall et al., 2006b). Insite hassuccessfully managed over 1000overdoses since opening, and a mathematical modelsuggests that the facility preventedbetween 8 and 51 fatal overdoses over 52 monthsof operation (Milloy et al., 2008).However, the effectiveness of the SIF in addressingall aspects of its clients’ needs isaffected by many factors, including currentfederal guidelines that prohibit assistedinjections and the division of drugs by clients withinthe SIF (Wood et al., 2006). Both ofthese practices are common among local injectors,with approximately one-third of localinjectors regularly requiring assistance withinjections (Wood et al., 2003c). This14particular behaviour, receiving assistance with injection, has been associated withheightened risk for HIV-infection among Vancouver IDUs (O’Connell et al, 2005).1.9 The Need for Ethno-epidemiological ApproachesImproved understandings of injection-related risk and drug-related harmamongIDUs require further information and knowledge regarding relationshipsbetweenindividuals and specific risk environments (Rhodes,2009), as well as the interactionbetween injection settings and drug consumption behaviours (Rhodes et al.,2006). Welack detailed knowledge regarding local injection settings inVancouver, includingpublic injecting venues and the SIF in the DTES, and howthese relate to the productionor reduction of drug related harm. Improved understandingsof both the supervisedinjection setting and the public injecting scenecould make an important contribution toknowledge regarding the role of injectionsettings within the risk environmentframework, efforts to develop tailored safer injection environmentinterventions andoptimise SIFs, as well as understanding theoperation of SIFs in relation to the widerrisk environment in a specific locale. Public injectionsettings are common to urbandrug scenes in North America, Australia, Europe,and Asia (Rhodes et al., 2006);however, the character of these venues and theirimpact upon drug-related harm andrisk reduction has not been thoroughlyinvestigated in many settings, includingVancouver. There is also a need for further in-depthdocumentation of the operation ofthe Vancouver SIF, as the international literatureregarding SIFs does not includeethnographic research on the perspectivesof IDUs who use these facilities (Rhodesetal., 2006), as well as detailed descriptions oftheir operations and the behaviour ofclients within supervised injecting environments(Koester et al., 2005; Bourgois, 2002).Ultimately, the processes within theSIF that might contribute to improvedhealthoutcomes are embedded in and intersectwith the DTES environment as wellas macro15level policy and regulatory contexts. More research is needed to examine therelationships amongst the functioning of the SIF, the DTES risk environment,and thepolicy/regulatory context. To date, efforts to evaluate Insite have relied mainlyondescriptive epidemiological research that employs quantitative techniques.Whileepidemiological approaches have been useful in describing importantaspects of thiscomplex phenomenon, the current dissertation uses ethno-epidemiologicalapproachesto investigate how the social context and drug use patterns withinthe local riskenvironment of the DTES intersect with the legal and regulatoryoperating context ofthe SIF to affect clients’ access to and experience of usingthe facility.In order to develop contextualized understandings of injectionsettings in theDTES, this dissertation makes use of multiple methodsand data sources. Ethnographicresearch is often mistakenly regarded as beingsolely “qualitative”, when in factethnographic research commonly utilizes diversesources of data including historicaldocuments, institutional records, demographic information,and quantitative data(Moore, 2005). The convention of employing multipleand varied data sources reflects adesire to obtain a holistic understandingof the subject being studied withinethnographic research.While the data analysed in this dissertationwas primarily collected through in-depth interviews and naturalistic observation,additional forms of data werealsocollected and analyzed, including photographs,information generated throughastructured environmental survey of public injectingvenues, review of documentsrelated to the regulatory framework governingsupervised injecting in Canada, as wellas quantitative data from the Insite database. Thesedata were integrated by developinga detailed description of each type of injection setting,which drew on all of thesetypesof data, to create the most complete and accurateunderstanding possible (Bluthenthal&Watters, 1995). Subsequently, as the analysis progressed,the influence of each type of16environmental influence (e.g., social or structural) was identified in order to illustratehow the interactions between various forces affects behaviour within these settings, aswell as shaping the very character of the settings themselves. Employing both datatriangulation and methodological triangulation (Janesick, 1998) within thisprojectpermitted unique insights into the injection settings examined, which resulted in greaterunderstanding of these settings than would have been possible if only asinglemethodology or type of data had been utilised (Bluthenthal & Watters, 1995).Triangulating data from different sources also serves to reducethe potential formisinterpretation, which could occur if findings werebased solely on data collectedthrough a single method, which may provide a skewed impressionof a particular facetof the phenomena being studied.1.10 Research ObjectivesThe objectives of the current study are to:1. Generate contextualised understandings of social relationsand consumptionpractices within local injection settings in Vancouver,including public injection venuesand the local supervised injection facility, and describethe relationship between thesetwo settings;2. Identify how various cultural, structural, andspatial forces influence socialrelations and consumption practices within theseinjection settings and shapethepotential for drug-related harm;3. Use the new information gathered in the currentstudy to identify researchopportunities and promising interventions thatare informed by the local drug-injectionenvironments as well as macro-level policy andregulatory contexts.The current study used ethnographicfieldwork techniques, includingobservation of activity within druguse settings and in-depth interviews with local17injection drug users (IDUs). Observational work was undertakento generateinformation regarding drug user activity within public injection settings and the localSIF, as well as the operation of the SIF. In-depth interviews with localIDUs wereutilised to generate detailed understandings of IDUs’ perspectives regardingtheseparticular local injection settings, including the physical environmentand socialcontext. By generating detailed descriptions of the settings investigated, andusinganalytical approaches informed by the risk environment framework, the influenceofvarious forces (e.g., local and distal) upon risk production/reduction in relationto theseinjection settings was documented.The aforementioned objectives, and the research activities thatflow from them,are informed by the perspective that public health researchexamining drug-relatedwithin injection settings has been characterised by anexcessive focus on therelationship between knowledge of risk and risk avoidance,and by consequence anoveremphasis on the individual as the primary unitof analysis. Throughout theresearch that follows, arguments and supporting data arepresented to emphasise thatassessments of risk in which individual behaviour isde-contextualised from theenvironment(s) in which it occurs impedethe development of effective andcomprehensive intervention strategies.The settings where drugs are injected areknown to play an important role in thesocial-structural production of injection-relatedrisk, and therefore constitute importantlocations for intervention efforts. In the chaptersthat follow, it is argued that, in orderto minimise the harm arising within injectionsettings and maximise the potential ofinterventions to promote safer injecting environments,understandings of injectionsettings and the associated harms must movebeyond conventional “risk factor”analyses. Work in this area needsto encompass more detailed contextualisedknowledge of risk behaviour and riskperceptions in relation to specific drug use18settings and related social, structural, economic and political conditions shapingtheproduction and reduction of drug-related harm.1.11 Organization of DissertationThe dissertation consists of five chapters. Following this introductory chapter,the subsequent chapters aim to:Chapter 2: Use data gathered through ethnographic fieldwork (e.g., fieldobservations, photographs, in-depth interviews with IDUs,and a structuredenvironmental survey) to describe public injection settings in Vancouver’sDTES and toillustrate how these settings influence the situated risk perceptionsof local injectors andthe potential for drug-related harm.Chapter 3: Use data from 50 in-depth interviews withIDUs who use the SIF, todevelop an in-depth description of injectors’ motivations forusing the SIF and theirperceptions regarding their experiences of using the facility.Chapter 4: Use data generated through ethnographicmethods (e.g., naturalisticobservation within the SIF, in-depth interviewswith SIF users, as well as analysis ofdocumentation regarding the establishment andoperation of the facility) to examinecontextual and programmatic features influencingIDUs’ access to the SIF and howthese features are influenced by interactionsamongst macro-level forces (e.g.,regulatory mechanisms), specific operational characteristicsof the facility, and featuresof the local drug scene.Chapter 5: Synthesize the findings of theanalyses presented in Chapters 2-4 anddiscuss recommendations and future researchdirections arising from this work.191.12 ReferencesAceijas C, & Rhodes T. 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Factors associated with persistent high-risk syringe sharing in thepresence of an established needle exchange programme. AIDS, 16(6): 941-943.Wood, E., Tyndall, M.W., Spittal, P.M., Li, K., Kerr, T., Hogg, R.S., Montaner, J.S., O’Shaughnessy, M.V.,&Schechter, M.T. (2001). Unsafe injection practices in a cohort of injection drugusers in Vancouver:could safer injecting rooms help? Canadian Medical Association Journal, 165(4): 405-10.Wood, E., Tyndall, M.W., Zhang, R., Montaner, J.S., & Kerr, T. (200Th). Rate of detoxification serviceuseand its impact among a cohort of supervised injecting facility users. Addiction, 102(6):916-9.26CHAPTER 2:PUBLIC INJECTION SETTINGS IN VANCOUVER: PHYSICALENVIRONMENT, SOCIAL CONTEXT ANDRISK’2.1 IntroductionIn cities where public spaces are used for the purposeof injecting drugs,concerns regarding community safety and public orderfrequently focus upon street-based illicit drug use (Bless, Korf, and Freeman,1995; Fischer, Turnbull, Poland andHaydon, 2004; Wood, Kerr, Small, Li, Marsh,Montaner et al., 2004b). Drug relateddisorder plays a prominent role in promptingfears regarding the liveabiity ofcommunities (Fischer, Turnbull et al., 2004;Fitzgerald and Threadgold, 2004; Rhodes,Kimber, Small, Fitzgerald, Kerr & Hickman, 2006),and public injecting scenes are oftenregarded “as a nuisance and a threat” (Broadhead,Kerr, & Altice, 2002). Urbanregeneration and neighbourhood renewal initiativesoften combine with communitysafety movements to highlight public drugand alcohol use as social problemsto beeliminated (Cusick, 2007; Rhodes et al.,2006). While the visible signs of injection druguse negatively colour perceptionsof community safety, evidence indicatesthat publicinjecting has a pronouncedimpact upon the risk management strategiesand overallhealth of individuals who consume illicitdrugs in public spaces (Kleeand Morris, 1995;Rhodes et al., 2006). City-basedinterventions need to address publichealth andcommunity safety concerns inways that do not compromise the healthand safety ofstreet-based socially marginalizedpopulations.Existing epidemiological studiessuggest that public injectionsettings can act asmicro ‘risk environments’, contributingto an elevated pattern of drug-relatedharm‘A version of this chapter hasbeen published. Small, W., Rhodes, T.,Wood, E., Kerr, T.(2007). Public injection settingsin Vancouver: Physical environment,social contextand risk. International Journalof Drug Policy 18: 27-36.27among injectors. Drug users who frequently inject in public have been foundto displayincreased risk for abscesses, injection-related vein damage, syringe sharing,HCVinfection and overdose (Latkin et a!., 1994; Klee and Morris, 1995; Suh,Mandell, Latkinand Kim, 1997; Darke, Kaye and Ross, 2001). While publicinjecting settings, andinjecting venues such as the ‘shooting gallery’, are increasingly notedas a ‘risk factor’(Dietze, Jolley, Fry & Bammer, 2005; Koester, Glanz& Baron, 2005; Page and LianusaCestero, 2006), we require greater understanding ofhow forces within theseenvironments foster the production of drug relatedharm (Carlson, 2000; Rhodes, 2002;Rhodes, Singer, Bourgois, Friedman and Strathdee,2005; Rhodes et al., 2006).Previously attention has focused specificallyupon how ‘context’ in injectingenvironments influences the impact of harm reductionprograms (Galea, Ahern andVlahov, 2003; Smyth, Barry & Keenan, 2005),but more research exploring the ‘livedexperience’ and social relations of injecting inpublic places is still needed (Carison,2000; Fischer, Rehm, Kim and Robins, 2002;Fitzgerald, Dovey, Dietze and Rumbold,2004; Page and Lianusa-Cestero, 2006; Rhodeset al., 2006).The limitations of educational and behaviouralhealth interventions focused onthe individual are now well established (Fee & Krieger,1993; Karpati, Galea, Awerbuchand Levins, 2002), though such approacheshave dominated responses to harmreduction associated with injection drug use(Moore and Dietze, 2005; Rhodes 1997).This has led to calls for harm reducinginterventions that mediate the rolethat social,structural and environmental factorsplay in the production and reductionof risk(Bourgois, 1998; Bourgois& Ciccarone, 2003; Moore, 2004; Rhodes, 2002;Rhodes,Singer, Bourgois, Friedman & Strathdee,2005). As public health perspectives haverecognized the merits of an ‘ecological’approach and interest in ‘structuralHIVprevention’ has grown (Blankenship,Friedman, Dworkin & Mantell,2006),commentators within the field ofdrug use and the addictions have emphasizedthe28potential of ‘environmental interventions’ that alter ecological conditions to facilitatethe adoption of harm reduction strategies (Des Jarlais, 2000; Moore & Dietze 2005;Rhodes, 2002).The physical settings in which drugs are injected comprise one aspect of themicro risk environment amenable to social and structural intervention, and this has ledto calls for “safer injecting environment interventions” (Rhodes, et al., 2006). Researchhas shown how shooting galleries and prison environments act as criticalenvironmental determinants of health among injection drug users (Celentano et al.,1991; Ouellet, Jimenez, Johnson & Wiebel 1991; Small, Wood, Jurgens & Kerr, 2005).Public injecting environments have not yet been sufficiently explored in relation to theproduction of risk and how social dynamics within such environmentsmay act asmediators of risk (Rhodes, Singer, Bourgois, Friedman and Strathdee, 2005). Previousqualitative work examining public injection settings has described these environments,and emphasized that the presence of high risk behaviour makes them important sitestotarget with intervention efforts (Dovey, Fitzgerald & Choi, 2001;Weeks et al., 2001). Wefocus here on describing specific public injecting settings withinVancouver with theobjective of exploring how public injecting settings mediate risk,and how existing city-based interventions can be strengthened to create safer injectingenvironments.2.1 .1 BackgroundThe city of Vancouver’s open drug scene ishighly concentrated in theDowntown Eastside (DTES), a neighbourhood characterizedby high levels of addictionand mental illness (Wood & Kerr, 2006). While low-costhousing is concentrated in theneighbourhood, a large population of homeless individualsis present and drug-relateddisorder has historically been a feature ofthe area. It is estimated that over 5,000 IDUreside within the DTES, and thousands of additionalinjectors regularly visit the29neighbourhood to purchase and consume drugs. Within the DTES, high levels ofpublicinjecting have customarily occurred and the majority of local injectors have previouslyreported injecting in public locations (Kerr et al., 2003b). This large publicinjectingscene has been the target of both public health and law enforcement initiativesin recentyears (Wood, Kerr, Spittal, Li, Small, Tyndall et al., 2003; Wood, Kerr,Small, Spittal,O’Shaughnessy and Schechter, 2004; Wood and Kerr, 2006). Efforts to address thecity’spublic injecting scene have included large scale police operations targeting drug-relateddisorder, as well as the establishment of North America’s firstsupervised injectionfacility (SIF) in 2003 (Wood, Kerr, Strathdee, Spittal, Wodak, Tyndallet al., 2003). TheSIF seeks to address the public health issues related to street-basedinjecting byproviding an alternate venue for consumption (Wood, Tyndall,Spittal, Li, Kerr, Hogg etal., 2001), and the facility’s ability to address publicorder issues by taking injectors “offthe street” is a crucial dimension of its politicalappeal (Fischer, Turnbull et al., 2004).Since its establishment, Vancouver’s SIF has been foundto have improved publicorder in the vicinity of the facility by reducing the levelsof public injecting occurring, aswell as the volume of injection-related debris(including discarded syringes) on thenearby streets (Wood, Kerr et al., 2004). The SIF hasalso attracted high risk injectorsand facilitated a reduction in high riskinjecting practices among users of the facility(Kerr, Tyndall, Li, Montaner and Wood, 2005).However, given the scale ofVancouver’s open drug scene, a single 12 seatSIF has been able to address only afraction of the public injecting behaviour thatoccurs in the neighbourhood. While theSIF may accommodate over 600 injections ona busy day, it is estimated that between10,000 and 15,000 injections occur in theneighbourhood each day (Kerr, Tyndall,Montaner and Wood, 2004).It is therefore unlikely that any single SIFwill provide adequate coverage for allpublic injectors within a city or eliminateall high risk public injecting. In Vancouver,30the SIF has led to reduced levels of public injecting, though injecting inpublic spacespersists. It is therefore important to consider the need and scope for community-basedinterventions to work alongside SIFs by seeking to reduce harms associated withinjecting in public settings. We therefore undertook preliminary ethnographic researchto describe the physical locations utilized for public injecting within the DTES, and theconditions within these environments that influence injection practices, risk anddrugrelated harm.2.2 MethodsThis study incorporated a structured environmental survey that involvedthe useof field observations to document the physical locations where public injectingoccurs,and analyses of data from qualitative interviews with local injectorsregarding publicinjection settings. This approach enabled the examination ofpublic injection settingswith regards to both the built environment and social context by combiningdata fromfield observations and IDU narratives regarding the utilizationof these physicallocations and their meaning. These research activitieswere undertaken as part of alarger, and ongoing, ethnographic investigation of publicinjecting that has also utilizedparticipant observation within local public injection settings (Smallet al., 2006).2.2.1 Environmental surveyThe use of a structured environmental surveyidentified the geographicaldistribution of public injection settings in Vancouver’sDTES, and documented thesephysical locations through field observations andthe use of photography. Based uponexperience in previous ethnographic data collectionactivities (Spittal et al., 2004), astudy area consisting of approximately 15 city blocksin the DTES was defined. Thestudy area contained the majority of the neighbourhood’shigh intensity drug market31locations and the alleys where the greatest amount of outdoor injecting had previouslybeen noted.Field surveys were conducted by a member of the research team(WS) withexperience in environmental surveying and mapping methods, and who hadpreviouslyspent over 3 years conducting ethnographic research in the community. A detailed mapof the city blocks comprising the study area was employed to record the presenceofpersons who were visibly injecting outdoors, publicly discarded syringesand injectionrelated litter. These indicators of public injecting activitypermitted the identification ofkey locales where public injecting frequently occurs. Thismethodology also allows forthe identification of the geographical distribution of publicdrug using activity (Singer,Stopka, Siano, Springer, Barton, Khoshnood et al., 2000; Dovey,Fitzgerald et al., 2001;Wood, Kerr et al., 2004; Taylor, Cusick, Kimber,Hickman and Rhodes, 2006).Observations were made during daylight hours ona schedule that encompassedmorning, mid-day, and afternoon outingson weekdays. We were unable to conductobservations during overnight hours dueto limited human resources dedicatedto thisproject. Structured surveys were originallyundertaken in the fall of 2003, and wereconducted on a quarterly basis until 2006.We also utilized photographs in orderto create a visual record of the physicallocations where public injecting often occursin Vancouver. The contribution thatvisualmethods bring to qualitative and ethnographicdrug use research, particularly withregard to describing and analyzingenvironments which influence risk andriskreduction practices, has been increasingly recognized(Rhodes, Briggs, Holloway, Jonesand Kimber, 2006; Rhodes and Fitzgerald,2006).322.2.2 Qualitative interviewsIn order to explore injectors’ perspectives regarding injection settings andrisk,this analysis drew upon data from 50 in-depth qualitative interviewsconducted fromNovember 2005 to February 2006. Interviewees were recruited from the ScientificEvaluation of Supervised Injecting (SEOSI) cohort of injection drugusers in Vancouver(Wood, Kerr, Lloyd-Smith, Buchner, Marsh, Montaner et al., 2004). Interviewparticipants were selected from among persons attending the researchoffice forquantitative interviews on a daily basis, and recruitment efforts intentionallycreated asample with differing levels of SIF utilization. Interviews were undertakenby threedifferent trained interviewers (two male and one female) and facilitated throughthe useof a topic guide encouraging discussion of injection settings, injection practices,as wellas perceptions of risk and safety within injecting environments. Interviewslastedbetween 40 and 80 minutes, were audio-recorded, and were latertranscribed verbatim.Qualitative interview participants were reimbursed with an honorariaof $20 CDN tocompensate them for their time. The research team discussedthe content of theinterview data throughout the data collection