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The impact of environmental factors on risk, harm, and health care access among people who inject drugs McNeil, Ryan 2013

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  THE IMPACT OF ENVIRONMENTAL FACTORS  ON RISK, HARM, AND HEALTH CARE ACCESS  AMONG PEOPLE WHO INJECT DRUGS  by  Ryan McNeil B.Phil., University of New Brunswick, 2003 M.Phil., University of New Brunswick, 2006    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2013 ? Ryan McNeil, 2013  ii ABSTRACT   Background: Growing awareness of the role social, structural, and environmental factors in producing harm among people who inject drugs (IDU) has underscored the need for safer environment interventions. However, emerging evidence underscores how current interventions are insufficient to bring about more significant reductions in drug-related harm. To date, there have been few studies examining how contextual forces operating within the wider risk environment shape the socio-spatial relations of IDU in relation to safer environment interventions and health care settings. This dissertation seeks to address this gap by examining the socio-spatial dynamics within three settings in Vancouver, Canada: the street-based drug scene; an ?unsanctioned? supervised drug consumption room (DCR); and, hospitals. Methods: This dissertation used an ethno-epidemiological approach, and the individual studies were undertaken in connection with ongoing prospective cohort studies of current and former drug users. Ethnographic fieldwork, including participant-observation, in-depth interviews and qualitative mapping exercises, sought to characterize the socio-spatial relations of IDU in relation to the abovementioned settings. Results: Study findings underscored how contextual forces shaped the socio-spatial relations of IDU, and thus access to and engagement with safer environment interventions and hospital settings. First, findings highlighted the role of gendered power relations within the street-based drug scene in shaping the spatial practices of highly vulnerable IDU, and constraining their access to a supervised injection facility. Second, findings demonstrated how, by permitting assisted injections, the DCR created a ?legitimate place? for IDU who require help injecting, and enabled them to enact risk reduction. Finally, social (e.g., stigmatization) and structural (e.g., abstinence-based drug policies) factors within hospital settings were found to  iii produce considerable suffering (e.g., inadequate pain management) and contribute to discharges from hospital against medical advice. Conclusions: The collective findings of this dissertation demonstrate how the socio-spatial relations of IDU, and the contextual forces that impact upon them, are key determinants of drug-related harm and access to interventions and hospital services. These findings point to the need to modify and scale up existing safer environment interventions, and expand these into hospital settings, to mitigate the impacts of contextual forces on IDU and better address their health needs.         iv PREFACE  This statement certifies that the work contained in this dissertation was conceived, conducted, and written by Ryan McNeil (RM). All empirical research undertaken for the completion of this dissertation was approved by the University of British Columbia/Providence Health Care Research Ethics Board (certificate H10-0838). The co-authors of the manuscripts include: Drs. Thomas Kerr (TK), Kate Shannon (KS), Will Small (WS), and Evan Wood (EW); Mr. Hugh Lampkin; and, Ms. Laura Shaver. These individuals made contributions only as were commensurate with supervisory committee, collegial, or co-investigator duties. The specific contributions of the author and co-authors are outlined below.  A manuscript incorporating sections of Chapter 1 into Chapter 2 is currently under review for peer-reviewed publication. RM, TK, and WS designed the study. RM conducted the systematic literature search, synthesized the data, and prepared the first draft of the manuscript. WS provided input on the draft and contributed to the revision of the manuscript. RM also revised the manuscript upon receipt of comments during the peer review process. The manuscript is under review as:  McNeil, R. & Small, W. ?Safer environment? interventions: A qualitative synthesis of the experiences and perceptions of people who inject drugs.  Chapter 3 is currently under review for peer-reviewed publication. RM, TK, KS, and WS designed the study. LS provided input as was commiserate with her role on the Board of Directors of the Vancouver Area Network of Drug Users (VANDU). RM took the primary role in data collection and analysis, and prepared the first draft of the manuscript. WS, LS, KS, and TK provided critical feedback on the draft and contributed to the revision of the manuscript. This manuscript is under review as: McNeil, R., Shannon, K., Shaver, L., Kerr, T. & Small, W. Negotiating place and gendered violence in Canada?s largest open drug scene.   v A version of Chapter 4 is currently under review for peer-reviewed publication. RM, TK, and WS designed the study. HL provided input as is commiserate with his role on the VANDU Board of Directors. RM took the primary role in data collection and analysis, and prepared the first draft of the manuscript. WS, HL, KS, and TK provided critical feedback on the draft and contributed to the revision of the manuscript. RM revised the manuscript following receipt of comments from peer reviewers.  This manuscript has been accepted for publication as:  McNeil, R., Small, W., Lampkin, H., Shannon, K. & Kerr, T. (In press). ?People knew they could come here to get help?: An ethnographic study of assisted injection practices at a peer-run ?unsanctioned? supervised drug consumption facility in a Canadian setting. AIDS & Behavior. Chapter 5 is currently under review for peer-reviewed publication. RM, WS, and TK designed the study. RM took the primary role in data collection and analysis, and prepared the first draft of the manuscript. WS, EW, and TK provided critical feedback on the draft and contributed to the revision of the manuscript. This manuscript is under review as:   McNeil, R., Small, W., Wood, E. & Kerr, T. Hospitals as a ?risk environment?: An ethno-epidemiological study of the experiences of people who inject drugs who have been discharged from hospital against medical advice. Chapter 6 is original, unpublished work produced by the author with substantive input from TK, AH, KS and WS.       vi TABLE OF CONTENTS   ABSTRACT ............................................................................................................................ ii PREFACE ............................................................................................................................... iv TABLE OF CONTENTS ..................................................................................................... vi LIST OF TABLES ................................................................................................................. ix LIST OF FIGURES ................................................................................................................ x LIST OF ABBREVIATIONS .............................................................................................. xi ACKNOWLEDGEMENTS ................................................................................................ xii DEDICATION. ................................................................................................................... xiv CHAPTER 1: INTRODUCTION ........................................................................................ 1 1.1 Introduction ................................................................................................................. 1 1.2 Environmental Interventions ................................................................................... 5 1.3 Study Setting ............................................................................................................... 9 1.4 Study Justification .................................................................................................... 12 1.5 Study Objectives ....................................................................................................... 14 1.6 Conceptual Framework ........................................................................................... 16 1.7 Study Approach ........................................................................................................ 19 1.8 Summary .................................................................................................................... 21 CHAPTER 2: SAFER ENVIRONMENT INTERVENTIONS: A QUALITATIVE SYNTHESIS OF THE EXPERIENCES AND PERCEPTIONS OF PEOPLE WHO INJECT DRUGS .................................................................................................................. 23 2.1 Introduction ............................................................................................................... 24 2.2 Methods ...................................................................................................................... 25 2.2.1 Search Strategy .................................................................................................... 25 2.2.2 Description of Articles ....................................................................................... 27 2.2.3 Analytic Strategy ................................................................................................. 27 2.3 Results ......................................................................................................................... 28 2.3.1 Environments to Escape Everyday and Structural Violence ........................ 28 2.3.2 Enabling Safer Drug Use Practices ................................................................... 30 2.3.3 Locating Interventions Within the Geography of Survival .......................... 31 2.3.4 Factors Constraining Safer Environment Interventions ............................... 33 2.4 Discussion .................................................................................................................. 34 CHAPTER 3: NEGOTIATING PLACE AND GENDERED VIOLENCE IN CANADA?S LARGEST OPEN DRUG SCENE ............................................................. 70  vii 3.1 Introduction ............................................................................................................... 70 3.2 Methods ...................................................................................................................... 75 3.3 Results ......................................................................................................................... 77 3.3.1 Place, Violence, and Masculinity in the Downtown Eastside ...................... 78 3.3.2 Gendered Violence and Geographical Restrictions ....................................... 79 3.3.3. Locating Geographies of Survival ................................................................... 83 3.3.4 Crossing Boundaries ? Entering ?Dangerous? Drug Scene Milieus ............. 85 3.4 Discussion .................................................................................................................. 87 CHAPTER 4: AN ETHNOGRAPHIC STUDY OF ASSISTED INJECTION PRACTICES AT A PEER-RUN ?UNSANCTIONED? SUPERVISED DRUG CONSUMPTION FACILITY IN A CANADIAN SETTING...................................... 96 4.1 Introduction ............................................................................................................... 96 4.2 Methods .................................................................................................................... 101 4.3 Results ....................................................................................................................... 104 4.3.1 Social and Structural Barriers to Safer Injecting ........................................... 105 4.3.2 Limits of Safer Injecting Education ................................................................ 107 4.3.3 The Everyday Violence of Assisted Injection Practices ............................... 108 4.3.4 Establishing Safer Injecting Routines ............................................................. 110 4.3.5 A Legitimate Place for People who Require Help Injecting ....................... 111 4.3.6 Enabling Harm Reduction Practices .............................................................. 113 4.4 Discussion ................................................................................................................ 116 CHAPTER 5: HOSPITALS AS A ?RISK ENVIRONMENT? ? AN ETHNO-EPIDEMIOLOGICAL STUDY OF THE EXPERIENCES OF PEOPLE WHO INJECT DRUGS WHO HAVE BEEN DISCHARGED AGAINST MEDICAL ADVICE .............................................................................................................................. 122 5.1 Introduction ............................................................................................................. 122 5.2 Methods .................................................................................................................... 126 5.2.1 Participant Recruitment ................................................................................... 127 5.2.2 Data Collection .................................................................................................. 127 5.2.3. Data Analysis ................................................................................................... 128 5.3 Results ....................................................................................................................... 128 5.3.1 ?Drug-seeking? and Pain Management .......................................................... 129 5.3.2 The Need to Manage Pain and Withdrawal ................................................. 131 5.3.3 Surveillance, Regulation, and In-Hospital Drug Use .................................. 133 5.3.4 Well-intentioned Departures from Hospital................................................. 135 5.3.5 Involuntary Discharge for In-Hospital Drug Use ........................................ 136 5.4 Discussion ................................................................................................................ 137 CHAPTER 6: CONCLUSION ......................................................................................... 143  viii 6.1 Summary of Findings ............................................................................................ 143 6.2 Unique Contributions ............................................................................................ 146 6.3 Limitations ............................................................................................................... 149 6.4 Recommendations .................................................................................................. 150 6.5 Future Research ....................................................................................................... 153 6.6 Conclusion ............................................................................................................... 155 REFERENCES .................................................................................................................... 156      ix LIST OF TABLES  Table 1. Search variables for systematic literature search ............................................. 43 Table 2. Details of retrieved articles (listed chronologically) ........................................ 44 Table 3. Key themes and limitations of included articles (listed chronologically) .... 51 Table 4. Distribution of themes and sub-themes across included articles .................. 64 Table 5. Selected data excerpts from included articles ................................................... 66      x LIST OF FIGURES  Figure 1. Risk environment framework ........................................................................... 23 Figure 2. Flowchart of meta-synthesis .............................................................................. 42 Figure 3. Map of Ellen's spatial practices ......................................................................... 94 Figure 4. Map of Alex's spatial practices .......................................................................... 95      xi LIST OF ABBREVIATIONS  BCCfE  British Columbia Centre for Excellence in HIV/AIDS CDSA   Controlled Drug and Substances Act DCR   Drug consumption room HIV   Human immunodeficiency virus HCV   Hepatitis C virus IDU   People who inject drugs SCC   Supreme Court of Canada SEOSI   Scientific Evaluation of Supervised Injecting SEP   Syringe exchange programme SIF   Supervised injection facility UHRI   Urban Health Research Initiative VANDU  Vancouver Area Network of Drug Users        xii ACKNOWLEDGEMENTS  I express sincere thanks to my co-supervisors, Drs. Amy Hanser and Thomas Kerr, and supervisory committee members, Drs. Kate Shannon and Will Small, for their mentorship and constant support throughout my doctoral training. I thank Amy for her unwavering support and encouragement as my research took new directions. I owe a great deal to Thomas and Will for their generous support and guidance over the past two years. This dissertation would not have been possible without their mentorship and the opportunities that they have afforded me. I express my gratitude to Kate for her close attention to the theoretical dimensions of my work.  The research completed as part of this dissertation would not have been possible without the contributions of the study participants. I thank them all for sharing their experiences with me. I extend a special thanks to the Vancouver Area Network of Drug Users and hope that this research will support their continued efforts to bring about positive changes in drug and health policy. In addition, I acknowledge the exemplary staff at the BC Centre for Excellence in HIV/AIDS for their research and administrative support: Zannie Biggs, Tricia Collingham, Cameron Dilworth, Amber Eastman, Ivan Fletcher, Deborah Graham, Carly Hoy, Rhiannon Hughes, Caitlin Johnston, Steve Kain, Will Lee, Jenny Matthews, Aaron McKinney, Emily Anne Paul, Carmen Rock, Guido Thylman, Lianlian Ti, Peter Vann, Sylvia Machat, Vanessa Volkommer, Pauline Voon, Cristy Zonnefeld. I express my sincere thanks to Cameron Dilworth, Ivan Fletcher, and Aaron McKinney for their assistance with participant recruitment.  I have been truly fortunate to have had the opportunity to learn from an unparalleled group of researchers, colleagues, and graduate students at the BC Centre for Excellence in HIV/AIDS. My fellow trainees have been a source of support, encouragement, and inspiration during my doctoral studies: Mr. Cody Callon, Dr.  xiii Kora DeBeck, Ms. Danya Fast, Ms. Andrea Kru ?si, Ms. Kanna Hayashi, Dr. Tara Lyons, Dr. M-J Milloy, Ms. Michaela Montaner, Dr. Lindsey Richardson, Ms. Lianping Ti and Mr. Daniel Werb.   Funding to support my doctoral studies was provided by the Social Sciences & Humanities Research Council and University of British Columbia. I also thank the Urban Health Research Initiative of the BC Centre for Excellence in HIV/AIDS for providing salary support over the course of my doctoral research.  I express my gratitude to my family and friends for their enduring support throughout my education. My parents and grandparents instilled in me a commitment to promoting social equity, and continue to be a source of strength. I thank our dog, Otis, for the many long walks that helped me to sort out ideas. Last but not least, I express my heartfelt gratitude to my partner, Laura Dilley, without whom none of this would have been possible. Her love and support have sustained me, and any accomplishments are as much hers as mine.       xiv        For Laura, always.     1 CHAPTER 1: INTRODUCTION 1.1 Introduction In Canada and internationally, injection drug use is associated with high levels of preventable morbidity and mortality (Degenhardt et al., 2011; Degenhardt, Singleton et al., 2011; Wood, Kerr, Tyndall, & Montaner, 2008), and in particular is a major driver of the global human immunodeficiency virus (HIV) and hepatitis C (HCV) epidemics. Of the estimated 15 million people worldwide who regularly inject drugs (Mathers et al., 2008), approximately 17% and 50% are believed to be living with HIV and HCV, respectively (Aceijas & Rhodes, 2007; Mathers et al., 2008). People who inject drugs (IDU) commonly experience injection-related infections (e.g., osteomyelitis, endocarditis) and other complications linked to unsafe and unhygienic injecting conditions (Binswanger et al., 2008; Lloyd-Smith et al., 2008). Non-fatal and fatal overdose are significant drivers of elevated morbidity and mortality among injection drug-using populations, and overdose has been identified as the leading cause of death among IDU in many settings (Degenhardt et al., 2011; Mathers et al., 2013).  Over the past decade, the interactions among social, structural, and physical environments operating across the micro-, meso- and macro-level have been identified as critical in shaping risk behaviours and the distribution of harm among injection drug-using populations (Rhodes, 2002; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Rhodes, 2009; Strathdee et al., 2010). Social-environmental factors, including social group norms (Bourgois, 1998; Bourgois & Schonberg, 2009; Fairbairn, Small, Van Borek, Wood, & Kerr, 2010) and the composition of IDU peer networks (Latkin, Kuramoto, Davey-Rothwell, & Tobin, 2010; Lovell, 2002; Neaigus et al., 1994), have been demonstrated to increase the likelihood of unsafe injecting practices (e.g., syringe-sharing) and thus potential exposure to HIV and HCV. Structural- 2 environmental factors, including but not limited to drug law enforcement (Cooper, Bossak, Tempalski, Des Jarlais, & Friedman, 2009; Cooper et al., 2012; Kerr, Small, & Wood, 2005; Pollini et al., 2008; Werb et al., 2011), the distribution of health and harm reduction services (Cooper, Bossak, Tempalski, Friedman, & Des Jarlais, 2009; Tempalski, 2007), and entrenched poverty and homelessness (Corneil et al., 2006; Galea & Vlahov, 2002), have been found to constrain access to harm reduction services and thereby the ability of IDU to enact risk reduction. Finally, the location and physical characteristics of injection settings (DeBeck et al., 2009; Klein & Levy, 2003), as well as their position in relation to national and international drug trafficking and distribution routes (Ciccarone, 2009; Rhodes & Simic, 2005), have been found to shape access to harm reduction services and the distribution of infectious diseases.  The interplay between these social, structural, and physical factors in any given social or physical setting has been termed the ?risk environment? (Rhodes, 2002; Rhodes et al., 2005; Rhodes, 2009). Within the risk environment, place is regarded to be a central determinant of risk, in that the spatial contexts in which social-, structural-, and physical-environmental factors intersect to create meaning are critical in structuring individual and group risk behaviours (Tempalski & McQuie, 2009). Importantly, the ?places? occupied by IDU are themselves structured by contextual forces. Diverse tactics of social control (e.g., zoning, urban design, street policing) are commonly mobilized to exclude IDU from ?prime places (e.g., business and commercial districts, residential and gentrifying areas) and relegate them to ?marginal places? within urban centres (e.g., inner-city neighbourhoods, industrial zones) (Beckett & Herbert, 2010; Mitchell, 2003; Mitchell, 2003; Snow & Mulcahy, 2001).  An emerging body of research has underscored how the contextual forces operating within these marginal places (e.g., public injecting settings, drug scenes) constitute important risk environments (Fast, Small, Wood, & Kerr, 2009; Rhodes et  3 al., 2007; Small, Rhodes, Wood, & Kerr, 2007). For example, ethnographic research into public injecting settings (e.g., alleyways, building alcoves) has highlighted how intersecting structural (e.g., homelessness, drug law enforcement) and physical (e.g., unhygienic conditions) factors operating within these settings amplified drug-related risks (e.g., rushed injections) and thus vulnerability to diverse harms (e.g., injection-related infections, overdose) (Small et al., 2007). Furthermore, research has characterized various social-structural processes that work to exclude injection drug-using populations from ?prime places? as key features within the broader risk environment (Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Cooper, Moore, Gruskin, & Krieger, 2005; Shannon et al., 2008b; Small, Kerr, Charette, Schechter, & Spittal, 2006). Notably, there is considerable evidence that municipal by-laws (e.g., anti-panhandling, zoning restrictions) and police crackdowns that aim to remove IDU from particular areas impair their ability to practice risk reduction (Cooper et al., 2005; Mitchell, 2003). Although a new area of investigation, and as yet poorly documented, environmental interventions have been shown to alter risk environments to enable IDU to enact risk reduction (Duff, 2010; Moore & Dietze, 2005; Rhodes et al., 2006). Syringe exchange programmes (SEP), supervised injection facilities (SIF), and peer outreach are three types of environmental interventions that have been documented to alter key social (e.g., group social norms), structural (e.g., legal access to injection-related paraphernalia) and physical (e.g., access to clean, regulated injecting environments) characteristics of risk environments of IDU(Rhodes et al., 2006). While progress has been made in evaluating the impacts of individual interventions, few studies have examined how contextual forces operating within the wider risk environment shape the socio-spatial relations of IDU in relation to these interventions and other settings associated with increased vulnerability to harm. Moreover, there  4 remains a need to identify potentially modifiable social, structural, and physical characteristics within the wider risk environment, as well as these specific settings, to strengthen existing approaches and outline new opportunities for intervention. This dissertation seeks to address these gaps by exploring how contextual forces operating within the risk environment in Vancouver, Canada, shape the socio-spatial relations of IDU. In particular, the individual studies that comprise this dissertation examine three settings that epidemiological evidence suggests are associated with, or have the potential to mitigate, drug-related risks and harm: (i) the street-based drug scene; (ii) an ?unsanctioned? drug consumption room (DCR); and, (iii) hospital settings. To date, there has been limited attention to how the contextual forces that shape the socio-spatial relations of IDU within these settings produce or reduce harm.  In addressing this research gap, this dissertation aims to provide valuable policy-relevant evidence to inform the further development and refinement of environmental interventions to address the harms and risks associated with injection drug use in these settings and beyond. Rather than seeking to outline ?policy truths? (i.e., ?absolute? solutions to social and health challenges), this dissertation instead aims to identify concrete, and incremental, steps forward to address ongoing public health challenges in the local context and elsewhere. In doing so, this dissertation aims to mobilize contextualized understandings of these challenges to strengthen capacity to avoid repeating past errors in public health planning, and thus improve health equity for IDU. Finally, whereas targeted policy recommendations are outlined in the individual chapters, this dissertation concludes considering how the collective insights of this work point to the need for macro-level changes.  5 1.2 Environmental Interventions Around the globe, public health prevention programmes have been mobilized to minimize HIV and HCV risks among IDU, and address a range of other harms. These interventions have traditionally encouraged individuals to enact changes in behaviours to bring about risk reduction. Such individually-focused interventions are founded upon models of rational choice decision-making that assume that risk is the product of individual action and promote concepts of personal responsibility (Rhodes, 2002). IDU are encouraged to modify risk behaviours (e.g., syringe sharing) to ?stay safe? (Fraser, 2004), and those not adhering to risk reduction strategies are often deemed irrational, or irresponsible, or in some other way deficient (Rhodes, 2002). This emphasis on ?individual responsibility? is situated within broader conceptualizations of neoliberal citizenship embedded in public health prevention discourses that seek to govern risk through the promotion of ?self-care? (Petersen, 1996).  Over the past decade, however, there has been growing acknowledgement that these interventions overlook the critical role of social, structural and environmental forces operating with risk environments in shaping drug-related harm (Rhodes et al., 2005). Within the situated rationality of IDU, seemingly 'risky behaviours' may constitute ?rational? responses to ?competing risks? (Connors, 1992)?that is, the suffering produced by the intersection of addiction and social and structural inequities (Bourgois, 1998; Bourgois & Schonberg, 2009). For example, in an ethnography among older male heroin injectors in homeless encampments in San Francisco (USA), Bourgois (1998) found that 'moral economies' structured the sharing of syringes and injection-related paraphernalia. Despite awareness of the associated health risks, the mutual obligations formed by sharing 'tastes' of heroin (i.e., residue remaining in injection-related paraphernalia following injection) enabled these men  6 to later gain access to minimal amounts of the drug when their resources were depleted and they were coping with opiate withdrawal.  Against this larger backdrop, it has been increasingly acknowledged that efforts to reduce drug-related harm must involve environmental interventions that address contextual forces constraining individual decision-making (Blankenship, Bray, & Merson, 2000; Des Jarlais, 2000; Duff, 2010; Moore & Dietze, 2005; Rhodes et al., 2005; Rhodes et al., 2006; Strathdee et al., 2010). Such approaches have been variously termed ?enabling environment? approaches (Duff, 2010; Moore & Dietze, 2005), structural interventions (Blankenship et al., 2000), and safer environment interventions (Rhodes et al., 2006). These environmental interventions seek to mitigate harm by modifying social, structural or physical environments to better enable risk reduction. Structural interventions and enabling environment approaches are primarily oriented toward the identification and alteration of macro-level determinants of risk (Blankenship et al., 2000; Moore & Dietze, 2005). These approaches emphasize the potential role of structural changes (e.g., drug decriminalization) in fostering environments conducive to changes in individual risk behaviours (Duff, 2010; Moore & Dietze, 2005). Given that macro-level changes (e.g., drug policy reforms) are slow-moving and unlikely to fully mitigate the impact of intersecting social and structural inequities that structure risk and harm, targeted environmental interventions occupy an important role in minimizing drug-related harms. In this regard, safer environment interventions have been increasingly identified as critical programmatic responses to contextual forces that produce risk (Rhodes et al., 2005; Rhodes et al., 2006). While safer environment interventions have been under-conceptualized in the literature, they may be understood to include a continuum of programmatic responses that seek to reconfigure the environmental contexts of injection drug use  7 (Rhodes et al., 2006). These range from interventions designed to increase access to harm reduction paraphernalia (e.g., SEPs) to interventions intended to reconfigure social networks (e.g., peer outreach interventions) to those that create safer drug use settings (e.g., SIFs, spatial programming). In the context of injection drug use, three types of safer environment interventions have garnered the most attention, and have both clear strengths and limitations. SIFs are regulated indoor environments where IDU can inject pre-obtained drugs under supervision. SIFs have been demonstrated to decrease unsafe injection practices (Kerr et al., 2006; Stoltz et al., 2007) and overdose mortality (Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Milloy, Kerr, Tyndall, Montaner, & Wood, 2008), and have been found to facilitate referrals to medical care and addiction treatment (Small, Van Borek, Fairbairn, Wood, & Kerr, 2009; Wood, Tyndall, Zhang, Montaner, & Kerr, 2007). Evidence suggests that the positive outcomes produced by SIFs may be limited to their immediate surroundings (Marshall et al., 2011), and do not extend to those unable to access these facilities due to restrictions on assisted injections (Fairbairn et al., 2010). The political-legal contexts in many jurisdictions have constrained the expansion of SIFs (Beletsky, Davis, Anderson, & Burris, 2008). Syringe exchange and distribution programmes (SEP) have operated in countries around the world since the 1980s in response to emerging HIV and HCV epidemics among injection drug-using populations (Bastos & Strathdee, 2000). SEPs operate under a variety of models (e.g., one-to-one exchange, unrestricted distribution) and aim to increase access to injection-related paraphernalia (Bastos & Strathdee, 2000). Research has underscored the role of SEPs in reducing drug-related harms, such as syringe-sharing (Bluthenthal, Kral, Gee, Erringer, & Edlin, 2000; Hartgers, Buning, van Santen, Verster, & Coutinho, 1989) and HIV transmission (Des Jarlais et al., 1996; Hurley, Jolley, & Kaldor, 1997). However, SEPs have faced  8 ideologically-driven opposition in various contexts that have limited their distribution (MacNeil & Pauly, 2010; Tempalski, 2007), or required them to adopt restrictive operating policies (e.g., one-to-one exchange).  