process, thusinforming the focus anddirection of subsequent interviews as well as developing a preliminarycoding schemefor partitioning the data categorically. The contentof transcribed interviews wascatalogued using a coding framework focused on injection settingand our analysis hereexplores emergent thematic patterns in relation to public injecting.The sample of qualitative interview participants was composedof 21 women, 28men and one transgendered individual. The ageof participants ranged from 25 to 60years. Twenty-four participants reported injectingin public locations recently, and 16participants reported both the SIF and public locationsas settings where they regularlyinjected drugs.332.2.3 EthicsAll participants in the qualitative study provided informed consent toparticipate, and the study was undertaken with appropriate ethical approvalfor allcomponents granted by the St. Paul’s Hospital/University of British Columbia ResearchEthics Board. There were no refusals of the offer to participate in the interviewand nodrop-outs during the interview process.2.3 Findings2.3.1 Public injection settings: The physical environmentIn Vancouver’s DTES, public injecting activity occurs primarily within alargenetwork of alleyways, which cross-cut the streets of the neighbourhoodbisecting manycity blocks (see Figure 2.1). While injecting activity also occursin locations like carparksand abandoned buildings, public injecting is concentrated in extensive‘injecting zones’(Dovey, Fitzgerald et al., 2001) within the alleys. Althoughpartially obscured from thestreet, alleyways accommodate vehicle traffic and areused by some residents aspedestrian walkways. The alleys also provideservice access for businesses in theneighbourhood, as commercial loading andgarbage removal take place here. A largevolume of injections have customarily occurredin these alleyways, as drug relatedactivities are out of the direct view of the public eyewhile in close proximity toimportant locations on nearby streets includingdrug markets and sources of sterilesyringes. This network of alleys has traditionally beenheavily patrolled by theVancouver Police Department, and during enforcementoperations targeting the opendrug scene an even higher level of police presenceis common (see Figure 2.2).Within the DTES, it is common for injectorsto use small recessed doorways andalcoves within the alleyways as “injection niches”.These outdoor injection niches arehighly marginal public spaces which have beenappropriated for the purpose of illicit34drug use (see Figure 2.3). These spaces accommodate public injecting activitiesbyproviding limited shelter from wind and rain, thus permitting a degree of physicalamenity when engaging in a ‘fix’. These niches are not exclusively used for injecting;they are also used for smoking crack, as well as resting and sleeping. Injection nichesare sometimes customized to provide better shelter or a greater measure of privacy, andoften contain artwork and messages to friends or other members ofthe drug usingcommunity.Given the lack of adequate surfaces for preparing injections, large garbagebins(‘dumpsters’; see Figure 2.2) are often used as tabletops to prepare injectionsor to layout equipment. There is a chronic shortage of public toilets in the neighborhood,whichresults in the alleys functioning as latrines, making these public injection settingshighlyunsanitary. During our survey activities, urine and faeces wereoften present within thealleys, particularly within ‘niche’ spaces. Although sterilewater for injecting isprovided through needle distribution outlets and programs, thelack of running waterin the alleys prevents injectors from following suggested hygieneroutines as there is noopportunity to wash one’s hands or bodily injection sites priorto injecting.The recessed alcove and doorway niches offera limited amount of privacy asthey are out of the sight from street, and are often obscuredfrom view unless one iswithin a few metres. Some public injectors achievea greater degree of privacy by usingcardboard and other debris to create makeshiftenclosures, as well as choosing hiddenor well-camouflaged spots which better concealtheir activities from the public, thepolice or other drug users. These spatial tacticswere evident in one injecting niche inwhich the alcove was protected by a door thatcould be closed and locked from theinside, providing a concealed and functionally“private” location for injecting in one ofthe busiest and most heavily policed alleywaysduring an intense police crackdown(Small, Kerr, Charette, Schechter and Spittal, 2006).35Despite the attempts of injectors to locate semi-private injecting areas,a numberof factors serve to actively deter the use of these public spaces including police patrolsand the presence of security guards. Deliberate modification of the builtenvironment,implemented by affected property owners, residents and businessesto discourageinjectors, also functions to spatially regulate injecting activities in the alleyways. Forinstance, the hidden doorway described above offered a concealed location withinthealleyway until the removal of the door panels eliminated the camouflage, making it lessattractive for street-based users (see Figure 2.4). Other partial ‘solutions’ totheappropriation of space for injecting include the installation of fences and lockedgates toprevent access to locations that are attractive to public injectors. Whilethesemodifications often succeed in blocking a particular injection niche,the unwelcomebehaviour of injectors is inevitably relocated to other nearby locations.2.3.2 Risk and the physical injecting environmentThe perspectives of interview participants indicate that the alleys,in contrast toprivate locations, are predominantly seen to be an undesirablevenue for injecting. Asone interviewee remarked, “I think the alley is probably theworst place you can do it”.Another respondent discussed the sense of fear thatmay accompany injecting in thealley, emphasizing the impact an injection setting mayhave on an individual’s mindset:I: What it’s like to inject in an alley?R: It’s paranoia, is what it is. Paranoiathat you’re going to get dirtin a cut. Paranoia that that you’re going to get bustedonce you doyour hit. It’s paranoia, y’know. . .you’re tweakingout in an alleyand... it’s filthy. It’s not something you wantto do. [Respondent#26, female]The unsanitary character of the physical environmentis a primary dimension ofhow alleys are seen to be unsuitable for injecting.36There’s something about fixing outside in an alleyway.. .youlookdown and it’s dirty. You’re in an alley behind dumpsters.. .it’sdirty back there. Man, these alleys are filthy. People piss and sleepand shit, all over. [Respondent #8, male]Users were aware of how injecting in an unsanitarysetting may precipitatehealth complications and opportunities for infection:There’s urine in almost every inch of the alley. Y’know. . . youcouldjust drop your plunger or your rig and you’ve contaminatedit.[Respondent #47, male]2.3.3 Risk and the social context of injecting environmentsThe street as a physical entity is associated with particularsocial meanings, and isconstructed through lived experience. Although individualswere concerned with theunsanitary nature of the injecting environment,the unregulated character of the‘street’fundamentally shapes multiple forms of“risk” that exist in public injection settings.I sometimes used to do it down in thelanes here. But I never reallyfelt very comfortable with that, and hada few problems with somepeople down there too. Yeah, therewas a guy who tried to robme, actually he did rob me once. Pulleda knife on me. [Respondent#11, male]In addition to fears of being physicallyassaulted or robbed by ‘street associates’,the possibility of being assaulted bythe police is also a source of anxietywhen injectingin public.I was in the alley before that. . . .andI was sitting in there,and thebike cops roll up... The womancop said, “Hey,” and I looked up,and she [pepper] sprayed me,and the other cop whacked my armwith the flashlight, knockedthe rig out. That was nasty. Couldn’tbreathe for about forty minutes.[Respondent # 35, male]Within the alleys, the risk of overdosingis accompanied by the possibility thataperson may not receive helpin a timely fashion:37Someone goes down [overdoses] in the alleyway, they’re gone.They’re not sticking around for the ambulance, they don’t wantnothing to do with it, right? [Respondent #37, male]The reality of being unable to access professional assistance was highlighted asone key dimension of how the alleys are unsafe injecting settings that increase thepossibility of negative outcomes:If somebody gets into trouble, there’s nobody qualified to doanything at the moment. I mean, y’know, it’s a back alley.[Respondent #25, male]As noted above, conditions in unregulated ‘public’ spaces may result inencounters with the police or street predators. These findings emphasize that one keyfeature of the social relations of public injecting is heightened risk awareness or anxietyassociated with a fear of interruption or disruption. In turn, this heightened sense of‘risk’ impacts upon health risk practices and the ways in which individualsinject. Asone interview participant emphasized, injecting in the alley equated to a situationwhere she was preoccupied with “hurrying and worrying” about threats that existinpublic injecting settings:I’m worrying about different things, y’know? Lookingaround.. .we’re fixing outside and you’re worrying about if the copsare going to come or if someone’s going to attack you or rob you....[Respondent #28, female]These concerns distract attention from the practices of injecting and focusattention on the environments of injecting. Preoccupations with risk arguablyshift fromconcerns relating to health and the specific harms of injecting,to either self and moregeneral concerns to protect oneself from police and other predators. Additionally,thefocus upon immediately consuming the drug, in orderto not lose the hit or theopportunity to prevent withdrawal, exacerbates environmental concernsthat detract38attention from injection practices. One consequence of this shift inrisk attention ispotential disruption to injecting safety routines. Inmany instances of public injection,the need to simply complete the injection supersedes thedesire to perform the injectionproperly or safely. The potential for interruption anda fear of disruption encourages‘rushing’ through the injection process, which can precipitatehealth complications:When I do it outside I feel like I’m being rushedor something,y’know, because you’re always thinking thecops are going tocome, or something’s going to happen. So you’re trying to reallyrush it. And when you rush.. .rush and try to hit yourself,thechance of not getting it right away is really high. [Respondent#16,female]Watching for police is an element of the perceived pressureassociated withpublic injecting which distracts from, or disrupts, normal injectingroutines:You got to sit there and fool aroundand then, y’know, lookaround, make sure nobody’s coming — thecops aren’t coming.There’s a few times where’s it’s happened — Ijust get the vein, andI see a cop driving by or something, and thenI go to look at it andtry and draw again, and I lost the vein.So I have to look for itsomewhere else. [Respondent #28, female]In the context of perceived threats of police interference,attention may shift fromthe ‘perfect’ injection (which requires time) to‘getting it in’ (which suffices when thereis no time):It’s rushed, hurried, y’know... notcalm. It’s just... get it into you asquick as you can before the cops come,basically. ‘Cause they’recoming, it’s just a matter of time. Youjust do it a lot quicker. Youdon’t really care if it’s perfect, y’know, it’sjust ‘get it done’. Yeah,get it in there. [Respondent #23, female]Yeah, I just don’t feel like I havethe time, ‘cause, y’know, you justwant to get it in and get the hellout. [Yeah, get going]. ‘Cause youfeel like, y’know, if the copscome, “Oh maybe — can they chargeme with the stuff that’s in myrig?” I want to get it in before theycome. [Respondent #38, female]39These conditions encourage users tO employ expedient preparation techniques,the “quickest form of doing it”, rather than adhering to safer injection practices.Preparing an injection is often done within a recessed niche, walking along the alley oralongside the large garbage containers. As the cooking and filtering of drugs priortoinjection is difficult and time consuming, these steps are often omitted. Preparing drugsdirectly in the barrel of the syringe, without cooking or filtering, by adding water andsimply ‘shaking’ is a practice commonly employed in the alleys.In the back lane, there’s no time to cook. So it’s just like shake andbake, kind of thing. But that’s the only time that I’ll do my dopewithout cooking it, is if I have to use the back alley, or outsideperiod. [Respondent #33, male]I will not take time to sit there and play with a cooker and stuff,filter it. That’s pretty dangerous, apparently ...I just don’t feel like Ihave the time. [Respondent #42, female]Cleaning of injection sites with alcohol swabs was also oftenreported to beomitted from the injection process due to the perceived timeconstrains in publicenvironments.Shifts in risk attention — from injecting practicesto the injecting environment —accentuate the management of multiple, contradictoryand situated forms of risk. Userswere aware of the health consequences of adoptingexpedient injection techniques,rather than the safest ones possible, and acknowledgedthe influence of public injectionsettings in discouraging safer injecting:See that’s another thing... you can hardly prepare itthe right way. Imean, you have to do what’s called a shaker.I know fromexperience, that it’s one of the most dangerousthings to do,because my wife actually had endocarditis fromdoing shakers. So,I know from experience what the risks are. Andapart from that,you can’t, like, pull out a spoon and start heatingand filtering.[Respondent #48, male]402.4 DiscussionIn Vancouver, public injecting often occurs in spaces characterized by unsanitaryconditions, which lack adequate amenities to enable hygienic injecting. Moresignificantly, the social context of these injection settings impedes individual ability toemploy safer injecting practices. Within the unregulated public environment, the threatof street violence or arrest encourages rushed injecting and the adoption of the mostexpedient injection practices possible. This analysis found that public injecting isassociated with a heightened awareness of risk associated with a perceived threat ofinterruption, which we suggest shifts risk attention among injectors from their injectingpractices to their injecting environments. One consequence of this shift in risk attentionis that context-specific concerns regarding protecting one’s self (for example, frompolice) and one’s drug (for example, in not ‘losing a hit’) may take temporaryprecedence over other immediate individual health concerns (such as injecting as safelyas possible). As ecological features in public injecting settings can promote unhygienicand unsafe injecting practices, these venues are prime locations for intervention efforts(Dovey, Fitzgerald et al., 2001; Weeks, et al., 2001; Rhodes, Singer et al., 2005). Webelieve that community-based interventions to create safer public injectingenvironments are warranted (Rhodes, Kimber et al., 2006), and should be consideredalongside safer injecting facilities in order to maximise the community impact ofinterventions seeking to reduce harm among street injectors.2.4.1 Risk environment and situated risk realityThe risk environment framework emphasizes that an array of context-specificenvironmental and social factors influence the production of risk, particularlywithinspecific micro-locations such as injection settings (Rhodes, 2002). Fears of encounterswith the police are a fundamental dimension of the ecological risks identified by publicinjectors as physical confrontations, confiscation of drugs, and arrest are seen as threats41to be avoided. Enforcement operations targeting street based scenes result in negativehealth impacts, both in Vancouver and many other settings internationally (Kerr, Smalland Wood, 2005). Police crackdowns may reduce access to sterile syringes and harmreduction programs, as well as fostering increasingly risky injection practices amongIDUs engaging in public injecting (Maher and Dixon, 1999; Maher and Dixon, 2001;Aitken, Moore, Higgs, Kersall and Kerger, 2002; Small, Kerr et al., 2006). Police actionsin public injection settings may even result in accidental syringe sharing, as IDUattempting to hide or store injecting equipment may unintentionally use anotherperson’s syringe (Small, Kerr et al., 2006). Despite knowledge of the harms stemmingfrom enforcement efforts targeting the street based drug scene, reliance on policinginitiatives has continued in Vancouver (Wood and Kerr, 2006) and a recent operationwas implemented with the explicit goal of discouraging public injecting (Howell,2005).IDU perspectives emphasize that public injection settings are far fromconduciveto injecting in the safest manner possible. The abilityto adhere to safer injectingstrategies (and protect one’s health while injecting) was seen to be overwhelmedbyother ‘risks’, including arrest and assault, which were perceivedto be of moreimmediate consequence and greater priority. The need to prioritizemultiple risksprovides a rationale for adopting expedient practices althoughthey are known to resultin negative health consequences. This is illustratedin the case of ‘doing a shaker’.Although the practice is known to increase the potential for infection, theexpediency ofthis method is attractive for public injectors. These ‘situated’ viewsof the risksassociated with public injecting emphasize the rolethe immediate environment exertsover injection practices, and the production ofrisk (Connors, 1994; Moore, 2004).422.4.2 Public injecting and safer injecting facilitiesThe establishment of the local SIF reduced the levels of public injecting visibleinthe DTES (Wood, Kerr et al., 2004), and local SIF users have reported significantlyreduced levels of participation in public injecting (Wood, Li, Montaner and Kerr, 2007).However, the total coverage of SIF in various settings is often limited in comparisontothe size of injecting populations and open drug scenes. For example, estimationsindicate that the SIF is able to accommodate approximately 5-10%of injections that maybe occurring in Vancouver’s DTES (Kerr, Tyndall et al., 2004; Kimber, Hickman,Degenhardt, van Beek and Coulson, 2005). Problems relatedto the coverage of SIFs areoften a reflection of the unwillingness of policy makersto move beyond tightly-controlled, small-scale pilot studies of SIFs asopposed to unwillingness on the part ofIDUs to use such facilities.The findings presented here suggest thatthe alternate setting for injectingprovided by the local SIF displays great potentialto address the ecological factorswithin public injection settings that impedeindividuals’ capacity to adopt saferinjecting techniques. The perspectives of thoseattending the SIF indicate that the facilityenables less ‘rushed’ injecting (Petrar, Kerr, Tyndall,Zhang, Montaner and Wood,2006), as well as enhancing individualability to employ safer injecting practices (Small,Wood, Fairbairn, Montaner and Kerr,2006). However, the potential of the SIFto impactthe public injecting scene has notyet been fully realized, due in partto the limitedcapacity of the existing facility. Further,IDU who require assistance with injections areprevented from attending the SIF, asthe facility is currently unable to permit assistedinjections on site (Kerr, Wood, Small, Palepu andTyndall, 2003). This rule has been thesubject of some debate given that localIDUs who require assistance with injectionsareknown to be at heightened risk forHIV infection (O’Connell, Kerr, Li, Tyndall, Hogg,Montaner et al., 2005).43In light of the above considerations and the findings of the current study, there isan urgent need to increase the scope and capacity of the local SIF in order to morecompletely address harms related to public injecting. Structural factors that perpetuateVancouver’s large public injecting scene should also be addressed through policyinterventions increasing access to affordable housing within the DTES. Further, effortsto increase the number of publicly accessible toilets in the neighbourhood wouldpositively impact the public injecting scene by reducing the amount of human wastepresent in the alleys, as well as enabling hygienic routines (e.g. hand-washing) prior toinjecting. Additional interventions that are directly focused on public injecting settingsare also required, and have been cited as a potential route to modifying ecologicalfeatures producing risks and harm (Rhodes, Kimber et al., 2006). By implementingmechanisms to ensure an immediate emergency response in case of an adverse incident(Fitzgerald, Dovey et al., 2004), innovative efforts may enhance personal safety andmediate overdose risks in public injecting venues. Additionally, interventions thatfoster personal safety would create a context more conducive to safer outdoor injecting.Although innovative measures towards these goals are likely to be met with politicalopposition in many urban settings, their potential to reduce drug related harm meritstheir exploration.2.4.3 The limits of individualism in harm reductionThe explicit and implicit assumptions of individually focused safer injectioneducation messages are often “oblivious to the social and economic constraintsthatrender the implementation of such procedures difficult or impossible” (Briggs, 2003).Educational prevention messages targeting IDUs contain inherent assumptionsregarding a “particular type of social context for injecting, one... characterized bystability and orderliness” (Moore, 2004). As the perspectives presentedin the current44study indicate, public injecting occurs in a context whichis characterized byunpredictability and disruption. While existing epidemiologicalresearch hasemphasized the negative public health consequences relatedto public injecting, thiswork suggests that attention to a social perspectiveon ‘risk’, as articulated by IDUs,would assist the development of safer environmental interventions.By modifyingcontextual factors that impede injectors’ ability to inject safely, interventionscreatingsafer environments would ‘enable’ the adoption of safer injectingroutines (Moore andDietze, 2005).2.4.4 The need for further ethnographic research on injectionsettingsAs this study is a preliminary ethnographic investigation of publicinjectingsettings in Vancouver, further inquiry utilising participantobservation should continueto investigate the influence of ecological factors upon injectionpractices. The currentstudy has limitations, as all interviewees had experienceof injecting within asupervised environment. Previous experienceof injecting within the SIF may have ledsome interviewees to redefine public injectingsettings negatively. However, ourqualitative sample was purposively selected to include intervieweeswith varying levelsof SIF use and many interviewees continued tofrequently engage in public injecting.As many important questions relatedto public injecting are beyond the scope of thecurrent study, further ethnographic research isrequired to understand how theselocations figure in the social lives ofinjectors, as well as the interplay betweenthesesocial relations and injecting practices, particularlyassisted injecting. Understandingthe micro-environments of public injectingvenues is necessary if we areto enhanceexisting structural interventions suchas SIFs and develop novel ‘ecological’interventions that complement individually-focusedprevention efforts.45Figure 2.1: Diagram depicting the spatial distribution of public injecting‘niches’ in the Downtown EastsidePublic injecting in the DTES most frequently occurs within narrow alleysthatcross-cut many city blocks. Within these alleys recessed ‘niche spaces’are used for thepurpose of injecting.X Niche SpaceStreet46Figure 2.2: Police presence in public injecting venuesExtremely high levels of police surveillance characterize public injecting venuesin Vancouver’s Downtown Eastside.47I.n 0—.