A range of peer outreach harm reduction interventions have been implemented with the intention of minimizing risks produced within injection settings, including harm reduction education (Dickson-Gomez, Knowlton, & Latkin, 2003; Latkin, 1998; Latkin et al., 2009), peer-based syringe exchange (Hayashi, Wood, Wiebe, Qi, & Kerr, 2010; Ngo, Schmich, Higgs, & Fischer, 2009), naloxone-based overdose prevention (Galea et al., 2006; Sherman et al., 2009; Tobin, Sherman, Beilenson, Welsh, & Latkin, 2009) and injection support interventions (Small et al., 2012). Many of these interventions have drawn on social network theory, in that they identify IDU as potential agents of influence within their social networks and seek to reconfigure risk-potential linkages (i.e., peer interactions) to minimize harm (Friedman & Aral, 2001). While these interventions have shown some effectiveness in intervening within drug use settings to disrupt social norms that promulgate harm, formal evaluations assessing their impact at the population-level have been limited.  In addition, there is evidence that integrating safer environmental approaches into health care settings alters their social- and structural-environmental contexts to promote access to care among IDU (Islam et al., 2012; Islam, Topp, Day, Dawson, & Conigrave, 2012; Krusi, Small, Wood, & Kerr, 2009). In many areas with injection drug use epidemics, syringe exchange and distribution services have been nested within community health clinics to promote contacts between IDU and health care professionals, and thus facilitate access to care (Islam et al., 2012). Furthermore, while the limited distribution of supervised injection services has constrained efforts to evaluate this approach in health care settings, one study found that integrating this approach into a community-based HIV care facility improved relationships between  9 IDU and nursing staff, and thereby promoted access to care (Krusi et al, 2009). Collectively, these safer environment approaches, along with the broader range of interventions, have proven critical to the response to the contextual forces driving risk and harm among IDU.  1.3 Study Setting Vancouver, Canada is the site of a longstanding injection drug use epidemic (McInnes et al., 2009). The city?s injection drug-using population is most concentrated in the Downtown Eastside neighbourhood, an approximately ten-block area that is currently home to an estimated 5,000 IDU (Wood & Kerr, 2006). This neighbourhood has been shaped by the intersection of entrenched poverty, homelessness, and injection drug use (Benoit, Carroll, & Chaudhry, 2003; Culhane, 2003; Wood & Kerr, 2006), as well as the displacement of IDU from other areas of the city (e.g., Yaletown, False Creek) (Olds, 1998). The scope and geographical concentration of Vancouver?s injection drug-using population has led to development of a multi-pronged public health response that includes multiple types of safer environment interventions, which have evolved over the past twenty-five years.  High levels of injection drug use, together with the global emergence of HIV and HCV, led to the 1988 opening of a fixed site SEP in the Downtown Eastside , which two years later expanded to include outreach services (Bardsley, Turvey & Blatherwick, 1990). This programme had more than 2600 registered users by the end of its first year of operation, and had exchanged more than 127,000 syringes (Bardsley, Turvey, & Blatherwick, 1990). Vancouver?s SEP originally operated under a strict exchange policy requiring IDU to return used syringes to obtain new ones (n.b., limits began at one-for-one but increased at various points in response to changing community drug use patterns) (Hyshka, Strathdee, Wood, & Kerr, 2012).  10 Despite high levels of SEP utilization (Hyshka et al., 2012), a rapid rise in HIV and HCV infections occurred among IDU in the Downtown Eastside?s injection drug-using population throughout the 1990s, with one study reporting the prevalence to be 23% and 88%, respectively (Strathdee et al., 1997). Epidemiological data linked the increase in HIV and HCV transmission to the increase in intensive cocaine injection in the neighbourhood (Tyndall et al., 2003), which involved ?binges? that often entailed up to twenty injections per day. In addition, various studies pointed to the critical role of diverse contextual forces operating within the local risk environment, including homelessness and housing instability (Harvey et al., 1998), restrictive syringe exchange policies (Harvey et al., 1998; Spittal et al., 2004), and drug law enforcement (Bastos & Strathdee, 2000; Wood et al., 2003), in constraining access to sterile syringes and IDUs? ability to enact risk reduction. An overdose epidemic also occurred in Vancouver during this period that resulted in the deaths of hundreds of IDU in the Downtown Eastside each year (Millar, 1998). Taken together, these overlapping epidemics led to alarming increases in morbidity and mortality among IDU in the Downtown Eastside, and prompted the Vancouver-Richmond Health Board to declare a public health emergency in the neighbourhood in 1997.  Consensus emerged that action was urgently needed to address the contextual forces contributing to adverse health outcomes among IDU in this neighbourhood, and the expansion of syringe exchange services and establishment of a safer injecting facility in the Downtown Eastside were identified as key components of this strategy (Kerr & Palepu, 2001; Kerr, Wood, Small, Palepu, & Tyndall, 2003; Wood et al., 2001). While the eventual shift from syringe exchange to distribution was critical in enhancing access to sterile syringes (Hyshka et al., 2012), greater acknowledgement of the role of injection settings in shaping the harms experienced by IDU further underscored the need for safe, regulated injection settings (Bourgois & Bruneau, 2000;  11 Harvey et al., 1998). A multi-year campaign that eventually brought together politicians, researchers, health professionals, activists, and drug users culminated in the September 2003 opening of North America?s only sanctioned SIF (Insite).  Insite was originally opened under a legal exemption to the Controlled Drugs and Substances Act (CDSA), which mandated that its health and public order impacts be rigorously evaluated (Wood et al., 2004). The scientific evaluation of Insite underscored the many public health benefits of this intervention, including decreases in overdose mortality (Marshall et al., 2011) and increased referrals to health and drug treatment services (Small et al., 2009; Tyndall et al., 2006; Wood et al., 2007). The evaluation also documented reductions in syringe-sharing (Kerr, Tyndall, Li, Montaner, & Wood, 2005), publicly-discarded syringes (Wood et al., 2004) and public injecting (Stoltz et al., 2007) following the opening of Insite. After the newly-elected conservative federal government, which was ideologically opposed to the facility, threatened not to renew Insite?s legal exemption, the Portland Hotel Society (which operates Insite) and two IDU pre-emptively filed a lawsuit to keep the facility open. Subsequent to the British Columbia Supreme Court and Court of Appeal ruling in favour of the service, the federal government appealed the decision to the Supreme Court of Canada (SCC). The SCC issued a unanimous judgement in favour of Insite in September 2011 (Supreme Court of Canada, 2011), which led to its permanent establishment.  By most measures, Vancouver includes the most comprehensive safer environment interventions of any city in North America (e.g., fixed site syringe exchange and distribution, supervised injection services) and, as outlined, these have been linked to reductions in drug-related harms. In addition to these interventions, the Vancouver Area Network of Drug Users (VANDU), a drug user-led organization made up of more than 1000 current or former IDU, has operated safer environment  12 interventions in the Downtown Eastside to drive further changes in local health policy and expand the distribution of harm reduction services, including syringe distribution services (Hayashi et al., 2010; Wood et al., 2003), injection support interventions (Small et al., 2012), and ?unsanctioned? supervised drug consumption facilities (Kerr, Oleson, Tyndall, Montaner, & Wood, 2005). 1.4 Study Justification While safer environment interventions have been documented to mitigate drug-related harm, evidence is mounting that existing interventions may be insufficient to bring about more significant reductions in morbidity and mortality among IDU. In Vancouver, an emerging body of research has identified factors that constrain access to safer environment interventions (Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Petrar et al., 2007; Small et al., 2011), as well as places that continue to be associated with diverse harms (Choi, Kim, Qian, & Palepu, 2011; Marshall, Fairbairn, Li, Wood, & Kerr, 2008). Further research is needed to explore how contextual forces operating within the broader risk environment impact the socio-spatial relations of IDU in relation to safer environment interventions and these places. A more complete mapping of the risk environment of IDU represents an important step toward identifying potentially modifiable social, structural, and physical characteristics of safer environment interventions, as well as the broader risk environment. In the local context, there are several key settings that require further inquiry: the street-based drug scene, an ?unsanctioned? drug consumption room (DCR), and hospital settings.  To date, relatively little attention has been paid to the role of social-environmental factors (e.g., gendered power relations, social norms) in shaping the socio-spatial relations of IDU in relation to safer environment interventions. Whereas diverse social-environmental factors (e.g., gendered power relations, social norms)  13 potentially shape access to interventions, drug scene violence is an especially prominent force impacting upon IDU, with evidence suggesting that approximately 70% of IDU will experience violence over a five-year period (Marshall et al., 2008). Although limited to drug-using women who exchange sex, local epidemiological data has indicated that women avoid areas within the Downtown Eastside where they have previously experienced violence despite the presence of health and harm reduction services (Shannon et al., 2008). However, further research is necessary to understand how violence structures the spatial practices of IDU within street-based drug scenes, and in relation to safer environment interventions.  Whereas structural-environmental barriers to supervised injection services have been documented, including current regulatory frameworks (e.g., prohibitions of assisted injections at Insite), operational capacity (e.g., number of injecting booths), and geographic distribution (Marshall et al., 2011; Petrar et al., 2007; Small et al., 2011), there remains limited evidence regarding the potential impacts of changes to the structural-environmental context of these services. Whereas these structural-environmental barriers each pose their own unique challenges, and as such warrant further attention, the prohibition of assisted injections is particularly salient. Approximately 40% of local IDU are estimated to sometimes require help injecting, and this population is twice as likely to acquire HIV (Wood et al., 2003). While the parameters of Insite?s exemption to the CDSA prevent assisted injections from occurring within the facility, VANDU has recently launched an ?unsanctioned? DCR in which trained peer volunteers provide assisted injections. Of particular importance given its potential impact on access to supervised injection services, there is an important need for research into how adopting this approach impacts upon the risk environment of IDU who require help injecting, and in particular their socio-spatial patterns.   14 Finally, there is a continued need for attention to specific places within the risk environment to understand how they produce harm, and identify aspects of these settings amenable to environmental interventions. In Vancouver, and elsewhere, there is evidence that hospitals represent an important risk environment for injection drug-using populations, in that IDU are more likely than other populations to be discharged from hospital against medical advice (Anis et al., 2002; Choi et al., 2011). Whereas safer environment interventions are integrated into the local public health system, hospitals continue to operate under abstinence-based drug use policies that potentially impact upon health access and care (Providence Health Care, N.D; Vancouver Coastal Health, 2008). Research into the experiences of IDU in hospital settings is needed to identify whether contextual forces operating in these settings produce discharges against medical advice, and to identify the potential role of extending safer environment interventions into these settings. 1.5 Study Objectives The overall aim of this dissertation is to examine the socio-spatial dynamics within the broader risk environment in relation to safer environment interventions. Specifically, this dissertation aims to: (i) conceptualize safer environment interventions by analyzing their diverse functions; (ii) explore how socio-spatial relations limit the effectiveness of safer environment interventions; (iii) examine how alternate approaches to safer environment alter the socio-spatial dynamics of the risk environment to enable risk reduction; and, (iv) explore the potential of extending safer environment interventions into emerging risk environments to enable risk reduction. Taken together, these objectives are intended to address gaps in the existing literature in regards to how safer environment interventions are understood, as well as how the socio-spatial dynamics within risk environments shape their effectiveness. These objectives will be met through the completion of ethno- 15 epidemiological studies linked to exploring the abovementioned risk environments that have been identified by local epidemiological literature as significant in producing harm among IDU. The specific objectives of this dissertation are as follows: 1. To develop a conceptual understanding of the functions of safer environment interventions informed by the experiences and perspectives of IDU. Chapter 2 uses a novel meta-synthesis approach to synthesize the qualitative literature on safer environment interventions and develop a conceptual understanding of the functions of these interventions that reflects how they are experienced and perceived by injection drug-using populations. This chapter also illustrates how greater understanding regarding the functions of safer environment interventions points to the need for changes in current approaches, as well as the need for large-scale health and drug policy reforms.  2. To examine how drug scene violence shapes the risk environment and spatial practices of highly-marginalized IDU, and potentially limits their access to safer environment interventions. Drawing on qualitative interviews and mapping exercises with IDU, Chapter 3 analyzes how contextual forces shape drug scene violence in the Downtown Eastside, and how violence and the threat of violence impact upon the socio-spatial relations of highly-marginalized IDU. This chapter examines how gendered power relations within the Downtown Eastside render women and highly-marginalized men vulnerable to violence, and how avoidance of areas perceived to be ?dangerous? constrains their access to Insite.  3. To explore how providing assisted injections within an unsanctioned DCR alters the social, structural, and spatial contexts of assisted injection practices and thus mediates drug-related harms. Chapter 4 draws upon ethnographic fieldwork conducted at VANDU?s ?unsanctioned? DCR, including participant-observation and qualitative interviews, to examine how providing assisted  16 injections in a regulated environment, and in accordance with a harm reduction policy, reshapes the risk environment of assisted injection practices. Chapter 4 also explores how the operating procedures of this ?unsanctioned? DCR established a place in the Downtown Eastside that IDU requiring help injecting could occupy and thus escape drug scene violence.  4. To examine the role of contextual forces operating within hospital settings in shaping discharges from hospital against medical advice among IDU, and to identify the potential of extending safer environment interventions into these settings in fostering social and structural-environmental contexts that increase engagement with care. Drawing on qualitative interviews with 30 IDU who have been discharged from local hospitals against medical advice, Chapter 5 explores the role of the social-structural contexts of hospital settings in producing these outcomes. Specifically, this chapter explores the role of abstinence-only drug policies in hospital settings in framing care, including pain management practices and the surveillance and regulation of drug use. Finally, Chapter 5 considers how changes to the social-structural contexts of hospital care, notably the integration of supervised injection services, may be needed to minimize discharges from hospital against medical advice. 1.6 Conceptual Framework  This dissertation draws on Rhodes? ?Risk Environment? framework (Figure 1) to explore how intersecting social, structural, and environmental forces produce or reduce drug and health harm within three distinct risk environments: i) the Downtown Eastside?s street-based drug scene; ii) an ?unsanctioned? peer-run supervised drug consumption facility; and, iii) hospital settings. The Risk Environment framework conceptualizes risk and harm as the product of the interplay between types of environments (i.e., social, physical, economic, and political)  17 operating at differing levels of environmental influence (i.e., micro-, meso- and macro-environmental levels) (Rhodes, 2002; Rhodes et al., 2005; Rhodes, 2009). While this framework serves to unpack how contextual forces produce or reduce drug and health harms, it is intended less as a system of categorization than a means to focus attention on the social (e.g., gendered power relations, social norms), structural (e.g., drug law enforcement, poverty), and environmental (e.g., characteristics of injection settings) forces operating within risk environments that shape harm (Goldenberg et al., 2011). In doing so, the Risk Environment framework counters prevailing models of public health governance characterized by neoliberal governmentality in redistributing responsibility for harm from the individual alone to the social, structural, and environmental forces that produce harm (Rhodes et al., 2006). Of central importance in the context of this dissertation is the emphasis that the Risk Environment framework gives to place as a determinant of drug and health harm (Rhodes et al., 2005; Tempalski & McQuie, 2009). This dissertation recognizes that the meanings that IDU give to specific places (i.e., the Downtown Eastside, an ?unsanctioned? supervised drug consumption facility, and hospitals) are structured by their lived experiences, which themselves are shaped by contextual forces. Whereas previous studies have adopted the Risk Environment framework to explore specific places, including public injection settings (Rhodes et al., 2007; Small et al., 2007), SIFs (Kerr, Small, Moore, & Wood, 2007; Small, Moore, Shoveller, Wood, & Kerr, 2012), sex work environments (Goldenberg et al., 2012; Maher et al., 2011; Shannon et al., 2008b), the meanings given to these places by IDU have been secondary to the risk behaviours occurring therein. This dissertation posits that the meanings that IDU give to specific places are critical in determining their behaviours and spatial practices and it is, therefore, critical to examine these relationships.   18 This dissertation also draws on concepts of ?structural? and ?everyday? violence to further situate the harms produced within ?risk environments? in relation to theoretical debates on social suffering (Bourgois, Prince & Moss, 2004; Shannon et al., 2008). Structural violence has been conceptualized as the product of social arrangements embedded in the organization of society that inflict injury upon vulnerable populations (Farmer, 2005), in this case IDU. These social arrangements are determined by large-scale forces (e.g., drug criminalization, income inequality) that are rooted in historical and economic processes (e.g., colonialism, globalization), and are implicated as primary determinants of the continued suffering among injection drug-using populations (Bourgois & Schonberg, 2009; Rhodes et al., 2012). More recent iterations have adopted the more neutral term ?structural vulnerability? to conceptualize social suffering as the product of ?positionality? (Quesada, Hart & Bourgois, 2011). An individual?s vulnerability to suffering is viewed as the product of their location within the hierarchical social order within society, which encompasses not only political and economic inequalities but also a wider range of cultural determinants (e.g., the medicalization/pathologization of ?at-risk? populations,  cultural views on the ?worthiness? of particular groups, etc.) (Quesada, Hart, & Bourgois, 2011). For the purposes of this dissertation, we make a distinction between ?structural violence? and ?structural vulnerability?, whereby the former is adopted when describing the immediate suffering produced by social, economic, and political forces and the latter is adopted when discussing how these forces create the potential for suffering.  Finally, the chapters comprising this dissertation draw upon the concept of ?everyday violence? to refer to the violence and suffering that is normalized within the specific places studied and thus rendered invisible (Bourgois, Prince, & Moss, 2004; Scheper-Hughes, 1992). This dissertation is concerned with how the  19 normalization of violence and suffering is produced by social hierarchies (e.g., gendered power relations) and cultural norms (e.g., stereotypes of injection drug-using populations) that disproportionately impact IDU depending upon their social position. Building on previous drug use research (Bourgois et al., 2004; Fairbairn, Small, Shannon, Wood, & Kerr, 2008; Shannon et al., 2008b), this dissertation recognizes that gender is a critical determinant of an individual?s ?positionality? within the diverse places occupied by IDU, where gender is viewed as encompassing a range of socially-constructed ?positions? rooted in constructs of ?masculinity? and ?femininity? that are dependent upon context and social performance rather than a binary system based on biological sex (male/female). 1.7 Study Approach  This dissertation used an ethno-epidemiological approach to explore how contextual forces operating within the abovementioned ?risk environments? influence drug and health harms among IDU. Ethno-epidemiology is an emerging approach within HIV prevention and drug use research that seeks to uncover how social meanings and contexts influence patterns of drug and health harms by merging epidemiological and ethnographic methods (Lopez et al., 2013; Wagner et al., 2012). Increased understanding of the role of contextual forces in shaping patterns and distributions of harm among injection drug-using populations is understood to be critical to informing the development of environmental interventions to mitigate these harms (Rhodes et al., 2006). Whereas epidemiology has traditionally dominated HIV prevention and drug use research, it alone cannot unpack the complex relationships between individual risk and the contextual forces operating within any particular risk environment (Lopez et al., 2013; Bourgois, 2002; Wagner et al., 2012).  Greater awareness of the limits of epidemiological approaches within HIV prevention and drug use research has led to the integration of ethnographic  20 approaches within larger epidemiological research programmes (Lopez et al., 2013; Moore & Maher, 2002). Ethnographic approaches are an important complement to epidemiological methods given their potential to shed light on how contextual forces operating within risk environments produce patterns and distributions of harm (Lopez et al., 2013; Wagner et al., 2012). Ethnographic research in HIV prevention and drug use research has involved the use of diverse methods (e.g., participant-observation, qualitative interviews, document analysis, etc.) and proven important in developing contextualized understandings regarding how harm unfolds within its social, structural, and spatial contexts (Bourgois, 2002).  The individual studies that comprise this dissertation were undertaken within the context of the Urban Health Research Initiative (UHRI) of the British Columbia Centre for Excellence in HIV/AIDS (BCCfE). Ethnographic data collection was linked with two ongoing prospective cohort studies based at UHRI: the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS). The VIDUS and ACCESS cohorts include more than 2000 current and former HIV-positive (ACCESS) and HIV-negative (VIDUS) drug users. At baseline and every six months, trained interviews administer structured surveys to cohort participants that collect detailed information regarding drug use patterns, drug-related risks, non-drug-related HIV and HCV risks, participation in drug treatment programmes, and health care access and utilization, among other topics (Tyndall et al., 2003; Wood et al., 2008). The studies included in this dissertation employed diverse ethnographic methods, including participant-observation, in-depth interviews, and qualitative mapping exercises, to explore the role of contextual forces in producing trends emerging from analyses of this cohort data that have implications for safer environment interventions. The individual study methods are outlined in detail in each individual chapter. In brief:   21 Chapters 3 & 4: Ethnographic data collection, including participant-observation, qualitative interviews, and qualitative mapping exercises, was conducted at VANDU between September and December 2011. As noted above, the objectives of this fieldwork were linked to trends previously documented by cohort data. Chapter 3 draws on interviews with 23 IDU recruited by referral from a VANDU staff member (7) and in the course of participant-observation (16) and accompanying qualitative mapping exercises in which these participants documented their spatial practices on neighbourhood maps. These data were used to explore how violence impacted the spatial practices of male and female IDU, including access to safer environment interventions. Chapter 4 draws on more than 50 hours of participant-observation at VANDU, including the supervision of assisted injections, and the 23 interviews with IDU accessing this facility, several of whom were also peer volunteers. These data were used to examine how the provision of assisted injection in VANDU?s ?unsanctioned? supervised injection room impacted drug-related harm. Chapter 5:  Qualitative interviews were undertaken in direct connection with the VIDUS and ACCESS cohorts to examine the contextual forces shaping discharges from hospital against medical advice. The cohort questionnaires ask individuals whether they have been hospitalized in the past six months, and whether they left hospital prior to completing treatment. Cohort participants who reported that they had left hospital prior to completing treatment in surveys completed since 2010 were invited to participate in qualitative interviews. Interviews were conducted with 30 IDU to explore this issue in-depth. 1.8 Summary   In summary, this dissertation consists of six chapters. Chapter 1 has provided an initial overview of the risk environment and safer environment interventions, including those implemented in the study setting (Vancouver), and identified  22 potential gaps in existing approaches. Chapter 1 then outlined how this dissertation will address local research priorities through the completion of ethno-epidemiological studies drawing on the Risk Environment framework and concepts of social violence. Chapter 2 uses novel meta-synthesis methods to synthesize the existing qualitative literature on safer environment interventions to develop a conceptualization of these interventions informed by their diverse functions. Chapters 3 and 4 outline social (drug scene violence) and structural (operating procedures prohibiting assisted injections) forces constraining access to safer environment interventions in the Downtown Eastside. Chapter 4 also examines the role of an ?unsanctioned? DCR in mitigating these barriers by adopting operating procedures that reshape the socio-spatial context of assisted injections. Chapter 5 examines a heretofore under-explored risk environment, hospital settings, and considers the potential of safer environment approaches in mitigating discharges from hospital against medical advice among IDU. Finally, Chapter 6 reviews the key findings of the individual chapters, policy and programmatic recommendations, and identifies avenues for future research. 23 Figure 1. Risk environment framework  24 CHAPTER 2: SAFER ENVIRONMENT INTERVENTIONS: A QUALITATIVE SYNTHESIS OF THE EXPERIENCES AND PERCEPTIONS OF PEOPLE WHO INJECT DRUGS 2.1 Introduction As outlined in Chapter 1, growing acknowledgement that social, structural, and physical-environmental forces operating within the risk environment of people who inject drugs (IDU) produce harm has underscored the urgent need for policy and programmatic reforms (Rhodes, 2002; Rhodes et al., 2005; Strathdee et al., 2010). Importantly, an understanding that risk environments shape harm conceptually redistributes responsibility for harm from the individual alone to these contextual forces, and thus highlights the need for ?safer environment? interventions (Rhodes et al., 2005; Rhodes et al., 2006; Strathdee et al., 2010). Safer environment interventions may be understood to be programmatic responses that directly intervene to produce social or physical settings that enable risk reduction among injection drug-using populations (Rhodes et al., 2006). These include interventions that aim to mediate access to syringes and injection-related paraphernalia (e.g., syringe exchange and distribution), intervene within social networks to enable risk reduction (e.g., peer support interventions), and establish safer injection settings (e.g., safer injecting facilities, spatial programming). To date, however, conceptual understandings of safer environment interventions have been limited, in that the overwhelming emphasis on ?risk reduction? has overlooked how these interventions are experienced by IDU and their broader range of functions. We undertook this meta-synthesis to develop a more comprehensive understanding of safer environment interventions informed by the experiences and perceptions of IDU. We were concerned with how contextual forces impact upon IDUs? experiences with and perceptions of safer environment interventions, and the range of functions that these interventions perform. We  25 focused on three types of interventions best represented in the existing literature: supervised injection facilities (SIF), syringe exchange programmes (SEP), and peer-based harm reduction interventions. Central to this meta-synthesis is the recognition that any analysis that juxtaposes ?risk? and ?safer environment interventions? in a straightforward manner obscures the possibility that these interventions themselves may produce risk (Duff, 2010) and it is therefore necessary to also acknowledge the limitations of present approaches. 2.2 Methods We undertook a systematic search of the qualitative research literature on experiences with safer environment interventions among IDU. We were particularly concerned with how social, structural, and environmental factors influence access to and engagement with these interventions among IDU. We used a meta-synthesis approach to analyze articles, focusing on the congruence and convergence of themes across interventions and settings. Meta-synthesis is an emerging approach to reviewing qualitative literature that aims to advance beyond narrative reviews through the systematic comparison and synthesis of themes across studies (Jensen & Allen, 1996). It aims to yield a higher level of abstraction, and thus more powerful findings, than any one study can produce on its own (Campbell et al., 2003; Jensen & Allen, 1996).  2.2.1 Search Strategy We aimed to identify articles that explored the experiences of IDU with safer environment interventions, with an emphasis on the social, structural, and spatial dimensions that shaped these experiences. Given that qualitative research is often poorly indexed, we executed a comprehensive search strategy to identify relevant articles (see Figure 2). We searched relevant academic databases (PubMed/Medline, EMbase, Sage Publications, Sociological Abstracts, Social Work Abstracts, Psychinfo,  26 Social Sciences Citations Index, Anthropological Index, and Google Scholar) using keywords reflecting the research area and methodology (see Table 1). We hand-searched selected substance use journals with a history of publishing qualitative research, including the International Journal of Drug Policy, Drug & Alcohol Review, Substance Use & Misuse, and Harm Reduction Journal. We used the advanced functions of Google Scholar to identify articles similar to or cited by those identified through the keyword search. We also reviewed reference lists of key articles to identify additional sources. Citations and abstracts of 572 articles were imported into Refworks, a reference management system, to assist with data management, screening, and analysis. 260 articles remained after we removed duplicates. We applied inclusion and exclusion criteria to the citations and abstracts to identify eligible articles. The inclusion criteria were: qualitative methods; English-language; publication in peer-reviewed journal; data collected among IDU; and, focus on safer environment interventions. The exclusion criteria were: quantitative research; opinion articles, commentaries, and editorials; literature reviews; non-English language articles; and, articles published prior to 1997. Articles published before 1997 were excluded in recognition that social-ecological approaches to addressing injection drug use did not gain traction until after this time. 48 articles met the initial inclusion criteria and were retrieved for further review. These articles were reassessed for relevance, quality, and methodological rigor by drawing on the Critical Appraisal Skills Programme (CASP) (Collaboration for qualitative methodologies, 1998), a diagnostic tool for evaluating qualitative research. In keeping with the approach outlined by Dixon-Woods and colleagues (2006), we exercised critical judgement during quality assessment, and prioritized the relevance of these articles and their potential contribution to thematic development over minor methodological shortcomings. Ultimately, we excluded an additional 19 articles at this stage that were  27 determined to lack relevance to our synthesis objectives or had major methodological flaws (e.g., content analyses of nursing records). 2.2.2 Description of Articles We included 29 papers representing 21 unique studies and included an aggregate number of more than 800 IDU. These articles were published from Canada (16), USA (6), Russia (4), and other settings (4). Twenty-six articles focus on experiences with safer environment interventions, including SEPs, SIFs, and peer-based harm reduction interventions. The remaining three articles report experiences with safer environment interventions as a secondary outcome, but were deemed to contain sufficient information to warrant inclusion in this meta-synthesis. Most studies were undertaken in urban or semi-urban settings with established drug scenes. All studies were undertaken in settings in which injection drug use is prohibited and regulated primarily through drug law enforcement. Table 2 provides an overview of the key characteristics of these articles. 2.2.3 Analytic Strategy We reviewed the articles by following the meta-synthesis approach outlined by Noblit and Hare (1988). We first reviewed the articles multiple times to identify and record key themes, as well as details about the study context. The resulting data table was used to identify key ideas and concepts across the studies (i.e., first-order constructs) and determine the ways in which they were related. We then systematically compared and contrasted study findings to identify points of convergence, translate the themes from studies into one another, and develop the thematic categories (i.e., second-order constructs). We then used these ?second-order? constructs to develop an overarching interpretation of the functions of safer environment interventions that was rooted in the experiences and perceptions of IDU. Given the overrepresentation of articles by a single research team in Vancouver  28 (Canada), and their potential to bias our findings, we adjusted our analytical procedures to ensure representativeness among our themes. Specifically, we worked to ensure that any themes included in the final interpretation occurred across multiple studies and jurisdictions. 2.3 Results Four primary themes emerged from our analysis: First, safer environment interventions were a refuge from unregulated drug scenes. Second, interventions were perceived to enable safer injecting practices by reshaping the physical or social context of injection drug use. Third, safer environment interventions were situated within a larger geography of survival and mediated access to a range of social and material resources. Finally, social-structural factors (e.g., drug law enforcement) constrained access to interventions. The distribution of themes across the 29 papers is detailed in Table 3. Supporting data excerpts from the individual articles are included in Table 4.  2.3.1 Environments to Escape Everyday and Structural Violence 2.3.1.1 Providing refuge from street-based drug scenes Studies included in this synthesis identified structural and everyday violence as defining characteristics of street-based drug scenes, and in particular drug law enforcement (Cooper, Moore, Gruskin, & Krieger, 2005; Kerr et al., 2007; Kimber & Dolan, 2007; Sarang, Rhodes, & Platt, 2008; Sarang, Rhodes, Sheon, & Page, 2010) and gender-based violence (Fairbairn et al., 2008; Fairbairn et al., 2010; Small et al., 2012). In this context, participants conceptualized safer environment interventions as refuges from structural and everyday violence. Variously referred to as ?refuges? (Fairbairn et al., 2008; Small, Moore et al., 2012), ?safe havens? (MacNeil & Pauly, 2011), and ?safe spaces? (McLean, 2012; Parker, Jackson, Dykeman, Gahagan, &  29 Karabanow, 2012), participants positioned these interventions as safe, regulated spaces that mitigated the dangers of the street-based drug scene.  Multiple studies articulated how participants accessed safer environment interventions to minimize the risk of violence. McLean (2012) observed that participants treated a New York-based SEP like a drop-in shelter, and used it to shield themselves from policing and other potential dangers on the street. Likewise, Fairbairn et al. (2008) explored how a SIF provided ?a refuge from the structural and interpersonal violence of the street that also serves [sic] to facilitate the safe preparation and injection of drugs? (p. 819). Mobile and peer-based interventions had less ability to reshape physical environments but intervened within social and spatial relations to disrupt inequities that typically shape these drug use environments, such as the exploitation of people who require assistance injecting (Sherman et al., 2008; Sherman et al., 2009; Small et al., 2012). For example, Small et al (2012a) found that a peer injection support programme, which provided safer injecting education and in some cases manual assistance injecting in public settings, ?was seen to offer some relief from exploitive relations with ?hit doctors?? (p. 496).  2.3.1.2 Contextualizing understandings of ?safety? Across multiple studies, participants articulated how they ?felt safe? when accessing these interventions, with understandings of safety reflecting a range of meanings. Several studies highlighted how these interventions increased physical safety by providing environmental supports that negated the risk of physical violence, including police beatings and assault (Fairbairn et al., 2008; McLean, 2012; Small et al., 2012; Small, Moore et al., 2012). In regard to a SIF, Small et al (2012b) suggested that this facility was perceived to be an injection setting representing ?an alternative to the potentially unpredictable character of public injection settings, where conflict and violence can quickly emerge? (p. 316). Other studies highlighted how interventions  30 increased safety from real or perceived stigma (Krusi et al., 2009; MacNeil & Pauly, 2011; McLean, 2012; Parker et al., 2012). For example, MacNeil and Pauly (2011) noted that SEP clients described the intervention as a place free of stigma, discrimination and judgement. These findings suggest that safer environment interventions have the profound effect of disrupting violence and stigma. 2.3.2 Enabling Safer Drug Use Practices 2.3.2.1 Reshaping the social and environmental contexts of injecting Studies emphasized the important role that changes in physical and social environments played in mediating safer drug use practices among participants. Most studies reported that safer environment interventions enabled harm reduction by reshaping physical and social environments, which were perceived as critical to fostering social and spatial conditions that reduced drug and health harms (e.g., HIV and HCV transmission, overdose). Changes to physical and social environments varied in accordance with the type of intervention, but were widely identified as conducive to harm reduction practices. Participants frequently articulated how interventions enhanced access to safer injecting equipment, thereby increasing their capacity to practice harm reduction in various injection settings (MacNeil & Pauly, 2011; Ngo et al., 2009; Parker et al., 2012; Power, Nozhkina, & Kanarsky, 2005; Sherman et al., 2008; Sherman et al., 2009; Small et al., 2012). In this regard, although limited in their ability to affect the physical injection setting, SEPs altered the risk environment by increasing access to material resources and safer injecting education. In comparison, IDU expressed that SIFs and selected peer-based interventions actively produced social and physical settings that enable safer practices (Fairbairn et al., 2008; Fast, Small, Wood, & Kerr, 2008; Kerr et al., 2007; Sherman et al., 2008; Small et al., 2012). For example, one participant described injecting at a SIF as ?the way to do it properly?because it?s not the alley? (Small et al., 2012, p. 315).   31 2.3.2.2 Situating understandings of safer injecting Experiences with safer injection were articulated across multiple studies and emphasized how these practices were shaped by social and environmental supports. Participants commonly reported that safer environment interventions established situations and spaces that enabled reductions in risk behaviours, such as rushed injections (Kerr et al., 2007; Small, Moore et al., 2012) and syringe sharing (Fast et al., 2008; Ngo et al., 2009; Parker et al., 2012; Power et al., 2005; Spittal et al., 2004). Accordingly, these interventions were felt to increase control over the injection process (e.g., access to injecting equipment, space to inject) and minimized the impact of social, structural, and spatial barriers to safer injecting (Fairbairn et al., 2008; Kerr et al., 2007; Krusi et al., 2009; McLean, 2012; Ngo et al., 2009; Parker et al., 2012). In the context of overdose prevention, Kerr et al (2007) observed that a SIF addressed ?many contextual factors and social processes that shape injecting practices and mediate overdose risk? (p. 43). Furthermore, understandings of safer injection extended to environmental features, with participants commonly describing interventions as hygienic and clean. Participants contrasted these ?clean? and ?hygienic? environments with alternate, and especially public, injection settings and felt that they reduced an array of risks (e.g., bacterial infection) (Kerr et al., 2007; Small, Moore et al., 2012).  2.3.3 Locating Interventions within the Geography of Survival 2.3.3.1 Mediating access to support and care Safer environment interventions featured prominently within the geographies of survival of drug-using populations?that is, the spaces and spatial relations that shaped how participants survived within street-based drug scenes (McLean, 2012; Mitchell & Heynen, 2009). Participants in every study were highly marginalized, and in particular disproportionately affected by poverty and homelessness, and  32 challenges to meeting everyday survival needs were common. Participants expressed that safer environment interventions mediated access to ancillary services (e.g., food and shelter) and fostered access to broader health and social supports (MacNeil & Pauly, 2011; Parker et al., 2012; Porter, Metzger, & Scotti, 2002; Power et al., 2005; Sherman et al., 2008; Small et al., 2009; Small, Wood, Lloyd-Smith, Tyndall, & Kerr, 2008). Participants articulated how access to support through these interventions was shaped by social, structural, and spatial conditions. For example, structural and spatial barriers to health and social services were minimized by safer environment interventions because these interventions were already situated in relation to the everyday spatial practices of participants and did not require drug abstinence. Accordingly, participant accounts emphasized that these interventions were ?convenient? and ?easy to access? (MacNeil & Pauly, 2011; McLean, 2012; Parker et al., 2012; Small et al., 2009).  2.3.3.2 Fostering trust to improve access to medical care Across the majority of studies, trust was identified as a critical factor in mediating access to medical care and support. In the broadest sense, trust between participants and programme staff was seen as important to fostering access to safer environment interventions and ancillary services. Trust was perceived to be an outcome of the non-judgmental, supportive approaches taken by these interventions (Krusi et al., 2009; MacNeil & Pauly, 2011; Porter et al., 2002; Small et al., 2009; Small et al., 2008). Safer environment interventions were frequently staffed by health professionals and integrated, to varying degrees, into the health and social care system. Participants commonly reported that these interventions were their primary source of medical care, contrasting these supportive environments with punitive, stigmatizing hospital settings (Krusi et al., 2009; MacNeil & Pauly, 2011; Porter et al., 2002; Small et al., 2009; Small et al., 2008). Several studies reported that, in spite of  33 negative experiences in hospital settings, participants were more likely to accept referrals to these settings by staff at safer environment interventions, insofar as their ?lack of judgment of drug use was key to facilitating the development of trust and linkages to other services? (MacNeil & Pauly, 2011, p. 30). 2.3.4 Factors Constraining Safer Environment Interventions 2.3.4.1 The impact of drug law enforcement While safer environment interventions altered the risk environment to minimize drug and health harms, studies indicated that access to these interventions was constrained by drug law enforcement, and in particular the threat of detainment for the possession of drugs or harm reduction paraphernalia (Andrade, Lurie, Medina, Anderson, & Dourado, 2001; Bluthenthal, Kral, Lorvick, & Watters, 1997; Cooper et al., 2005; Finlinson et al., 2000; Ngo et al., 2009; Rhodes et al., 2003; Sarang et al., 2008; Sarang et al., 2010; Sherman et al., 2008). Studies included in this synthesis were undertaken in settings where the possession of illicit drugs is prohibited and the majority of studies reported law enforcement, and specifically street-level policing, to be the primary response to regulating injection drug use. Studies across multiple settings reported that arbitrary arrests and detainment and police harassment, beatings, and crackdowns were common within local drug scenes (Andrade et al., 2001; Bluthenthal et al., 1997; Cooper et al., 2005; Rhodes et al., 2003; Sarang et al., 2008; Sarang et al., 2010). As a consequence, several studies described how street-level policing fuelled ?a pervasive sense of risk and fear of arrest, or detainment, among injection drug users, which in turn is linked to their reluctance to carry needles and syringes? (Sarang et al., 2010, p. 816). Accordingly, participants in multiple studies articulated how street-level policing constrained their capacity to practice harm reduction and thus produced drug and health harms (Andrade et al., 2001;  34 Bluthenthal et al., 1997; Cooper et al., 2005; Rhodes et al., 2003; Sarang et al., 2008; Sarang et al., 2010).  2.3.4.2 Barriers due to operating procedures and regulations Several studies included in this synthesis explored how the operating procedures and regulations of safer environment interventions restricted access to and the effectiveness of these interventions (Bourgois & Bruneau, 2000; Fairbairn et al., 2010; Kerr et al., 2007; Small, Ainsworth, Wood, & Kerr, 2011; Small et al., 2011; Small et al., 2012; Spittal et al., 2004). These restrictions were largely the result of regional or national legal frameworks, which constrain the parameters of harm reduction programmes. Closer attention to these operating procedures and regulations reveals that the resulting programmatic barriers restrict access to safer environment interventions, especially regulations limiting access to new syringes through SEP policies (e.g., one-to-one exchange policies, limits on numbers of syringes distributed) (Bourgois & Bruneau, 2000; Finlinson et al, 1999; Rhodes et al., 2003; Sarang et al., 2008; Sarang et al., 2010; Spittal et al., 2004) and those restricting the range of injection practices permitted at SIFs (e.g., prohibitions on assisted injections) (Fairbairn et al., 2008; Fairbairn et al., 2010; Kerr et al., 2007; Small et al., 2011; Small et al., 2011; Small et al., 2012). For example, one study exploring access to syringes in three Russian cities found that policies requiring one-to-one exchange were a disincentive to accessing SEPs because of the considerable risks associated with carrying syringes (e.g., police beatings) and costs to travel to these facilities, which were not located in close proximity to the drug scene (Sarang et al., 2008).  2.4 Discussion  In summary, this synthesis demonstrates how safer environment interventions foster social and physical environments that mediate harm reduction practices, while facilitating access to social and material resources critical to survival. Whereas drug  35 scenes are characterized by structural and everyday violence, safer environment interventions functioned as critical environmental supports that allowed IDU to escape the street, and thereby minimize exposure to violence and street policing. However, safer environment interventions operated within a larger societal context where drug law enforcement remains the primary response to regulating illicit drug use and are thus subject to policing practices and regulatory frameworks that limit their effectiveness. Although safer environment interventions examined in this synthesis are generally characterized as micro-environmental interventions, we found that they mediated meso- and macro-environmental forces that function to produce harm among IDU. Much as risk environments are produced by the interplay between types of environmental factors occurring across levels of environmental influence (Rhodes et al., 2005; Rhodes, 2009), this synthesis demonstrates that safer environment interventions intervene across these environmental dimensions to reshape the social, structural, and environmental contexts of injection drug use. For example, multiple studies included in this synthesis illustrate how a SIF in a Canadian setting minimized exposure to meso-environmental risks, such as street-level policing and drug scene violence (Fairbairn et al., 2008; Small, Moore et al., 2012), and served as a micro-environmental setting that fostered safer injecting practices (Fast et al., 2008; Kerr et al., 2007).  In this regard, safer environment interventions may be understood to alter risk environments at the points where these micro-environmental interventions intersect with meso- and macro-environmental factors to disrupt social, structural, and environmental processes that produce harm. Accordingly, whereas empirical studies of risk environments have generally focused on delineating risk within discrete levels of environmental influence (e.g., micro, meso, and macro-level), future research on safer environment interventions may benefit by focusing on the interplay  36 within risk environments to explore how points of convergence between varying types and levels of environmental influence (e.g., micro/meso, meso/macro) serve to mediate drug-related risks. In this regard, it is critical that researchers locate and examine how types and levels of environmental influence intersect in the operation of safer environment interventions, and how these intersections impact upon the reduction or production of risk. This synthesis demonstrates that, while the potential role of safer environment interventions in reducing drug-related harms has been emphasized in the literature, these interventions have a range of additional functions that are critical to their success and were viewed by IDU as of equal importance to risk reduction. Accordingly, conceptualizations of safer environment interventions should be adjusted to acknowledge that these ?latent functions? are defining characteristics of these interventions. Furthermore, given that within the situated rationality of injection drug-using populations these other concerns (e.g., maintaining safety, accessing food and shelter) may be elevated above risk reduction (Rhodes, 2009), emphasizing these ?latent functions? when designing safer environment interventions may avoid making risk reduction and survival an either/or proposition.   Acknowledging that risk and safety encompass a range of meanings is an important first step toward developing interventions situated in relation to the lived experiences of IDU and, in turn, responsive to meso- and macro-environmental factors that shape their experiences. Studies included in this synthesis demonstrate that ?safety from stigma? is an important function of safer environment interventions that mediates access to these interventions. For example, several studies illustrated that safer environment interventions were perceived as fostering social and physical environments that were stigma-free and thereby improved interactions between IDU and health and social care providers (Krusi et al., 2009; MacNeil & Pauly, 2011;  37 McLean, 2012; Parker et al., 2012). In doing so, these micro-environmental interventions disrupted macro-social stigmatization processes that often serve as barriers to care for injection drug-using populations. Minimizing stigma, and thereby fostering social inclusion and support, is critical to encouraging engagement with safer environment interventions and future interventions would be well served to draw upon approaches that have proven successful in accomplishing this. In addition, more broadly including IDU in the design and operation of these interventions may only serve to further disrupt stigma by promoting greater engagement with safer environment interventions. An important feature of safer environment interventions is that they mitigate intersecting meso and macro-environmental forces (e.g., drug law enforcement, poverty) that leave IDU without spaces that they can occupy without the fear of arrest. It has been widely observed that drug law enforcement and street-level policing practices are structural forces that erode the spaces that this population can occupy through social regulation and dislocation (Beckett & Herbert, 2010; Cooper et al., 2005; Shannon et al., 2008a; Small, Kerr, Charette, Schechter, & Spittal, 2006). Around the globe, IDU experience an array of health harms as a result of these dislocations, notably physical and sexual violence (Maher & Dixon, 1999; Shannon et al., 2008a; Small et al., 2006; Wood, Spittal et al., 2004) and complications due to unsafe injection practices (Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Marshall, Kerr, Qi, Montaner, & Wood, 2010; Small et al., 2006). This synthesis demonstrates that safer environment interventions provide a refuge for IDU, in that they are places that they can freely occupy and thus escape the structural and everyday violence that characterizes street-based drug scenes. This synthesis suggests that the disruptions in structural and everyday violence produced by providing injection drug-using populations with safe, regulated spaces that they could occupy were a defining feature of safer environment  38 interventions. Although safer environment interventions are typically implemented to bring about improvements in health outcomes, this synthesis underscores how their latent benefits (i.e., disrupting structural and everyday violence) are perceived by injection drug-using populations as part of their primary function. Many of the safer environment interventions reviewed in this synthesis served as de facto drop-in shelters, highlighting the necessity of providing broader environmental supports alongside harm reduction services in order to maximize their impact.  We found that safer environment interventions mediated access to social and material resources that helped IDU survive within the larger context of poverty and social marginalization. IDU accessed interventions to meet basic survival needs, as well as receive social support. Of particular importance is the role that safer environment interventions played in mediating access to medical care. Previous epidemiological studies have observed that safer environment interventions are a source of medical care and referrals (Bastos & Strathdee, 2000; Tyndall et al., 2006). Increased attention to the qualitative literature demonstrates how this access to medical care is a product of the social and spatial contexts of safer environment interventions. Notably, safer environment interventions fostered supportive environments in which IDU were able to receive care or referrals, in large part because they disrupted stigmatization processes and improved trust in programme staff. In addition, because interventions were situated in relation to the everyday spatial practices of injection drug-using populations, they were convenient and easy to access. Greater attention is needed to these factors during the planning and implementation of safer environment interventions (e.g., siting interventions in close proximity to key drug scene locales), while also balancing the needs of IDU in peripheral locations. Finally, while there remains an urgent need to embrace safer environment interventions as a means to minimize health and social harms associated with  39 injection drug use, including the need to address geographical disparities in access to these interventions (Tempalski, 2007), reforms to national and international drug laws are needed to maximize their benefits. Around the globe, law enforcement is the primary response to regulating injection drug use, with billions of dollars invested annually to enforce supply-side policies seeking to decrease the availability of illicit drugs. In turn, strategies used by law enforcement to regulate IDU generally include surveillance within drug scenes and a range of police practices intended to disrupt drug markets and reduce drug-related disorder, which are frequently accompanied by police violence and harassment (Maher & Dixon, 1999; Rhodes, Platt et al., 2006; Small et al., 2006). Consistent with previous research (Kerr, Small, & Wood, 2005), this synthesis has shown that street-level policing constrained access to safer environment interventions and, in turn, produced considerable harm. Studies included in this synthesis commonly reported that IDU were adversely impacted by arbitrary arrests and police beatings, which made them less likely to access safer environment interventions. Given that the ?war on drugs? produces widespread social suffering (Bourgois, 2003a; Rhodes et al., 2005; Rhodes et al., 2012), and billions of dollars have been spent supporting policies that have largely proven ineffective, there is a need for global drug policy reforms that shift emphasis away from law enforcement and toward public health (Global Commission on Drug Policy, 2012; Wood et al., 2010). These reforms would likely be interpreted as a threat to law enforcement, and thus face considerable resistance, but have the potential to minimize harm and free up funding for demand-side interventions (e.g., drug prevention and treatment) that have potential to decrease drug use. Furthermore, they may enable the redeployment of policing resources to address other concerns within communities. While not discounting the need for larger legal reforms, police and public health partnerships represent another means to lessen the impact of street-level  40 policing on access to safer environment interventions (Burris et al., 2004; DeBeck et al., 2008). For example, the partnership between police and health agencies in Vancouver, Canada has helped to ensure that street policing practices do not restrict access to the local SIF and SEPs (DeBeck et al., 2008; Small, Krusi, Wood, Montaner, & Kerr, 2012). Importantly, evidence indicating that these interventions decrease public disorder problems has been critical in establishing police support for these programmes (DeBeck et al., 2008; Small et al., 2012). Although policing structures and cultures may hinder the development of these interventions, those charged with marshalling support for safer environment interventions would be wise to develop these partnerships.  There are important limitations of this synthesis that should be taken into consideration. The individual articles included in this synthesis have several limitations, and many did not adequately describe their study methodology or theoretical perspective. Several articles were based on the same study, and in particular the majority of those on SIFs, and may be limited in the diversity of participant views contained therein. Also, the majority of safer environment interventions surveyed were implemented in urban areas in a few select countries and may have limited applicability outside of these settings. The extent to which findings are transferable to other interventions and settings warrants further attention. This synthesis also represents only one possible interpretation of these articles and other interpretations, especially those that aim to address different questions, would likely yield different findings. While we employed a systematic search strategy, it is possible that relevant articles were not identified and included in this synthesis. Importantly, it is worth considering that fully accounting for social, cultural, and political factors that shape individual studies is beyond scope of qualitative meta-syntheses and the translation of themes across articles necessarily loses many of their  41 individual nuances. Whereas this remains an ongoing limitation of qualitative meta-syntheses, it follows that individual nuances are typically lost when presenting interpretations of any qualitative data (Weed, 2005). As Weed (2005) notes, it is therefore instructive to include as detailed information as is possible regarding the individual cases. To this end, we have included extensive information regarding the individual articles included in this meta-synthesis in the supplementary online materials.  In spite of these limitations, this synthesis has potential to shape understandings of and approaches to safer environment interventions. A narrow focus on reducing drug-related risks potentially overlooks how these interventions are perceived and utilized by drug-using populations.  Future safer environment interventions would benefit from greater consideration of how they can address a range of needs, and address constraining forces within broader risk environments, and thereby promote health. Finally, although these interventions are an important step toward reducing harm, the need for broader changes to drug policy persists and the importance of efforts to achieve these reforms cannot be ignored.        42 Figure 2. Flowchart of meta-synthesis           572 articles identified following the execution of the literature search. Citations and abstracts imported into Refworks for data management and review.  260 articles remained following the removal of duplicates. Titles and abstracts reviewed in accordance with inclusion criteria. 48 articles met initial inclusion criteria. Full articles were retrieved and reassessed for relevance and quality in accordance with the guiding questions and criteria outlined in the Critical Appraisal Skills Programme.  19 articles were excluded for not meeting the inclusion criteria or not being of sufficient quality to merit inclusion. 29 articles were included in the qualitative synthesis. Data were extracted and analyzed using a meta-synthesis approach.   312 duplicate articles removed from database. 212 articles that failed to meet review criteria were excluded at this stage.  43 Table 1. Search variables for systematic literature search Intervention AND Method  Syringe exchange  Needle exchange Syringe distribution Needle distribution Peer-baseda Peer interventiona Overdose prevention Overdose response Supervised injection facility Supervised injection room Supervised injection site Supervised drug consumption facility Supervised drug consumption room Safer injection facility Safer injection room Safer injection site Safer drug consumption facility Safer drug consumption room Drug consumption room  Qualitative Semi-structured interviews In-depth interviews Focus groups Case study Ethnography Ethnographic Participant-observation Naturalistic observation a. Population-specific search terms were added (i.e., injection drug use and drug user) when searching for peer interventions.       