(D I-—0 I-. rtr 0—_“00Figure 2.4: A formerly hidden injection nicheThis location was a formerly hidden niche and is no longer camouflaged sincethe panels were removed from the door.492.5 ReferencesAitken, C., Moore, D., Higgs, P., Kersall, J.& Kerger, M. (2002). 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Requiring helpinjecting independently predicts incident HIV infection among injection drug users. Journal ofAcquired Immune Deficiency Syndromes, 40(1): 83-88.Ouellet, L., Jimenez, A. D., Johnson, W. A., & Wiebel, W. W. (1991). Shooting galleries and HIV disease:Variations in places for injecting drugs. Crime and Delinquency 37: 64-85.Page,J.B., & Lianusa-Cestero, R. (2006). Changes in the “get-off’: social process and interventionin risklocales. Substance Use & Misuse, 41: 1017-28.Petrar, S., Kerr, T., Tyndall, M.W., Zhang, R., Montaner, J.S., & Wood, F. (2007). Injectiondrug users’perceptions regarding use of a medically supervised safer injection facility.Addictive Behaviors, 32,1088-1093.Rhodes, T. (1997). Risk theory in epidemic times: sex, drugs, and the social organizationof ‘riskbehaviour’. Sociology of Health and Illness, 19(2): 208-227.Rhodes, T. (2002). The ‘risk’ environment: A framework for understanding and reducingdrug relatedharm. 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American Journal of Public Health, 90(7): 1049-56.Small, W., Kerr, T., Charette,J.,Schechter, M., & Spittal, P. (2006). Impacts of intensified police activity oninjection drug users: Evidence from an ethnographic investigation. International Journal of DrugPolicy, 17: 85-95.Small, W., Wood, E., Fairbairn, N., Montaner,J.,& Kerr, T. (2006). Injection drug users’ reasons forattending North America’s first medically supervised safer injecting facility. XV1 InternationalAIDS Conference, Toronto, Canada.Small, W., Wood, E., Jurgens, R., & Kerr, T. (2005). Injection Drug Use, HIV/AIDS AND Incarceration:Evidence from the Vancouver Injection Drug Users Study (VIDUS). HIV/AIDS Policy Law Review,10(3): 5-10.Smyth, B. P., Barry,J.,& Keenan, E. (2005). Irish injecting drug users and hepatitis C: the importance ofthe social context of injecting. International Journal of Epidemiology, 34(1): 166-72.Spittal, P., Small, W., Laliberte, N., Johnson, C., Wood, E., & Schechter, M.T. (2004). How otherwise wellmeaning exchange agents can contribute to limited sterile syringe availability in Vancouver,Canada. International Journal of Drug Policy, 15: 36-45.Suh, T., Mandell, W., Latkin, C., & Kim,J.(1997). Social network characteristics and injecting HIV-riskbehaviors among street injection drug users. Drug & Alcohol Dependence, 47(2): 137-43.Taylor, A., Cusick, L., Kimber,J.,Hickman, M., & Rhodes, T. (2006). The social impactof public injecting.York, Joseph Rowntree Foundation.Weeks, M. R., Clair, S., Singer, M., Radda, K. E., Schensul,J.,Wilson, D. S., et al. (2001). High risk druguse sites, meaning and practice: Implications for AIDS prevention. Journalof Drug Issues, 31(1):781-808.Wood, E., & Kerr, T. (2006). What do you do when you hit rock bottom? Respondingto drugs in the Cityof Vancouver. International Journal of Drug Policy, 17(2): 55-60.Wood, E., Kerr, T., Lloyd-Smith, E., Buchner, C., Marsh, D. C., Montaner,J.S., et al. (2004). Methodologyfor evaluating Insite: Canadas first medically supervised safer injectionfacility for injection drugusers. Harm Reduction Journal, 1(1): 9.Wood, E., Kerr, T., Small, W., Li, K., Marsh, 0. C., Montaner,J.S., et al. (2004). Changes in public orderafter the opening of a medically supervised safer injecting facility for illicitinjection drug users.Canadian Medical Association Journal, 171(7).Wood, E., Kerr, T., Small, W., Spittal, P. M., O’Shaughnessy,M. V., & Schechter, M. T. (2004).Displacement of Canada’s largest public illicit drug marketin response to a large policecrackdown. Canadian Medical Association Journal, 170, 1551-1556.Wood, E., Kerr, T., Spittal, P. M., Li, K., Small, W., Tyndall,M. W., et al. (2003). The potential public healthand community impacts of safer injecting facilities: evidence from a cohort of injection drugusers. Journal of Acquired Immune Deficiency Syndromes, 32(1): 2-8.53Wood, E., Kerr, T., Montaner, J.S., Strathdee, S.A., Wodak, A., Hankins, C.A., Schechter, M.T., & Tyndall,M.W. (2004a). Rationale for evaluating North America’s first medically supervised safer-injectingfacility. Lancet Infectious Disease, 4(5):301-6.Wood, E., Tyndall, M. W., Spittal, P. M., Li, K., Kerr, T., Hogg, R. S., et al. (2001). Unsafe injectionpractices in a cohort of injection drug users in Vancouver: could safer injecting rooms help?Canadian Medical Association Journal, 165(4): 405-10.54CHAPTER 3:RISK AND SAFETY WITHIN INJECTION SETTINGS: INJECTIONDRUG USERS’ REASONS FOR ATTENDING A SUPERVISEDINJECTINGFACILITY23.1 IntroductionPublic health research examining illicit drug usehas tended to focus on therelationship between knowledge of risk and risk avoidance,with the individual as theprimary unit of analysis (Rhodes, 1997; Rhodes, Stimson& Quirk, 1996). Critiques ofthis approach have noted that reliance on technical “objective”assessments of risk, inwhich individual behaviour is de-contextualisedfrom the environments in which itoccurs, impede the development of effective andcomprehensive intervention strategies(Rhodes et al., 1996; Duff, 2003). Rhodes’(2002) ‘risk environment’ frameworkrepresents an explicitly ecological modelof injection-related risk among injectiondrugusers (IDUs); its adoption has broughtincreased recognition of how social,structural,economic and political conditions shape boththe potential for drug-related harm,aswell as opportunities to attenuate risk(Rhodes, Singer, Bourgois, Friedman& Strathdee,2005). Risk in this framework is seento be the product of complex and dynamicinteractions between individuals andenvironments, situated within anddependentupon the contexts and structures inwhich drug use behaviour occurs(Rhodes, 2002;Rhodes et al., 2005). Although macro-levelstructural forces, such as legaland policyframeworks that criminalise druguse, represent important determinantsof healthamong IDUs (Burns et aL,2004), the role of contextual influencesoperating at themicro-level within the venues wheredrugs are injected have also becomea priority forresearch and intervention (Kerr,Kimber & Rhodes, 2007). Whileepidemiological2A version of this chapter willbe submitted for publication. Small,W., Moore, D.,Shoveller,J.,Wood, E., Kerr, T. Risk and safety withininjection settings: Injectiondrug users’ reasons for attendinga supervised injection facility.55studies have documented associations between drug-related harm and specific injectingvenues (Rhodes et al., 2005), we require improved understandings of riskbehaviourand risk perceptions in relation to specific drug use settings andsocial contexts(Rhodes, 2009).Ethnographic research has established that IDUs’ risk perceptionsare basedupon socially and culturally situated knowledge (Bourgois, 1998; Moore,2004; Rhodes,1995), emerging from lived experience (Connors, 1992).Injection-related health risks,including HIV infection and overdose, are understoodin relation to the “everydayrisks” that characterize the lives of injectors includingpotential for arrest, incarceration,losing drugs to police or predators, drug withdrawal,as well as multiple forms ofviolence (Connors, 1992; Bourgois, 1998).The concept of “situated rationality” has beenutilized to explicate the high-risk behavioursof drug users, which may be viewedasadaptive strategies employed by highly marginalizedindividuals to manage multipleand sometimes competing forms of risk (Bourgois,1999; Connors, 1992; Moore, 2005).Within the “cultural logics” of these injectors,some high-risk practices afford anopportunity to mediate exposure to otherforms of everyday risk (Bourgois,1998). Forexample, when injecting in outdoor settings, hurryingthe injection process may reducethe chance of arrest or assault, but increase therisk of overdose or injection-relatedinfections (Maher & Dixon, 1999). Salient risk prioritiesamong drug users are sociallyand culturally mediated (Rhodes et al., 1996)and the effectiveness of public healthinitiatives targeting IDUs is hindered whenthese initiatives fail to incorporateconsideration of the lived experienceof drug users (Bourgois, 1998; Moore,2004).3.1.1 IDU perceptions of risk and safety withininjection settingsMicro-environments where drugsare injected (i.e., injection settings)play aunique role in the social-structuralproduction of injection-related risk(Rhodes et at,562005) and represent a key location for interventions seekingto reduce drug-relatedharm (Rhodes et al., 2006; Weeks et al., 2001). Injection settings consistof the immediatephysical environment and social context in which consumption occurs,but are alsoinfluenced by the wider socio-cultural context (Moore, 1993), includingpublic healthinterventions and public discourses regarding drug use (Rhodeset al., 2006). The socialand physical context of injection settings shape potential forharm by either facilitatingrisk reduction practices or limiting individual abilityto adopt risk reduction strategies(Rhodes, 2002; Rhodes et al., 2005; Page, 1990). Potentialfor harm in these venues isheavily influenced by the availability of HIV preventionmaterials, such as sterilesyringes, at both the neighbourhood level (Singeret al., 2000) and within the settingswhere drugs are injected (Page, 1990; Ouelletet al., 1991).Ethnographic research examining specific injectionsettings suggests that thesevenues represent an important site where IDUsnavigate the potential for drug relatedharm, and attempt to balance competingforms of risk (Dovey, Fitzgerald & Choi, 2001;Rhodes et al. 2006; Duff, 2003). For example, whilesome IDUs recognize that “shootinggallery” settings may hold increased potentialfor exposure to HIV (Page, Smith,&Kane, 1998), these venues function to provideIDUs with an off-street location forinjecting, which may conferan element of “safety” by mediating the riskof arrest orstreet violence (Ouellet, Jimenez, Johnson& Wiebel, 1991; Parkin & Coomber,2009;Page, Smith & Kane 1998). Similarly,injectors try to balance competingforms of riskwhen injecting in public venues, managinginjection-related risks and the potentialforencounters with the police, losing drugsto confiscation or predators, and street violence(Small et al., 2007: Rhodes, et al., 2006).573.1.2 Environmental interventions and Supervised Injection Facilities (SIFs)Recognition of the limits of behavioural and educational interventions to reducedrug-related harm has led to increased interest in “environmental” interventions whichseek to modify contextual factors surrounding drug use behaviour (Rhodeset al., 2006;Moore & Dietze, 2005). These types of interventions are not intendedto replaceinitiatives encouraging individual behaviour change, but rather seekto complementeducational efforts by creating environments that “enable” individuals to adopt risk-reduction strategies (Moore & Dietze, 2005). “Safer injectionenvironmentinterventions” represent explicit attempts to alter contextualfeatures to reduce risk invenues where drugs are injected (Rhodes et al., 2006)and include efforts targetingexisting injection settings as well as the creation of purpose-built drugconsumptionvenues. Both approaches seek to minimize “the likelihood ofpolice or publicinterference, the disruption of injecting safety and hygiene routinesand the need forhurried or hasty injection” (Rhodes et al., 2006),while maximizing opportunities forreducing injection-related risk by enhancingthe availability of sterile injectingequipment, sterile water, adequate lighting, cleanworking surfaces, and syringedisposal. Supervised injection facilities (SIFs) arepurpose-built, and sanctioned, venueswhere IDUs can inject pre-obtained drugsunder the supervision of healthcare staffwithin a hygienic environment (Hedrich,2004; Kimber, Dolan & Wodak, 2005). Theearliest SIFs were established in Switzerland,Germany and the Netherlands (Hedrich,2004). North America’s first and to-date onlySIF, Insite, was established in Vancouver,Canada, in September 2003.3.1.3 Injection drug use settings within Vancouver’sDowntown EastsideVancouver’s Downtown Eastside (DTES) has historicallybeen the centre of thecity’s open drug scene, and high levels of addiction,homelessness, and mental illnesscharacterize the neighbourhood (Wood & Kerr,2006). Within the DTES, injecting58behaviour occurs within three primary types of injection settings: public injectionsettings (located in streets, alleyways and parks), single-room occupancy (SRO) hotels,and Insite (the local SIF).Public injection settings are often utilized by individuals who are homeless, lackaccess to private space, reside outside the DTES, desire to consume drugs at the point ofpurchase, or who cannot inject within their living quarters (Small et al., 2007). Thesepublic settings are generally unsanitary and local injectors perceive them to bedangerous injection settings (Small et al, 2007). Many local injectors require helpinjecting and rely on other drug users to manually administer injections (O’Connell etal., 2005). These individuals often receive assistance with injecting withinpublic settingsfrom so-called “hit doctors” and frequently provide paymentfor the service with ashare of drugs or a small amount of money. Injecting also takes placewithin the smallnumber of public washrooms that exist in the area,as well as the washrooms of localservices and businesses, although proprietors actively discourageinjecting in thesevenues.Large numbers of injectors live withinsubstandard accommodation in SROhotels, and a substantial proportion of injections havecustomarily occurred in thesesettings (Shannon, Ishida, Lai & Tyndall, 2006).Residents and guests regularly inject inthese rooms, and visitors may gain access forthe purpose of injecting on the basis of asocial relationship, as well as through the provisionof a share of drugs. Access to someparticular SRO hotels is limited by rules prohibitingvisitors during specific hours, and“guest fees” which require visitors to pay for entryto the building (O’Shaughnessy,2009).Insite, Vancouver’s SIF, is open 18 hours aday and operates from lOAM to 4AM,365 days a year. The facility is a three-stageclinical-model SIF (Broadhead et al, 2002)consisting of a reception area and waiting room,an injecting room (with 12 individual59injection “booths”), and a “chill-out” lounge where clients can spend time priortoexiting to the street (Wood et al., 2006). Within the SIF, nurses are present at all times tosupervise injections, intervene in overdoses, provide education regarding safer injectiontechniques and guidance with the injection process, as well as to provide nursing careto IDUs attending the facility (Wood et al., 2006). Regulations governing the facilityprohibit the sharing of drugs between clients and assisted injections, requiring clients toself-administer injections. Insite operates at full capacity with over 500 injectionsoccurring within the facility on a daily basis (Tyndall et al., 2006). Line-ups to accessaninjecting booth are common due to the heavy demand for theinjecting room.3.1.4 Study purposeWhile ongoing evaluations suggest that SIFs generate avariety of health andcommunity benefits (Hedrich, 2004; MSIC Evaluation Committee,2003; Wood et al.,2006), most research has utilized conventionalepidemiological approaches (primarilyusing quantitative methodologies), with onlya few qualitative studies examining theperspectives and experiences of 1DUs regarding Vancouver’sSIF (Kerr et al., 2008;Fairbairn, Small, Shannon, Wood & Kerr, 2008).In light of the importance of SIFsas anenvironmental intervention and the novelty of thistype of injection setting in the NorthAmerican context, the current study usedqualitative methods to examine IDUs’motivations for injecting within the VancouverSIF and to discuss how the supervisedinjection setting is perceived to mediate experiencesof risk and safety when injectingdrugs.3.2 MethodsIn order to gather data regarding IDUs’ reasonsfor attending Insite, 50 in-depthindividual interviews with SIF clients wereconducted. Interviewees were recruitedfrom the Scientific Evaluationof Supervised Injecting (SEOSI) cohort, whichis60composed of over 1000 randomly selected SIF users in Vancouver andis representativeof the population of IDUs who use the SIF (Wood et al., 2006). Between November2005and February 2006, SEOSI cohort members were invited to participatein an in-depthinterview. Quota sampling techniques were employedto ensure that the interviewsample included male (n=28) and female (n=21) IDUs, as wellas Aboriginal (n= 13) andnon-Aboriginal (n= 37) participants. Recruiting efforts for in-depthinterviews yielded asample that reflected the socio-demographic profile of the local populationof SIF usersand included individuals with differing levels of SIFutilization (Tyndall et al., 2006).Interviews were undertaken in a private research office,located a few blocksfrom the SIF, and were conducted by three separate interviewers(two male and onefemale). Interview questions were open-ended andan interview guide was used toencourage discussion of various topics, including:SIF use, reasons for using the facility,barriers to attending the SIF, as well as injectionpractices when injecting within thefacility. All interview participants were askedwhy they chose to inject at the SIF andfurther questions elicited a full accountof their reasons for selecting the SIFas a settingfor injection. The interview guide also containedquestions that asked participants todescribe situations when they chose to injectelsewhere as well as to provide detaileddescriptions of their perspectives on the SIFand other injection settings. Interviewslasted 40-80 minutes, were audio-recorded,and later transcribed verbatim.The content of the interviewswas reviewed throughout the data collectionprocess, thus informing the focus ofsubsequent interviews as well as thedevelopmentof a coding scheme for categorisingthe data. All text segments relatedto reasons forusing the SIF, characteristics ofthe supervised injection setting, andreasons forinjecting in locations other than theSIF were catalogued. This analysis presentsexcerptsfrom the interview datato illustrate motivations for attendingthe SIF and how it wasperceived to mediate experiencesof risk.61Additional data collected during ethnographic fieldwork regarding the localdrug scene and key injection settings conducted by the first author (WS), was used tofurther contextualise interview data. A detailed account of the ethnographicobservational data gathered in public injection setting and the SIFis provided inChapter 2 and Chapter 4 respectively, although a brief overview of the techniquesusedfollows here. The ethnographic fieldwork investigated the physical environmentandsocial context characterizing drug use settings in the DTES through direct observationof injecting behaviour within DTES public injection settingsand Insite.3.2.1 EthicsApproval to conduct the interviews and ethnographicfieldwork was granted bythe Providence Health Care/University of British ColumbiaResearch Ethics Board. Allinterview participants provided written informedconsent.3.3 Findings3.3.1 Interview participantsThe sample of interview participants was composed of21 women, 28 men andone transgendered individual. The age of participantsranged from 25 to 60 years, andthe median age of participants was 38.Table 1 illustrates the demographiccharacteristics of the interview participants incomparison to the overall group of IDUsenrolled in the SEOSI cohort. Table 1 alsoprovides details regarding the drugmostfrequently used, education, housingstatus, and estimated monthly expenditureondrugs among interviewees. All interview participantshad previously used the SIF,withthe majority of participants (39individuals, 78% of interviewees) performingmore than25% of their injections within thefacility during the past 6 months.623.3.2 The injection setting provided by the SIFReported reasons and motivations for injecting at the SIF were related to:accessing an alternative to injecting within public and private venues, mediatinginjection-related health risks, the sanctioned nature of the injection setting, the regulatedinjection environment, and mediating multiple hazards which characterizeunsupervised injection settings.3.3.3 An alternative to injecting in public and private venuesIn the local setting where large numbers of injectors regularly inject outdoorsinpublic spaces, the ability to inject within an indoor, off-street location wasa primarymotivation for utilizing the SIF. Many participants reportedusing the SIF because theywere homeless, and the clean, indoor environment of the SIFwas often contrasted withthe experience of injecting outdoors. The following outlines thereasons for injecting atthe SIF described by one 43 year old female drug user whoprimarily injects speedballs(a combination of cocaine and heroin), illustrating how it isperceived to be a moresuitable injection setting than local public injectionvenues:Because I don’t have a place. Because it’s safer[...]And morecomfortable. It’s cold out; you can’t get a veinin the cold. Like, it’sjust safer, it’s cleaner. [Female Participant# 11]Additionally, accessing the injection settingat the SIF was reported to provide analternative to injecting within private residencesbelonging to other individuals.Injecting in another person’s private residencewas perceived to be problematic duetothe expectation that visitors will provide a shareof drugs in exchange for access to thevenue, and social conventions whichprescribe sharing drugs with other people whomay be present:I prefer to use Insite due to the fact thata lot of my friends don’t useneedles. And if they do I don’t feelright going there [friend’s63residence] because... y’know, “house favours” or whatever. It’salways polite to offer half or at least something. But I don’t havethat money to be offering it every time, so with Insite everybody’sgot their own dope. [Female Participant # 38 - 28yrs old, injectsspeedballs, currently homeless]The above description emphasises that within the SIF, the obligation to sharedrugs is eliminated, which some participants perceived to be a benefit of the supervisedenvironment. The ability to inject at the SIF without paying forentry is viewed as beinga beneficial alternative to injecting within the private residences belongingto others, asusers often lack the resources necessary to compensate others foraccess to private spaceor fulfil expectations regarding the sharing of drugs.3.3.4 Reducing injection-related health risksThe availability of sterile syringes and ancillary injecting equipment,and theassociated perception that injecting within the SIF reducedthe potential for blood-bornevirus transmission, were frequently cited asa reason for injecting within the facility.The following quote, from a 47-year-oldmale who primarily injects heroin, suggeststhat users of the SIF recognise that the supplyof sterile syringes and other injectionequipment reduces the potential for infection withblood-borne viruses:Well, you’re not likely to catch AIDS. [...]And hepatitisC, I don’tsee how you could get it there. You’re usingall sterile equipment.