44 Table 2. Details of retrieved articles (listed chronologically) Reference Country Aims Intervention Sample Characteristics Data Collection Methods Bluthenthal et al., 1997 USA  To examine how law enforcement impacts IDU access to SEPs. SEP Unspecified number of IDU accessing SEPs in two cities. Informal interviews and observation Finlinson et al., 1999 Puerto Rico To explore IDUs? access to sterile syringes. SEP Unspecified number of IDU accessing 12 SEP sites. Sub-sample of 40 IDU (gender not specified) recruited through SEPs to participate in interviews. Interviews and observation Bourgois & Bruneau, 2000 Canada To explore HIV risks associated with SEP utilization. SEP Unspecified number of IDU accessing an SEP. Observation Andrade et al., 2001 Brazil To describe the opening of an SEP and impact of increased crack cocaine use on SEP utilization. SEP 304 IDU accessing four SEPs. Sub-sample of 16 IDU (gender not specified) recruited through the SEPs to participate in in-depth interviews. In-depth interviews and observation  Porter et al., 2002 USA To examine how IDU perceive and SEP 46 IDU (25 male, 21 female), recruitment strategy not specified. Semi-structured interviews  45 Reference Country Aims Intervention Sample Characteristics Data Collection Methods use services provided by SEPs. Rhodes et al., 2003 Russia To explore factors that shape syringe exchange practices. SEP 57 IDU (29 male, 28 female), recruited by outreach workers using purposive sampling. Semi-structured interviews Spittal et al., 2004 Canada To explore IDUs? access to sterile syringes. SEP Unspecified number of IDUs accessing mobile SEP. Informal interviews and participant observation Cooper et al., 2005 USA To explore how police crackdowns impact harm reduction practices. SEP 40 IDU (21 male, 19 female), recruited through snowball sampling. In-depth interviews Power et al., 2005 Russia To describe how IDU experience SEP initiatives. SEP 38 IDU (27 male, 11 female), recruitment strategy unspecified.  Semi-structured interviews and participant observation Kerr et al., 2007a Canada To examine the impact of a SIF on overdose risk among IDU.  SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively sampled to reflect varying levels of use. Semi-structured interviews  46 Reference Country Aims Intervention Sample Characteristics Data Collection Methods Kimber & Dolan, 2007 Australia To explore shooting gallery attendance before and after the opening of a SIF. SIF 17 IDU (13 males, 4 female) attending shooting galleries before and after the opening of a SIF, contacted through a peer recruiter and snowball sampling. Semi-structured interviews Sarang et al., 2008b Russia To explore IDUs? access to sterile syringes. SEP 209 IDU (140 males, 69 females) in three cities, recruited by outreach workers using snowball sampling methods. Semi-structured interviews Sherman et al., 2008 USA To examine IDUs? experiences with peer-based overdose response. Peer intervention 31 IDU (25 male, 6 female), contacted through SEP and researcher referral.  Semi-structured interviews Fairbairn et al., 2008a Canada To examine female IDUs? experiences at a SIF. SIF 25 female IDU, contacted through SIF and purposively sampled to reflect varying levels of SIF usage. Semi-structured interviews Fast et al., 2008a Canada To explore the delivery of safer injection education in a SIF. SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively Semi-structured interviews  47 Reference Country Aims Intervention Sample Characteristics Data Collection Methods sampled to reflect varying levels of use. Small et al., 2008a Canada To investigate the impact of a SIF on IDUs? access to care for injection-related infections. SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively sampled to reflect varying levels of use. Semi-structured interviews Ngo et al., 2009 Vietnam To assess the effectiveness of a peer-based SEP. Peer intervention; SEP 23 key informants (e.g., public health personnel, government officials, etc.) and unspecified number of IDUs. Interviews, focus groups, and participant observation Sherman et al., 2009 USA To examine IDUs? experiences with peer-based overdose response. Peer intervention 25 IDU (16 male, 9 female), contacted through intervention using convenience sampling. Semi-structured interviews Krusi et al., 2009 Canada To evaluate the impact of a supervised injecting room on HIV-positive IDUs? access to HIV care. SIF 22 HIV-positive IDU (15 male, 7 female) accessing a care facility with a supervised injecting room, contacted through research advertisements posted at the facility. Semi-structured interviews  48 Reference Country Aims Intervention Sample Characteristics Data Collection Methods Small et al., 2009 a Canada To examine how SIF use impacts access to health and social services. SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively sampled to reflect varying levels of use. Semi-structured interviews Sarang et al., 2010 b Russia To explore impact of policing on drug and HIV risks, including access to sterile syringes. SEP 209 IDU (140 males, 69 females) in three cities, recruited by outreach workers using snowball sampling methods. Semi-structured interviews Fairbairn et al., 2010 Canada To explore the context of assisted injection practices in the presence of a SIF. SIF 20 IDU (7 male, 13 female) who required assistance injecting in the previous six months, recruited through cohort study and purposively sampled.  Semi-structured interviews MacNeil & Pauly, 2011 Canada To describe the meanings of SEPs among IDU. SEP 33 IDU (23 male, 10 female), recruited using convenience sampling at four SEP sites Semi-structured interviews Small et al., 2011aa Canada To examine IDUs? perspectives on the design and operation of a SIF. SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively Semi-structured interviews  49 Reference Country Aims Intervention Sample Characteristics Data Collection Methods sampled to reflect varying levels of use. Small et al., 2011ba Canada To examine how operating policies and local drug culture impact access to a SIF. SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively sampled to reflect varying levels of use. Semi-structured interviews and observation McLean, 2012 USA To explore the social geography of SEPs. SEP Unspecified number of IDU accessing an SEP. Sub-sample of 11 IDU (gender unspecified) recruited through SEP to participate in semi-structured interviews. Semi-structured interviews and participant observation Parker et al., 2012 Canada To explore access to harm reduction services among IDU in rural areas. SEP 115 IDU (gender unspecified), recruited through fixed site and mobile SEPs and snowball sampling. Semi-structured interviews Small et al., 2012a Canada To explore the development, operation, and impact of an assisted Peer intervention 10 peer outreach workers and 9 IDU programme participants (gender unspecified). Unspecified In-depth interviews and observation  50 Reference Country Aims Intervention Sample Characteristics Data Collection Methods injecting intervention. number of programme participants observed. Small, Moore et al., 2012a Canada To examine how IDUs? perceptions of risk shape SIF attendance. SIF 50 IDU (28 male, 21 female, 1 transgender), contacted through SIF and purposively sampled to reflect varying levels of use. Semi-structured interviews a. Based on data collected as part of an evaluation of a supervised injection facility. b. Based on data collected as part of a larger study of HIV risk in three Russian cities.      51 Table 3. Key themes and limitations of included articles (listed chronologically) Reference Key Findings Key Limitations Bluthenthal et al., 1997 Police interference with unsanctioned SEP limited access to these services among IDU and discouraged volunteer involvement.   IDU cited fear of arrest as a primary reasons for not accessing syringe exchange services.  Authors did not clearly situate findings in relation to theoretical debates.  Authors used mixed methods (including surveys) to determine impact of policing on SEP access, and their overview of the qualitative data was limited.  Finlinson et al., 1999 Limited operating hours constrained access to syringe exchange services among IDU.  Secondary syringe exchange was common among IDU, and viewed as a means to gain access to syringes when harm reduction services not available. Authors did not clearly state theoretical perspective.  Authors overlooked participant perceptions of SEP.  Bourgois & Bruneau, 2000 Local political conditions produced restrictive SEP policies (one-to-one exchange) that limited access among IDU, and thus led to the development of informal exchange networks.  Specific drug use practices (e.g., binge cocaine use) were critical in shaping access to syringe exchange services, and increased the potential from harm.  Authors provided only limited information regarding the study methodology, which makes it difficult to assess rigor.    52 Reference Key Findings Key Limitations Andrade et al., 2001 Limited scope of syringe exchange services constrained access to syringes and led to syringe-sharing among IDU.  Syringe-sharing not viewed as potentially harmful among many study participants.  Shifts in local drug use patterns after the introduction of crack cocaine led to a substantial decrease in SEP utilization.  Street-policing in response to increased crack cocaine use constrained access to SEP among IDU. Authors drew upon mixed methods (including surveys) and emphasized quantitative findings. Authors did not clearly state theoretical perspective, nor did they situate findings in relation to larger theoretical debates. Porter et al., 2002 IDU viewed syringe exchange services as an intervention that mediated access to medical care and referrals.  Authors developed a typology for medical care and referrals provided through syringe exchange services (from no access to a primary point of referral).  IDU indicated that they trusted syringe exchange workers. Potential for positive bias among study participants. Triangulation of data may have been needed to verify referrals. Rhodes et al., 2003 Fear of being stopped by police exacerbated concerns about the risks of carrying injecting equipment, which in turn was linked to increased syringe sharing and in particular at Limited data collection among regular SEP clients.  53 Reference Key Findings Key Limitations the point of sale. Myth circulated that it is bad luck to buy syringes in advance. A minority of study participants reported that they had ever been to the two fixed site NEPs, and emphasized the fear of police as a primary barrier.  Spittal et al., 2004 Restrictive SEP policies (one-to-one exchange) undermined access to syringes. SEP workers issued ?loaners? on an individual basis based on the perceived ability of IDU to return these syringes. Inconsistencies in issuing ?loaners? led to tension with IDU, and constrained their access to syringes. Limited data collection among IDU. Context of interactions with IDU potentially limited the depth of the data. Cooper et al., 2005 Intensified street-policing undermined the ability of injection drug users to practice harm reduction (e.g., rushed injections) and interfered with SEP access. Policing practices (e.g., random physical searches, surveillance) reconfigured how injection drug users perceived of their bodies and public spaces. Data collection did not begin until the police crackdown was underway, limiting the capacity to document changes in SEP access.  54 Reference Key Findings Key Limitations IDU tried to avoid carrying syringes and obtained them primarily from peers prior to injecting. Power et al., 2005 Police harassment, including forced registration with drug use services, undermined access to SEPs. IDU trusted and valued outreach workers, and interacted with them to meet range of health and social care needs.  IDU were reluctant to take referrals to other agencies due to concerns about registration with drug use services. Limited data collection among regular SEP clients may negatively bias findings. Kerr et al., 2007a Participants felt that the immediacy of the response to overdoses was important, particularly in contrast to other settings Participants articulated how taking their time?to ?taste?at the SIF allowed them to implement common overdose prevention strategies and increase safety. Environmental supports mitigated fears of injecting alone without requiring them to share their drugs.  Potential for positive bias among study participants. Theoretical perspective not clearly outlined.  55 Reference Key Findings Key Limitations Common narrative was that the facility saved lives that would otherwise be lost to overdose. Kimber & Dolan, 2007 Shooting gallery attendance declined following the opening of a SIF. Article focused primarily on shooting gallery attendance. Limited discussion of how the opening of the SIF changed the structural-environmental context of the street-based drug scene. Authors do not state theoretical perspective or situating findings in relation to broader theoretical debates. Sarang et al., 2008b Syringe exchange services rarely utilized due to range of factors, including: geographical barriers; and, fear of police interference.  Restrictive syringe exchange policies (one-to-one exchange) limited the perceived benefits of SEP attendance (syringe access outweighed by time needed to access services). Limited information provided regarding IDU encountered during ethnographic fieldwork.  Sherman et al., 2008 IDU weighed the fear of legal consequences (i.e., arrest) against desire to save lives when responding to overdose. Peer volunteers were able to intervene (e.g., administer naloxone, revive individuals) Authors did not explore how recipients of naloxone experienced this intervention. Authors do not clearly state theoretical perspective.  56 Reference Key Findings Key Limitations when responding to overdoses in diverse drug use settings. Potential for positive bias among peer volunteers. Fairbairn et al., 2008a Women accessed SIF to escape structural and everyday violence within the street-based drug scene. Women were able to gain increased access over the injection process, and thereby minimize drug-related risks and exploitation. Women viewed this intervention as a place where they could receive range of supports, and emphasized that it was judgement-free.  Potential for positive bias among study participants. Study did not account for perspectives of women who face barriers to accessing facility.   Fast et al., 2008a Authors identified that gaps in safer injecting knowledge were linked to unsafe injecting practices among IDU. Safer injecting education was accessible because it was delivered in a drug use setting (i.e., natural context of drug use).  Study participants emphasized the supports provided by nurses, together with the broader environmental supports, created a safer injecting environment.  Potential for positive bias among study participants. Observation of nurse-delivered safer injecting education would have strengthened study findings. Theoretical perspective not clearly stated.  Small et al., 2008a Onsite nurses increased the accessibility of medical care and referrals, especially among Potential for positive bias among study participants.  57 Reference Key Findings Key Limitations IDU who were not otherwise seeking care for injection-related infections.  The receipt of medical care in this SIF was viewed as critical in addressing infections before they worsened. Participants emphasized the positive interactions with nurses in this setting. Theoretical perspective not clearly stated. Ngo et al., 2009 Peer-run syringe exchange services, together with larger advocacy efforts, led to a change in community attitudes toward IDU. Police crackdowns were an ongoing barrier to peer syringe exchange services, with those arrested referred to mandatory drug treatment. Arrests led to a high turnover of peer volunteers, which interfered with the intervention?s sustainability. Qualitative findings lacked depth and nuance. Authors did not clearly outline how multiple data sources were triangulated. Theoretical perspective not clearly stated. Potential for positive bias among study participants.  Sherman et al., 2009 Overdose prevention rarely discussed among IDU despite high prevalence of overdoses in local context.  During the intervention, information regarding overdose prevention (peer-administered naloxone) was disseminated Potential for positive bias among study participants. Study did not look at the impact of the program on overdoses or experiences of program recipients.  58 Reference Key Findings Key Limitations more quickly through peer networks and improved perceived safety of injecting. Krusi et al., 2009 Participants perceived this supervised injection services as increasing the safety associated with injection drug use (e.g., hygiene, overdose prevention, safety). Broader environmental supports strengthened this programme (e.g., safer injecting education). Participants emphasized the positive relationship with nurses, and indicated that these mediated access to wider range of services. Potential for positive bias among study participants. Theoretical perspective not clearly stated. Small et al., 2009a Supervised injection facility was viewed as ?welcoming? environment where IDU could receive a range of supports, including medical care. The facility location was convenient to access, which reduced the time and effort needed to access medical care. Study participants received a range of services and referrals in this facility, and indicated that they may not have otherwise received this care. Potential for positive bias among study participants. Theoretical perspective not clearly stated.  59 Reference Key Findings Key Limitations Sarang et al., 2010b Study participants expressed that the fear of arrest, detainment, and police violence constrained their access to syringe exchange services. Authors characterize the oppression of IDU as structural violence. Limited data collection among regular SEP clients. Fairbairn et al., 2010 Participants reported that the rule prohibiting assisted injections at the SIF were a significant barrier to accessing that services. Potential for positive bias among study participants. Theoretical perspective not clearly stated. MacNeil & Pauly, 2011 Participants situated their substance use within the context of social suffering. Syringe exchange services were viewed as a ?safe haven?, and a place to receive a range of services and supports. Study participants emphasized how the non-judgemental approach taken by syringe exchange workers created a ?stigma-free? space. Syringe exchange services helped to establish trust between IDU and health professionals, which was critical in mediating access to wider range of services. Potential for positive bias among study participants.  60 Reference Key Findings Key Limitations Small et al., 2011aa Study participants emphasized how the SIF was a hygienic environment, and contrasted this setting with public injection settings. The overall design of the facility improved the ability to safely prepare drugs. Study participants indicated that the limited capacity of the facility was a barrier to access (during peak periods) and also noted that some operating procedures (prohibition of assisted injections) were a barrier.  Potential for positive bias among study participants. Small et al., 2011ba Operating procedures disproportionately impacts those who share particular drugs (e.g., solid pills that must be diluted and cooked) and those individuals may opt to use elsewhere. Individuals taking longer time to inject impeded turnover, particularly during peak periods. Longer waits were viewed as a significant barrier, with IDU opting to inject elsewhere due to the urgency of their needs (e.g., ?dopesickness?). Authors may have overlooked additional barriers due to limited observation outside of SIF.   61 Reference Key Findings Key Limitations Rules prohibiting assisted injections were a significant barrier to services, especially among women. McLean, 2012 Study participants access syringe exchange services to meet a broad range of health and social care needs (?geography of survival?), and the parameters of service delivery allowed them to have structured relationships with staff. Syringe exchange site served as an informal marketplace where a wide range of resources could be exchanged. Study participants indicated that the SEP was a ?safe space? that they could access within the broader context of poverty, homelessness, and displacement.  Safety from police harassment was identified as a particularly salient theme. Potential for positive bias due to limited observation in other settings.  Parker et al., 2012 Study participants in urban areas had increased access to syringes due to availability of SEPs, while outreach services did increase access in rural areas. Potential for positive bias among study participants. Theoretical perspective not clearly stated.  62 Reference Key Findings Key Limitations Syringes were reused or shared by study participants when unable to access services (e.g., outside of operating hours).  SEPs were viewed as a unique and supportive space where IDU could receive a range of services and supports, and interact with SEP workers and nurses without experiencing stigma. Small et al., 2012a Peer support intervention was critical in mediating access to safer injecting education in natural drug use settings (e.g., alleyways, etc.). Assistance provided by peers was viewed as critical in decreasing reliance upon ?hit doctors? in the street-based drug scene, and thus minimizing violence and exploitation. Potential for positive bias among study participants. Limited data collection among program recipients. Small, Moore et al., 2012a SIF was viewed as the ?proper? place to inject, and contrasted with other injecting settings. Study participants viewed SIF as critical in minimizing risks associated with injection drug use (e.g., overdose, injection-related infections, etc.) by allowing them to inject ?properly?. Potential for positive bias among study participants.  63 Reference Key Findings Key Limitations Study participants emphasized the importance of a sanctioned injecting environment, and noted the benefits of police not interfering with intervention. Participants cited safety as a primary motivator of accessing SIF, with safety encompassing a range of meanings. a. Based on data collected as part of an evaluation of a supervised injection facility. b. Based on data collected as part of a larger study of HIV risk in three Russian cities.  64 Table 4. Distribution of themes and sub-themes across included articles 1. Physical and social environments to escape everyday and structural violence 1.1. Providing refuge from the drug scene Fairbairn et al., 2008; Kerr et al., 2007; Kimber & Dolan, 2007; Krusi et al., 2009; MacNeil & Pauly, 2011; McLean, 2012; Parker et al., 2012; Power et al., 2005; Sherman et al., 2008; Sherman et al., 2009; Small et al., 2012a; Small et al., 2012b 1.2. Understandings the contexts of safety Fairbairn et al., 2008; Kerr et al., 2007; Krusi et al., 2009; MacNeil & Pauly, 2011; McLean, 2012; Parker et al., 2012; Rhodes et al., 2003; Small et al., 2011b; Small et al., 2012b 2. Enabling safer drug use practices 2.1. Reshaping the social and environment contexts of injecting Bluthenthal et al., 1997; Fairbairn et al., 2008; Finlinson et al., 2000; Kerr et al., 2007; Kimber & Dolan, 2007; Krusi et al., 2009; MacNeil & Pauly, 2011; McLean, 2012; Ngo et al., 2009; Parker et al., 2012; Power et al., 2005; Sherman et al., 2009; Small et al., 2011a; Small et al., 2011b; Small et al., 2012a; Small et al., 2012b 2.2. Situating understandings of safer injecting Fairbairn et al., 2008; Fairbairn et al., 2010; Fast et al., 2008; Kerr et al., 2007; Krusi et al., 2009; Parker et al., 2012; Power et al., 2005; Sherman et al., 2008; Sherman et al., 2009; Small et al., 2011; Small et al., 2012a; Small et al., 2012b; Spittal et al., 2004 3. Locating interventions within the geography of survival 3.1. Mediating access to support and care Fairbairn et al., 2008; Fast et al., 2008; Kerr et al., 2007; MacNeil & Pauly, 2011; Porter et al., 2002; Power et al., 2005; Sherman et al., 2008; Sherman et al., 2009; Small et al., 2008; Small et al., 2009; Small et al., 2012a Small et al., 2012b 3.2. Fostering trust to improve access to medical care  Krusi et al., 2009; MacNeil & Pauly, 2011; Porter et al., 2002; Small et al., 2008; Small et al., 2009   65 4. Factors constraining the effectiveness of safer environment interventions 4.1. The impact of drug law enforcement Andrade et al., 2001; Bluthenthal et al., 1997; Cooper et al., 2005; Fairbairn et al., 2010; Finlinson et al., 1999; Finlinson et al., 2000; Ngo et al., 2009; Power et al., 2005; Rhodes et al., 2003; Sarang et al., 2008; Sarang et al., 2010; Sherman et al., 2009 4.2. Barriers due to operating procedures and regulations Bourgois & Bruneau, 2000; Fairbairn et al., 2008; Fairbairn et al., 2010; Kerr et al., 2007; Krusi et al., 2009; Rhodes et al., 2003; Sarang et al., 2008; Sarang et al., 2010; Small et al., 2011a; Small et al., 2011b; Small et al., 2012a; Small et al., 2012b    66 Table 5. Selected data excerpts from included articles 1. Physical and social environments to escape everyday and structural violence 1.1.Providing refuge from the drug scene  ??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, and they start arguing with one another there. That gets shut down right away. If it does [start], it gets shut down real quick. So it?s a nice thing? Another safety factor for people there. [Male injection drug user discussing a SIF, Canada] (Small et al., 2012b, p. 316)  "At the beginning the police were always around the place and we were very scared to go. But one of the outreach workers told us the police were staying away and it would be safe. They had come to some kind of an arrangement. So I took a chance and went one day and it was okay and there?s been no trouble since. I hope it stays that way." [Male injection drug user discussing a syringe exchange program, Russia] (Power et al., 2005, p. 74)  1.2.Understandings the contexts of safety  Yeah, yeah, it?s looked after, and like I said I feel safe in there. Like, I don?t have to worry about someone coming up and like, if I?m high and I?m sitting there, and fuckin? me around ?cause I?m high. They know they can take advantage of the situation. I know I don?t have to worry about that. I don?t feel rushed. I don?t feel threatened or insecure by any means. [Female injection drug user discussing a supervised injection facility, Canada] (Fairbairn et al., 2008, p. 819)   ? It?s not like [SEPs] are drug stores or anything. They don?t look down upon you for being here. And they [SEP staff] socialize with you. It?s a comfortable environment anyway. It?s not like when you walk into a drug store and ask for a bag of needles, and they go behind the counter and give you a stare that could kill you. [Male injection drug user discussing a syringe exchange programme, Canada] (Parker et al., 2012, p. 158)   2. Enabling safer drug use practices 2.1. Reshaping the social and environment contexts of injecting  "I think they?re a lot more careful at the Insite than they would be outside of the site. Like I said, you?re in a big hurry [when injecting outside] and you?re wondering, so you do everything really quick so you?re not as careful in the alley as you would [be] at the Insite [i.e., supervised injection facility].? [Female injection drug user discussing a supervised injection facility, Canada] (Kerr et al., 2007, p. 39)  67 2.1. Reshaping the social and environment contexts of injecting  "[A friend] was staying with me ? her and her fianc? ? and ?I knew that she went out [overdosed]. I pulled up like one CC and just had it there and I said to her fianc?, ?hold onto ?this?. . . Because I didn?t give him too many instructions or anything, but I just wanted to if she goes out and she?s not coming back. . . I said ?just shoot it in her thigh,? because I had already pulled up the right amount, you know what I mean, and I put the cap back on there, and I just left it there. Because I didn?t want him fumbling for anything, I just wanted him to know that, that needle right there had stuff that would bring his girlfriend back." [Male injection drug user describing peer-based naloxone distribution program, USA] (Sherman et al., 2009, p. 140)  2.2. Situating understandings of safer injecting  They offer cleanliness and hygiene, it?s real good. Now I use an alcohol swab more, I didn?t use them before . . . That?s why a lot of people get abscesses, because of the hygiene.  And, plus after 27 years of using, I wasn?t doing it right. [Male injection drug user discussing supervised injection services integrated into an HIV/AIDS care facility, Canada] (Krusi et al., 2009, p. 640)  ?[The medically-supervised injection centre] doesn?t cost. That?s the main factor... 99% would say they would go there and think?well I would go there because I know it?s clean, it?s safe, it?s medically supervised...nothing can go wrong virtually...Why would someone pick to pay $10 to go to a filthy dirty room [i.e., shooting gallery] that you could get hepatitis A just from touching the benches to go to a safe environment? That would be just silly.? [Injection drug user, gender not specified, Australia] (Kimber & Dolan, 2007, p. 216)  3. Locating interventions within the geography of survival 3.1. Mediating access to support and care  ?Well, number one, it?s something to do when you are?You can get a cup of coffee here [syringe exchange programme]. You can get some food here. Because a lot of money doesn?t go on food. Another reason is because it?s just getting out of the house. I feel, personally, closed in sometimes, and you think more about your withdrawal feeling.? [Female syringe exchange client, Canada] (Parker et al., 2012, p. 158)    68 3.1.  Mediating access to support and care  ??There?s a bunch of other things you can go there for, you know, health problems. If you need to talk to someone, they?re there. I mean they?re very friendly and helpful in a lot of ways. I mean, I went there before ?cause I had a toothache, and they told me where to go . . . because I didn?t know where else to go. And I was like, well the needle exchange, let me ask one of them. Maybe they know. And, and they told me where to go. And I got the help I needed.?? [Male client of syringe exchange, USA] (Porter et al., 2002, p. 1314)  3.2. Fostering trust to improve access to medical care  "People here are great. My spouse is HIV positive and has hepatitis C so have a lot of questions. Had a lot of questions which I have had answered. They?ve given me multiple times to come back and talk to them." [Syringe exchange client, Canada] (MacNeil & Pauly, 2010, p. 29)  ?I think it?s actually a good thing. Because you [the nursing staff] get to know what drug addicts are as individuals. And without making an 8 act play about your life, they just got to get to know you . . . It builds a relationship.? [Male injection drug user discussing supervised injection services at an HIV/AIDS care facility, Canada] (Krusi et al., 2009, p. 640)  4. Factors constraining the effectiveness of safer environment interventions 4.1. The impact of drug law enforcement   ?Fear. Fear. This is the very main reason [for sharing syringes]. And not only fear of being caught, but fear that you will be caught, and you won?t be able to get a fix. So on top of being pressured and robbed [by police], there?s the risk you?ll also end up being sick. And that?s why you?ll use whatever syringe is available right then and there.? [Female injection drug user, Russia] (Sarang et al. 2010, p. 818).  ??[We] were on a roof [injecting] and [the police] came running up there and they literally beat us down with sticks?We were basically cleaning up and they came up, searched us?took [the syringes], broke them, and commenced beating.?? [Male injection drug user, USA] (Cooper et al. 2005, p. 679).   4.2.  Barriers due to operating procedures and regulations  69  ?I: What about that rule at [Canadian supervised injection facility] where you can?t get help with an injection? R: That?s the reason why I won?t go there. I think that sucks. That, it?s not good, it?s, they should do something about something like that. ?Cause what happens if I want to go in there, and need help and nobody will help me? Well what?s this place here for then?? [Male injection drug user describing barrier to supervised injection facility, Canada] (Fairbairn et al., 2010, p. 5)  ?There is this programme in the AIDS centre, they exchange, but you have to bring one [used syringe], and they give you a new one in exchange, so it?s like ?one-to-one?, so I think just more money will be spent on the transport, its much simpler just to buy [a syringe in a pharmacy]?. [Male injection drug user discussing syringe exchange policies, Russia] (Sarang et al., 2008, p. S30)     70 CHAPTER 3: NEGOTIATING PLACE AND GENDERED VIOLENCE IN CANADA?S LARGEST OPEN DRUG SCENE 3.1 Introduction Street-based drug scenes are widely acknowledged to be one of the primary risk environments for injection drug-using populations (Rhodes, 2002; Rhodes, 2009). These are typically defined as geographically bound areas within urban centers that are characterized by the presence of high concentrations of people who use drugs and active street-based drug dealing (Hough & Natarajan, 2000). Street-based drug scenes constitute complex risk environments that encompass multiple interlocking drug scene milieus that include but are not limited to public injection settings (Rhodes et al., 2007; Small et al., 2007), shooting galleries (Ouellet, Jimenez, Johnson, & Wiebel, 1991; Tobin, Davey-Rothwell, & Latkin, 2010), homeless encampments (Bourgois, 1998; Bourgois & Schonberg, 2009), and sex work ?strolls? (Shannon et al., 2008a; Shannon et al., 2008b).  While the dynamics within specific drug scene milieus vary, exposure to these settings has been consistently identified as a risk factor for violence (El-Bassel, Gilbert, Wu, Go, & Hill, 2005; Klein & Levy, 2003; Shannon et al., 2008a). IDU are significantly more likely to experience violence than the general population (Chermack & Blow, 2002; Finlinson et al., 2003; Marshall, Fairbairn, Li, Wood, & Kerr, 2008), with one recent study finding that more than 70% and 66% of male and female IDUs, respectively, experienced violence over a five year period (Marshall et al., 2008). While women were found to be more likely to be assaulted by acquaintances, partners and ?dates? (i.e., sex trade clients), men were more often assaulted by strangers or police (Marshall et al., 2008).  There is now nearly two decades of evidence illustrating how violence within street-based drug scenes operates at the ?structural? (Farmer, 2005), ?everyday?  71 (Scheper-Hughes, 1992), and ?symbolic? levels (Bourdieu & Wacquant, 1992). Structural violence is produced by social arrangements within our society (e.g., entrenched poverty, drug criminalization) determined by large-scale forces (e.g., racism, sexism, poverty, etc.) that inflict injury upon vulnerable populations (Farmer, 2005). Everyday violence refers to the normalization of violence that is rendered invisible due to its pervasiveness (Scheper-Hughes, 1992), and is often embedded within gendered power relations (Bourgois, Prince & Moss, 2004). Finally, symbolic violence is conceptualized as the product of social and cultural forces that lead vulnerable groups to ?misrecognize? their subordination as the natural order of things and blame themselves for their position in social hierarchies (Bourdieu & Wacquant, 1992). Epidemiological data underscore how intersecting structural inequities that impact upon street-based drug scenes, including homelessness and housing stability (Duff, Deering, Gibson, Tyndall, & Shannon, 2011; Marshall et al., 2008; Shannon et al., 2009; Wechsberg et al., 2003) and drug and sex work law enforcement (Kerr, Small, & Wood, 2005; Shannon et al., 2008a; Werb et al., 2011), increase exposure to violence among drug-using populations. For example, there is evidence that lack of access to private space due to homelessness and housing instability promotes immersion within street-based drug scenes (Debeck et al., 2012), which, in turn, is linked to an increased risk of violence (Debeck et al., 2011). Ethnographic and qualitative studies have further underscored how social norms operating within street-based drug scenes (e.g., gendered power relations) perpetuate everyday violence toward injection drug-using populations (Bourgois et al., 2004; Bourgois & Schonberg, 2009; Epele, 2002; Shannon et al., 2008b) - that is, violence that is normalized and rendered invisible due to its ubiquitousness (Scheper-Hughes, 1992). Previous research has been particularly concerned with how the subordination of women within street- 72 based drug scenes is commonly expressed through interpersonal violence, particularly that directed from ?boyfriends? (i.e., male IDU who control the resources that women generate through exchanging sex) and ?dates? (i.e., sex work clients) (Bourgois et al., 2004; Bungay, Johnson, Varcoe, & Boyd, 2010; Epele, 2002). Furthermore, the tendency among IDU to identify the subordination of women as the ?natural? underscores the symbolic dimensions of drug scene violence (Bourgois et al., 2004). Violence among injection drug-using populations is an urgent public health concern given its immediate impacts and association with drug-related risks and harms. Previous studies into the impact of violence on drug-related harms have primarily concentrated on drug-using women (Braitstein et al., 2003; El-Bassel et al., 2005; Vlahov et al., 1998), linking previous experiences of violence to elevated rates of syringe-sharing (Braitstein et al., 2003), inconsistent condom use (El-Bassel et al., 2005), and accidental overdose (Braitstein et al., 2003). Furthermore, violence or the threat of violence in settings in street-based drug scenes where drug-using women exchange sex have been found to undermine women?s ability to negotiate sex work transactions, including condom use (Shannon et al., 2008b). Although men who inject drugs are as likely to experience drug scene violence as women, limited attention has been paid to the associated risks outside of studies linking this violence to higher risk of homicide among male IDU (Clausen, Waal, Thoresen, & Gossop, 2009). The lack of attention to violence among drug-using men reflects an overall emphasis on gender-based violence in the drug use literature, where this is viewed primarily as violence perpetrated against women by men (Frye et al., 2007; Marshall et al., 2008). Epidemiological studies into drug scene violence have tended to view ?gender? as a binary, and their analyses have emphasized women?s vulnerability to inter-partner violence or violence in the context of sex work  73 (El-Bassel et al., 2005; Shannon et al., 2009). Whereas several ethnographic and qualitative studies have linked violence against women within drug scenes to gendered power relations, and examined how it is produced by social norms within drug scenes that subordinate women (Bourgois et al., 2004; Bourgois & Schonberg, 2009; Bungay et al., 2010; Shannon et al., 2008b), they have not considered the role of a wider range of ?gender positions? in shaping violence. A more nuanced view may consider how gendered violence is produced by hegemonic forms of masculinity operating within the street-based drug scene that render both women and ?marginal men? vulnerable to violence on the basis of their position within gendered hierarchies. Inherent in this is the recognition that women and some men are subordinated in accordance with how these forms of masculinity structure gendered power relations (Connell & Messerschmidt, 2005). While the roles some women occupy within sex work and drug scenes allow greater claims to agency (Maher, 1997; Shannon et al., 2008b), women are nonetheless largely confined to marginal positions (Maher & Hudson, 2007). Although limited, evidence suggests that the structure of the street-based drug economy reflects and reinforces masculine hierarchies, in that men occupying more prominent roles (e.g., drug dealers) subordinate ?marginal men? ? that is, those whose marginal positions are determined by the lower status accorded to their sources of income (e.g., panhandling, recycling) (Bourgois & Schonberg, 2009). Following Connell and Messerschmidt (2005), we extend this definition of ?marginal men? in the context of street-based drug scenes to include those men who do not - or cannot - occupy dominant roles, often as a function of older age, social isolation, complex medical needs or disabilities. While recognizing that women and marginal men?s experiences of violence are complex and unique, evidence from other settings suggest that dominant forms of masculinity increase vulnerabilities to violence and adverse health outcomes among women (Holland et  74 al., 1998; Jewkes & Morrell, 2012) and marginal men (Canetto & Cleary, 2012; Courtenay, 2000; Emslie, Ridge, Ziebland, & Hunt, 2006; Stoudt, 2006), but this has been underexplored as a driver of violence within the context of street-based drug scenes.  The Downtown Eastside neighbourhood in Vancouver, British Columbia is the site of Canada?s largest street-based drug scene (Strathdee et al., 1997; Tyndall et al., 2003; Wood & Kerr, 2006), with an estimated 5,000 people who inject drugs (IDU) living in this approximately ten-block area (Wood & Kerr, 2006). This neighbourhood has been shaped by the complex interplay between entrenched poverty, homelessness, and drug use (Wood & Kerr, 2006), as well as the enduring legacy of the colonialization and marginalization of Canada?s Aboriginal peoples (Benoit, Carroll, & Chaudhry, 2003; Culhane, 2003). Whereas numerous environmental supports are available to IDU in this neighbourhood, including North America?s only sanctioned supervised injection facility (Insite) and some safer sex work environments (Krusi et al., 2012), research has continuously documented the significant impact that violence has on IDU living in this neighbourhood (Lazarus, Chettiar, Deering, Nabess, & Shannon, 2011; Marshall et al., 2008; Shannon et al., 2008b). Notably, in a social mapping study among drug-using women in sex work, Shannon and colleagues (2008a) found that women commonly avoided main streets and core areas of Downtown Eastside with high concentrations of health and social services due to gendered violence and police harassment.  Notwithstanding the important contribution of this research in linking violence to restricted access to harm reduction services, there remains a need to further explore how women?s understandings of place and violence shape their spatial practices?that is, how they actively negotiate space in the context of their everyday lives (de Certeau, 1984). Furthermore, studies into experiences of violence  75 among men have not explored how these are linked to their spatial practices, or embedded with gendered power relations. Given the continued pervasiveness of violence in the Downtown Eastside, and the limited understanding regarding how it impacts the social geographies of IDU, we undertook this study to explore the everyday geographies of drug users in the Downtown Eastside and their experiences of violence in relation to space. We were particularly concerned with how gendered violence shapes the spatial practices of IDU, and whether these impacted their access to health and harm reduction services, including Insite. 3.2 Methods This study is based upon qualitative interviews and mapping exercises conducted with IDU in the Downtown Eastside neighbourhood between September and December 2011. This research was undertaken in partnership with the Vancouver Area Network of Drug Users (VANDU), with whom members of our research team have collaborated for more than a decade. Two research team members (McNeil & Small) conducted semi-structured interviews with twenty-three IDU who regularly accessed VANDU, which has served as a drop-in centre for highly-marginalized IDU in this area. We aimed to oversample women relative to their representation within the local drug scene (n.b., approximately one third of IDU in the neighbourhood are women) due to their disproportionate vulnerability to violence and drug-related risks (Braitstein et al., 2003; Lloyd-Smith et al., 2010). Approximately one third of our participants (7) were recruited by referral from VANDU staff, while the remaining participants were recruited within the context of a larger ethnographic project that was based within VANDU. The majority of interviews (20) were conducted at an established storefront research office in this neighbourhood, and the remaining interviews (3) were conducted in a private office at VANDU. Participants provided informed consent prior to their interviews and received an honorarium ($20 CAD)  76 following the completion of their interview. Interviews were audio recorded and averaged approximately 45 minutes in length. Interviews were transcribed verbatim and reviewed for accuracy by the lead author. Ethical approval for this study was obtained from the Providence Healthcare / University of British Columbia institutional research ethics board prior to commencing this research. We used an interview topic guide to facilitate discussion regarding how participants experienced place in the Downtown Eastside, and how these experiences shaped their access to Insite. Given the prevalence of violence in this neighbourhood, we were especially interested in how the social geographies of our participants were shaped by perceptions of safety. Interviews were accompanied by a qualitative mapping exercise that sought to link experiences to specific locations in the neighbourhood. During the interview, participants and interviewers made notes on neighbourhood maps to link diverse experiences (e.g., experiences of violence, encounters with police) and activities (e.g., drug use settings, drug dealing and sex work locations) to specific locations in the neighbourhood. Participants were also asked to highlight areas that they perceived as ?safe? or ?unsafe?, including any areas in the neighbourhood that they avoided.  Interview transcripts and maps were imported into NVivo (v. 9) to facilitate data management and coding. We used a multi-step process to analyze our data. We first analyzed maps to identify patterns in the socio-spatial practices of our participants. We noted that these patterns were distinctly gendered, in that, while violence produced similar spatial patterns among women and marginal men, these were positioned differently. We subsequently adjusted our analytical process to account for these similarities and differences. We then developed a preliminary coding framework based on these socio-spatial patterns (e.g., areas perceived as 'dangerous', locations where participants experienced violence, explanations of  77 spatial practices), and used this to code the interview transcripts and fieldnotes. We then linked this data to the mapping data to develop thematic descriptions of the social geographies of our participants. Finally, we drew upon concepts of everyday (Bourgois et al., 2004; Scheper-Hughes, 1992), structural (Farmer, 2005), and symbolic violence (Bourdieu & Wacquant, 1992), and hegemonic masculinity (Connell & Messerschmidt, 2005), to advance beyond thematic description and situate the spatial practices of our participants within their gendered social and structural contexts. 3.3 Results The twenty-three individuals participating in semi-structured interviews included eleven women and twelve men. All of the men interviewed were identified as ?marginal men? in accordance with the roles and positions outlined above, while all of the women participating in this study occupied marginal roles within the street-based drug scene. Participants averaged approximately 40 years of age (range 27-59 years), and eight self-identified as a member of a visible minority (e.g., Aboriginal ancestry, African-Canadian, or Indo-Canadian). The vast majority of participants (20) indicated that they used drugs daily, with crack cocaine (20), heroin (12), hydromophone (8), and cocaine (6) identified as the most commonly used drugs. All participants reported that they had lived in the Downtown Eastside within the past five years, and most (19) currently lived in the neighbourhood. Nearly half of our participants were staying in emergency shelters (8) or sleeping outside (3), while the remaining participants reported that they lived in single room occupancy hotels (6) or apartments (6). Nearly all participants received income primarily from social assistance payments (22), most of the women interviewed reported that they regularly engaged in sex work (exchange of sex for money and/or drugs).  78 3.3.1 Place, Violence, and Masculinity in the Downtown Eastside  Central to participant narratives of place in the Downtown Eastside neighbourhood were gendered experiences of drug scene violence. Nearly all women and marginal men specified locations where they had been ?threatened?, ?punched out? or ?attacked?, while those remaining commonly spoke of locations where they had witnessed violence. Our findings demonstrate how the street-based drug scene was structured by a hegemonic form of masculinity predicated on violence and the subordination of women and marginal men. Women and marginal men were deemed to occupy lesser positions than ?dominant men? (e.g., drug dealers, gang members, aggressive ?boyfriends?) within the gendered power hierarchy in the street-based drug scene, participants emphasized their ?weakness? and ?vulnerability?. Participants indicated that women and marginal men were unable to protect themselves from violence and exploitation, and indicated that this marked them as the ?targets? for predatory dominant men when entering drug scene milieus (e.g., public injection settings, drug dealing locations). For example: One guy?s in a wheelchair and he?s paralyzed on one side. He?s been a heroin addict for thirty years and he had a stroke?Every time he used to go to the alley, he?d get ripped off, beaten up, lose everything, you know. [Caucasian Female, 59 years old]  Whereas marginal men emphasized their vulnerability to physical violence and robbery, women indicated the additional risks of violent sexual assault. I?ll smoke [crack cocaine] in the alley and I hate it...It?s scary. Anybody could walk up behind you with something and beat you and try to rob you ?cause they want your drugs. It?s just scary...I?ve been raped [in an alleyway]. [Caucasian Female, 28 years old]   Participant accounts underscored how gendered violence was understood to be a natural consequence of drug scene involvement, and thus operated as a form of  79 symbolic violence. Many participants expressed that this normalized, gendered violence was most evident in the expectation that dominant men would seek to control the material resources (e.g., money or drugs) or labour (e.g., contexts in which they exchanged sex for money or drugs) of women and marginal men. For example: The girls make the money [through involvement in sex work]. Guys know they got the money. The guys don?t make money, and that way they have to beg, borrow or steal in between cheques...So, of course they [i.e., women] are going to be manipulated...These guys, you know, [are] muscling them or doing anything to get what they?ve got [i.e., drugs or money]. [Caucasian Male, 46 years old] 3.3.2 Gendered Violence and Geographical Restrictions While gendered violence was critical in shaping the everyday geographies of women and marginal men, our findings demonstrated that how women and marginal men positioned their geographical restrictions varied. Whereas women and some marginal men explicitly linked their spatial restrictions to violence, other men sought to position their spatial practices in a manner that resisted marginalized identities. 3.3.2.1. ?Just not safe outside? ? Avoiding ?dangerous areas?  While the everyday violence experienced by women and marginal men fuelled their perception that the neighbourhood was unsafe, their lack of access to private space, together with the realities of active addiction and entrenched poverty, promoted immersion within the street-based drug scene. In this regard, this intersection of structural and everyday violence profoundly increased their potential risks. Accordingly, participants spoke of how they enacted spatial strategies to maintain their safety within the context of everyday violence. Mapping data further demonstrated that most of the areas in the neighbourhood where women and marginal men experienced drug scene violence were concentrated in high traffic drug  80 market locations (e.g., areas along Hastings Street and west of Main Street, Oppenheimer Park) and areas that were relatively secluded (e.g., alleyways and industrial locations). These participants indicated that they actively avoided these ?dangerous? and ?scary? drug scene milieus to limit their overall exposure to aggressive and violent men. While specific geographical restrictions varied among these participants in accordance with their individual experiences and perceptions of violence, their spatial strategies may be understood to be an adaptive response to the violent, hegemonic form of masculinity operating within the street-based drug scene. Importantly, this strategy had the effect of severely limiting the scope of the spatial practices of those women and marginal men who had frequently experienced violence, as well as those who viewed themselves as especially vulnerable to violence due to their gender or disability. For example, ?Ellen? was a woman in her early forties who had lived in the Downtown Eastside for twenty years, having been originally drawn to the neighbourhood by the easy availability of heroin. She had cycled between emergency shelters and single room occupancy hotels depending on her access to income (indoor and outdoor sex work), intensity of her substance use patterns, and on-again, off-again relationship with her ?boyfriend?. Ellen had recently begun injecting crystal methamphetamine (in addition to continued heroin injection) and the subsequent intensification of her substance use patterns (multi-day binges) precipitated eviction from her single room occupancy hotel. Ellen discussed how her subsequent immersion in the street-based drug scene led to a violent assault by a male drug user and, in turn, caused her to restrict the geographical scope of her activities to avoid specific areas and, to the greatest extent possible, men. I had no place to go, right, so I was either at the [emergency shelter] or [drop-in centre]. Just walking around?s not safe.  People approach you, men approach you. [It is] just not safe outside if you?re a girl... I had my armed chopped [by a man]  81 with a machete. [Participant shows interviewer extensive scarring] I kind of got scared...At that point in time, I was really nervous of guys. [...] I try to avoid Oppenheimer [Park] and I try to avoid [the] Abbott and Pender [intersection]. I don?t like it there. That?s where my accident [i.e., machete attack] happened and Oppenheimer?s just scary.  The map generated by Ellen underscored the extent to which gendered experiences of violence constrained her movements within the neighbourhood (Figure 3). In addition to the abovementioned geographical restrictions, Ellen indicated that she generally avoided drug scene milieus west of Main Street where she had previously experienced violence (i.e., violent assaults and robberies). Similarly, our data demonstrated that intersecting inequities (e.g., poverty, homelessness) promoted participant immersion within the male-dominated drug scene, while at the same time producing gendered violence that led them to restrict the scope of their spatial practices. This had the effect of leading some women and marginal men to confine their movements to small areas that in some cases encompassed a few short blocks. 3.3.2.2. ?I want the best dope? ? Resisting marginalized masculinities Despite their low status within the street-based drug scene and frequent experiences of violence, some men actively resisted marginalized masculinities by expressing that they would go ?anywhere? in the neighbourhood. Nonetheless, mapping data revealed that these men tended to avoid high intensity drug market locations characterized by elevated levels of violence (e.g., alleyways, high-traffic drug dealing locations). These men attributed their geographical restrictions to the perceived quality of drugs (particularly heroin) sold by dealers in these areas. These men had limited or precarious sources of income (e.g., social assistance, panhandling, recycling), and articulated how the need to maximize their drug purchases, together with the desire for intense intoxication, led them to seek out highly potent drugs and  82 reliable drug dealers. While the local street-based drug market is most established along Hastings Street and west of Main Street, these men characterized the drugs sold in this area as ?shitty? or ?crap? (i.e., as having inconsistent potency), and several reported that they had previously been ?bunked? (i.e., sold counterfeit drugs) by dealers in that area. These men emphasized how the inferior quality of the drugs sold in these high intensity drug market locations left them with little reason to visit these areas. Our analysis of participant accounts and maps suggests that these concerns about ?dope quality? served to allow these men to maintain claims to dominant forms of masculinity while enacting spatial strategies (i.e., avoiding violent drug market locations) that limited their exposure to violence. Even as men attributed their geographical restrictions to poor "dope quality", their narratives of these drug scene milieus were interwoven with accounts of drug scene violence at the hands of aggressive and violent men, and many feared further violence. For example, ?Alex? was a thirty-something homeless male IDU who had recently moved to Vancouver from Eastern Canada after hearing stories of the drug availability and quality in the Downtown Eastside. He had been living in an emergency shelter for several months, and the intensity of his drug use patterns (daily injection drug use) had led him to quickly gain familiarity with the street-based drug scene, including area drug dealers. Alex indicated that drug dealers in several high intensity drug market locations sold "shitty dope", and that he thus avoided those areas. [Around the] bottle depot [located one block west of Insite], there is always a crowd of people [selling drugs]. There?s about five ? I don?t know how many dealers. The dope is not that good. Me, as a junkie, I want the best dope I can get for my money.  However, interview and mapping data suggest that Alex was primarily motivated by the need to avoid violence in these drug scene milieus. Notably, Alex had experienced  83 violent assault at the hands of violent drug dealers or other male drug users in areas that he avoided, and otherwise perceived to be unsafe (Figure 4). The following excerpt describes an assault that took place when he was buying drugs in the vicinity of the abovementioned drug market location: Two guys came to me...They punch me in the face and I?m laying down, and there's two pretty big guys and one says, ?This is a fucking controlled block.? And pow! I get another one [punch] in the face. [It] pretty much knocked me out. They showed me their tattoos and I?m pretty sure they?re bikers because we don?t buy from the [high intensity drug market location]...They want us to buy their dope. ...Now, I?m a little scared of people that might want to rob me, that want to, like, fucking punch me out. I?m a tough man. I can fight too but I lost a lot of weight.  3.3.3. Locating Survival in the Downtown Eastside Whereas gendered violence restricted the spaces occupied by women and marginal men, their accounts illustrated how they leveraged social resources (e.g., health and social care services) to negotiate survival in the Downtown Eastside. Several low-threshold housing programs (e.g., low barrier emergency shelters, women-only supportive housing, safer sex work environments), health care services (e.g., health clinics, case management), and peer-run organizations (e.g., VANDU) operating east of Main Street figured prominently in participant accounts. Women and marginal men commonly expressed that these were places where they could escape drug scene violence, with women emphasizing the importance of women-only spaces. The availability of these spaces was especially important among homeless or unstably housed women and marginal men who otherwise lacked access to spaces in which they could escape drug scene violence. For example, ?James? - a homeless IDU who had recently been released from prison - spoke of how he spent as much time as possible at a drop-in program:  84 There?s like 40 crack dealers down by the bottle depot.I feel way safer [at the drop-in program] because [there is] none of that action [i.e., drug scene violence]...I was there [drop-in program] at 10 o?clock this morning and I?ve been in there since...I think they should be open 24 hours.  Many woman and marginal men contrasted the areas immediately surrounding these facilities with other drug scene milieus, and emphasized how the former were ?safer? because of the additional environmental supports provided by these facilities, including regulated indoor environments.  Our analysis of participant accounts and maps further demonstrated that the availability of these environmental supports were critical in enabling women and marginal men to engage in a wide range of activities critical to surviving (e.g., obtaining food and shelter, receiving medical care) or generating the income necessary to support continued drug use (e.g., sex work, engaging in stipended volunteer work). Many marginal men had limited involvement in the street-based economy, and their limited access to money (most of which was allocated to drug use) meant that they were dependent upon these programs to obtain material resources (e.g., food, clothing), medical care, and social support that allowed them to survive within the context of entrenched poverty. Nearly all of the women that we interviewed engaged in sex work, and leveraged these organizations to increase their safety while working. Some women indicated that they worked primarily in close proximity to these organizations to limit their exposure to more dangerous drug scene milieus. Several women were also living in women-only housing programs that function as safer sex work environments (n.b., these ?unsanctioned? safer sex work environments have been described in detail elsewhere; see Krusi et al., 2012), and the availability of these supports was crucial in establishing a space for them.  85 3.3.4 Crossing Boundaries ? Entering ?Dangerous? Drug Scene Milieus  Among women and marginal men, there was a stark contrast between ?dangerous? drug scene milieus characterized by male perpetrated violence (e.g., locations along Hastings Street and west of Main Street, Oppenheimer Park, alleyways) and ?safer? areas located within their geographies of survival. For many participants, these areas were separated by clearly defined boundaries that were only crossed under extreme duress, primarily when unable to obtain drugs from usual sources or as necessary for income-related reasons (e.g., cashing social assistance cheques). Participants described themselves as "stressed" or "worried" when they were compelled to venture into these "violent" and "dangerous" drug scene milieus, and emphasized how these border crossings increased their vulnerability to male perpetrated violence. For example, ?David? was in a motorized wheelchair due to a recent stroke, and had frequently been ?ripped off? by men (including some he knew) in drug scene milieus in the neighbourhood. While David regularly exchanged prescribed oxycodone (n.b., interview occurred prior to the delisting of ?Oxycontin?) for hydromorphone with his longstanding drug dealer, he was sometimes unable to obtain his preferred drug in this way. The urgency of his opiate dependency (i.e., injecting several times daily to ward off dopesickness) led him to incur considerable risk by venturing into ?dangerous? drug scene milieus where he had previously experienced violence. Once I get down to that area [i.e., high traffic area in drug scene where prescription drugs are sold], I have to watch for people watching to see what I got...The only reason I?m there is if my regular connection [drug dealer] doesn?t have pills, and I?m forced to go down there to look for pills...Security is one of the reasons [for avoiding this area]...You just never know if they?re going to follow you and jump you. It just takes 20 seconds for them to run up.   86 Mary, a twenty-something Aboriginal woman who had been entrenched in the street-based drug scene since her early teens, was frequently the target of predatory men seeking control over the money or drugs that she received through sex work. Mary worked primarily in the area immediately surrounding her non-market single room occupancy hotel, which functioned as an unsanctioned safer sex work environment (see Krusi et al., 2012), and spoke negatively of ?unsafe? and ?ruthless? drug scene milieus west of Main Street. Nonetheless, there were income-related reasons why she had to occasionally cross this boundary. Everybody?s so fucking ruthless and cold down there [i.e., drug market locations west of Main Street]. [...] They?ll fucking stab you if they wanted something you have...They try their hardest to fucking bring you down 'cause they don?t want to see you doing better than them. [...] If I go past Main [Street], it's like, "Ho, where's my fucking money?" or "give me that!" Down there it?s all negativity and violence and money and bullshit. I don?t want [that], don?t need [that]...I don?t go past Main [Street unless] it?s for something that, like, I have to have to. Then, I will. Like, on Mondays, I go to the cheque cashing place on Main... [That is] the only time I go on that side of Main.  Other than that, I don?t even bother.  