[Male Participant #35]The physical environment and regulations,which permit only one persontoinject within each injection boothand require that each booth be cleaned by SIFstaffbefore the next individual can enter, were perceivedto eliminate the potential ofunknowingly utilizing another person’s syringe:I’m not around people. There’s nopossibility of sharing [syringes]or getting anything mixed up. [MaleParticipant # 18 - 26 years old,primarily injects heroin]64The segregation of injecting behaviour into individual spaces was seen asanother mechanism through which the SIF reduces the potential for blood-borne virustransmission. Although there are other drug users present in the facility’s waiting areaand in other booths, participants often characterised their injections within the SIF asinjecting in “isolation”, emphasising that the social interactions that normally surroundinjecting are altered. While this was perceived to reduce the potential for blood-bornevirus transmission, others reported a preference for social interactions during injectingand viewed the individual booths as a negative aspect of the injection setting at the SIF.Participants often acknowledged that injecting alone in publicand privateinjection settings reduces the potential to be assisted in the event of an overdose, andparticipants frequently reported that medical supervision was areason why theyinjected at the SIF:I prefer the Insite because there’s staff[...]I’ve had overdoses in thepast, and I know there’s nurses there in case I overdose... [FemaleParticipant # 21]The above comment from a 34-year-old female, wholives in a house and injectsboth heroin and cocaine, highlights the importanceof nurse supervision and theemergency response provided in the case of an opiateoverdose, within motivations forinjecting at the facility. The emergency nursingresponse, including the injection ofNaloxone (Narcan), was seen to reduce the potentialfor a fatal opiate overdose as wellas the harm resulting from a non-fatal overdose.In addition to managing overdoses, nurseswithin the injection room alsoprovide safer injection education, and they oftenguide clients through difficulties withthe injection process and assist with venousaccess:Yeah, yeah I mean, if you ever need any information,or sometimesI have a hard time fixing, right? And I mean,they don’t do it for65you, but they help me, y’know, “Okay, try a different vein,” orwhatever, right? Y’know, it’s just very good for information.[Female Participant #12- 44 years old, regularly injects cocaine]Information about injection techniques and guidance with the injection processwas reported to be another reason that the SIF was preferred over other injectionsetting.3.3.5 Sanctioned injecting environmentThe government granted the SIF an exemption from the Canadian ControlledDrugs and Substances Act (CDSA), which allows it to operate legallyand protectsparticipants from charges of drug possession. This is a key characteristicof the injectionsetting provided at the SIF, and many participants reported that they injectedat the SIFbecause they would not encounter the police, orbe arrested for consuming drugs.Potential for arrest or encounters with police within othertypes of injection settingswere a major concern for IDU, and participants emphasizedthat the SIF represents aunique type of injection setting because consumptionactivities are permitted under thelaw:Because it’s off the street and I know that the policeare not going tointerrupt me in the middle of my injectionand take my drugsaway.[...]And by going — as soon as I go through those doorsatthe SIS [Insite], I know that there’s... an understandingbetweenlaw enforcement and the people that run it that theseinjection drugusers are safe here. And I know I’mnot having my drugs takenaway, and that means a lot to me as a druguser. [Male Participant# 17—48 years old, injects heroin]Beyond the potential for arrest, the risksinvolved in encountering the police alsoinvolved the confiscation of drugs,which represents the loss of a scarce resourceforinjectors. Having drugs confiscatedby the police was an important form of “everyday”risk attributed to public injection settings inlocal alleys, in part because losingdrugsmay precipitate withdrawal symptomsin the near future:66It’s fucking tense in the alley because... what if you get busted byan asshole cop. He’s going to take your dope or fucking makeyousquirt it out or whatever. Step on your rig. You’re fucked. You werejust working all day to make ten bucks to get your fix. [MaleParticipant # 25 - 47 years old, primarily injects heroin]In addition to precluding encounters with the police, the SIF was also seenas the“correct” place to inject, rather than injecting in public spaces orwithin indoor venueswhere drug consumption is prohibited (e.g., communityservices for drug users) orproblematic (e.g., a friends’ residence):I don’t have a home. I didn’t have friends that had places,and evenif they did, normally I don’t feel comfortable...[.. .1I did not haveanother option. And I’m not saying I use Insite justbecause it’snow another option, I’m using Insite because it’s theway to do itproperly. That’s the reason I use Insite.Because it’s not the alley.[Male Participant # 27- 26 years old, primarilyinjects heroin]The SIF was seen as an injection setting that mediatesinjection-related healthrisks by facilitating injecting ‘properly’ rather thaninjecting in an unsafe mannerorsetting. Participants also referred to attending theSIF as being “the proper thing to do”(Male Participant #13). For example, a numberof participants emphasised thattheyinject within the SIF because it does not exposelocal residents and the generalpublic totheir injecting behaviour. Engagingwith the SIF was characterised as the“responsible”thing for injectors to do.3.3.6 Regulated environmentThe fact that the supervised injectionsetting at the SIF is a regulatedenvironment, and “not the street”,was frequently cited as a reasonfor attending thefacility. Most participants reportedthe SIF environment to be calm, stableand “hassle-free”:It’s nice and calm. The staff arereally helpful and good and stuff.Y’know? There’s never any big riotsor chaos going on. Once in a67while, you get people arguing and stuff like that, but otherwise, it’sa nice environment, I find. I think it’s a safe place. [FemaleParticipant # 23 — 29 years old, injects cocaine and crystalmethamphetamine]The SIF provides an alternative to the potentially unpredictable character ofpublic injection settings, where conflict and violence can quickly emerge:‘cause a lot of stuff that happens on the street, it’s like, they [clients]have street beefs and, y’know, if they run into each other there, andthey start arguing with one another there. That gets shut downright away. If it does [start], it gets shut down real quick. So it’s anice thing.[...] Another safety factor for people there. [MaleParticipant # 40 — 31 years old, primarily injects speed]A primary motivation for injecting within the regulated injection environment isthat it is perceived to effectively mediate the potential for violence orrobbery. This wasespecially important in the perspectives of female participants,who frequentlydescribed how injecting at Insite eliminated concerns regardingbeing attacked orrobbed.Regulations prohibiting drug sharing and passingdrugs to other clients, coupledwith the presence of staff, were reported to eliminate the potential forattempts to obtaindrugs through begging, coercion or intimidation(often referred to as ‘grinding’):Well, it’s, I feel safe there. Very safe there,and I’m not worriedabout people robbing me. I mean, I’ve beendown here fifteenyears and still, I get people who try to grind you for yourdope[...]Like, they’re lookin’ at you and they’re waitingfor you. And it’speople you see every day, y’know? [FemaleParticipant # 12 — 44years old, primarily injects cocaine]The regulated setting at the SIF was viewedas having altered the social relationsthat normally surround injecting, providingtemporary relief from exploitative streetrelationships and “grinding”. This aspect of the regulatedsetting was discussed by bothmale and female participants, but was moreprominent in the narratives of female drug68users. They described how male drug users often attempt to expropriatetheir drugswithin unsupervised injection settings, althoughit was acknowledged that theseinteractions continued to occur outside of the facility.While the regulated injection setting was often cited as a positive aspectof theSIF environment, some participants viewed the specific regulationsplaced onbehaviour negatively. The rules governing thefacility’s operation were largelyperceived as being “reasonable”; however, some participantsexpressed the opinion thatthe facility placed too many constraints on behaviour orwas “too institutional”. Forexample, regulations that prohibit sharingdrugs among clients and assisted injections(which are common practices among local injectors) wereviewed by some as beingoverly restrictive. The enforcement of site rulesand the monitoring of clients who areheavily intoxicated also evoked descriptionsof negative interactions with staffinrelation to the surveillance of clients and client behaviour.This suggests that SIF clientsmay endorse specific aspects of the regulatedenvironment, or agree with the rulesinprinciple, but that there are challengesinherent in the regulation of IDUs’behaviourwithin the facility (see Chapter4).3.3.7 A “safer” environment: mediatingthe risks associated with other injectionsettingsThe perception that the SIF mediates multipleforms of hazard is reflected inrepeated references to “safety”, andbeing “safer”, as the motivation forattending theSIF:The safety is just generalized forcops, for people taking your dope,for just doing it wrong and not havinghelp if I overdose. Just safetyin general. [Male Participant # 27—26 years old, injects heroin]As employed by participants, theterm “safe” encompasses health andhygiene,personal security from violence,as well as protection from legalprosecution.Participant narratives include frequentreferences to the ways in whichthe SIF69addresses multiple forms of everyday risk, and identified how specific features of theinjection setting mediate risk:It’s safe and comfortable. And you don’t have to worryabout.. . getting ripped off, or disturbed, or not preparing your doperight.[.. .1all the supplies you need are there, and there’s peoplewho have medical training who can help you if you’re in trouble.There’s a lot of reasons... I know that if I go in there, I don’t have toworry about all those things. [Male Participant #48- 47 years old,injects heroin]Participants described how the SIF addresses a constellationof hazardsassociated with injecting drugs in unsupervised settings, and while participantsrecognized that the SIF did not provide unconditional safety frominjection-relatedrisks, motivations reported for using the SIF often referred to the reductionof multipleforms of risk.3.3.8 A contextualised view of risks and safety: constraintson ability to utiise the SIFSome participants explicitly described their risk priorities in relationto theselection of an injection setting, and the narrativeof this 26-year-old male who injectsheroin highlights how the SIF enables the avoidance of multiplehazards associatedwith injection in public settings, including losingdrugs and being arrested:R: If I want to use safely, and I want to, that’s whatI gotta do [go tothe SIF]. If I want to risk going in an alley and riskall the otherthings that go along with it, that’s my choice. My choiceis to waitin the line-up and...I: You’ve never found yourself in a situation whereyou’re reallydopesick orR: Yeah, I have. But I still chose to y’know stickit out and bite thebullet [wait], and that’s it. I’d be rather dopesickfor that extra tenor fifteen minutes [during the wait] thango in an alley and windup having my dope taken away. Maybe be dopesickand go to jail.Y’know. It just... common sense, I guess.To me it is. [MaleParticipant # 27— 26 years old, injects heroin]70This individual described choosing to inject at the SIF, despite the inconvenienceof waiting to access the injection room and the discomfort of heroin withdrawal,representing it as a “rational” decision based upon avoidance of the risks relatedtoinjecting in public. It is important to note that the above narrative, describingacalculation of costs and benefits, perhaps downplays the significance of factorsthatconstrain individual ability to attend the SIF. Participants frequentlyreported thatinjecting at the SIF was beneficial in a number of ways, and “worth the wait”,but that anumber of imperatives often resulted in selecting another venue for injection.Forces reducing individual ability to inject within the SIF were describedasbeing biological (being in opiate withdrawal), psychological(the desire to inject cocaineimmediately, situations where they wantedto enjoy an intense heroin high), social(wanting to inject together with friends), as wellas being related to features of thefacility (the wait to access the injection room) includingregulations (being unable toshare jointly purchased drugs or receive assistedinjection). These dynamics indicatethat while injecting at SIF addresses importantrisk priorities among IDUs and offersnumerous practical advantages, ability to injectat the SIF is constrained by bothimperatives related to street-based drug use aswell operational and programmaticfeatures of the facility itself.3.4 DiscussionThis study documented the perspectivesof SIF users on the reasons why theyinject at Vancouver’s SIF and described theirsituated risk perceptions regarding theinjection setting within the facility,as well as the injection settings outside of it.IDUparticipating in this study reportedthat they inject at the SIF because it providesanalternative to public and private injectionsettings. The medical supervision andsterileinjecting equipment providedat the SIF were seen to reduce the health risks stemming71from injection including overdose and blood-borne virus infection. The fact that thesanctioned injection setting eliminates the potential for arrest or encounters with thepolice was an important motivation for attending the SIF. In addition the SIF wasperceived as the “proper” venue for injecting, in order to reduce health risksas well asto relocate injection behaviour from public settings. Participant accounts alsoemphasized that the regulated environment at the SIF provided protection fromstreetviolence, being robbed, and having drugs expropriated or confiscated, althoughsomeparticipants found that the SIF placed too many constraints on their behaviour.3.4.1 Protecting health and keeping safeSIF users perceived Insite to be ‘safer’ than the other venues wheretheycustomarily inject. While public health perspectives regarding thesafety conferred bythe supervised environment relate to reduced potential for drug-relatedharm includingblood-borne virus infection and overdose, IDU perceptionsof safety focus uponprotection from a wider range of hazards consistingof health risks related to injectingas well as everyday risks including violence, arrest, criminalprosecution and loss ofdrugs. While reducing injection-related health riskswas an important component ofIDUs’ reported motivations for injecting at theSIF, participants in this study alsoarticulated non-health reasons, including mediatinglegal and personal risks related tounsupervised injection settings, more frequentlythan health issues. Some dimensions ofthe safety provided by the injection setting at theSIF are created because the facilityfundamentally alters the social relations andthe social context surrounding injection(Kerr et al, 2007; Fairbairn et al., 2008). Regularuse of the SIF has been associated withimprovements in injection practices, including cookingand filtering drug solutions aspart of the preparation process and reduced occurrenceof “rushed” injecting (Stoltz etal., 2007); injection of drugs within settingswhere there is reduced potential for72interruption have been associated with reductions in injection-related risk among street-based IDU (Koester et al, 2005). The provision of sterile syringes and the individualinjection booths at the SIF also reduce the potential for unintentional syringe sharingthat may occur when groups of injectors engage in intense cocaine use (Tyndall, 2003),when syringes are stored or hidden in public settings for future use (Small et al., 2006;Rhodes et aL, 2005), or in shooting galleries when a used syringe is presentedas ‘new’(Page, 1990).Gender appears to be an important influence on the ways in which the SIFwasperceived to mitigate violence against IDUs. Avoiding encounters withthe police,which may involve violence, confiscation of drugs, arrestor incarceration, featuredstrongly in the interviews with male participants. The salienceof this form of hazard formale IDUs is likely related to the higher prevalence of criminaljustice involvement(Milloy et al., 2008) and lifetime experience of violentencounters with police amongmale IDUs in the local context when compared to femaleIDUs (Marshall et al., 2008).While both male and female drug users identified theloss of drugs as representingakey risk related to unsupervised injection settings,the ability to reduce the likelihoodthat a scarce resource will be expropriated through violence orintimidation representsan important benefit of using the SIF withinthe narratives of female participants.Within street—based drug injection settings, femaleIDUs are often victimized andexploited by male drug users (Bourgois, Prince& Moss, 2004). Injecting within the SIFappears to provide some relief from the violencecharacterizing street-based drugscenes for female IDUs (Fairbairn et al, 2008). Thecurrent study indicates that violenceis also a concern for male drug users, particularlyviolent interactions with the police.Epidemiological research indicates thata large proportion of local IDUs havehistorically participated in public injecting,especially those who are homeless orwholack access to privatespace, and commonly employ unsafe injection practices (DeBeck73et al., 2008b), . IDUs in this locale perceive public injection settings to be dangerousandan ansuitable venue for injecting (Small et a!., 2007) and indicated thatthey are willingto navigate some important programmatic and operational barriers (e.g.,wait-times andspecific operating regulations) in order to access a suitable alternativeat the SIF.3.4.2 Social and spatial relationsOverall, the SIF was perceived to fit withinthe cultural logics of street-basedinjectors by providing an acceptable and appropriateplace to inject, although someparticipants viewed the differences between thesocial and spatial relations within theSIF and public injection settings negatively. Forthem, the regulated environment couldnot accommodate a number of customarypractices common among local drug users,particularly sharing drugs and assisted injections.Additionally, the enforcementofregulations and the monitoring of drug usersbehaviour by SIF staff were alsoa sourceof tension according to the accounts ofsome participants. While these findings pointtoa divergence between insider and outsider viewsof the risks related to the settingswhere drugs are injected, the currentstudy also draws attention to theimpacts the SIFis having on the wider risk environmentin the DTES and the cultural logicsof localIDUs.Strategies customarily employed byIDU to manage the risks related to overdose,violence, and robbery in street-baseddrug scene of the DTES involve usingdrugstogether with other individualsas well as engagement witha ‘running partner’3(Connors, 1992; Bourgois, 1998). For femaledrug users, engagement with intimatemalepartners offers some “protection” withinstreet settings, and these male partnersoftenprovide assistance with injection(Bourgois, Prince, & Moss, 2004).The studyAn individual who regularlyparticipates in joint income generationand drugconsumption activities is often calleda ‘running partner’.74participants described how the SIF re-structures the social relationssurroundinginjection and indicated that they feel “alone” or “isolated” wheninjecting at the SIF.What remains unclear is how the alterations in social relationshipswithin the SIF might‘spill over’ into the street, as only a fraction of an IDU’sday is spent within the SIF. Forexample, income generation and obtaining drugs continuesto take place in street-basedsettings. Additionally, many IDUs require manual assistancewith injection and rely onother drug users to deliver assisted injections outsidethe SIF (Rhodes et al., 2006). Eachof these activities (which occur outside of the SIF)is deeply embedded in the social andspatial arrangements of the street.3.4.3 On being ‘responsible’SIFs represent a drug consumption environmentbuilt within a health and legalframework that is heavily influenced by neo-liberalconcepts emphasizing the role ofthe individual as being responsible forprotecting health (Fischer, Turnbull, Poland&Haydon, 2004). However, few examinations haveconsidered how power relations andwider neo-liberal discourses shapeIDUs’ experiences with these facilities.SIFs, to anextent, reflect neo-liberal concepts andvalues, and similar to other harm reductionandpublic health programs targeting IDUs(e.g., needle exchange, methadone therapy),their operation often emphasises the productionof “responsible” subjects (Moore, 2009;Campbell & Shaw, 2008). The operationof these programs occurs in a context wherepublic discourses serve to construct drug usersas “disorderly” and “chaotic” (Fraser&Moore, 2008), denying these individualsthe capacity for rational actiondue to theirdrug use and seemingly “irrational”behaviours. Drug users frequentlyendorse andpractice harm reduction strategies(Campbell & Shaw, 2008), but theircommentsregarding these programs are oftenconnected to wider discourses surroundingdruguse and drug users. Police, publichealth, outreach, and communitycampaigns75operating in the DTES have targeted IDUs (particularly public injectors) andencouraged them to relocate their injecting behaviour to the SIF (DeBeck et al, 2008). Asinjecting at Insite becomes established as the “proper thing to do”, so too might theconcepts of rationality and responsibility gain strength in public discourse regardinginjection drug use — potentially permitting the identification of a “responsible” druguser (and conversely the social construction of “irresponsible” drug users). Within sucha context, we risk diverting attention from the social and structural forces that drivedrug-related practices and unintentionally perpetuate stigmatisation of those who aredeemed to be “irresponsible”.The narratives of study participants also sometimes reflected their adoption ofthe language of service-providers, although in many cases the IDU employed thislanguage for their own purposes (Moore, 2009). Participant narratives regarding themediation of health risks (addressing blood-borne virus transmission andoverdose)reflect elements of public discourse surrounding Insite and may represent an element of“strategic accommodation”. Strategic accommodation maybe employed as a strategy toestablish identification as a responsible drug user, who utilises andcomplies with apublic health program (Moore, 2009). Juxtaposing the orderlinessof the SIF withdisorderly public injection settings may have helped somestudy participants toposition themselves as responsible people and to distance their self-perceptionsfromthe “chaos” of public injection settings. Few of the narratives referredto the ways inwhich “disorderly” public injection settings are shapedby particular priorities andimperatives, which are dissonant with neo-liberal values(Moore, 2009).Public health strategies targeting IDUs also areoften built upon assumptionsregarding rational decision-making, prioritizing health risks over othereveryday formsof hazard, which impedes the uptake and effectivenessof risk reduction initiativeswhen these health priorities do not “fit” with the lived experienceof drug users76(Bourgois, 2002; Moore, 2004). It also has been argued that when exploring motivationsfor specific drug use practices, including selecting a venue for injection, there is a needto go beyond understanding these actions as being shaped by rational “cost-benefit”calculations in order to recognize the biological, social, cognitive and emotionaldimensions involved (Measham, 2004). Discourses that represent SIF use as an obviousand common-sense decision are derived from an ontological position that constructsthedecision of where one injects drugs as a rational choice, potentially minimising the roleof other salient considerations related to injection practices in the everyday lives ofIDUs.3.4.4 LimitationsThe data presented here details the perceptions of a sample of 50 SIFclients anddoes not include individuals who did not previously use the facility.3.5 ConclusionWhile previous epidemiological research has documented the impactof the SIFupon injection-related risk, this study suggeststhat IDUs inject at the facility because itaddresses multiple salient risk priorities, includingbut not limited to health concerns.This analysis highlights the importance of takingthe perspectives of IDUs intoconsideration, while it also underscores thecontradictions inherent in public healthprograms seeking to reduce drug-related harm.Public health programs targeting IDUsoften attempt to operate in a low-thresholdmanner, or meet people ‘where theyare at’,and the value of this approach is well recognised.However, in the process ofattempting to bring about individual behaviourchange, these programs routinelysubject drug users to various forms of regulationthat emphasise the adoption of‘responsible’ behaviour among IDUs. Public discoursesthat construct negative healthoutcomes stemming from injection druguse as the result of ‘irrational’ and77‘irresponsible’ behaviour, which are in part shaped by public health initiatives,serve tocomplicate interactions and encounters between drug users and programswhich seekto facilitate risk reduction and reduce drug-related harm.78Table 3.1 Characteristics of interview participants compared to members oftheSEOSI cohort (a representative sample of SIFclients)Interview SEOSI CohortCharacteristics Participants n(%);n = 1090n(%);n=50AgeMedian (mm-max) 38 (25-60)38 (19-64)GenderFemale 21 (42) 313 (29)Male 28 (56) 773 (71)Trans-gendered 1 (2) 4 (<1)Aboriginal EthnicityYes 13 (26) 211(19)Monthly Expenditure on DrugsMedian (IQR)Drug most frequently injectedHeroinMorphineCrystal MethamphetamineOtherEducationLess than High schoolAny High schoolAny CollegeHousing StatusStableUnstableOther900 (450-2000)26 (52)10 (20)6 (12)3 (6)2 (4)3 (6)19 (38)26 (52)5 (10)17(34)29 (38)4 (8)CocaineHeroin & Cocaine793.6 ReferencesBourgois, P. 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CanadianMedical AssociationJournal, 175:1399—1404.83CHAPTER 4:INJECTION DRUG USERS’ ACCESS TO A SUPERVISED INJECTIONFACILITY IN VANCOUVER, CANADA: THE INFLUENCE OFOPERATING POLICIES AND LOCAL DRUG CULTURE4.1 IntroductionIn response to the ongoing health and social harms of illicit injection drug use(Aceijas, Stimson, Hickman & Rhodes, 2004; Aceijas & Rhodes, 2007), a growingnumber of municipalities throughout the world have established supervised injectionfacilities (SIFs) (Broadhead, Kerr, Grund & Altice, 2002). SIFs are legally sanctioned,purpose-built venues where injection drug users (IDUs) can inject pre-obtained drugsunder the supervision of healthcare staff (Kimber, Dolan, van Beek, Hedrich & Zurhold,2003; Hedrich, 2004). These facilities seek to reduce drug-related overdose andtransmission of viral and bacterial infections among IDUs (Broadhead et al., 2002;Kimber et al., 2003; Kerr et al., 2007a), increase uptake of health services, and reducelevels of injecting in public spaces. SIFs seek to address the environmental andcontextual forces that fuel injection-related risk within unregulated injection settings(Broadhead et al., 2002), including “shooting galleries” and public injection settings.Within SIFs, safer injecting is facilitated through the provision of sterile syringes andancillary injecting equipment, education regarding safer injection techniques, as well asamenities such as adequate lighting, clean working surfaces, and syringe disposalservices (Rhodes et a!., 2006). In addition, these facilities provide an immediateemergency response to drug-related overdose (Broadhead et al., 2002), and alsoeliminate distractions that can serve to disrupt hygienic injecting practices, includingA version of this chapter will be submitted for publication. Small, W., Shoveller,J.,Moore, D., Tyndall, M., Kerr, T. Injection drug users’ access to a supervised injectionfacility in Vancouver, Canada: The influence of operating policies and local drugculture.84encounters with the police, which foster rushed injection practices in other types ofinjection settings (Rhodes et al., 2006).A government-sanctioned SIF, named Insite, opened in Vancouver, Canada, inSeptember 2003 (Wood et al, 2004a). To date, positive outcomes attributed totheVancouver SIF include reduced levels of public injecting in the immediate vicinity(Wood et al., 2004b), reductions in syringe sharing (Kerr et al., 2005a), and increaseduptake of detoxification and addiction treatment programs (Wood et al., 2006). Insitehas also successfully managed over 1000 overdoses since opening with nofatalities(Milloy et al., 2008).The ‘risk environment’ framework (Rhodes, 2002; Rhodes et al., 2005) emphasisesthat a range of contextual forces and programmatic features can influence accessto anduptake of conventional HIV prevention and harm reductionprograms, includingcharacteristics of the local environment and the local populationof IDUs (i.e., factorsexternal to programs), as well as operating policies and regulations(i.e., factors internalto programs). Indeed, concern has been expressed regardingthe impact of poor accessto and lack of coverage of existing HIV prevention and harmreduction programs forIDUs (Institute of Medicine, 2007), suchas needle exchange programs and drugsubstitution therapies. Previous ethnographicinvestigations have revealed how therestrictive policies of needle exchanges and methadoneprograms too often fail toconsider the day-to-day realities and practicesof IDUs (Bourgois, 2000; Bourgois&Bruneau, 2000), noting how over-regulationimpedes IDUs’ access to the HIVprevention materials provided through these programs.The emphasis on individualbehaviour change within public health programstargeting IDUs often diverts attentionfrom how social and structural factorsmay constrain the operation of harm reductionprograms as well as utilisation of programsby IDUs (Rhodes, 2002). To ensure theoptimal impact of SIFs at an individual, populationor neighbourhood level, facility85operations must be tailored to the characteristics of the local drug scene andbeaccommodating of local drug use practices (Broadhead et al., 2002;van der Poel,Bargendregt & van de Mheen, 2003). Existing evaluation research revealsa relationshipbetween intensity of SIF use and the extent of behaviour change amongIDUs using thefacility (Kimber et al., 2003; Milloy & Wood, 2009). Identifying relevantforces affectingaccess to SIFs and addressing those through service re-designand policy reform istherefore an important area of research.Insite is generally well accepted by IDUs in Vancouver(Wood et al. 2005a; Woodet al., 2006). However, emerging evidence suggests thatit is operating under conditionsthat may restrict its ability to fully meet the needs of its target population.There areconcerns that the current capacity of the facility, wait-times toenter the injecting room,and regulations governing its operation could be constrainingthe utilisation of the SIF(Kerr et al., 2007; Petrar et al., 2007; McKnight et al., 2007), althoughthe impact of thesebarriers has not yet been systematically investigated.In general, little is known abouthow macro-level contextual influencesaffect the operation of SIFs and how they shapeaccess to and coverage of such facilities.Ethnographic research techniques can provideinsight into how IDUs’ access to SIFs is shapedby policies and regulations, as well aswider social, economic and cultural structures,including those that produce complexbarriers to harm reduction among marginaliseddrug users (Moore, 2004; Moore, 2005).A contextualised understandingof the operation of Vancouver’s SIF may thereforeprovide crucial information for the optimisationand scaling-up of SIFs in Canada andelsewhere.864.2 Study Context4.2.1 Policies and legislation: the regulatory framework governing supervisedinjectionin CanadaWhile the operation of SIFs is technically illegal in Canadaas per the federalControlled Drugs and Substances Act (CDSA), a number of legal and administrativemechanisms have been employed to minimize the criminal liability relatedto operatinga SIF, including administrative agreements (between health authorities,governmentagencies, law enforcement and public prosecutors) and exemptions from the provisionsof the CDSA (Health Canada, 2002). Section 56 of the Act allows the federalMinister ofHealth to grant an exemption from all or some of its provisions, ifnecessary for medicalor scientific purposes, or if it is otherwise in the public interest(Elliot, Malkin & Gold,2002; Health Canada, 2002). The federal government opted toemploy a Section 56exemption for the scientific purpose of generating knowledgeregarding SIFs in order topermit the legal operation of Insite. This three-year exemptionprotects staff andregistered users from being charged with offences related tothe possession of drugsunder the CDSA (Health Canada, 2002) providedthat the SIF is subjected to a rigorousscientific evaluation (Health Canada, 2002). Insitewas therefore established as a small-scale pilot facility to enable the evaluation of the impact ofsupervised injection on arange of health and social outcomes (HealthCanada, 2002; Wood et a!, 2004a). TheMinisterial exemption places its operationunder strict government control anddetermines many aspects of the facility’s designand operation (Health Canada, 2002).4.3 Features of the Local Drug Scene in the DowntownEastside of VancouverWithin the City of Vancouver, injection druguse activity is highly concentratedin the Downtown Eastside (DTES) neighbourhood,where an intense HIV epidemic wasidentified in 1997 (Strathdee et al.,1997) and large numbers of IDUs died of drugoverdoses during the 1990s (Tyndall etal., 2001). The neighbourhood has been87characterised historically by an open drug scene, a large homeless population,deteriorating housing stock including dozens of single-room occupancy (SRO) hotels,and an active sex trade (Wood & Kerr, 2006). It has been estimated that approximately5,000 IDUs live in the DTES, while thousands of additional IDUs visit theneighbourhood regularly to purchase arid consume drugs (Wood & Kerr, 2006).Approximately 17% of the IDU population in the DTES are HIV positive (Tyndallet al.,2006a) and over80%are infected with the hepatitis C virus (HCV) (Wood et al., 2001).While heroin and cocaine are each commonly injected by local IDUs, cocaineinjectionhas been linked to the rapid escalation in HIV infection in thecommunity (Tyndall etal., 2003). Further, it is estimated that approximately40% of local IDUs regularly requireassistance with injections (O’Connell etal, 2005); this practice has been linked to anelevated pattern of drug-related harm (Kerr et al., 200Th). Jugular injectionsand assistedinjections are also commonly practiced within the local drugscene (Rhodes et al., 2006).Public injecting (including injecting in outdoor venues)is practiced widely in the DTESand is concentrated in alleyways that are in close proximityto the open drug market(DeBeck et al., 2008, Small et al., 2007). Further, in Vancouver,all recipients of monthlysocial assistance benefits receive their cheques onthe last Wednesday in the calendarmonth (known locally as “cheque day”) and increased levelsof injecting activity areevident in the open drug scene at this time (O’Shaughnessy,2009).4.3.1 Operational context within InsiteInsite is located in the DTES and operates 18hours per day (10 am-4 am). Thefacility operates 7 days a week, 365 daysa year. The facility includes: (1) a receptionarea and waiting room; (2) an Injecting Room(IR) featuring 12 individual ‘booths’forinjection, a nurse’s station and a privateroom for the provision of nursing careandtreatment; and (3) a post-injection“chill-out lounge”, where clients can rest priorto88exiting to the street. As a clinical model SIF, staff members must adhere to strictlydefined service protocols and clients must comply with an explicit code of conduct.Nurses supervise injections, respond to overdoses, and provide nursing care on-site.Insite also offers safer injecting education, needle exchange services, counselling,andreferrals to a range of health and social services including addiction treatment (Woodetal. 2004a). The staffing complement at any given time includes at least one ResponsiblePerson in Charge (RPIC), 2 nurses, 5 “program support workers”, and 2 “peersupport”workers (formerIactive drug users).4.3.2 Statement of study purposeInsite seeks to engage street-based IDUs by providing servicesin a “low-threshold” or “barrier-free” manner. However, little is knownabout the ways in whichIDUs’ access to Insite and utilisation of the facility are simultaneouslyinfluenced by: (1)policies and legislation which shape the regulatoryframework governing supervisedinjecting in Canada; (2) features of the localdrug scene, including characteristics andinjecting behaviours of the drug user population;and (3) the operating environmentwithin Insite, including operational procedures,site regulations and the client code ofconduct. Accordingly, the purpose of this paperis to determine how the operatingcontext of Vancouver’s SIF affects local IDUs’access and utilization of the facility,aswell as the potential of the SIFto promote risk-reduction in the broader DTESneighbourhood.4.4 MethodsThis study draws on data generated throughethnographic methods, includingnaturalistic observation over aperiod of 12 months and a series of 50 in-depthindividual interviews with SIF users,as well as analysis of documentation regardingthe89establishment of the facility, the regulatory framework governing SIFs in Canada, andoperating procedures specific to hisite.4.4.1 Naturalistic observation:The author (WS) generated data regarding the operation of the facilitybyregularly visiting Insite and spending significant amounts of time in all areas of thefacility. Observational work within the SIF began in August 2006; and whilepreliminary fieldwork involved occasional visits to the facility,the majority of site visitswere conducted between September 1, 2008 and August31st,2009. Site visits generatedobservational data regarding the utilisation patterns, physicallayout, traffic flow, andmanagement of prohibited behaviour within the SIF as wellas interactions betweenclients and staff. Observational work also entailed extensive discussionswith staff anddrug users at the facility regarding the site’s operation, regulations,and patterns ofutilisation. During observational work, WS identifiedhimself as a researcher who wasdocumenting the operation of the facility;he also clearly indicated to all SIF clients thathe interacted with that he was not an Insite staff member. Conversationswith IDUs andstaff, as well as observations of activities withinthe facility were recorded in field notes.Observational work within the SIFwas complemented by examination of the Insitedatabase, which records information regardingall client visits to the site, including thenumber of injections, suspensions, overdoses,nursing treatments and referrals.Information regarding the local drugscene was generated through other ethnographicfieldwork outside of the SIF (Smallet aL, 2007), including investigation of DTES publicinjection settings.4.4.2 In-depth interviews with localIDUs who use the SIF:This analysis also draws ondata from 50 in-depth individual interviewsconducted with SIF clients. Study participantswere recruited from the Scientific90Evaluation of Supervised Injecting (SEOSI) cohort, which is composed of over 1000randomly selected SIF users in Vancouver, and is representative of the largerpopulation of SIF clients (Wood et al., 2006). Between November 2005 and February2006, a sub-sample (n=50) of the SEOSI cohort members participated in in-depth, open-ended interviews to discuss: utilisation of the SIF, reasons for using the facility, barriersto attending the SIF, the design and operation of the facility, as well as behaviour andinteractions within the facility. Interviews lasted 40-80 minutes, were audio-recorded,and transcribed verbatim. Analysis began early in the data collection process andcontinued as the subsequent interviews were completed. Thus, emergent analysis ofearly interviews was used to inform the focus of subsequent interviews as well as theongoing development of the analytic results related to the ways in which the design andoperation of Insite were perceived to influence IDUs’ experiences when using thefacility.4.4.3 Document analysis:To complement the data gathered during naturalistic observations and in-depthinterviews, a document analysis was also conducted to assess how the currentregulatory frameworks structure the operating policies and regulations of Insite, andhow these institutional features shape the experiences of SIF users. The scope of theanalysis included documents related to legal frameworks surrounding SIFs in Canada,the details of the exemption granted to Insite, as well as the protocols, policies andprocedures specific to operations within Insite. The following documents werereviewed: Health Canada’s guidelines for “Application for an Exemption under Section56 of the Controlled Drugs and Substances Act for a Scientific Purpose for a PilotSupervised Injection Site”, the application for an exemption submitted to HealthCanada by Vancouver Coastal Health and the Portland Hotel Society in 2003, the letter91from the Assistant Deputy Minister of Health Canada to the site operators whichconstitutes the “Approval of the Application for an Exemption”, and Insite operationalmanuals detailing service protocols, site regulations and the client code of conduct.4.4.4 EthicsApproval to conduct the interviews and naturalistic observation withinthe SIFwas granted by the Providence Health Care/University of British Columbia ResearchEthics Board. All interview participants provided written informed consent and verbalconsent was obtained from individual drug users and staff within theSIF forobservational work.4.5 ResultsThis analysis illustrates how the interplay between a range of contextualfeaturesshape the potential for the SIF to reduce drug-related harm.These include Insite’soperational characteristics and environmental features, whichinfluence the ways inwhich the facility functions and also affects utilisation and accessby local IDUs. Whileethnographic techniques were used to generatethe data employed in this analysis, theprimary goal of this paper is not to provide an in-depth descriptionof the facility’s day-to-day operation or drug user behaviour within the facility, although,in the first sectionbelow, a brief description of the facility’s operationsis provided. Instead, an analysis ofhow cultural, structural, and spatial forces shapeIDUs’ utilisation of the facility (basedupon data derived via document reviews, interviewsand observational activities) ispresented to illustrate the importance of these interactions forunderstanding access tothe SIF in the local context.4.5.1 Site utilisationUtilisation statistics indicate that Insite is a highvolume SIF in comparison tofacilities operating in other countries (Broadheadet al., 2002; van der Poel, 2003; Wolf et92al., 2003). From September1st,2008, to August31st,2009, there were 274 141 visitsto thefacility, with an average of over 22 000 visits per month. Duringthis period, 175 980visits to the injecting room occurred, with a monthlyaverage of 14 665 injections.Within this 12-month period, the facility received anaverage of 751.3 visits per day, andan average of 482.1 injections took place each day. Not all site visitsresult in injections,as clients may attend the facility to access services otherthan the injecting room,including referrals to off-site services.4.5.2 Site regulations and code of conductAt the time of their first visit to the facility,IDUs are required to register andselect a unique identifier which is used torecord within the computerized database allsubsequent SIF visits, referrals, nursing treatments,overdoses, and temporary accesssuspensions. Registration also requires clients,who must have a history of injectiondrug use and be over 16 yearsof age, to sign a waiver agreeing toadhere to all siteregulations and the code of conduct.Site regulations strictly prohibit dealingdrugs within the facility, as well asthepassing of drugs between clients.Preparation or injection of drugsoutside of theinjecting room is also prohibited.Clients are limited to one injectionper visit to theinjecting room and may consumedrugs through injection only. Smokingor snortingdrugs is prohibited within the SIF.Self-administration of drugs is required,althoughstaff may provide education regardinginjection techniques and guidancewith venousaccess. Manual assistance with injectionsis not permitted, although self-injectingintothe jugular vein is permitted. Thereis no official limit on the amountof time anindividual may spend in the injectingroom.The code of