As these cases demonstrate, within the situated rationality of women and marginal men, there were instances when it was necessary to cross boundaries and enter into potentially violent drug scene milieus. Notably, none of the women or marginal men that we interviewed cited accessing harm reduction services as a motivation for crossing these thresholds, despite the fact that the area immediately surrounding Insite was the most commonly avoided area. It was striking that most of our participants indicated that they rarely injected at Insite because they avoided the area and approximately one third had never injected at Insite, underscoring how gendered drug scene violence was critical in constraining access to these services. For example, ?Alice?, a homeless woman in her late twenties who frequently exchanged  87 sex for money or drugs, had recently been attacked on the same block as Insite. Whereas she avoided the area surrounding Insite because it was perceived to be more ?dangerous?, her need to inject pushed her into other unsafe drug scene milieus. I feel very, very unsafe down by the injection site [i.e., Insite]? I don?t go past Main [Street] anymore?There?s some very dangerous dealers down there?That?s where I was robbed and beaten badly?This guy robbed me and beat me up. [...] I don't go there at all [now]. [...] If I have to use, I?ll use anywhere. I go into the alleys and I feel less safe [there]. 3.4 Discussion  In summary, we found that hegemonic forms of masculinity operating within the Downtown Eastside perpetuated everyday violence experienced by women and marginal men. Women and marginal men restricted the geographic scope of their activities to avoid drug scene milieus where they had experienced violence or those that were perceived to be ?dangerous?. While some men attributed their geographical restrictions to the need to acquire good quality drugs, their heavy emphasis on drug scene violence suggested that this merely allowed them to maintain claims to dominant forms of masculinity while still enacting spatial strategies necessary to their safety. Our findings highlight how the environmental supports provided by some health and social care agencies were critical in enabling women and marginal men to negotiate geographies of survival within the context of gendered drug scene violence. Whereas access to harm reduction services, including Insite, was not sufficient to motivate our participants to enter into ?dangerous? drug scene milieus, women and marginal men ventured into these areas when they were not able to obtain drugs from regular drug dealers, or when necessary for income-related reasons. Of note, our findings point to the central role of hegemonic masculinity in subordinating ?marginalized men? (e.g., those occupying low statuses within the drug scene), and thus shaping how they negotiate safety and survival in the Downtown  88 Eastside. Our findings underscore how hegemonic masculinity operated at the symbolic level, in that marginal men seemingly accepted that their lower status within the drug scene rendered them vulnerable to violence. Marginal men?s narratives of place in this neighbourhood were interwoven with experiences of extreme violence that profoundly impacted their spatial practices. Even as some men resisted marginalized identities (e.g., attributing spatial restrictions to ?dope quality?), their spatial practices were linked to the need to maintain safety from the violence and aggression of those men who occupied dominant roles within the street-based drug scene. Indeed, whereas the hegemonic form of masculinity within the street-based drug scene was largely tied to the street-based drug economy, men (and women alike) identified violence and aggression as its defining characteristics. While the concept of hegemonic masculinity has increasingly been employed to understand men?s health (Canetto & Cleary, 2012; Cleary, 2012; Emslie et al., 2006) and risk-taking (Iwamoto, Cheng, Lee, Takamatsu, & Gordon, 2011; Peralta, 2007), it has received only limited attention in drug use research, where it has focused primarily on the roles occupied by women and men within street drug economies (Bourgois, 2003; Hutton, 2005) and the cultural logics of specific injection practices (Bourgois & Schonberg, 2009; Nasir & Rosenthal, 2009).  Our findings underscore how the current tendency within the drug use research to homogenize male actors overlooks the extent to which their experiences likely vary as a function of the diverse masculine subject positions operating within street-based drug scenes. Greater attention to the contexts of masculinity in drug use research is warranted given their considerable potential to explain variations in the distribution of harm among men (e.g., access to harm reduction services, incarceration, rates of violence). In this regard, ethnographic and qualitative research that examines the structure of gendered power hierarchies within street-based drug scenes is likely  89 to prove important in typologizing ?masculinities? in any given context, and thus informing more nuanced epidemiological analyses. Together, the combination of these approaches have the potential to inform targeted interventions to meet the needs of those who are disproportionately vulnerable to harm.  Whereas previous research has emphasized the role of street policing in displacing women within street-based drug scenes (Cooper, Moore, Gruskin, & Krieger, 2005; Maher, 1997; Shannon et al., 2008b), our findings expand upon more recent evidence identifying drug scene violence as a contributor to women?s displacement from drug scene milieus (Shannon et al., 2008a). Importantly, although drug and sex work law is a form of structural violence that remains the defining characteristic of many street-based drug scenes, the lack of discussion of street policing in women?s narratives likely reflects recent shifts away from the strict enforcement of drug possession and sex work laws in the Downtown Eastside (Deering et al., 2012; Small, Krusi, Wood, Montaner, & Kerr, 2012). Furthermore, these women (as well as the men interviewed) lacked involvement in other activities other than sex work (e.g., drug dealing, selling stolen goods) that might have drawn the attention of police. Conversely, consistent with the broader literature linking gendered power relations and how women negotiate urban geographies (Mehta, 1999; Pain, 1997; Valentine, 1989; Wilding, In press), we found that the dominant form of masculinity that structured gendered power relations in Downtown Eastside, and normalized violence toward women, was critical in shaping women?s geographies. Specifically, our findings highlight how gendered violence dictated women?s spatial practices, and thus excluded them from drug scene milieus. While it is critical that future mappings of women?s geographies within street-based drug scenes locate these within the context of gendered violence, it is equally important that such mappings consider how environmental interventions can be mobilized to mitigate  90 violence by providing women with increased supports and opportunities to achieve safety from drug scene milieus perceived to be dangerous. It is noteworthy that, within the context of normalized drug scene violence, women and marginal men were able to negotiate survival by leveraging social resources (e.g., low-barrier emergency shelters, women-only spaces, etc.) available in the neighbourhood. These organizations provided women and marginal men with spaces that they could occupy with limited risk of violence, and thus engage in a wide range of activities critical to their survival (e.g., obtaining food and shelter, sex work). Similarly, recent evidence underscores the critical role of targeted environmental supports, including safer sex work environments (Krusi et al., 2012) and low-threshold women-only housing (Lazarus et al., 2011), in mitigating the deleterious impacts of gendered violence within street-based drug scenes. Scaling up these and other interventions within street-based drug scenes (e.g., targeted housing and drop-in programs for older men and men with disabilities, mobile outreach), is likely necessary to promote safety among women and marginal men. Our findings demonstrate how violence constrained access to supervised injection services among women and marginal men. Although previous research has found Insite to be a ?refuge? from drug scene violence for women accessing the facility (Fairbairn et al., 2008), we found that some women and men are unable to even access the facility due to the perceived threat of violence in the surrounding area. Accordingly, our findings suggest that a greater diversity of supervised injection facilities may be needed to ensure appropriate harm reduction coverage in some settings. Despite growing calls to expand these services in Vancouver, and increased awareness of the limitations of the current centralization of supervised injection services (Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Petrar et al., 2007), there remains a need to scale up these services in the Downtown Eastside and elsewhere in  91 Vancouver with established drug scenes (e.g., Downtown South, Kingsway Corridor) (Deering et al., 2011). Situating supervised injection services within the existing geographies of survival of women and marginal men (e.g., integrating services into emergency shelters and supportive housing, drop-in centers, and health clinics) or implementing mobile safer injecting services may prove critical in ensuring their responsiveness to the social geographies of these highly-vulnerable IDU.  Finally, our findings demonstrate the need for broader policy reforms to maximize the impact of targeted environmental interventions, as well as to create an environment in which highly-marginalized IDU can minimize their exposure to violence. Chief among them, the extent to which immersion in the street-based drug scene was driven by homelessness and housing instability underscores the need to increase investment in safe, affordable housing. Despite recent efforts by the provincial government in British Columbia to increase the availability of social housing in the Downtown Eastside, the demand for these units far exceeds the supply, and a more comprehensive approach that involves all levels of government is needed. Furthermore, our findings lend support to continuing calls for reforms to sex work legislation to enable those engaged in sex work to negotiate safety (Krusi et al., 2012; Shannon et al., 2008a; Shannon et al., 2008b). Consistent with previous research (Krusi et al., 2012), our findings demonstrate that the availability of safer sex work environment was critical in improving women?s safety, and policy reforms to better enable those engaged in sex work to have access to regulated and safe indoor environments is urgently needed. There are several limitations to our study that should be taken into consideration. First, the spatial strategies described herein reflect those of our study participants, and cannot be considered to be representative of other drug users in the Downtown Eastside. It is possible that drug users recruited in other locales in this  92 neighbourhood would have dramatically different spatial practices. Second, our recruitment and data collection were undertaken in connection with VANDU as part of a larger ethnographic study, and the study insights may thus be limited to the perspectives of a very particular group of IDU. In particular, the relative homogeneity of women participating in this study limited our ability to generate insights into their diverse experiences of violence. Third, we have likely underrepresented the perspectives of some IDU, and, notably, our study did not include any transgender participants. Furthermore, all but one of our participants self-identified as ?straight? and our findings thus do not reflect the perspectives of lesbian, gay, bisexual, transgender, and queer (LGBTQ) IDU. It is possible that gendered violence may be further linked to sexuality, and further research is needed to disentangle these relationships. Fourth, given that we relied upon self-reported data, it was difficult to verify the accuracy of participant accounts, and it is possible that participants overstated or understated their experiences of violence. Finally, our research was undertaken in a neighbourhood that is distinct in many ways (e.g., concentration of IDU, presence of Insite), and the social geographies that we described may differ greatly from those in other street-based drug scenes.  Despite these limitations, our study demonstrates the critical role of gendered violence in restricting the geographies of both women and marginal men within the street-based drug scene, and further underscores the need for environmental interventions that mitigate these harms. Notwithstanding the important contributions of existing environmental supports for women and marginal men in the street-based drug scene, our findings indicate that there is an immediate need to scale these up and implement further targeted interventions to minimize violence among these highly-vulnerable IDU. Furthermore, mapping harm reduction services, including supervised injection services, onto these interventions will be critical in promoting  93 risk reduction, and mitigating the negative impact that gendered violence currently has on access to these services.    94 Figure 3. Map of Ellen's spatial practices     95 Figure 4. Map of Alex's spatial practices   96 CHAPTER 4: AN ETHNOGRAPHIC STUDY OF ASSISTED INJECTION PRACTICES AT A PEER-RUN ?UNSANCTIONED? SUPERVISED DRUG CONSUMPTION FACILITY IN A CANADIAN SETTING 4.1 Introduction There is mounting evidence that the distribution of drug-related harm within injection drug-using populations varies in accordance with population characteristics and the unique social, structural, and spatial factors that shape injection drug use in any given particular risk environment (Cooper, Bossak, Tempalski, Friedman, & Des Jarlais, 2009; Fast, Small, Wood, & Kerr, 2009; Rhodes et al., 2005). Within this context, risk may be understood to be variegated, in that specific injection drug-using populations are more or less vulnerable to harm, often as a result of where they inject (Parkin & Coomber, 2011; Rhodes et al., 2007; Small et al., 2007), how and with whom they inject (Bourgois et al., 2004; Bourgois & Schonberg, 2009; Epele, 2002; Fairbairn et al., 2010), and contexts within which they exchange sex (Shannon et al., 2008a; Shannon et al., 2010). An understanding that risk is variegated underscores the heterogeneity within the injection drug-using population and, subsequent to that, draws attention to how drug-related risks vary across the diverse subject positions occupied by IDU. Given these inequities in the distribution of harm, there is a need for increased attention to how social, structural, and spatial forces operating within key risk environments render specific subpopulations of injection drug users vulnerable to drug-related harm.  Over the past decade, a growing body of research has demonstrated that people who require help injecting (i.e., those who are injected by another person) are one such subpopulation that is disproportionately vulnerable to drug-related harm (O'Connell et al., 2005; Wood et al., 2003). Requiring help injecting is associated with HIV and HCV infection (Kral, Bluthenthal, Erringer, Lorvick, & Edlin, 1999; Maher et  97 al., 2006; Miller et al., 2002; O'Connell et al., 2005; Wood et al., 2003), with epidemiological data suggesting that people who require assistance injecting are approximately twice as likely to acquire HIV and HCV in comparison to those who self-inject (Miller et al., 2002; O'Connell et al., 2005). In addition, a range of health and social harms have been documented among people who require help injecting, including elevated rates of syringe-sharing (Evans et al., 2003; Kral et al., 1999; Robertson et al., 2010; Wood et al., 2001), injection-related infections (Lloyd-Smith et al., 2010; Lloyd-Smith et al., 2008), overdose (Kerr et al., 2007; Milloy et al., 2008), and victimization (Marshall et al., 2008).  Ethnographic and qualitative research draws attention to how these assisted injection practices are shaped by social, structural, and environmental factors and, in turn, how these factors reflect larger material inequities which in turn shape the distribution of harm among injection drug-using populations. Given that women are disproportionately represented among those who require help injecting (Evans et al., 2003; Lloyd-Smith et al., 2010; Wood et al., 2003), researchers have largely concentrated on how assisted injection practices are shaped by gendered power relations within intimate partnerships and drug scene milieus. For example, Bourgois and colleagues (2004) found that assisted injection experiences among young women entering the drug scene in San Francisco?s Haight-Ashbury neighbourhood were shaped by everyday violence?that is, normalized violence within the drug scene that is rendered invisible due to its pervasiveness (Bourgois & Schonberg, 2009; Scheper-Hughes, 1992). Older male injectors competed with one another to control these young women, notably by initiating them to injection drug use. Male injectors then assumed control over the resources that the woman generated (typically via street-based sex work) and the injection process, often forbidding women from self-injecting or being injected by anyone else under the threat of physical violence (Bourgois et al.,  98 2004). Accordingly, these women were especially vulnerable to HCV and HIV given that the prevailing cultural logics of these partnerships held that the men injected themselves first before injecting their female partners with the same syringe (Bourgois et al., 2004). Studies undertaken in the United Kingdom (Tompkins, Sheard, Wright, Jones, & Howes, 2006; Wright, Tompkins, & Sheard, 2007), Canada (Fairbairn et al., 2010; Shannon et al., 2008b), and elsewhere in the United States (Epele, 2001) have documented similar gender dynamics surrounding assisted injection practices. To date, few interventions have been developed to reduce risks among drug users who require help injecting. In many regards, existing legal frameworks constitute a barrier to the development of interventions for this population. In Canada, legal experts have noted that provisions in the Canadian Criminal Code may expose individuals administering injections to criminal liability (Pearshouse, Elliott, & Canadian HIV/AIDS Legal Network, 2007) and it is likely that many other jurisdictions impose similar liabilities. Specifically, those administering injections may face several charges, including: (i) possession of a controlled substance (i.e., for possessing the drug prior to the injection); (ii) administering a noxious substance with the potential to cause harm (i.e., administering the injection); and, (iii) assault, manslaughter, or murder in the event of injury or death (Pearshouse et al., 2007).   Accordingly, existing interventions for individuals who require help injecting are primarily oriented toward teaching them to self-inject (Fast et al., 2008; Small et al., 2012; Wood et al., 2005; Wood et al., 2008). These interventions have primarily encouraged individual-level changes in risk behaviours by promoting messages designed to facilitate improved venous access during the injection process, such as ?tie off to find a vein?.  Some safer injecting education campaigns have included in situ demonstrations of injecting techniques (i.e., showing how to inject during the injection process but stopping short of administering the injection) and have been  99 shown to increase the capacity to self-inject (Fast et al., 2008; Small et al., 2012; Wood et al., 2005; Wood et al., 2008). However, such individually-focused safer injecting education programs cannot always overcome barriers to self-injecting, underscoring the need for safer environment interventions responsive to these barriers. Vancouver, Canada has a longstanding injection drug use epidemic, which is heavily concentrated in the city?s Downtown Eastside neighbourhood. This approximately ten-block neighbourhood has been characterized in media and public discourses as a metonym for urban disorder (Woolford, 2001) and is the home to one of North America?s largest open drug scenes (Strathdee et al., 1997; Wood, Spittal et al., 2004; Wood & Kerr, 2006). Approximately 5,000 IDU live in this neighbourhood (Wood & Kerr, 2006) and it is estimated that roughly 40% of this population sometimes requires help injecting (O'Connell et al., 2005). Assisted injections are commonly administered in outdoor drug scene venues by ?doctors? (i.e., individuals who administer injections), typically in exchange for money or drugs (Fairbairn et al., 2006)). In 2003, North America?s only sanctioned supervised injection facility (SIF) opened in the Downtown Eastside in response to overlapping HIV, HCV, and overdose epidemics among the local injection drug-using population (Wood et al., 2004). While this safer environment intervention has been shown to reduce an array of harms, notably HIV risk behaviours (Kerr, Tyndall, Li, Montaner, & Wood, 2005; Wood et al., 2006) and overdose deaths (Marshall et al., 2011; Milloy, Kerr, Tyndall et al., 2008), it operates under an exemption to the Canadian Controlled Drugs and Substances Act that imposes operating regulations stipulating that clients must self-inject (Small et al., 2011). Accordingly, this regulation is situated within the broader legal interpretation of peer injecting, and has been cited as a significant barrier to safer injecting for this population (Fairbairn et al., 2010; Small et al., 2011; Small et al., 2011; Wood et al., 2006).  100 In recognition of the continued harm experienced by people who require help injecting, the Vancouver Area Network of Drug Users (VANDU), a drug user-led organization in the Downtown Eastside made up of more than 1000 current and former drug users, has undertaken efforts to facilitate safer injecting among this population. Over the past decade, this organization has launched several harm reduction programs with the goal of driving changes in drug and health policy (Kerr, Oleson, Tyndall, Montaner, & Wood, 2005; Small et al., 2012; Wood et al., 2003). From 2005 to 2009, the organization operated a pilot outreach initiative, the Injection Support Team, through which trained peer volunteers patrolled the Downtown Eastside and provided education, support, and, in some cases, assisted injections to people who require help injecting (Small et al., 2012). In this regard, the organization and peer volunteers considered the potential criminal liabilities of administering assisted injections against the harms associated with not providing this service (e.g., HIV and HCV transmission, violence, etc.), and determined that this action was needed to alleviate social suffering. After the cancellation of this program due to a lack of funding, VANDU opened an ?unsanctioned? supervised drug consumption room (DCR) that accommodated people who require help injecting (services have since been expanded to accommodate anyone who injects drugs). Assisted injections are administered by peer volunteers (i.e., experienced injectors who have completed training in CPR and overdose response) and in accordance with a strict harm reduction policy. This policy prohibits the sharing of drugs and injection paraphernalia (e.g., cookers, cottons, and syringes) and mandates peer volunteers to adopt universal precautions (e.g., wear latex gloves, disinfect the injection site, and discard syringes in sharps containers). It is recommended that, in the event that the person has recently abstained from using or drugs are from a new or unfamiliar source, peer volunteers inject them with a  101 smaller dosage of drugs. In addition, peer volunteers are prohibited from receiving compensation for providing assistance injecting. While individuals may receive assisted injections at supervised injection facilities in Geneva (peer administered) and Barcelona (nurse administered) (Solai, Dubois-Arber, Benninghoff, & Benaroyo, 2006), the impact of providing assisted injections within a supervised drug consumption facility has yet to be studied. Given the prevalence of assisted injection practices in Vancouver and elsewhere, and the fact that this population is disproportionately vulnerable to harm, there is an urgent need to identify strategies that have the potential to mitigate these harms (Kerr et al., 2005). We undertook this study to explore how people who require help injecting experience assisted injection support within this unsanctioned DCR, with an emphasis on how these assisted injections differed from those received within the street-based drug scene. In this regard, we were concerned with how this safer environment intervention reshapes the social, structural, and spatial contexts of assisted injection practices, and thus how it affects experiences of structural and everyday violence. Finally, we sought to situate this intervention within the larger context of the local drug scene, while linking our micro-level observations to meso-and macro-level policy and practice recommendations. 4.2 Methods This study is based upon ethnographic fieldwork conducted at VANDU from September to December 2011. Members of our research team have collaborated with VANDU over the course of the past decade (Kerr et al., 2006; Small et al., 2012). We maintained close communication with the organization's Board of Directors over the course of this project, although the study was conducted in an arm?s length manner and participants were assured that their participation was confidential. We obtained  102 approval from the Providence Healthcare/University of British Columbia research ethics board prior to commencing this research. The lead author (RM) conducted more than 50 hours of observational work at VANDU to document the operation of the unsanctioned SIF, including the observation of assisted injections as well as 23 formal interviews and numerous informal interviews over the course of this study. Because community drug use patterns vary over the course of the month, typically intensifying in the days following the disbursement of social assistance payments (Riddell & Riddell, 2006; Small et al., 2011), observation sessions were conducted on varying days of the month. Observation sessions lasted two to three hours in length and brief fieldnotes were recorded in a research log during the course of observation sessions and later elaborated. Informal interviews were conducted with people at VANDU during the course of participant-observation and notes regarding these conversations were likewise recorded in a research log. Verbal consent was obtained prior to informal interviews using an approved consent script.  Formal, semi-structured interviews were undertaken with VANDU members by two interviewers (RM & WS). We aimed to recruit participants with varying levels of use of and exposure to VANDU?s supervised drug consumption services, including peer volunteers. In recognition of the disproportionate drug and health harms experienced by women in the local drug scene, we aimed to oversample women relative to their representation among the VANDU membership by ensuring that approximately half of semi-structured interview participants were women. Interview participants were initially recruited through referral via a VANDU staff member so as to identify individuals who had long-term experience using at the unsanctioned SIF, with the remaining participants recruited through the course of observational activities. Most interviews were conducted at a research office located less than a  103 block away from VANDU, while the remaining interviews were conducted in private spaces at VANDU. All participants provided informed consent prior to their interview and received a $20 CDN honorarium for participating in semi-structured interviews.  We used an interview topic guide to facilitate discussion regarding the social, structural, and spatial factors that shaped assisted injections at this supervised DCR. This interview guide addressed a range of topics, including but not limited to: a) factors that shaped assisted injection practices within the local drug scene; b) how the unsanctioned DCR shaped assisted injection practices, particularly in comparison to other injection settings; and, c) the social context of assisted injections performed within this unsanctioned DCR. Additional lines of inquiry were informed by participant-observation and informal interviews with VANDU members. Importantly, observation of and informal interviews with many interview participants were conducted prior to their semi-structured interview and helped to facilitate discussion of specific factors that shaped their drug use practices. Interviews were audio recorded and ranged from 25 to 75 minutes, although the majority were approximately 45 minutes in length. Interviews were transcribed verbatim and reviewed for accuracy.  Our analysis focused on how providing help injecting in a regulated environment and in accordance with harm reduction practices shaped drug and health harms by exploring the contrast between assisted injections administered at VANDU and those in other drug scene venues. The overall goal was to situate this intervention within the larger context of the local drug scene, with an emphasis on how restructuring the social, structural, and spatial contexts of assisted injection practices affects everyday violence and structural vulnerability. We began analysis while conducting fieldwork, with team members meeting regularly to discuss data  104 collection and emergent themes. We developed a preliminary coding framework by drawing on our discussions and extracting a priori categories from the interview topic guide and fieldnotes. We imported data into NVivo qualitative analysis software (QSR International, 2008) to facilitate data management and analysis. Data were analyzed thematically using an inductive and iterative process, and we revised the coding framework during subsequent team meetings. We also drew upon the Risk Environment framework and concepts of everyday violence and structural vulnerability when interpreting our findings to advance beyond thematic descriptions. We presented preliminary findings to the VANDU Board of Directors to obtain feedback and enhance our study?s interpretive validity. 4.3 Results We conducted semi-structured interviews with 23 participants, including 11 women and 12 men. Participants were an average of 40 years of age (range 27-59 years), with 35% self-identifying as a member of a visible minority (i.e. Aboriginal, African-Canadian, or Indo-Canadian). 17 participants reported that they had injected drugs within the past thirty days, with the most frequently injected drugs being heroin (12), hydromorphone (8), and cocaine (6). 15 of these participants (11 women, 4 men) reported that they regularly required help injecting, including 8 who always required help injecting (6 women, 2 men). The remaining 6 participants who had not injected drugs in the previous 30 days had a history of injection drug use. 8 participants (3 women, 5 men) worked as peer volunteers at VANDU and regularly provided manual assistance injecting. Peer volunteers quoted in this paper are identified as such, while all other participants quoted are service recipients. We did not collect demographic information on people observed or informally interviewed, although, with the exception of the larger proportion of women, we believe that our  105 interview sample corresponds to the demographics of those observed using the unsanctioned SIF. 4.3.1 ?You?re probably excluding 25 percent of the population? ? Social and Structural Barriers to Safer Injecting Participant accounts highlighted how the legal framework governing the operations of the sanctioned SIF, which prohibits assisted injections due to the potential for criminal or civil liabilities (Pearshouse et al., 2007), served as a structural-environmental barrier that constrained access to that facility and produced inequities in access to harm reduction services. We found that highly vulnerable drug users, and in particular women and people with disabilities, were disproportionately represented among those who required help injecting. A primary feature of participant narratives was that barriers to self-injecting were embodied and intersubjective. Many participants reported that they were unable to self-inject due to poor venous access (e.g., ?faint?, ?shot? or ?shitty? veins) or physical impairments (e.g., being ?shaky? or ?paralysed?), which they attributed to their gender, disability, and long-term injection drug use. I have to use this one [motions to vein in left arm] but because I?m left handed it?s very hard for me. I take this one drug [for Parkinson?s disease] to try to steady [myself] cause I?m shaking so much. [Participant #9, Male, Caucasian] My veins are really shitty, okay, from years of using.  Like, I used in the eighties and it was heroin and the proper cocaine.  