conduct reinforcesthe site regulations and outlinesthe furtherconditions of use and consequencesfor breaches of conduct,which all clients agree to93upon registration. Clients are required to follow the directions of staff members. Clientswho violate the site regulations or the code of conduct will be temporarilyprohibitedfrom the facility. Clients are expected to occupy the injecting boothto which they areassigned and stay out of the booths of others. Clients are asked to limit their stayin theinjection room to the amount of time needed to inject and then proceedto the chill-outlounge.At the time of registration, clients are informed that prohibited behaviourismanaged through temporary suspensions. The most common form of accesssuspensioninvolves a 24-hour temporary prohibition, whichexpires automatically, and iscommonly issued to deal with disruptive behaviour,or failure to comply with the codeof conduct. The only types of access suspensions thatendure for more than 24 hours arethose issued to address serious disruptions, threatsand violence. These suspensionsrequire the client to discuss the incident withone or more site coordinators, andnegotiate the terms of their re-entry before regainingaccess.Admission for registered clients is subjectto a number of additional conditionsand individuals will be denied accessif they: do not provide an Insite identifier; haveamedical condition requiring emergencyattention; have a child or childrenwith them; orare currently suspended from usingthe facility. Notably, site protocols do notspecifically prohibit intoxicated clientsfrom entering the facility or the injectingroom,and operating policies state that clientshave the right to access services evenwhenunder the influence of alcohol or otherdrugs.The exemption to the CDSA grantedto Insite plays a central role in determiningthe facility’s operating policies.The conditions of the exemptionspecify that thecapacity of Insite is limited to 12 injectionbooths, and require that allinjections be selfadministered within the facility,necessitating the prohibition onassisted injection(Health Canada, 2002). In addition,the exemption protects staff and registeredusers94from charges of drug possession, but does not extend to activities related to trafficking.These stipulations are encoded within the exemption granted to Insite and prevent thesite operators from creating operating policies that deviate from the parametersimposed upon the program, or expanding the capacity of the facility.4.5.3 Waiting to access the injection roomEthnographic data indicate that when drug users possess drugs and have arrivedat the SIF, they typically want to inject as quickly as possible. There isgreat demand forthe facility’s injection room (IR) and a queuing system is used to organize accessto theinjecting booths, based upon order of arrival. The number of injection boothsis verysmall compared to the large number of individuals who seek admittance to the JR.While there are some times when the JR can be accessed immediately uponarrival,most clients wait at least 5 to 10 minutes to enter the IR and itis commonplace to see agroup of clients queuing in the waiting area. At busy times,waits may exceed 15minutes and when the facility is busiest clients may have towait as long as 30 minutesto access an injection booth. Long wait times often result in individuals leavingthe SJFbefore they access the IR, so that they can inject assoon as possible. Many clientsasserted that they opt to inject elsewhere if they have to wait toaccess the IR, reportingthat a queue of more than 3 people on the waitlist is“too many”, or that “15 minutes[wait] is too long”. The ability of drug users towait in the queue is further reduced insituations when they experience opiate withdrawal,because even a moderate wait“feels like an eternity”. The need to alleviatewithdrawal symptoms providesapowerful motivation to inject immediately, evenoutside the SIF. For other clients, theanticipation of injecting cocaine, which mayinvolve a desire to inject immediately,motivates users to inject in other settingsin light of waits to access the JR.95Data from the Insite database, which tracks the volume of clients who seekto usethe injecting room and subsequently leave due to the wait, confirms the impact of wait-times. Over the 12-month study period, on average 8.6% of all the site visits whereclients sought to use the JR resulted in the client leaving before they coulduse the JRbecause of wait times. Duiing some months, as few as5%of individuals left the SIFbefore accessing the JR due to the wait, while other months as many as 11.8%left due towait times. In addition to the individuals who are put on the waitlist and subsequentlyleave, numerous clients were observed entering the site andupon seeing the queue inthe waiting room, leaving without asking to be puton the wait-list.4.5.4 Time spent within the injecting roomWhile the average length of a visit to the injectingroom is approximately 20minutes (Tyndall et al, 2006b), there is great variation inthe amount of time thatindividuals spend within the IR. For example,many visits to the JR last an hour orlonger, which impedes the turnover of booths and exacerbatesproblems related to waittimes to use the facility.Some lengthy IR visits are due to problemswith the injection process includingsituations where clients have difficulty locatinga viable vein in order to deliver aninjection. After clients have completed theirinjection, there may be delays beforeanindividual vacates their booth. Thecharacter of these delays is often relatedto the drugsinjected. Subsequent to injecting heroin, clientsmay enter a drowsy state, commonlyreferred to as a “nod”, and this candelay individuals in leaving their booth.Subsequentto injecting cocaine, many clientsengage in “tweaking”, which includes repetitive,compulsive, or obsessive behavioursas well as rare cases of cocaine-induced psychosis(Kerr et al., 2003). While Jnsite staffmembers are skilled in encouragingcocaineinjectors to leave the JR and enterthe chill-out lounge, post-injection “tweaking”96frequently distracts these clients from vacating their booth in a timely manner. Assistingclients who are having trouble exiting to the post-injection “chill-out” lounge, due to thesleep-deprivation and exhaustion that is common among street-based injectors (as wellas the effects of both heroin and cocaine), also is important to maintaining client flowout of the JR.Sometimes it is necessary to suspend clients who are spending “too long” withinthe JR. Staff members will employ access suspensions only when a client has establisheda pattern of regularly staying “too long”, or when the site is extremely busy and thewait to enter the JR is lengthy. Although these types of access suspensions are issuedjudiciously, they compose a significant proportion of all the suspensions issued. Forexample, in March 2009 when 86 suspensions occurred, a total of 14 (16.2%) accesssuspensions were issued in relation to JR visits that lasted in excess of 120 minutes.Notably, the number of access suspensions issued in relation to long stays in the JRincreases around “cheque day”, when the number of visits to the facility is greatest.4.5.5 Regulations prohibiting sharing or splitting drugsAlthough Jnsite’s operating regulations prohibit clients from sharing, dividing orpassing drugs within the facility, local drug users commonly engage in these practicesoutside of the SJF. Clients asserted that the prohibition on sharing drugs fails toaccommodate highly common “everyday” practices regularly employed by drug users,which play a significant role in social relationships. Pooling money to purchase drugs,obligations to give drugs to other drug users in order to address debts or reciprocateprevious “gifts”, as well as social norms which encourage “helping out” friends andassociates by providing a small amount of drugs, were described as representingimportant reasons why JDUs frequently “share” drugs. The regulation prohibiting97sharing drugs affects utilisation of the facility and represents a barrier to SIF useinrelation to instances when IDUs “need” to divide or share drugs.Many clients recounted occasions when they divvied up drugs outside priortoinjecting at the SIF. They described these situations as being hazardous(e.g., they mightencounter the police, lose or spill drugs during the process of division, orbe robbed oftheir drugs). In addition, some clients reported that when they had founda relativelysecluded location to divide their drugs, they would simply injectin that location, ratherthan returning to inject at the SIF (and possibly waiting to enterthe IR). Studyparticipants discussed how the regulation prohibiting splittingdrugs within the SIFdisproportionately affects injectors who have jointly purchased drugs thatoriginally aresold in pill form, including morphine, hydro-morphone,dilaudid, and oxycodone,which are commonly used by SIF clients (Tyndall et al., 2006b). Clientsexplained thatsplitting these drugs entails a complicated process.As the pill must be prepared in aliquid solution before it can be divided, IDUswill opt to inject in the location wherethey perform this preparation process, rather than returningto the SIF.4.5.6 Regulations prohibiting assisted injectionEthnographic data indicates thatSIF regulations prohibiting assisted injectionsmay discourage clients from using the SIF, particularlyamong some sub-groups ofIDUs who have difficulty self-administeringinjections. Difficulty self-administeringinjections may be precipitated by low levelsof knowledge regarding injectiontechniques, vascular problems (e.g., damagedveins), physical disabilities, as wellassituations where IDUs are sleep deprived,intoxicated or experiencing withdrawal(Wood et al., 2003). When IDUs have troublewith venous access within the SIF, theyfrequently call upon nursing staff for guidanceand advice, but the nurses arenotpermifted to physically assist with the injections.When advice from nursing staff was98not sufficient to manage problems with the injection process, clients may leave theJRwithout completing their injection in order to receive physical assistancewith theirinjections from other drug users, which is how IDUs customarilynavigate inability toself-inject (O’Connell et al, 2005).Clients expressed the view that it wouldhave been beneficial if a nurse or fellowdrug user attending the SIF could have supplied manualassistance with injecting. Someclients thought that permitting assisted injectionswithin the SIF would facilitateopportunities for them to relocate their injecting practicesfrom dangerousenvironments (e.g., public injection settings in localalleys) to the safer environment ofthe SIF.The dynamic associated with assisted injectingis important among women whoare regular SIF users. As one woman explained,she injects outside of the SIF whensheneeds “somebody to do it for me” (Interviewee#21, 34 years old), particularly whensheis experiencing heroin withdrawal. Inaddition, a small number of interviewparticipants, again primarily female injectors,recounted instances where they haddifficulty self-administering an injection withinthe SIF, and after repeated attempts,leftthe JR in order to seek manual assistancewithin another location, often in publicinjection settings. Male interview participantswho regularly serve as “doctors”(i.e.,individuals who administer injectionsto other drug users) described instanceswhenthey had been approached withinthe SIF by female injectors whowere havingdifficulty self-administering theirinjection and were seekingto arrange an assistedinjection outside of the SJF.4.5.7 Frequent visits bycocaine injectors and the impactof synchronised welfarepaymentsThe high prevalence of cocaine injectionamong SIF users, and the fact thatwelfare payments are issued toall recipients at one point in eachmonth, pose99operational challenges for the SIF. Because cocaine injectors need to inject frequently(e.g., some perform more than 20 injections over the course of a day), many of theseindividuals are “frequent flyers” among the clientele of the SIF. Observation ofIDUs’usage of the facility indicates that cocaine injectors may make more than 10 visitsperday, quickly returning to the queue in the waiting area after completingtheir injection(in comparison, heroin injectors usually inject 2-4 times perday). In addition to posingchallenges to maintaining client flow through the SIF, the injectingpractices of cocaineusers do not fit well with the site policy of ‘one fix per visit’.Due to the increased levels of drug use and the elevated levelof activity withinthe local open drug scene during the time when social assistancebenefits are paid, thelength of the queue to enter the JR and wait timesare the longest on “cheque day” (andthe 2 days following it). During these days of peak traffic,the proportion of clients wholeave due to the wait increases toa level far above the monthly average, up to15%-20%of those seeking to use the IR.4.5.8 Ensuring complianceIn addition to addressing the service needsof SIF clients and regulating clientflow through the facility, staff are requiredto constantly monitor client behaviourwithin the SIF to ensure compliancewith the conditions of the exemption fromtheCDSA. Clients reported that they may attemptto inject within the waiting room orthechill-out lounge (where injecting behaviouris prohibited) when the site is busy, in orderto avoid the long wait to enter the JR. Temporaryaccess suspensions, lasting 24 hours,are regularly issued in order toaddress injecting behaviour in areasoutside the JR.Over the course of March 2009, when86 access suspensions were issued, atotal of 20(23.2%) were issued for injecting orattempting to inject in areas other thanthe IR.100The prohibition on dividingor passing drugs, which is defined astraffickingunder the law, alsorequires that staff monitorparticipants to ensure thatthesebehaviours are notoccurring within the facility.Clients explained that they mayattempt to divide and passdrugs within the facilitywithout being detected by staff,dueto the difficulty and hazardsentailed in partitioning drugsin other locations, primarilyoutdoor venues. While someattempts to divide or passdrugs occur within the waitingroom, this behaviour is moststrictly monitored within theJR. where clients are requiredto stay within theirown injection booth and are discouragedfrom entering the boothsof others, partially to preventattempts to pass drugs. Whenstaff members observe twoor more clients attempting to passdrugs, each of the offendingclients will receive a 24-hour temporary access suspension.During March 2009, approximately20% of thesuspensions issued were in relationto attempts to pass drugs toanother individualwithin the facility.Ensuring compliance withthe Insite code of conductand site regulationssometimes results in seriousconflicts between staff and SIFclients. Upon beinginformed of their suspension, clientsmay become aggressive, threatenstaff, or refuse toleave the facility, which resultsin a longer-term suspensionand requires a meeting withone or more site coordinatorsbefore client access is reinstated.Clearly, the need toenforce regulations is importantto the functioning of theSIF, although it may also limitaccess to the facility, especiallyfor SIF clients who receive multiplesuspensions over thecourse of a single month (forexample).4.6 DiscussionA contextualised understandingof the operation and regulationsof Insitehighlights how the interactionsbetween regulatory mechanisms,operational featuresof the facility, and the local drugusing context influence access toVancouver’s SIF. This101analysis illustrates how macro-level forces (e.g., parameters of the legal exemptionwhich permits the site to operate) shape the operation of Insite through regulation andlegal controls. Moreover, this examination demonstrates how these specific operationalcharacteristics of Insite interact with features of the local drug scene (e.g., the largepopulation of injectors, the frequent visits of cocaine injectors, synchronised welfarepayments) to shape the experience of accessing and using the SIF. While the clinicalservice model at Vancouver’s SIF attempts to maximise access and minimize barriers tothe service, major challenges affect its operation.4.6.1 Capacity versus demand for the serviceThe legal exemption under which Insite operates stipulates that thefacility islimited to 12 injection booths within the premises. The capacityof Insite is thereforelimited to the number of clients that those 12 booths can accommodate.Observationsand data from the electronic SIF database regarding wait-times provideevidence thatthe demand for Insite’s services exceeds its current capacity. Withinthe cultural logicsof local injectors, there is a relatively low threshold for waiting toaccess the supervisedinjection setting, partially due to the pre-existingand established culture of publicinjecting within the local environment, which often involves injectingimmediately afterdrugs are obtained (Small et al., 2007). This dynamicis corroborated by a quantitativestudy which found that those SIF users who reportedwait-times to be a barrier to theirutilisation of the SIF were 3 times more likelyto inject in public, when compared tothose who did not report wait-times to bea barrier (McKnight et al., 2007).The synchronised payment of social assistance benefits,which precipitatesincreased levels of drug use within the localdrug scene, exacerbates the gap betweenthe capacity of Insite and the demand for its services,as a dramatic increase in demandis evident on “cheque day” and the days immediatelyfollowing it. Coincidentally, the102number of hospital admissions for non-fatal drug-related overdose increases around“cheque day” (Riddell & Riddell, 2006), due to the increased levelsof drug use at thispoint in time. This temporal increase in non-fatal overdoses, whichoccurs when thedemand for the SIF is the greatest, is a key feature of thelocal drug scene whichinfluences SIF utilisation. Unfortunately, the clients who cannotwait to inject within thesafety of the SIF (where no overdose deaths have occurred) insteadinject in othervenues, where there is an elevated risk of overdose and reduced potentialfor assistance.In these ways, the nexus of the regulatory context and localdrug scene restricts thecapacity of the SIF to promote risk reduction, a phenomenonalso observed in relationto needle exchange and methadone programswhich are subject to similar formsofregulation (Burns et al., 2004; Neale, 1999).4.6.2 Governing access and useAll SIFs worldwide havebasic logistical arrangements and many SIFshavesimilar “house rules” (Broadheadet al., 2002), which ensure injectionhygiene andcreate a controlled environment.However, there are several featuresof Insite thatdistinguish it from other SIFs (Kimberet al., 2003). For example, jugularinjections areprohibited in SIFs operating in othercountries (e.g., Australia) (van Beek,2003), but arepermitted at Insite, due to the highprevalence of this injection behaviourin the DTES.Approximately 25% of localIDUs regularly inject in the jugularvein (Hoda, Kerr, Li,Montaner & Wood, 2008) and it appearsthat jugular injection is commonwithin thelocal public injecting scene (Rhodeset al., 2006). Allowing this practicepotentiallyenhances SIF utilisation. Similarly,unlike some SIFs, Insiteallows intoxicated drugusers to access the IR, acknowledgingthat refusing access to intoxicatedindividualswould likely result in them injectingin other settings wherethe chance of receivingassistance in the event of overdoseis reduced (Kerr et al., 2007a).103However, some activities that are prohibited within Insite are allowed inotherSIFs (Kimber et al., 2003). For example, not all SIFs prohibit clients from sharing orsplitting drugs (Broadhead et al., 2002; Kimber et al., 2003). The clinicalSIF in Sydney,Australia, permits clients to share drugs if they arrive at the facilitytogether (van Beek,2003); and an unsanctioned, peer-run SIF in Vancouver, which operatedwithout agovernment exemption prior to the establishment of Insite, allowed clientsto share anddivide drugs while prohibiting the sharing of injection equipment (Kerr et al., 2005b).Drug “sharing” represents a key survival strategy among street-based IDUswho havelimited access to financial resources and engage in precariousincome-generationstrategies (Bourgois, 1998; Grund, 1996). Insite cannotaccommodate this importanteveryday practice under the current regulations. This limits the abilityof the facility topromote risk-reduction strategies (e.g., the use of sterile materialsto prepare drugs) inrelation to the collective preparation of drugsamong IDUs, which continues to occur inunregulated and unhygienic settings, which may provideopportunities for blood-bornevirus transmission, particularly hepatitisC, when previously utilised syringes areemployed (Koester, Glanz & Baron, 2005; Koester,Booth & Zhang, 1996).The federal regulations governing Insiteprohibit assisted injection and requirethat all injections within the facility be self-administered(Health Canada, 2002).Although injecting within the SIF hasbeen documented to facilitate capacity for self-injection and reduce reliance upon assistedinjection (Wood et al., 2005b, Fairbairn et al.,2008), the current study indicates thatmany SIF clients continue to receiveassistedinjections outside the SIF, often within publicinjection settings. Local IDUs who receiveassisted injections are twice as likely tobecome HIV positive when compared to IDUswho do not require help injecting (O’Connellet al., 2005) and are at increased risk fornon-fatal overdose (Kerr et al., 200Th).While regulations that prohibit assisted injectionreduce willingness to use a SIF amongIDUs (Fry, 2002; Kerr et al., 2003), it appears that104this particular regulation may disproportionately affect willingness to attend andusethe SIF among female injectors (Kerr et al., 2003). In the Vancouver setting, femaleinjectors are known to be twice as likely to require help injecting (Wood et aL, 2003) andare more likely to become HIV-positive when compared to male IDUs (Spittal etal,2002). Some of the HIV risks experienced by female injectors are shaped by genderdynamics within intimate partnerships, where women are often “secondon the needle”,receiving assisted injections from male partners with previously used syringes(Bourgois, Prince & Moss, 2004). Some SIFs in European countries permit peer-to-peerassisted injections (Kimber et al., 2005), as did the unsanctioned SIF thatoperated inVancouver prior to the opening of Insite (Kerr, Oleson & Wood, 2004).By ensuring theuse of sterile syringes when assisted injections were delivered, Vancouver’sunsanctioned SIF demonstrated that it is possible to accommodate assistedinjectionswithin the supervised environment which reduces therisks associated with this practice(Kerr, Oleson & Wood, 2004).4.6.3 Implementing the ‘rules’Previous research has demonstrated that the implementation ofsome SIF rulescan be problematic to the successful functioning of thesefacilities (Fry, 2003). Ourfindings illustrate that IDUs adapt to those operating features ofthe SIF that they findproblematic by selectively utilising the facility (e.g., injectingelsewhere when wait-times are long) and by violating site regulationsto accommodate their needs (e.g.,attempting to pass drugs within the SIF). In mostcases, these adaptations reduce IDUs’utilization of the SIF and prompt them to accessother less safe injecting environments.Additionally, the management of these behavioursplaces staff in a problematic dualrole, where they act as care-givers but are alsocompelled to enforce site regulations toensure compliance with the conditions of the exemption.105Clearly, the safety of staff and other clients at Insite is a priority, but theneed toenforce site regulations, which do not fit with the everyday practices of IDUs, createsanextremely complex operating environment and can foster “everyday acts of resistance”by drug users within service settings (Moore, 2009). As well, the enforcement of rulesmay inadvertently (re)produce a set of social relations(e.g., confrontational dynamicsbetween drug users and authority figures like the police) that serve to perpetuatethestigma and marginalization experienced by people who injectdrugs (Simmonds &Coomber, 2009). While these issues affect operations withinthe SIF, it must berecognised that the number of suspensions is relativelysmall when the number of sitevisits is taken into consideration.4.6.4 Structural forces shaping SIF operation in CanadaWhile most public health programs are affectedby the political and legal contextin which they operate (Blankenship, Bray, & Merson,2000), this analysis indicates thatthe particular approach adopted by the Canadianfederal government to permit thelegal operation of SIFs in Canadahas important implications for the deliveryandoperation of the service. Utilising a Ministerialexemption for scientific purposesrepresents one strategy to permit legal operationof SIFs under the CDSA, butthismechanism severely restricts the establishmentof this form of health intervention,limiting SIFs to a single pilot facility operatingas part of a scientific evaluation.Canada’s Minister of Health stated in 2006 thatthe federal government would not grantadditional exemptions to the CDSA, whichprevented the establishment ofanyadditional SIFs in Canada, despite positive findingsemerging from evaluation research(Wood et al., 2008).While the federal government’s approachto regulating SIFs has been criticisedfor placing undue restrictionson this form of interventionand impeding the106establishment of additional SIFs (Wood et al., 2008), critics have pointed out thatthespecifics of the exemption place greater emphasis on reducing risks to institutionsandtheir staff than on reducing risks to the vulnerable population theSIF is designed toserve (Fischer, Turnbull, Poland & Haydon, 2004). The current guidelines prohibitassisted injections within SIFs, despite the documented harms stemming fromthispractice and the existence of alternative strategies to address criminaland civil liabilitystemming from assisted injections occurring within SIFs (Pearshouse& Elliott, 2007).The federal guidelines for Insite’s operation prioritise minimisingthe potential for legaland institutional liability over the creation of the most accessibleSIF and the potentialfor maximum impact upon injection-related risk among marginalisedIDUs (Fischer etal., 2004).Optimizing the operation of SIFs in Canadawill require modifications to publicpolicies beyond the health sector, including amendmentsto current legal frameworks.For example, it has been recommended thatassisted injection be permitted withinCanadian SIFs (Pearshouse & Elliott, 2007), whichwould require amendments to thecurrent regulatory framework governingsupervised injection as well as modificationsto Canadian criminal and civil law to address legalliability related to providing assistedinjections. Modifying SIF regulationsto permit the division of drugs and assistedinjections also would entail complex amendmentsto Canadian legislation regardingcontrolled substances, but represents animportant step towards realigningtheoperation of SIFs to accommodatethe everyday practices of IDUs.The barriers posedby the delays in accessing the injection roomalso could be addressedin part throughincreasing the number of injectionspaces available, as well as theaddition of other SIFsin the neighbourhood (Broadheadet al., 2002).While there is limited potentialto initiate changes to any of these facets of Insite’soperation under the Health Canada exemption,recent legal developments may prompt107a restructuring of the regulatory framework governing SIFs in Canada. The FederalMinister of Health previously extended Insite’s exemption; however, the current federalgovernment appears to be opposed to the continued operation of SIFs inCanada (Small,2008) and the operators of Insite anticipated that the exemption would be revokedinorder to close the facility. However, legal experts have observed that because SIFsrepresent a healthcare program targeting addicted individuals, the federal governmentmay be constitutionally required to eliminate legal barriers to the operation of SIFsunder the Canadian Charter of Rights and Freedoms (the Charter) (Elliot, Malkin &Gold,2002).A recent legal case in the Supreme Court of British Columbia (B.C.) challengedthe authority of the Federal Government to restrict the operation of Canadian SIFs,arguing that access to SIF as a healthcare program is ensured under the Charter. Thejudge in this case decided that the CDSA cannot take precedence over theCharter,granted Insite a constitutional exemption to the relevant sections of the CDSAand gavethe federal Government one year to modify the CDSA to accommodatethe operation ofthe SIF (Small, 2008; Pitfield, 2008). Since the announcement of that decision,the federalgovernment filed an action to appeal this legal decision, and the B.C. Court ofAppealsubsequently dismissed that appeal (Hall, 2010). While a further appeal is anticipatedto occur in the Supreme Court of Canada (Hall, 2010), the operators ofInsite recentlyannounced plans to establish a second SIF in the DTES area (Howell, 2009)in order tobetter accommodate the overwhelming demand for Insite.4.6.5 Potential complementary interventionsEven if many of the aforementioned barriers to theservice were removed, it isimportant to recognize that a proportion of IDUsmay still be unwilling to use the SIF(Fry, 2002; Kerr et al., 2003). In light of the limitations ofSIFs, there is a need to develop108new interventions (and expand existing programs) to reduce injection-related riskandmaximise injection safety within locations where IDUs customarily inject drugs,including public injection settings and private residences. These efforts may involveincreasing access to sterile injection equipment, enhancing personalsafety withininjection settings by supplying an element of monitoring, and providing overdosemanagement, potentially through the distribution of naloxoneto drug users.While these pragmatic efforts have potentialto reduce injection-related riskwithin existing injection settings by fostering injectionsafety and response to overdose(Rhodes et al., 2006), there also is a need for policy reformsthat can address structuralfactors which drive injection-related risk in unregulatedsettings and foster publicinjecting behaviour. For example, policy reforms increasingaccess to housing in theDTES could simultaneously help to mediate thehigh burden of drug-related harmamong homeless IDUs (Corneil et al.,2006), reduce the volume of public injectinglocally, and subsequently, potentially reducesome of the excess demand for theSIFwhich currently poses operational difficulties.Similarly, modifying disbursementschedules for social assistance, by staggeringpayments or issuing benefits at twopointsover the course of the month, represents animportant strategy to address anenvironmental factor shaping a temporal increasein the potential for overdose in thelocal context (Riddell & Riddell, 2006), whichcoincides with an increase in unmetdemand for the STE Rescheduling the paymentof social assistance may reduce theimpact of “cheque day” upon barriersto the SIF, as well the operation of other servicesthat engage with highly marginalisedsubstance users in the Vancouvercontext (Li etal., 2007), including medically manageddetoxification.Finally, this study has limitationsthat should be noted. Asan ethnographicexamination of the operation ofone SIF in the Canadian context, the specificcontextualissues identified may not influencethe operations and utilisation of SIFs inother109settings. However, all SIFs must be considered as existing at the intersection of broadregulatory policy and local drug scenes, therefore this analysis may be informative forefforts to contextualise the operation of SIFs in other jurisdictions. While a number ofoperational issues that influenced access to the SIF were identified, this study did notseek to quantify the impact of these barriers, and future research could morepreciselymeasure the number of visits and clients affected by specific programmaticfeatures.4.7 ConclusionThe current study illustrates the ways in which IDUs’ accessto Insite issimultaneously influenced by the interaction between contextual forces,regulatorymechanisms, and programmatic features of the facility. The operatingenvironmentwithin Insite (e.g., operational procedures; clientcode of conduct) heavily affects localIDUs’ experiences in accessing and utilisingthe SIF. While the SIF facilitates risk-reduction among the IDUs who inject within thefacility, its current operating format isunable to accommodate the demand for the supervisedinjection setting, and manypractices that are commonly employed by localIDUs. To ensure the optimal impact ofSIFs across settings, efforts must be made toensure an appropriate number of SIFs tomeet local demand, reform policies that restrictaccess to SIFs, and provide servicedelivery models that consider the local environmentand practices of IDUs.1104.8 ReferencesAceijas, C., Stimson, G.V., Hickman, M., & Rhodes, T. (2004). Global overview of injecting druguse andHIV infection among injecting drug users. AIDS, 18(17): 2295-303.Aceijas, C., & Rhodes T. (2007). Global estimates of prevalence of HCV infection among injecting drugusers. 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Publicinjecting and the need for ‘safer environment interventions’ in the reduction of drug-relatedharm. Addiction, 2006; 101: 1384-1393.Simmonds, L., & Coomber, R. (2009). Injecting drug users: a stigmatised and stigmatisingpopulation.International Journal of Drug Policy, 20(2):121-30.Small, D. (2008). Fighting addiction’s death row: British Columbia SupremeCourt Justice Ian Pitfieldshows a measure of legal courage. Harm Reduction Journal, 28; 5:31.Small, W., Rhodes, T., Wood, E., Kerr, T. (2007). Public injection settings inVancouver: Physicalenvironment, social context and risk. International Journalof Drug Policy, 18: 27-36.Spittal, P.M., Craib, K.J., Wood, E., Laliberté, N., Li, K., Tyndall, M.W., OShaughnessy,M.V., & Schechter,M.T. (2002). Risk factors for elevated HIV incidence rates among female injectiondrug users inVancouver. Canadian Medical Association Journal, 166(7):894-9.Strathdee, S.A., Patrick, D.M., Currie, S.L., Cornelisse, P.G.,Rekart, M.L., Montaner, J.S., Schechter, M.T.,& O’Shaughnessy, M.V. (1997). Needle exchange is not enough: lessonsfrom the Vancouverinjecting drug use study. AIDS, 11(8): F59-65.Tyndall, M.W., Craib, K.J., Currie, S., Li, K., O’Shaughnessy,M.V., & Schechter, M.T. (2001). Impact ofHIV infection on mortality in a cohort of injection drugusers. Journal of Acquired ImmuneDeficiency Syndromes, 28(4): 351-7.Tyndall, M.W., Currie, S., Spittal, P., Li, K., Wood,E., O’Shaughnessy, M.V., & Schechter, M.T. (2003).Intensive injection cocaine use as the primary riskfactor in the Vancouver HIV-1 epidemic. AIDS,17(6), 887-93.Tyndall, M.W., Wood, E., Zhang, R., Lai,C., Montaner, J.S., & Kerr, T. (2006a). FIIV seroprevalence amongparticipants at a Supervised Injection Facility in Vancouver,Canada: implications for prevention,care and treatment. Harm Reduction Journal, 18: 3:36.Tyndall, M.W., Kerr, T., Zhang, R., King, E., Montaner,J.,Wood, E. (2006b). Attendance, drug usepatterns, and referrals made from North America’s firstsupervised injection facility. Drug &Alcohol Dependence, 83: 193-198.114van Beek, I. (2003). The Sydney Medially Supervised Injecting Centre: A clinical model. Journalof DrugIssues, 3:625-638.van der Poel, A., Bargendregt, C., & van de Mheen, D. (2003). Drug consumption roomsin Rotterdam: Anexplorative description. European Addiction Research, 9:94-100.Wood, E., Spittal, P.M., Kerr, T., Small, W., Tyndall, M.W., O’Shaughnessy, M.V.,& Schechter, M.T.(2003). Requiring help injecting as a risk factor for HIV infection in the Vancouver epidemic:implications for HIV prevention. Canadian Journal of Public Health, 94(5):355-9.Wood, E., Kerr, T., Montaner, J.S., Strathdee, S.A., Wodak, A., Hankins, C.A., Schechter, M.T.,& Tyndall,M.W. (2004a). Rationale for evaluating North Americas first medically supervisedsafer-injectingfacility. Lancet Infectious Disease, 4(5):301-6.Wood, E., Kerr, T., Small, W., Li, K., Marsh, D.C., Montaner,J.S., et al. (2004b) Changes in public orderafter the opening of a medically supervised safer injecting facility for illicitinjection drug users.Canadian Medical Association Journal, 171(7): 731-4.Wood, E., Tyndall, M.W., Li, K., Lloyd-Smith, E., Small, W.,Montaner, J.S.G., & Kerr, T. (2005a). Dosupervised injecting facilities attract higher-risk injectiondrug users? American Journal ofPreventive Medicine, 2005; 29(2): 126-130.Wood, E., Tyndall, M.W., Stoltz,J.,Small, W., Zhang, R., O’Connell,J.,et al. (2005b). Safer injectingeducation for HIV prevention in a medically supervisedsafer injecting facility. InternationalJournal of Drug Policy 16: 281-284.Wood, E., & Kerr, T. (2006). What do you do when you hitrock bottom? Responding to drugs in thecityof Vancouver. 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International Journalof Drug Policy, 19(3):220-5.115CHAPTER 5:DISCUSSION AND SYNTHESIS OF DISSERTATION FINDINGS5.1 OverviewThis dissertation used ethno-epidemiological approaches to investigate how thesocial context and drug use patterns within the local risk environment of the DTESintersect with the legal and regulatory operating context of the SIF to affect clients’access to and experience of using the facility. Drawing on descriptions of social relationsand drug consumption practices (Chapter 2), the complex interface between publicinjection venues and Insite, Vancouver’s SIF, was investigated (Chapter 3). In Chapter4, the cultural, structural, and spatial forces that shape the potential for the SIF toreduce drug-related harm are described. In this final section of the dissertation, Chapter5, the findings of the dissertation are briefly synthesized and a set of methodologicalreflections is provided. Finally, the new information gathered in the current study isused to identify promising interventions and new research opportunities that mightcomplement existing efforts to address Vancouver’s injection drug-related problem.While this work revealed that contextual features within unregulated injectionsettings pose barriers to risk-reduction, it also demonstrated that SIFs address many ofthese contextual features and foster risk-reduction. However, in order to maximiseaccess to SIFs, features of the facility must be tailored to the local drug scene, whichrequires knowledge regarding the risk environment, injection settings within the locale,and local practices among IDUs. No single intervention, including SIFs, canaccommodate all injectors or eliminate injection-related risks completely (Rhodes et al.,2006). While efforts to enhance amenities and foster injection safety within existinginjection settings must be pursued (Rhodes et al., 2006), these efforts must becomplemented by structural interventions focused on addressing the social and116material inequalities implicated in the production of drug-related harm amongstreet-based injectors (Moore and Dietze, 2005; Rhodes, Singer, Bourgois, Friedman &Strathdee, 2005).5.2 Interpretation of Findings and ReflexivityIn interpreting the results of this dissertation, which were generatedusingethnographic approaches, my role as a field researchershould be considered. Duringdata collection, my presence provided a catalyst for discussionsas I introduced myselfto clients within the SIF, or explained why I was present inthe alleyways whereinjecting regularly occurs. When I explained thatI was spending time in public injectionsettings and the SIF in order to understandthe relationship between theseenvironments and how they shape behaviour,this precipitated many lengthyconversations with IDUs regarding public injecting,the events that occur in localalleyways, and people’s engagement withthe SIF. A recurrent theme intheseconversations was that IDUs positionedthe SIF as an exceptional drug consumptionenvironment. Although the SIF had been operatingfor a number of years by the time Ibegan my fieldwork, it was seen as being unique,and users consistently reminded meof how it is “not the street”, discussingnumerous ways that the supervisedenvironment differs from street-settings. Whilethe differences between the SIF and thestreet were not always constructedas being positive, these conversations drewmyattention to how the physical environmentand social context within the SIFserved tofundamentally alter customary socialand spatial relations among drug users.During my fieldwork, I spentdozens of days, in both summerand wintermonths, interacting with peopleas they were injecting within the SIFand in localalleyways. While I had previouslyspent considerable time interactingwith drug usersin the streets of the DTES, observingpeople consuming drugs within theinhospitable117and unsanitary environments of the alleyways of the DTES was sometimes unnerving;and, the atmosphere in these settings was often quite tense. Although drug usersperceive the SIF to be a more “humane” environment, some people visiting the SIF wereextremely distraught during their visits due to current events in their lives (e.g., havingjust been evicted from their residence; learning that their boyfriend had just beensentenced to years in prison; grieving the recent death of a friend). One of the moststriking aspects of my fieldwork was being constantly exposed to the complicatedhealth problems that are a part of everyday life among IDUs in the DTES. For example,I was reminded of the severity of these health issues when I encountered a man who Iwould see on a regular basis, who had recently had a limb amputatedas a result ofcomplicated injection-related infection. Another recurring reminder of the significanceof these health problems were the many deaths in the community of IDUsthat weredescribed to me by the people who spoke to me during my fieldwork.It seemed thatevery month people were talking about a memorial or a funeral servicefor someonewho had recently passed away. Witnessing this level of suffering was oftendifficult, butnecessary, to adequately develop contextualised understandings ofthe circumstancesand experiences of some highly vulnerable sub-groups of people whoinject drugs inVancouver’s DTES.In addition, some of the venues where drug users usuallycongregate are unsafeand! or unsuitable for ‘outsiders’ to visit, which meant that in order for me gain‘entry’(and maintain some degree of personal security) in thesesettings, I had to establish my‘credentials’ and communicate that I was not an undercover policeofficer, some kind ofvoyeur, or drug ‘tourist’. My established relationshipswith individual drug users andprevious research experiences in the community,which included accompanying anoutreach team operated by the Vancouver AreaNetwork of Drug Users (VANDU) whoregularly visited public injection settings, wereoften helpful in this regard. In some118situations, people who knew me from previous encounters, “vouched”for me,communicating to other drug users that I was “okay”. However, on many otheroccasions, I needed to engage in prolonged discussions regarding myreasons for beingpresent where people were consuming drugs, the potential risks and benefits ofmywork, and my relationship to the DTES community and its residents.Although my identity as a graduate student working on a PhD at a localuniversity meant that I was an “outsider” in many dimensions, my presence andwillingness to discuss my research activities facilitated many interesting conversations.In addition, my familiarity with the DTES and my previous experiences in theneighbourhood often helped me to communicate to people that I was not simplyaresearcher that was ‘parachuting’ into the community with my own research agenda,but that some of my previous work was relevant to the health of local drug users.Interestingly, many drug users in the DTES also recognise the social role of “researcher”to have relevance to the local street scene, as they themselves perceive a need tocommunicate to the “general public” how deplorable living conditions are for somepeople in the DTES.Over the course of the 8 years that I have been working in the DTES community,in various research-related roles, I have been allowed access to parts of drugusers’worlds that not many other non-users have seen (apart from physicians, health outreachworkers, and service providers). However, some people who faced themost seriousbarriers to accessing SIF also may not have been willingto engage with me during myfieldwork (including the observations and interviews); and,therefore, their perspectivesmay be inadequately represented in the data. For example, while Iwas able to interactwith dozens of drug users within the SIF, and made an active effortto communicatethat I was not a SIF staff member and that my research was part of the independentevaluation of the facility, some people may have perceivedthat I was employed as a119researcher by Insite. Clearly, during fieldwork, the ways that study participantsperceived me may have shaped the data collected for this research.5.3 Ethno-epidemiological Approaches to Complex Research ProblemsWhile ethnographic research methods have well-recognised ability to reveal thecomplexity of barriers to risk-reduction among drug users (Moore, 2005), the detailedinformation generated through the current research highlights how complexinteractions amongst environmental influences (e.g., economic, political, cultural, andstructural forces) shape the experience of using the supervised injection setting inVancouver. The rich and detailed data that was gathered using these methods suggestthat these techniques enabled me to tap into deeper insights than would havebeenotherwise documented using traditional epidemiological methods.Of particularimportance is the integration of ethnographic research activities within a broaderpublichealth evaluation of a pilot supervised injection facility, which was predominantlyquantitative and epidemiological (Wood et al., 2004). The ethnographic work conductedduring the current study adds important tools to overall effortsto evaluate SIFs. Forexample, a recent SIF evaluation project in Sydney, Australia, did notinclude eitherobservational work within the facility or in-depth interviews withIDUs who use the SIF(Salmon, 2008), although these data may have generated importantinformation to helpinvestigators better understand barriers to access (for example).Independentethnographic research has the capacity to