I used to shoot up right and then, later, it was just that my veins are so shitty. [Participant #14, Female, Aboriginal]  Several women reported that they were primarily injected by 'boyfriends' (i.e., intimate partners who controlled the money and drugs that they generated through sex work). It was evident that, as noted elsewhere (Bourgois et al., 2004; Epele, 2002), these assisted injection practices were shaped by gender and power relations that  106 subordinated women, restricted agency, and produced harm. These women stated that they did not know how to self-inject, were unable to, or liked feeling ?close? to their ?boyfriends?, although their controlling ?boyfriends? ultimately determined when, how, and with whom they injected. One of these women, matter-of-factly, described how injecting at the sanctioned SIF was not an option due to this policy:  If you can?t inject yourself, you can?t use [at Insite]. You have to inject yourself and I can?t inject myself because I have? my veins are very faint. I need my boyfriend [to inject me]. [Participant #4, Female, Caucasian] Formal and informal interviews with this woman?s ?boyfriend? emphasized how he controlled the injection process and restricted her agency, underscoring how rules prohibiting assisted injections at the sanctioned SIF unintentionally reinforce the subordination of women within the local drug scene. Me and my wife, we stick together. We get high together and Insite don?t allow that. I?m the only one who shoots my wife up. She can?t shoot herself and she won?t let no one else shoot her up. Actually, I won?t either because this is our little thing...She brings in the money and I take care of keeping the drugs. [Participant #18, Male, Caucasian] Many participants expressed that they were ?angry? or ?upset? that this policy excluded people who cannot self-inject. Several of these participants characterized this policy as discriminatory. These participant accounts illustrate how the legal framework governing the sanctioned SIF inscribed a neoliberal subjectivity on that facility by requiring that clients be autonomous, independent, drug users capable of self-injecting (Moore & Fraser, 2006). Given that the resulting operating procedures assumed such a neoliberal drug-using subject, it was felt that this rule overlooked the abovementioned physical and intersubjective factors that prevented self-injecting. Accordingly, many participant accounts emphasized those who were denied access  107 to this facility due to their subject position. For example, one participant with paralysis on his left side explained:  They won?t assist me and I told them about that. I said, ?You?re probably excluding 25 percent of the [injection drug-using] population here with that rule.? ?Oh, I?ll assist you. We?ll show you how to do it.? ?Well, what about a blind person? How do you assist them?? [Participant #8, Male, Caucasian] 4.3.2 ?God, why can?t you just do this for me?? ? Limits of Safer Injecting Education Approximately half of our participants reported at least one attempt to self-inject at the sanctioned SIF in an effort to exercise greater control over the injection process or ?get off the street?, especially those participants who did not have a reliable ?doctor? or were homeless or marginally housed. Nurses at that facility provided safer injecting education, including, as one participant described, ?pointing the needle on the vein? (i.e., aligning the syringe with a vein so that an individual only has to register the vein and depress the plunger) in an effort to facilitate self-injecting. However, participants articulated how the effectiveness of individually-focused education was constrained by physical barriers to self-injecting, such as disabilities or active opiate withdrawal. Participants variously described unsuccessful attempts to self-inject at the sanctioned SIF as ?frustrating? and ?annoying?. One participant explained: When you?re sick and you have to fiddle around, you?re not getting it [the vein]. You?re frustrated, so then it?s making it harder. I?m getting the nurse, you know, kind of?frustrated. Frustrated both of us because I can?t get it and I?m like, ?God, why can?t you just do this for me?? [Participant #16, Female, Caucasian] These unsuccessful attempts to self-inject at this facility led participants to leave in search of a ?doctor? elsewhere or to generate income to replace drugs that had coagulated and could no longer be injected. For example:  108 If I?m really dopesick [experiencing opiate withdrawal] and I can?t hit myself, I need the help or I can?t get better. I?ll sit there [at the sanctioned SIF] and cry for hours and hours?I end up throwing out my dope and having to go back to work [i.e., sex work]. [Participant #20, Female, Caucasian] 4.3.3 ?In the alleyways there?s treacherous people? ? The Everyday Violence of Assisted Injection Practices The vast majority of participants described experiences of being injected by ?doctors? in street and off-street settings when attempts to self-inject failed. Some participants reported that they had an established relationship with a ?doctor?, while other participants reported that they would ask ?a friend? or ?somebody that they don?t know? to inject them. In either case, participants reported that they were at the mercy of ?doctors?, particularly when ?dopesickness? (i.e., opiate withdrawal) increased their urgency to inject so as to alleviate withdrawal symptoms and thus reduced their capacity to assess risks. Our analysis of participant accounts revealed an overarching narrative of everyday violence that underscored how assisted injection practices were shaped by intersecting social and structural factors that increased vulnerability to violence, exploitation, and infectious diseases. Three key themes emerged from our analysis of these accounts.  First, requests for payment (i.e., money or drugs) by ?doctors? exploited the desperation of participants, especially those experiencing ?dopesickness?. The latter were especially vulnerable given the urgency to alleviate the extreme physical discomfort associated with opiate withdrawal. Given the precariousness of work opportunities (most participants generated income through exchange of sex for money or drugs to sustain their drug habit and low-level drug dealing), this was an ongoing source of anxiety and led some participants to take additional risks to generate the necessary income (e.g., less control over the conditions of sexual transactions due to the immediate need to alleviate withdrawal symptoms and  109 sustain drug habit). One participant described the unequal power relations between ?doctors? and injectees: [Providing] part of your drugs or you have to pay them...If I have it, I don?t care but, if I don?t, then obviously it?s a little bit upsetting because they won?t do it without it?The guy just wanted me to give him five bucks and I didn?t have it so then they wouldn?t do it. [Participant #7, Female, Caucasian] Second, participants described how receiving an assisted injection within the local drug scene, as one participant explained, ?can be life and death?. Participants variously described how they had been ?grinded? (i.e., coerced for drugs), ?bunked? (i.e., robbed), ?beaten? and ?raped? when seeking assistance injecting, particularly when those encounters took place in alleyways or other marginal spaces. It was evident within participant accounts that women were especially vulnerable to violence because of overriding social norms (e.g., gendered power relations) that view women?s position in street-based drug markets as a means to generate resources (i.e., via sex work) but otherwise subject them to high levels of interpersonal violence and exploitation. Participants frequently described the violence directed toward women: One member of ours was blind and her husband ended up in jail. He used to always fix [inject] her.  She was getting beat up, you know, drugs taken off of her? She needed someone to help [her inject] and in the alleyways there?s treacherous people. [Participant #13, Female, Caucasian, Peer Volunteer] Finally, participant narratives demonstrated how assisted injection practices within the local drug scene occurred within social and environmental contexts that increased vulnerability to infectious diseases (e.g., receptive syringe sharing, injecting in unhygienic conditions, etc.). In many cases, participants did not carry harm reduction paraphernalia and relied on ?doctors? to provide these materials, thereby increasing the likelihood that they would be injected with a previously used syringe. Several participants also described how ?doctors? would ?switch rigs? when  110 administering an injection (i.e., replacing syringes with potentially used ones with lesser amounts of drugs, drugs of unknown purity, or other substances, such as water).   They would go and ask somebody [to inject them on the street]. That person would either outright rip them off or switch their rigs on them and they would end up being infected [with HIV or HCV]. [Participant #19, Male, African-Canadian, Peer Volunteer] Several participants reported that they were injected in unsanitary conditions, such as alleyways or behind dumpsters, and that ?doctors? did not take the precautions necessary to minimize the risk of contracting an injection-related infection (e.g., clean the injection site with alcohol prior to administering the injection). 4.3.4 ?It?s safer for people? ? Establishing Safer Injecting Routines Our findings illustrate how, by removing structural-environmental barriers to constrain access to the local SIF (i.e., rules prohibiting assisted injections), VANDU mediated access to supervised injection services for people who require help injecting and, in turn, was critical in establishing safer injecting routines. Several participants, including some who had previously received assistance from the Injection Support Team, had regularly received help injecting since this service was launched and had integrated it into their regular injecting routines. These participants arrived at VANDU at regular intervals to receive the injections necessary to ward off dopesickness. During observation sessions, many people were observed visiting this facility for the first time. Although VANDU did not openly publicize that they were providing these services, information regarding this facility circulated within drug user peer networks.  The majority of participants described how it was ?easy? or ?convenient? to receive assistance injecting at VANDU because the peer volunteers were trained and readily available. Someone wishing to receive ?an assist? generally checked in at the  111 front desk upon entering the facility and, once a space in the injection room was available (up to four people are permitted in the room at a time), would proceed to the room along with a peer volunteer. Some participants reported that they continued to receive assistance injecting in other settings because of situational factors (i.e., proximity to where drugs were purchased, need to alleviate dopesickness, etc.) but VANDU was generally identified as a ?preferred? injection setting.  Participants reported that they were able to exercise increased control over resources and the injection process because peer volunteers were available to help them inject. In this regard, VANDU reshaped social relationships characterized by unequal power relations by decreasing dependence upon ?boyfriends? and ?doctors?. For example, several women who were typically injected by their ?boyfriends? were observed receiving assistance injecting from peer volunteers, which increased their individual agency and control of resources and the injection process. 4.3.5 ?People knew they could come here to get help? ? A Legitimate Place for People who Require Help Injecting  Our findings highlight how, beyond fostering safer injecting routines, VANDU served as a legitimate place for a population that was so often out of place. A prominent feature within participant narratives was that macro-social/structural (i.e., poverty and homelessness, drug laws, etc.) and meso-social/structural factors (i.e., policing practices, rules governing the sanctioned SIF and emergency housing, etc.) restricted their access to safe indoor and outdoor environments. Especially among those who were homeless or marginally housed, participants lacked access to places that they could occupy without the risk of harassment or arrest for drug use. In contrast, VANDU served as an alternate environment that participants could occupy because it not only accommodated their diverse subject positions (e.g., as drug users, people who require assistance injecting, etc.), but also recognized them as members.  112 Accordingly, participant variously emphasized that VANDU was a place ?for drug users? and a place where they could turn to ?for help?.  So many people were doing injections in the alley in our back parking lot and in front of VANDU...A lot of times, it was people that were getting injected by people. It?s not right... Insite, they can?t go there...People knew that they could come here to get help. [Participant #23, Female, Caucasian, Peer Volunteer] In addition, participants articulated how having access to an indoor off-street environment enabled them to escape the violence and exploitation that shaped the local drug scene, and in particular assisted injection practices. While assisted injection practices within the local drug scene were characterized by everyday violence, this intervention fostered a safer environment that mitigated these risks. Our findings demonstrate how, in spite of the fact that interpersonal conflicts sometimes occurred (several minor arguments were observed), prevailing social norms in this peer-run environment limited these disruptions, with peer volunteers frequently intervening to resolve disagreements. Furthermore, our observations indicate that acts of violence and exploitation associated with assisted injections within the local drug scene (e.g., ?grinding?, ?bunking?, etc.) did not occur within the unsanctioned SIF because injections were performed by peer volunteers and in accordance with the organization?s harm reduction policy. Accordingly, participants commonly reported that they ?felt safe? at VANDU because, in the words of one participant, members ?take care of their fellow man?.  They come here because it?s safe.  They know they?re not gonna be ripped off.  They know they?re not gonna be asked for money.  [Participant #13, Female, Caucasian, Peer Volunteer] ?It?s safer for them to come here and have somebody here [inject them] than to go in the alley or find somebody in the alley that could switch a rig and inject them with something else. [Participant #12, Male, Aboriginal]  113 4.3.6 ?Keepin? the diseases from being spread? ? Enabling Harm Reduction Practices Our data highlight how the interplay between organizational policy (i.e., harm reduction policy), social relationships (i.e., peer volunteer support), and physical environment (i.e., ?legitimate space? to be injected) created a micro-injecting environment conducive to harm reduction practices. Of particular significance is that the harm reduction policy implemented by the organization, as well as the role of peer volunteers in reinforcing this policy, prevented VANDU from becoming a ?shooting gallery? (i.e., venues where IDU gather to inject, in many cases with the requirement that they pay the ?gallery operator? in money or drugs to gain entrance) (Ouellet et al., 1991). On the contrary, participant accounts, as well as our observations, illustrated how assisted injections were administered in accordance with the organization?s harm reduction policy.  I?ll wear gloves because I know they bleed a lot and they?re hard to hit? I might use two or three rigs `cause I?ll only stick a needle in somebody twice.  If I miss on two pokes, I?ll put it in the new rig. [Interview #15, Male, Caucasian, Peer Volunteer] Notably, participants stated that these harm reduction practices were critical to limiting injection-related infections and the spread of infectious diseases. For example: You?re at someone's mercy when you?re asking them to help fix you. A lot of people contracted diseases that way.  As far as I know, this is the one and only place where you can get assistance and not have to worry about paying for it or getting your rigs switched...[VANDU is] definitely keepin? the diseases from being spread. [Participant #5, Male, Caucasian, Peer Volunteer] However, in spite of these advances in minimizing health risks, participants continued to engage in unsafe injection practices outside of VANDU's operating  114 hours (the facility is opened from 10am to 8pm on weekdays and 4pm to 8pm on weekends). In these cases, participants either relied on ?doctors? in the street-based drug scene or attempted to self-inject. In both cases, participants were at an increased risk of violence, exploitation, or health complications. One participant described an injection event that ultimately led to an injection-related infection: Two nights ago...That time I cried [laughter]...I was just in a lot of pain and I was really sick. I couldn?t find anybody to help me anywhere and it was like eight thirty at night. I was just frustrated and upset and I just burst into tears. You know, I?m supposed to be a grown up but I wasn?t apparently that night...I ended up muscling [i.e., injecting directly into the muscle]. [Interview #11, Female, Caucasian] 4.3.7 ?I would?ve been dead? ? Overdose Prevention & Response Whereas assisted injections are associated with increased overdose within the local drug scene, no overdoses were observed during the course of our fieldwork and, according to staff and peer volunteers, only two overdoses (both non-fatal) have occurred since this supervised DCR was launched. Interestingly, and consistent with local discourses on supervised injection services, overdose prevention and response were identified as primary goals of providing assisted injections. Several participants offered that this service reduced the risk of overdose: It [receiving assistance injecting at VANDU] minimizes the overdose risk right away. You?re looking at probably, if not zero, very close to zero casualties. [Participant 11, Female, Caucasian] If we overdose, there?s help. There?s countless benefits [of receiving assistance injecting at VANDU]. [Participant #20, Female, Caucasian] Our findings indicate that this facility mitigated overdose risks and complications by intervening to reshape the local risk environment. Participant accounts, as well as our observations, underscored how assisted injections are social  115 processes that are negotiated between injector and injectee. Accordingly, and in keeping with the organization?s harm reduction policy, these social processes reinforced key overdose prevention strategies, such as ?halving your hit? and ?not using alone?. Whereas these overdose prevention strategies typically emphasize individual-level behaviour changes, participant accounts illustrate how, in the context of assisted injection practices, these strategies are relational and, in turn, may be supported by social-environmental interventions. For example, several participants reported that peer volunteers insisted that individuals ?halve their hit? (i.e., be injected with approximately half of the typical amount of drugs) to minimize ?problems? (i.e., overdose risks).  A person wanted to shoot [be injected] and [the peer volunteer] was just like, ?No, I don?t think so. That?s too much. I?m not going to assist you, if that?s what you?re going to do. If you want to cut it in half, I?d be more than happy to help you. But I?m not going to ? that?s almost like a death sentence?You might as well be playing Russian roulette.? I think the person, because they wanted the shot so badly, agreed. [Participant #8, Male, Caucasian]  Furthermore, although overdoses were rare at VANDU, peer volunteers were trained to respond by contacting emergency medical personnel and, if necessary, administer naloxone. One participant described how this increased safety by contrasting overdose responses at VANDU with those in other injecting environments: I?ve seen this happen so many times that somebody would go down [overdose]?Everyone?s pretending it?s a seizure. I?ve seen other people go through their pocket rather than do CPR on them. [The unsanctioned SIF] cleans up all that. [Participant #7, Female, Indo-Canadian] We interviewed one woman who had experienced an overdose at VANDU, who reported that peer volunteers saved her from certain death:   116 They were on it. They guy ran and he got me help right away?I just remember looking up and having them all standing around me?[Had I not been at VANDU] I would?ve been dead?Hundred percent I would?ve died. [Participant #20, Female, Caucasian] 4.4 Discussion In summary, our findings underscore how people who require assistance injecting, and especially women and people with disabilities, are vulnerable to an array of health harms due to intersecting social and structural factors that constrain access to the sanctioned SIF. We found that, by providing assistance injecting in a regulated environment and in accordance with a harm reduction policy, this peer-run ?unsanctioned? supervised drug consumption facility mitigated these barriers, and in turn was functioning to establish safer injecting routines and provide an escape from everyday violence. Furthermore, our findings emphasize how VANDU disrupted social practices that produce HIV and HCV risks, while reinforcing overdose prevention messages.  Interventions targeting people who require help injecting have traditionally encouraged individual changes in risk behaviours, while overlooking social and structural forces that produce risk behaviours (Rhodes, 2002; Rhodes et al., 2005; Rhodes, 2009; Strathdee et al., 2010). In this regard, traditional interventions may be characterized as a manifestation of neoliberal governmentality, in that they emphasize individual responsibility while overlooking factors that constrain individual agency and thus the ability of individuals to adopt harm reduction measures (Moore, 2004). Consistent with the Risk Environment framework (Rhodes, 2009), we found that rules prohibiting assisted injections were a structural-environmental barrier that constrained access to the sanctioned SIF. Our study builds upon the literature demonstrating that social, structural, and environmental factors restrict individual agency and limit the effectiveness of individually-focused harm  117 reduction messages and programs (Moore, 2004; Moore & Fraser, 2006; Shannon et al., 2008b; Small et al., 2007). Importantly, while this rule prohibiting assisted injections has previously been identified as a structural-environmental barrier to the sanctioned SIF (Fairbairn et al., 2010; Kerr et al., 2003; Small et al., 2011), our study more closely examined how this is intertwined with particular subject positions. Our study suggests supervised injection services promulgate neoliberal subjects (i.e., autonomous, responsible individuals capable of self-injecting) to the detriment of alternate drug-using subjects (i.e., people who require help injecting). Accordingly, the distribution of harm within the injection drug-using population is uneven because of ideological assumptions embedded in the legal frameworks that govern supervised injection services. We found that specific subpopulations (i.e., women and people with disabilities) were vulnerable as a result of intersubjective injection practices (i.e., being injecting by a ?boyfriend?) or embodied subjectivities (i.e., having poor venous access or difficulty injecting due to disability). While acknowledging the potential of harm reduction programs to reinforce governmentality by regulating and controlling the bodies of drug users (Bourgois, 2000; Fischer, Turnbull, Poland, & Haydon, 2004; McLean, 2011), greater attention is needed to how harm reduction programs emphasize particular bodies at the expense of others. Furthermore, given that drug use is shaped by social processes, it is critical to also consider how these affect access to harm reduction services.  In this context, our findings indicate that changes to supervised drug consumption facilities are urgently needed to accommodate a wider range of drug-using subjects, and thereby minimize structural vulnerabilities to drug-related harm. Specifically, there is a need for changes to the existing legal frameworks (e.g., the Canadian Criminal Code, and parameters of the CDSA exemption) and regulations governing the operations of supervised drug consumption facilities so that they are  118 able to accommodate assisted injections. It may be argued that the current prohibition of assisted injections undermines the right to security of person for those who cannot self-inject. In Canada, while provisions within the criminal code currently prohibit assisted injections and potentially lead to criminal liabilities (Pearshouse et al., 2007), reforms to these provisions may be necessary to comply with national human rights law (i.e., Charter of Rights and Freedoms), which upholds the right to security of person. Given that the Supreme Court of Canada has upheld the right of the sanctioned SIF to operate on the basis that its closure would contravene this right to security of person (Supreme Court of Canada, 2011), it would appear that assuring this right is paramount. In addition, our findings demonstrate that drug user-led organizations can play a central role in the delivery of harm reduction programs and may, in fact, be highly responsive to emerging trends within the drug user community. Over the past decade, VANDU has launched various harm reduction programs in an effort to increase harm reduction coverage (Boyd, Osborn, & MacPherson, 2009; Kerr et al., 2005; Wood et al., 2003), particularly for those who encounter structural and programmatic barriers to accessing mainstream services. Several ?unsanctioned? programs drove changes in public health policy that may not have otherwise been possible, including the opening of the sanctioned SIF (Boyd et al., 2009; Small, Palepu, & Tyndall, 2006; Wood et al., 2003) and expansion of syringe exchange programs (Kerr et al., 2010; Wood et al., 2003). Although several programs were subsequently discontinued or reorganized (with the local health authority in some cases assuming greater control), our findings suggest that some IDU may be more receptive to peer-based service delivery models and the wider adoption of peer-based approaches should be considered. One possible explanation is that, in contrast to harm reduction programs operating under ?provider-client? models, whose power dynamics  119 potentially attribute non-adherence to harm reduction practices as an individual failure (Moore, 2009), people who require help injecting may more readily respond to peer volunteers who share similar life experiences (Mackenzie et al., 2012; Sherman et al., 2009). Consistent with previous research (Fairbairn et al., 2008), we found that this supervised drug consumption facility increased safety compared to street-based drug use settings, and thereby allowed this population to reduce exposure to everyday violence. Researchers have increasingly noted that, due to intersection of pervasive poverty and drug law enforcement, drug-using populations have been left without spaces that they can legitimately occupy (Beckett & Herbert, 2010; Cooper et al., 2005; Mitchell, 2003). Within this context, fixed site harm reduction initiatives, such as supervised drug consumption facilities and syringe exchange programs, have been variously identified as ?refuges? or ?safe havens? for injection drug-using population (Fairbairn et al., 2008; MacNeil & Pauly, 2011; McLean, 2012; Parker et al., 2012). In particular, Fairbairn and colleagues (2008) have previously found that a supervised injection facility allows women to escape the male-dominated culture of the street-based drug scene, and thus minimize their risk of violence or exploitation when injecting. Our findings similarly emphasize how this supervised drug consumption facility served as a critical environmental support that, in many cases, created stability for participants. An increased appreciation of the importance of this micro-environment in minimizing a range of harms, and not only unsafe injecting practices, underscores the importance of providing broader environmental support alongside supervised drug consumption services, including drop-in shelter services. Finally, our findings demonstrate that drug-related risks were minimized when assisted injections were performed by trained peer volunteers and in accordance with a harm reduction policy. In this regard, our findings indicate that  120 these risks are less produced by the assisted injections per se than by the social, structural, and environmental contexts that shape how they are administered. Whereas power imbalances shape assisted injections in drug scene venues, which in particular place women at an increased risk of violence and receptive syringe-sharing (Bourgois et al., 2004; Epele, 2001; Tompkins et al., 2006; Wright et al., 2007), VANDU provided ready access to safer assisted injections and thus decreased dependence on ?boyfriends? and ?doctors?, while also facilitating the establishment of safer injecting routines. Critical to the success of this intervention was the fostering of positive relationships between injectors and injectees that reinforced harm reduction practices. For example, peer volunteers reinforced overdose prevention messages by negotiating the amount of drugs injected, and thereby minimized overdose risks. Social relations have previously been identified as a potential site for intervention to promote harm reduction (Rhodes et al., 2006) and yet few peer-based harm reduction interventions have been evaluated. Following Rhodes and colleagues (2006), our findings indicate that intervening within existing social relations to encourage collective ?social responsibility? is effective in mitigating drug-related harms and future efforts would be wise to consider doing so through the adoption of peer-based approaches. This study has several limitations that should be taken into consideration when interpreting its findings. First, our findings may not be representative of the experiences of all those who require help injecting within the local drug scene, especially those who do not access this facility, and might therefore overlook important factors that shape access to this supervised DCR. Furthermore, people who use drugs may give socially desirable responses during research interviews; however, we believe that our observation sessions reduced the impact of this limitation. Finally, it is important to note that, because of the unique combination of social, structural,  121 and spatial factors that shape injection drug use in any particular locale, our findings might not be transferable to supervised drug consumption facilities in all settings.  In spite of these limitations, we found that this ?unsanctioned? supervised drug consumption facility was critical to reducing drug-related harm among people who require help injecting, and thus overcame barriers that this population faces to safer injecting. Notwithstanding the continued need to expand supervised drug consumption facilities, particularly in those areas with high levels of injection drug use, our findings indicate that the operating regulations of these facilities need to accommodate those who require assistance injecting. In this regard, individually-focused interventions alone are not enough to mitigate the harms associated with assisted injections and more comprehensive social, structural, and environmental supports that include the provision of assisted injections are urgently needed.    122 CHAPTER 5: HOSPITALS AS A ?RISK ENVIRONMENT? ? AN ETHNO-EPIDEMIOLOGICAL STUDY OF THE EXPERIENCES OF PEOPLE WHO INJECT DRUGS WHO HAVE BEEN DISCHARGED AGAINST MEDICAL ADVICE 5.1 Introduction Current estimates suggest that more than 15 million people worldwide regularly inject drugs (Mathers et al., 2008). The health sequelae of injection drug use can be severe, and include infectious disease acquisition and other direct complications of injecting (e.g., overdose). As a consequence, people who inject drugs (IDU) suffer from disproportionately high levels of HIV/AIDS (Mathers et al., 2008) and hepatitis C (HCV) (Aceijas & Rhodes, 2007) that, in combination with high rates of non-fatal overdose (Warner-Smith, Darke, & Day, 2002), injection-related infections (Binswanger et al., 2008; Cooper et al., 2007; Lloyd-Smith et al., 2008), and other co-morbidities common among this population, lead to frequent hospitalizations (Gebo, Diener-West, & Moore, 2003; Kerr et al., 2005; Palepu et al., 2001). Although national and regional population surveillance data on hospital admissions and discharges that take into account injection drug use are limited, evidence suggests that IDU are admitted to hospital significantly more often than the general population (Kerr et al., 2005).  There is mounting evidence that IDU are the population most likely to be discharged against medical advice (Anis et al., 2002; Choi, Kim, Qian, & Palepu, 2011; Jeremiah, O?Sullivan, & Stein, 1995; Yong et al., 2013). Discharges from hospital against medical advice among IDU lead to severe health complications, and this population is significantly more likely to be readmitted for the same condition and have longer eventual hospital stays than those who completed treatment (Anis et al., 2002; Choi et al., 2011; Glasgow, Vaughn-Sarrazin, & Kaboli, 2010; Hwang, Li, Gupta, Chien, & Martin, 2003). Furthermore, those discharged against medical advice are at  123 an increased risk of mortality (Choi et al., 2011; Yong et al., 2013), with one Canadian study finding that this population is approximately three times as likely to die in the year following their discharge (Choi et al., 2011).  