systematicallyexamine the perspectives ofdrug users engaging with public health interventions (includingSIFs), while accountingfor the complexities of local drug scenes as well as macro-levelstructures (includinglegal frameworks and regulations) (Moore, 2005).My ethnographic work was designed to complementthe ongoing cohort study ofSIF users by providing additional, in-depth documentationof the operation of the SIF120as well as the context in which it operates. Although my study was independentof theSIF evaluation efforts, there were some complementarities in terms of implementingmymethodological approach. For example, the cohort studyteam permitted me to selectfor in-depth interview participants from the SEOSI cohortstudy, which permittedrecruitment of a group of SIF clients with varying levels of SIF utilisationand whosedemographic and drug use profile was reflective ofthe entire population of SIF clients.In addition, conducting the observational work withinthe SIF in connection with thescientific evaluation afforded opportunities to draw on datafrom the facility’s electronicdatabase which records detailed information regardingall site visits, injections, andaccess suspensions. Examination of this database onan ongoing basis as theobservational work was being conducted, includingreal-time consideration of trafficflow and wait-times as clients moved throughthe facility, permitted identification oftrends in client utilisation andbarriers to access through inductive analysis.Forexample, observations conducted on specificdays suggested that an increased numberof site visits occur in the time period surrounding‘cheque-day’, and this time period isalso characterised by increased wait-timesand an increase in the number of clientswholeave without accessing the injectingroom. Detailed examination of the facilitydatabaseconfirmed the accuracy of these inferences,and corroborated the existence ofthesetrends within the larger 12-monthstudy period, including the increasedproportion ofvisitors who seek access to the injectingroom and leave due to the wait occurringin thetime surrounding cheque-day.The ethnographic examination ofpublic injection settings also employedamultiple data collection techniques includingfield observations, photographs,in-depthinterviews with IDUs, anda structured environmental survey,to document thesemicro-environments. The combinationof these multiple data generationactivitieshelped to develop detailed understandingsof the physical environment, distributionof121injection niches across geographical space, as well as the social meaning of theseinjection settings for individuals who engage in public injecting. The use ofphotographs has been noted to be particularly effective in communicating the characterof drug consumption practices (Rhodes & Fitzgerald, 2006); and, the current researchrepresents a rare example of the use of photography to document the physicalenvironment characterising public injection settings(see Chapter 2) (Rhodes, 2002;Rhodes et al., 2006).By employing triangulation and integrating multiple datasources, uniqueinsights surfaced during the analysis that contributedto the development of greaterunderstanding of each injection setting as wellas the relationship between the twosettings. While in-depth interviews provided detailedaccounts of activity within bothtypes of injection settings, this form of data was complementedby the information fromobservational activities within the two settings.Naturalistic observation within publicinjection venues provided information aboutthe physical environment and socialcontext that characterizes these locations. Observationalactivities within Insite enableddetailed understanding of the day-to-dayoperation of the SIF and how particularfeatures shape IDUs’ access to the supervisedenvironment. The review of documentspertaining to the regulatory framework governingsupervised injecting in Canadaprovided data regarding how structural forces,legislation, and public policy shapetheparticular features of Insite, which contributedimportant information not readilyavailable through observational activities orinterviews with IDUs. Examinationofutilization statistics and the electronicdatabase within Insite permitted identificationoftemporal trends (e.g., increased visits around“cheque day) and confirmed theinterpretations emerging fromobservational work at Insite(e.g., how wait-timesinfluence access to the injection room).122Collectively, analyzing different types of data from various methodsand sourcesallowed me to identify how different types of environmental influences(e.g., social,physical, economic, & policy) operate within the two types of injectionsettings to shapethe production or reduction of injection-related risk. Comparingand contrasting thevarious forms of data, and considering the i.mique information providedby each source,yielded analyses that were more holistic and in-depththan what may have beenproduced if only data from interviews and observationswere analyzed. Bycontinuously considering data from various sources throughoutthe analyses, I came tounderstand that these forces not only shapeactivities and behaviour within thesesettings, but also shape the actual venues themselves.For example, the large publicinjecting scene in the DTES exists partiallydue to the high levels of homelessnessamong injectors and the lack of access to privatespace. However, it is also shapedbythe particular public policies that have createdthe unique risk environment thatcurrently exists in the DTES, as discussedin the introductory chapter. Considerationofthe diverse types of data utilized in this dissertationsupports the perspective that thedifferent types of environmentalinfluence identified by the risk environmentframework are indeed inseparable, and are constantlyinteracting with each other.Dueto the complexity of forces which shapethe particular injections settings whichexist inthe DTES, and the interplay betweenvarious types of environmental influence,it wouldnot have been possible to generatethe descriptions and understandingscontained inthis dissertation without integratingdata from different sources and differentmethods.Finally, this dissertation illustrates theneed to understand injection settingsaslocal and particular phenomenarather than relying on genericconceptualisations ofthese venues, which are in many waysinadequate for understandingsof injectionrelated risk and efforts to develop setting-basedinterventions to address drug-relatedharm (Rhodes et aL, 2006). Ethnographicresearch is essential in this regard; dueto its123ability to document the local form of a cultural practice (e.g., public injecting) aswell asthe particular features of a public health intervention (Moore, 2004), in this case theoperational and programmatic characteristics of Insite as a SIF.5.4 Study Limitations and StrengthsWhile each of the study chapters (2-4) includes a description of the strengths andlimitations associated with each individual work, several of these issues warrantconsideration in relation to the dissertation as a whole.First, for all the advantages that are conferred through ethnographic researchmethods, it also should be acknowledged that the descriptions of the people and placesare based on interactions with study participants and observations sitesat particularpoints in time (providing a somewhat a cross-sectional view of the situation). Forexample, as conditions within the local drug scene and SIF operationchange over time,(or as IDUs gain more experience with the facility), it will be importantto review thefindings presented here to determine their relevance overthe long term. As well, the in-depth interviews were conducted with a relatively small group of IDUs within theVancouver setting who are SIF clients (and, therefore, do not represent theperspectivesof IDUs who have not accessed the SIF).Also, the environmental (e.g., local drug scene) and structural issuesidentified(e.g., legal and regulatory contexts) are largely specificto Insite, as the current studysought to understand this particular facility in relation to its localenvironment,therefore, these particular findings may not be as relevant toSIFs in other settings,although the complexities of the intersections betweenthe local drug scene and broaderhealth and social policy, clearly has implicationsfor understanding SIFs in otherjurisdictions. Similarly, findings regarding the characterand extent of public injectionsettings are also specific to the Vancouver setting, although someof the particular124features which influence the situated risk perceptions of injectors(e.g., unsanitaryconditions, potential for interruption by the police) are similar to those describedinpublic injecting venues in other locales (Rhodes et aL, 2006; Dovey, Choi,andFitzgerald, 2001).The limitations inherent in my dissertation work should be balanced againstthemany strengths stemming from the use of different data generationmethods andanalysis of data from various sources. Data presented in thesestudies were generatedthrough multiple and complementary data collection and analysis activities,includingin-depth interviews with individual IDUs and directexposure to drug user behaviourthrough naturalistic observation within the SIF and street-basedsettings. In addition,insights garnered through interview and observationaldata regarding access to the SIFand patterns of utilisation were confirmed throughexamination of an external datasource, the electronic database within theSIF. The methodological triangulationpermitted through the use of multiple modes of inquiryrepresents a strength of thedissertation.5.5 Promising Policy and Practice ActionsThe findings of my dissertation point to severalinterventions that hold promisefor addressing injection-related risk in Vancouver.Innovative strategies are urgentlyneeded to enhance personal safetyand reduce the potential forinterruption anddisruption of injecting routines within these settings.As indicated in previous research(Maher & Dixon, 1999), this wouldentail ensuring that police operationsin the opendrug scene do not compromisepublic injectors’ efforts to protect theirhealth byavoiding intervening at the point of injection.Additionally, enhancing accessto sterilesyringes and ancillary injectingequipment, as well as providing amenitiesincludingadequate lighting, working surfaces,and facilities to permit hand-washing, would serve125to promote hygienic routines and safer injection practices within these settings. Effortsalso should be made to provide monitoring, potentially through peer supervision, inorder to improve the response to overdoses in public settings (Fitzgerald, Dovey, Dietze& Rumbold, 2004). Finally, the potential of naloxone prescriptionand/or distribution ofnaloxone to drug users should be explored, as existing researchindicates that theadministration of naloxone by drug users is effective in avoiding fatalitiesresultingfrom opiate overdoses (Kim, Irwin & Khoshnood, 2009; Piper et al., 2008;Strang et al.,2008).With regards to maximising the potential of SIFs to addressinjection-related riskand reduce drug-related harm within the Vancouver context, efforts shouldbe made toexpand the capacity of the current facility and modifythe existing regulations toimprove access and remove barriers to utilisation. This wouldentail amendments to thecurrent regulatory framework governing supervised injection,to permit assistedinjections and the sharing of drugs betweenclients, as well as modificationstoCanadian criminal and civil law to address legal liabilityrelated to providing assistedinjections within SIFs (Pearshouse & Elliott, 2007).The barriers posed by the delays inaccessing the injection room also could be addressed inpart through increasing thenumber of injection spaces available,as well as the addition of other SIFs in theneighbourhood. The changes to public policiesand legislation that would be requiredtooptimise Vancouver’s SIF could alsohave important implications for the establishmentof additional facilities in other Canadiancities where they are needed.Moreover, efforts need to be undertakento transform the conditions underwhich IDUs in Vancouver’s DTES live. Policyreforms that increase accessto affordableand assisted housing in the DTES shouldbe a primary component of these effortsasthis would help to mediate thehigh burden of drug-related harmamong homelessIDUs (Corneil et al., 2006).In addition, improving access to housing, andreducing126homelessness among injectors, could also serve to reduce the volume of public injectinglocally (DeBeck et al., 2008), which would also potentially reduce some of the excessdemand for the SIF which currently poses operational difficulties.5.6 Future ResearchContinued efforts are needed to examine drug user perspectives regardingparticular injection settings, as well as their lived experience within thesemicroenvironments. IDUs’ perspectives on risk priorities and situated riskperceptions arecrucial to policy and program planning efforts. In theVancouver context, an importantpriority would be to examine IDUs’ experiences in injectionsettings within local singleroom occupancy (SRO) hotels, as these locations represent animportant type of venuewhere a significant volume of injecting behaviourtakes place (Shannon, Ishida, Lai &Tyndall 2006).It is also important that research specific to SIFs beginsto follow a more naturalprogression that is more closely aligned withthe normal evolution of health serviceevaluation. Specifically, when a novel interventionis found to meets its most basicobjectives (i.e., benefits to health) and is not foundto produce harms, efforts should bemade to progress to second generation evaluationquestions, including those focused onoptimizing programs through re-design,modification of service delivery,and scaling-up (Kerr et al, 2008). In other words, future SIFresearch needs to move beyond thequestion of whether or not SIFs are effectivein meeting the objectives of reducingpotential for blood-borne virus transmissionand harms stemming from illicitdrugoverdose, to questions such as “what isthe optimal number and configurationof SIFsfor a given location” and “how canrules and regulations be modifiedto promotemaximum access and coverage of SIFs”.1275.7 Knowledge Translation: From Research to ActionThe current dissertation makes important contributions to the public healthliterature regarding the role of injection settings as a crucial dimension ofthe riskenvironment, as well as SIFs as a form of safer injecting environmentintervention.Chapter 2 has been published and Chapters 3 and 4are ready to be submitted to peer-reviewed journals for consideration for publication. However,the knowledgetranslation actions associated with this dissertationgo well beyond scholarlypublications.This work contributes to a growing body of researchthat attempts to understandthe lived experience of IDUs in orderto foster the development, and refinement, ofinnovative health programs that reduce injection-related riskand improve the health ofmarginalised drug users. While reliable statisticsare a prerequisite for developingappropriate public health and harm reductionprograms, ethnographic data on the livedexperience of the individuals who are the targetof these programs is also a vital partofthe evidence base informing such strategies.The ability to identify theimplicitassumptions underpinning public health programs,and highlight the ‘disconnect’between these assumptions and the livedexperience of highly marginalisedIDUs, is afundamental reason why ethnographic workhas provided “reality checks” forpolicymakers over the past decades (Moore,2005).While some researchers have arguedthat drug policies emphasisingharmreduction merely represent new,and perhaps more politically correct,forms ofgoverning the “unruly bodies” of drugusers, this interpretation may precipitatea formof “paralysis” among social scientistswho are reluctant to contribute to theseforms ofsocial control (Bourgois, 1998; Bourgois,2000). As part of this debate, othershavecontended that while an element ofsocial control may be mobilised throughharmreduction program, this should notprevent social scientists workingin the realm of128drug policy from takingpractical actionas a response, and seekingto improve existingapproaches (Bourgois,1998; Bourgois, 2000;Moore, 2005). Whileproviding informationcrucial to the improvementand refinementof existing harm reductionprograms, it isimportant thatsocial research also considershow the widerneo-liberal context,andunequal powerrelations betweenIDUs and services,shape drug userinteractions withthese programs.While socially orientedresearch examiningthe lives of marginaliseddrug users is essentialto the developmentand optimisationof risk-reductioninterventions,we must not losesight of the ethicalresponsibilityto advocate forformsof governance that ultimatelyreduce social sufferingamong marginalisedcitizens whoinject drugs (Moore,2009; Moore, 2004).1295.8 ReferencesBourgois, P. 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Lancet Infectious Disease, 4(5):301-6.131*2j—.#7APPENDIX A: HUMAN ETHICS APPROVAL CERTIFICATEUBcPROVIDENCE HEALTH CARE UBC/Providence Health CareIOFFIce OF RESEARCH SrRvxcfs1ji‘$r’ Research InstitutejjthFloor Hornby Site - SPHdo 1081 Burrard St, Vancouver, BC V6Z 1Y6Phone: (604) 806-8567 Fax: (604) 806-8568Certificate of Final ApprovalI IPrincipal Investigator: Department: Reference Number:Dr. Thomas Kerr BC CfE P05-0186Co-investigators:Ors. J. Stolz, E. Wood, M. Tyndall, Mr. W. SmallSponsoring Agencies:Health CanadaProject Title:Ethnographic investigation of the natural history of injection drug useDate Submitted: Date Ethical Approval: Date Final Approval:June 2, 2006 June 29, 2006202006The IJBC/PHC Research Ethics Board has granted ethical approval for theabove-referenced research project. I am pleased to inform you that all necessaryapprovals and agreements/contracts are now in place and that you havepermission of the hospital to begin your research.‘//Dr. Yvonne tefebvreVice Pretdent Research and Academic AffairsProvidence Health CareDate: 14AJ) 7o132IUBCI 4PROVIDENCE HEALTH CAREResearch InstituteUBC-Providence Health CareResearch InstituteOffice of Research Seivices11th Floor Hamby Site - SPHdo 1081 Burrarri StVancouve, BC V6Z 1Y6Tel: (604) 806-8567Fax: (604) 806-8568ETHICS CERTIFICATE OF EXPEDITED APPROVAL:ANNUAL RENEWALEXPIRY DATE OF THIS APPROVAL: May 12, 2010PRINCIPAL INVESTIGATOR: DEPARTMENT: JBC-PHC REB NUMBER:homas KerrIH05186NSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT:InstitutionISiterovidence Health Care St. Pauls Hospitalther locations where the research will be conducted:nsite (139 East Hastings Street) Dr. Peter Centre (1110 Comox Street) VIDUS otTice (215 Dunlevy Avenue) ARYS office:807 Drake Street)O.INVESTIGATOR(S):Evan WoodAark W. Tyndallo-Anne StoltzVilliam G. SmallSPONSORING AGENCIES:Danadian Institutes of Health Research (CIHR) - Exploring the natural history of injection druguse: A qualitative;tudy of social and environmental influencesROJECT TITLE:Exploring the natural history of injection drug use: A qualitative study of social and environmentalinfluencesftPPROVAL DATE: May 12, 2009ERTIFICATION:The membership of the UBC-PHC REB complies with the membership requirements forresearch ethicsboards defined in Part C Division 5 of the Food and Drug Regulations ofCanada.2. The UBC-PHC REB carries out its functions in a manner fully consistent with Good ClinicalPractices.3. The LJBC-PHC REB has reviewed and approved the research project named on this Certificate of Approvalincluding any associated consent form and taken the action notedabove. This research project is to beconducted by the principal investigator named above at the specified researchsite(s). This review of theUBC-PHC REB have been documented in writing.The UBC-PHC Research Ethics Board Chair or Associate Chair, has reviewed the documentationfor theabove named project. The research study, as presented in the documentation, was found tobe acceptable onethical grounds for research involving human subjects and was approved forrenewal.Approval of the UBC-PHC Research Ethics Board or Associate Chair, verifiedby the signature of one of thefollowing:Dr. Kuo-Hsing Kuo, Dr. 3. Kernahan,Dr. I. Fedoroff,Chair Associate ChairAssociate Chair133LTH CAREUBCIPROVIDENCE HEALTh CAREOFFICE OF RESEARCH SERVICESCertificateof Final ApprovalPrincipal Investigator:Department:RVeience Number:Dr. Michael V. OShaughnessyCfEP030057 - -Co-Investigatois:Sponsoring Agencies:Term (Years):Vancouver Coastal HealthAuthority1Project Title:Vancouver SupervisedInjection Site ScientificResearch Pilot ProjectProposal: An Application For AnExemption Under SectIon56 of the ControlledDrugs and SubstancesActDate Submitted:Date Ethical Approval:Date Rnal Approval:March 18, 2003AprIl 29, 2003AprIl 29, 2003The above-mentIonedstudy has recentlybeen approved by theUBCJPHC ResearchEthicsBoard. All othernecessary departmentalapprovals (Nwth,gand Medical Reco,dsare nowIn place and I ampleased to Inform youthat you havethe permission of the hospitalto begInyour study.FDr. M.V. ó’ShaVice PresIdent, iProvidence Health CareDate: Aonl 29.2003134UBCETHICS CERTIFICATE OF EXPEDITED APPROVAL:ANNUAL RENEWALPRINCIPAL INVESTIGATOR: EPARTMENT: JBC-PHC REB NUMBER:Thomas KerrHCRt lO3-5OO57INSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT:InstitutionISiteProvidence Health Care St. Paul’s HospitalOther tocaliona where the research will be conducted:Insite (139 East Hastings Street) Dr. Peter Centre (1110 Comox Street) VIDtJS office (215 Dunlevy Street)CO-INVESTIGATOR(S):Robert S. HoggEvan WoodMark W. TyndallWilliam G. SmallJulio S.G. MontanerSPONSORING AGENCIES:Canadian Institutes of Health Research (CIHR)Vancouver Coastal Health Research Institute - Supervised Injection Site EvaIuationPROJECT TITII:The Scientific Evaluation of Supervised Injecting (SEOSI) CohortEXPIRY DATE OF THIS APPROVAL: April 29, 2010APPROVAL DATE: April 29, 2009CERTIFICATION:1. The membership of the UBC-PHC REB complies with the membership requirements for research ethicsboards defined in Part C Division 5 of the Food and Drug Regulations ofCanada.2, The UBC-PHC REB carries out its functions in a manner fully consistent with Good Clinical Practices,3. The UBC-PHC REB has reviewed and approved the research project named on this Certificate of Approvalincluding any associated consent form and taken the action noted above.This research project is to beconducted by the principal investigator named above at the specified research site(s). This review of theUBC-PHC REB have been documented in writing.The UBC-PHC Research Ethics Board Chair or Associate Chair,has reviewed the documentation for the abovenamed project. The research study, as presented in the documentation, wasfound to be acceptable on ethicalgrounds for research involving human subjects and was approved for renewal.Approval of the UBC-PHC Research Ethics Board or Associate Chair, verifiedby the signature of one of thefollowing:IUBC-Pmvkience Health CareResearch institute14PROVIDENCE HEALTH CAREOfficeofResearchServices,V%WResearch Institute11th FfrorHomby Site - SPHdo 1081 BurrardSl.Vancouve, BC V6Z 1Y6Tel: (604) 806-8567Fax: (604) 806-8568Dr. Kuo-Hsin Kuo, Dr. J. Kernahan,Dr. I. Fedoroff,Chair Associate ChairAssociate Chair135


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