Whereas epidemiological analyses of hospital admissions and discharge data have identified individual-level risk factors for departures against medical advice among IDU, including female gender, younger age, and Aboriginal ancestry (Anis et al., 2002; Chan et al., 2004), comparatively less attention has been paid to contextual forces linked to these discharges. Several studies have noted that IDU are most likely to be discharged against medical advice in the days immediately following the disbursement of social assistance payments (Anis et al., 2002; Riddell & Riddell, 2006), and that these may be mitigated to some degree by providing access to inpatient methadone maintenance treatment (Chan et al., 2004). However, the lack of attention to the potential role of intersecting social (e.g., stigmatization), structural (e.g., abstinence-only drug policies), and environmental (e.g., physical characteristics of hospitals) forces operating within hospital settings in shaping discharges against medical advice among IDU means that these explanations are incomplete. In addition, these individual-level explanations primarily attribute discharges against medical advice to ?active drug use? in a manner that risks locating responsibility for these outcomes solely with IDU. This overlooks social and structural-environmental characteristics of hospitals that potentially lead to discharges against medical advice, and absolves hospitals from the need to modify these environmental characteristics to promote equitable access to care. This research gap is striking given more than a decade of evidence demonstrating the need for increased attention to ?risk environments? - that is, the social and physical settings in which factors exogenous to the individual (i.e., social situations, structures, and places) interact to produce or reduce the harms associated  124 with injection drug use (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Rhodes, 2009). The emergence of the ?risk environment framework? has focused attention on the interplay between physical, social, economic, and policy factors operating across the micro-, meso-, and macro-environmental levels in any particular setting produce harm among drug-using populations (Rhodes, 2002; Rhodes, 2009). Concepts of structural vulnerability and everyday violence have further proven instructive in framing the suffering experienced by drug-using populations within diverse risk environments (Fairbairn, Small, Shannon, Wood, & Kerr, 2008; Sarang, Rhodes, Sheon, & Page, 2010; Shannon et al., 2008; Shannon et al., 2008). Structural vulnerability refers to how social arrangements embedded in the organization of society render particular populations disproportionately vulnerable to harm (Quesada, Hart, & Bourgois, 2011). Everyday violence refers to the normalization of suffering within any particular context due to the contextual forces that render it invisible (Scheper-Hughes, 1992). Together, these concepts give further focus to how the structural context of drug use (e.g., drug criminalization) produces vulnerability to an array of drug- and health-related harms, and reflect dominant power structures that normalize these harms as the natural consequences of drug use. Sorting out the complex contextual forces operating within the diverse risk environments of drug users is critical to understanding their role in shaping health outcomes - in this case, discharges against medical advice - and thus informing social-ecological interventions.  While qualitative research into the experiences of injection drug-using populations in hospital settings is limited, and has yet to systematically explore the experiences of those who have left prior to completing treatment, it has generated preliminary insights into the social forces operating within the hospital ?risk environment? (Berg, Arnsten, Sacajiu, & Karasz, 2009; Merrill, Rhodes, Deyo, Marlatt,  125 & Bradley, 2002; Neale, Tompkins, & Sheard, 2008). Notably, in an ethnographic study exploring patient-physician interactions in an American urban teaching hospital, Merrill and colleagues (2002) outlined how ?mutual mistrust? frames the hospital care of IDU. Whereas physicians attributed their difficulty in managing pain to the fear of being ?deceived? by ?drug-seeking? patients and the lack of clinical protocols for pain management among injection drug-using populations, IDU viewed physicians with suspicion and believed that their treatment was primarily shaped by discrimination (Merrill et al., 2002). Whether or not this, in combination with other contextual factors, plays a role in departures from hospital prior to completing treatment warrants further attention.  These issues are of considerable relevance in Vancouver, Canada, the site of a longstanding injection drug use epidemic. An estimated 15,000 IDU live in Vancouver, comprising approximately 3% of the city?s total population (McInnes et al., 2009). The vast majority of the city?s injection drug-using population will visit an emergency department each year (Fairbairn et al., 2011; Kerr et al., 2005), and approximately 17% of these visits result in hospitalization (Fairbairn et al., 2011; Palepu et al., 2001). In Vancouver, as elsewhere in Canada, IDU are covered by universal, publicly-funded health care insurance. However, while comprehensive harm reduction services, including a supervised injection facility, are integrated into the local public health system, hospitals in Vancouver and the surrounding area operate under abstinence-based drug use policies (Providence Health Care, N.D; Vancouver Coastal Health, 2008). IDU in this setting are frequently discharged from hospital against medical advice (Anis et al., 2002; Choi et al., 2011; Palepu et al., 2001), and in one urban teaching hospital account for more than half of such discharges (Choi et al., 2011).  We undertook this ethno-epidemiological study to explore how intersecting social, structural, and environmental forces shape the experiences of IDU in hospital  126 settings and contribute to discharges against medical advice. We were particularly concerned with the role of abstinence-based drug policies in hospital settings in framing the social and structural-environmental contexts of hospital care, pain management practices, and in-hospital drug use. Finally, we aimed to identify ways in which the hospital ?risk environment? could be modified to minimize the potential for adverse outcomes, including discharges against medical advice. 5.2 Methods This ethno-epidemiological study was undertaken in connection with two ongoing prospective cohort studies: the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS). These cohort studies include more than 2000 current and former drug users, and their methods have been described in detail elsewhere (Tyndall et al., 2003; Wood et al., 2008). Ethno-epidemiology seeks to uncover how social meanings and contexts influence patterns of drug and health harms by merging epidemiological and qualitative methods (Lopez et al., 2013; Wagner et al., 2012). Increased understanding of the contextual forces that shape patterns and distributions of harm?in this case, discharges from hospital against medical advice?is critical to informing the development of structural and environmental interventions to minimize harms (Rhodes et al., 2006). Between December 2011 and February 2013, we undertook qualitative interviews with thirty cohort participants who reported that they had been discharged from hospital against medical advice during follow-up surveys that are part of their participation in the aforementioned cohort studies. All study activities were approved by the Providence Healthcare/University of British Columbia Research Ethics Board.  127 5.2.1 Participant Recruitment Cohort participants were eligible for participating in this study if, during routine follow-up surveys completed in the past two years, they had answered ?yes? to the following question: ?In the past six months, did you leave hospital before your treatment was complete?? We chose this follow-up period to ensure an adequate pool of potential participants, while minimizing biases due to poor recall of events. We used recruitment quotas to ensure that the perspectives of women and people of Aboriginal ancestry were adequately represented in our sample. Eligible participants were identified through database queries of cohort data and contacted by cohort study personnel, who described the study and invited them to participate in an interview. Study personnel also recruited cohort participants who reported that they had been discharged against medical advice during follow-up surveys administered over the course of our study. 5.2.2 Data Collection All interviews were conducted by the lead author (RM) at the cohort study office. Prior to the interview, the lead author explained the study to participants, answered any questions, and obtained written informed consent. There were no refusals to participate and no dropouts during the interview process. Participants each received a $20 CAD honorarium upon completion of the interview. Interviews were facilitated through the use of an interview topic guide adapted from previous qualitative work on health care access among drug-using populations (Krusi, Small, Wood, & Kerr, 2009; Small, Wood, Lloyd-Smith, Tyndall, & Kerr, 2008), and revised to include questions and prompts specific to our study objectives. This interview topic guide aimed to facilitate discussion regarding how social, structural, and environmental forces shaped experiences in hospitals, including in-hospital drug use, and led to discharges against medical advice. Interviews were audio recorded and  128 averaged approximately 45 minutes in length. Interviews were transcribed verbatim and reviewed for accuracy by the lead author. 5.2.3. Data Analysis Data collection and analysis took place concurrently, and emerging themes informed lines of inquiry during subsequent qualitative interviews. We imported interview transcripts into NVivo (version 9) to facilitate data management and coding. Transcripts were coded thematically using an inductive and iterative process (Corbin, Strauss, & Strauss, 2008) and regular meetings were held to discuss emerging themes. Once the final themes were established, the lead author re-coded sections of the transcripts to enhance the reliability and validity of these categories. To advance beyond thematic description, we then drew upon the risk environment framework and concepts of structural vulnerability and everyday violence to interpret our themes and situate them within their social, structural, and environmental contexts. 5.3 Results A total of thirty individuals participated in in-depth interviews, including sixteen men, thirteen women, and one transgender individual. Participants were an average of 45 years of age (range 29-59 years). Seventeen participants reported Aboriginal ancestry, while the remaining participants self-identified as Caucasian (12) and African Canadian (1). Half of our participants (15) had been diagnosed with HIV, while twenty-two had been diagnosed with Hepatitis C. Five participants who had been diagnosed with HIV reported suboptimal HAART adherence prior to hospitalization, while another five reported that they were HAART-na?ve. Prior to their most recent hospitalization, participants reported that they lived in single room occupancy hotels (17), non-market housing (5), emergency shelters (3), or were unhoused (5). All participants had a history of injection drug use, and twenty-two reported that they currently injected drugs. All participants reported that they had  129 used drugs in the thirty days prior to their most recent hospitalization, with crack cocaine (22), heroin (18), powdered cocaine (12), and prescription opioids (7) reported as the most commonly used drugs. The most commonly reported reasons for hospitalization were injection-related infections (8), pneumonia (5), and traumatic injury (4). Nearly all of our participants (28) reported multiple hospitalizations within the past five years, with half (15) reporting four or more hospitalizations. 5.3.1 ?They felt maybe I was getting high? ? ?Drug-seeking? and Pain Management Our analysis of participant accounts underscored the role of social and structural forces in shaping pain management practices and, in turn, producing suffering that framed their overall experiences in hospital settings. All of our participants reported co-morbidities that, in combination with their presenting illness or injury, resulted in complex pain management needs. The vast majority of our participants (25) had a history of opiate dependence, and those who were injecting heroin or prescription opioids at the time of their hospitalization indicated that their pain management needs were compounded by ?dopesickness??that is, the extreme discomfort and pain accompanying opiate withdrawal. Participants described their level of pain as ?excruciating? and ?like being stuck with electric volts?, with those experiencing dopesickness adding that they felt ?nauseous? and like they were ?coming unglued?. The following excerpts highlight experiences of pain and opiate withdrawal, respectively, typical among our participants:  It was really, really bad at the beginning...I got shots of pain that were so severe I actually cried? I had to cry out more once or twice within two or three hours.  It was really, really excruciating. Every fifteen minutes or so, like, the pain was just unbelievable. [Participant #29, African-Canadian Male, 53 years old]  I was constantly tired, no energy.  Nauseous all the time, vomiting, couldn?t eat, and [had] the runs. My eyes were  130 leaking all the time.  My nose was leaking.  To me, that was all withdrawal symptoms. [Participant #13, Caucasian Female, 44 years old]  With very few exceptions, however, participants reported that their pain management needs were unmet. Participant accounts underscored how narcotics control (macro-structural force) intersected with stereotypes of ?drug-seeking addicts? (macro-social force) to frame pain management practices in hospital settings. Whereas these intersecting social-structural forces are situated within larger cultural discourses characterizing drug use as ?immoral?, ?irresponsible?, and ?pleasure-seeking?, participants positioned their ?dopesickness? as a legitimate medical concern and emphasized how opiate maintenance was necessary to ?get better? or ?get straight?. Furthermore, even among those experiencing opiate withdrawal, most participants viewed narcotics as necessary to alleviate the high levels of pain caused by their primary diagnoses (e.g., osteomyelitis, endocarditis, broken ribs). Our findings underscore how the perception that participants were simply ?drug-seeking? was critical in shaping the social-environmental context of hospital care, and, in turn, likely delegitimized the very real pain and suffering that they endured. Nearly all participants spoke of how they were routinely denied pain medication or given dosages that did not account for heightened tolerance. Some participants spoke of how physicians and nurses were dismissive of their concerns and characterized them, in the words of one participant, as ?just another junkie addict looking for free drugs?. This approach to pain management for drug-using populations was experienced as a form of everyday violence, in that the pain and suffering experienced by participants was normalized as a natural part of their care that was reproduced through the routine denial of pain medication. For example: I was in pain and I didn?t want to bitch about being in pain?The last time I went in there and I told them, ?Excuse me, I?m very sore and it?s taking forever. Could I please see somebody  131 or get something?? And, they said, ?We can?t give you anything until you see a doctor.? [?] Because I was there often with this problem [abscess in leg], they thought I was looking for pain pills. [Participant #11, Aboriginal Female, 51 years old]  They [nurses] were very combative with me. When I was done my surgery, it was very painful and I needed my morphine upped because it just wasn?t working...I can only guess and say that maybe they felt maybe I was getting high or something. I kept trying to tell them that it?s not enough...I had major surgery on my colon. I couldn?t even move...The nurses wouldn?t listen to me they?re.  I felt they didn?t believe me and they were a little combative in speaking with me.  [Participant #20, Aboriginal Male, 45 years old]  Furthermore, the minority of participants (6) who were administered methadone in hospital reported disruptions in their regular dosing schedules, including the dosage of methadone that they were administered. It is noteworthy that, while these participants acknowledged that hospital staff lacked experience in methadone maintenance treatment, they also expressed that their subsequent methadone withdrawal was a low priority among nurses and physicians.  I have to have methadone every day.  I?m on fifty milligrams and, if I don?t have it, I?m in bad shape.  I kept asking them, "I take it at five thirty every morning and I want it." [...] Well, they did it whenever they felt like it.  They don?t understand that methadone is keeping me functional. [...] I wanted to get the heck out of there. [Participant #24, Female, Caucasian]  5.3.2 ?Between a rock and a hard spot? ? The Need to Manage Pain and Withdrawal Within this social-structural context, most participants expressed that heroin and nonmedical prescription opioid use were the only avenues available to them to address pain and opiate withdrawal. It is important to note that, while a minority of participants attributed their continued drug use to the craving associated with cocaine  132 use, the vast majority indicated that drug use during the period of their hospitalization was primarily motivated by the need to manage pain and opiate withdrawal. Whereas some participants expressed that it was not ?normal? to inject heroin or prescription opioids while hospitalized, in that it contradicted the ?curative? nature of hospital care, they nonetheless emphasized the anticipated relief from pain and opiate withdrawal. In some cases, participants articulated how the pain and withdrawal symptoms that they experienced directly interfered with treatment, and that only after addressing these immediate needs would they be ?strong? enough to recover. As one participant explained: I had to get out of there while I could move because I was losing so much weight?When I begged and begged to get some help [i.e., prescription opioids], they couldn?t, weren?t gonna do anything and so I just said, "Fine, I?m leaving." [...] I was concerned [about the health consequences of leaving hospital]. You know, I got this other thing [opiate dependency] and it?s...it?s like you?re stuck between a rock and a hard spot. I mean, how can I even fight off the infection if I can?t stop puking and shitting? [Participant #15, Caucasian Female, 47 years old]  At its most extreme, one participant articulated how his transition to daily heroin injection was the consequence of inadequate pain management in hospital settings, and represented this as the only means to address the extreme pain associated with osteomyelitis. I started using heroin when I had that osteomyelitis. I was in so much pain and morphine wasn?t cutting it... [The reason why] I started using the heroin actually was to kill the pain. [...] The pain and the osteomyelitis...it was so crippling I felt, like, so stiff... If they [hospital staff] had given me the right dose, I probably wouldn?t even be using heroin...  [The morphine] wasn?t enough and they weren?t giving it into my I.V. They were shooting it into my muscle and that wasn?t killing my pain...The heroin I was using, I?d do right into my bloodstream  133 and it would kill the pain. [Participant #5, Aboriginal Male, 44 years old]  5.3.3 ?Like I was in jail? ? Surveillance, Regulation, and In-Hospital Drug Use Whereas the social-structural context of pain management practices in hospital settings perpetuated the need to inject drugs, participant accounts underscored how larger structural-environmental context of hospital settings was shaped by the enforcement of abstinence-only drug policies (macro-structural force). Among our participants, hospitals were characterized as ?jails? or ?prisons?, and hospital personnel viewed as playing the role of ?cop? in enforcing abstinence-only drug policies. Nearly all participants described how some nurses and security guards subjected them to surveillance and regulation by ?policing? their drug use. Many participants reported that some nurses closely monitored their behavior for outward signs that they were injecting drugs in hospital. Other participants reported that they were subjected to physical searches by security guards when suspected of possessing drugs. As one participant explained:  [Security guards] yell and scream at you?When there?s nobody around, [they say], ?You fucking junkie.? [?] A few times, I?ve been shaken down [searched] by [security guards] even though [I had] nothing to get high [i.e., had no drugs in her possession].  They search you, destroy your property, cause a scene, and make sure everybody there knows that you?re a drug addict. [...]They use their authority to pull power trips more or less.  It?s not right. [Participant #12, Aboriginal Female, 29 years old]  These forms of surveillance functioned to reinforce participants? marginal status as ?drug addicts?. Participants expressed dissatisfaction with these forms of surveillance and regulation, with one participant describing that they made her feel ?like I was in jail.?   134 Rather than preventing drug use, this surveillance and regulation produced structural vulnerability to drug and health harms. Most participants continued to use drugs during the period of their hospitalization to cope with pain and opiate withdrawal or due to craving associated with cocaine use, and half of our participants reported in-hospital drug use. Participant accounts illustrated how the strategies enacted to avoid detection by nurses and security guards compromised their ability to practice harm reduction. Many participants expressed that they could not request syringes without attracting suspicion or risking involuntary discharge. Some participants subsequently reused syringes that they had snuck into hospital and hidden in their personal belongings, and which were potentially contaminated with bacteria which could further cause osteomyelitis or cellulitis. As one participant with recurring injection-related infections explained, ?I always try to have a rig on me? [The nurses] don?t know I have them. [I keep it] in my coat, a bag or whatever I bought?. Other participants relied on visitors to bring injecting equipment and subsequently injected with syringes of an unknown origin. One participant explained the challenges and risks associated with accessing syringes in hospital settings:   They [i.e. nurses] don?t give rigs [i.e. syringes] to us...I think that they should. If not, we?re reusing our rigs or we?re having to risk getting kicked out for stealing them or people?ll be sharing them. [...] I know one girl was using her same rig for days to the point where it was tearing and she was suffering every time she?d do her fix. She just didn?t have it in her to go and try and steal clean rigs.  Whereas for me, my friend that I was with had no problem. She would just sneak in and grab some for both of us. [Participant #30, Aboriginal Female, 28 years old]   The most common strategies enacted by participants to avoid detection when injecting was to use drugs in locked hospital washrooms. Very few of our participants had been assigned private rooms, and instead shared rooms with up to five other patients. Participants indicated that washrooms were one of the only spaces over  135 which they could exert control and thus evade surveillance. Despite widespread awareness among IDU in the local context of the overdose risks associated with injecting alone, the situated risk perceptions of our participants elevated other concerns (e.g., pain management, avoiding involuntary discharge) above the need to mitigate these risks. For example:  If you?re sharing a room with somebody, there?s always that threat that somebody?s just gonna come in and not realize you?re in there [the bathroom] and open [the door]. [?] I think they pretty much have zero tolerance in [the hospital]. I was worried about getting kicked out and then not getting the proper health care that I needed to get better. [?] I?d turn the tap so, if they came in my room to check to see if I was okay, then they?d hear the water running so they?d figure oh she?s just in the bathroom. [Participant #25, Caucasian Female, 44 years old]  5.3.4 ?I?ll just run out? ? Well-Intentioned Departures from Hospital Approximately half of our participants reported that they left hospital altogether when using drugs. Some participants simply ?snuck out? of the hospital in the hope that they would return before nurses discovered they had gone. Other participants had been admitted to hospital wards that regularly issue ?day passes?, which allow patients to leave hospital for a specified amount of time (typically up to six hours) at the discretion of nurses or physicians without being discharged against medical advice. Participant accounts suggest that day passes were used by some wards to accommodate ongoing drug use, in that it was expected that participants would consume drugs off-site and not return to hospital until the immediate effects of drug intoxication had subsided. Most homeless or unstably housed participants stayed in close proximity to the hospital and used drugs in nearby public settings (e.g., parks, alleyways), while housed participants returned to their apartment or single room occupancy hotel. For example:  136 I only had a pass so my plan was just to go grab some dope and then go back to the hospital. [I] stopped a couple of blocks away from there to do some dope. [I] just ended up staying in that one little spot in the park there and getting high for the day and then went and checked back in. [Participant #9, Male, Caucasian]  While nearly all participants intended to return to hospital, most did not return until after their passes had expired (resulting in discharge) and many did not return at all. Several participants emphasized how their health deteriorated after they left hospital. For example: The first time it was just, "OK, I?ll just run out. They won?t know I?m gone." And then, I got stuck out there. Like, I was to a point where I wouldn't stop [binge cocaine use]. And then, I finally came back the next day 'cause I was afraid of losing my leg [due to a soft tissue infection]. [...] And then, the second time [I left hospital], I couldn?t walk at all and my leg swelled up twice the size and there was pus draining out of it. [Participant #13, Caucasian Female, 44 years old]  Some participants later returned to the same hospital to resume treatment and were readmitted through the emergency department. These participants reported that, subsequent to returning to hospital, they were subjected to greater scrutiny by some nurses, with several noting that they were denied day passes.  5.3.5 ?Get the fuck out? ? Involuntary Discharge for In-Hospital Drug Use Whereas all participants indicated that they had been admitted to hospital for complex health problems (e.g., osteomyelitis, pneumonia, meningitis), and required extensive treatment, approximately one third of our participants reported that they were involuntarily discharged for in-hospital drug use. Participant accounts underscored how, while many injected in locked bathrooms in an attempt to conceal their drug use, these were highly-regulated spaces that were actively monitored by nurses and security guards. In turn, most participants reported that they had been  137 involuntarily discharged after they were caught, or suspected of, injecting drugs in bathrooms. For example:  I went to use the bathroom, and they sent the police in the bathroom. They said I was taking too long and they thought I was using drugs in there. I was on the toilet, and the cop walks in with the key. [...] He says, ?You?re taking too long. Get the fuck out.? He?s swearing at me. He?s standing there with the security guards, and couple of the staff from the hospital. [...] They physically escorted me out. They told me they were going to arrest me if I step back on the property. They said I was creating a disturbance. [...] I was just using the bathroom. [Participant #1, Aboriginal Male, 39 years old]  Some participants acknowledged that they were disruptive during these encounters (e.g., swearing at nurses and security guards), which likely discouraged nurses and security guards from exercising discretion (i.e., seizing and disposing of the drugs but stopping short of involuntary discharge). However, these participants did not wish to discontinue treatment and expressed concern regarding the potential health consequences of involuntary discharge, and nearly all were later re-hospitalized.  5.4 Discussion In summary, our findings highlight how abstinence-only drug policies, in combination with inadequate pain management fuelled by narcotics control and negative stereotypes (i.e., the ?drug-seeking addict?), frame hospital care, and produce structural vulnerability to harm among IDU. Diverse forms of social control that function to regulate drug use in hospitals (i.e., surveillance and regulation of IDU) increase the potential for drug-related harm and discharges against medical advice. In this regard, our findings demonstrate that hospitals constitute not just a setting to receive treatment and care for IDU, but also a ?risk environment? whose social and structural conditions are critical in producing discharges against medical advice and, in turn, more complicated and protracted medical treatment.   138 Conceptualizing hospitals as ?risk environments? allows us to better appreciate how contextual forces operating within hospital settings shape diverse harms, including discharges against medical advice, and thus advance beyond individualized approaches that associate risk with moral culpability and lack of awareness of potential consequences (Rhodes, 2002). Consistent with research in drug scene milieus (Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Cooper, Moore, Gruskin, & Krieger, 2005; Rhodes et al., 2007; Sarang et al., 2010; Shannon et al., 2008; Small, Rhodes, Wood, & Kerr, 2007), our findings demonstrate the role of drug criminalization in perpetuating systems of social control that render IDU vulnerable to harm. Previous research on public injection settings has described how street policing, in combination with the stigma associated with injection drug use, leads to a sense of urgency when injecting that compromises IDUs? ability to follow harm reduction practices (Rhodes et al., 2007; Small et al., 2007).  It is worth considering that, although hospitals are distinct from typical public injection settings in many ways, these same social and structural forces shape the social- and structural-environmental context of hospital care, and similarly constrain IDUs? ability to practice harm reduction. Notably, we found that IDU went to extreme measures to conceal in-hospital drug use from hospital staff, and thereby minimize their likelihood of being caught and involuntarily discharged. Several of these measures (e.g., injecting alone in locked washrooms, injecting with syringes of an unknown origin) dramatically increase the risk of fatal overdose or HIV/HCV transmission. In this regard, our findings highlight the importance of considering how diverse settings constitute risk environments for injection drug-using populations, and how drug criminalization frames the structural vulnerability of IDU in these settings.   139 Although it has been widely reported that complex co-morbidities, together with inadequate pain management, contribute to high levels of unmanaged pain among IDU (Breitbart et al., 1996; Neighbor, Dance, Hawk, & Kohn, 2011; Passik, Kirsh, Donaghy, & Portenoy, 2006), only limited attention has been paid to how pain shapes their experiences in hospital settings (Merrill et al., 2002; Neale et al., 2008). Previous research has underscored the complexities of pain management among IDU, and emphasized how perceptions of drug users shape prescribing practices (Berg et al., 2009; Merrill et al., 2002). In a qualitative study of physician experiences treating chronic pain among IDU, Berg and colleagues (2009) found considerable variation in prescribing practices, and explored how this was influenced by larger discourses that characterize IDU as ?drug-seeking?. Accordingly, many physicians consciously undertreated pain because they were concerned about promoting continued drug use (Berg et al., 2009). Our findings extend this research by demonstrating how this powerful cultural stereotype shapes hospital care for IDU and possibly leads to treatment decisions that increase the likelihood of discharges against medical advice. Notably, our participants described how inadequate pain management was normalized within hospital settings, and characterized their treatment by nurses and physicians as abusive. This approach to pain management may be understood as a manifestation of the ?everyday violence? endured by IDU and underscores the urgent need to rethink pain management practices for drug-using populations and reorient them toward alleviating suffering.  Greater acknowledgement that contextual forces operating within hospital settings produce suffering, and contribute to discharges against medical advice, necessarily begs the question of whether changes to the environmental contexts of hospital settings can improve care for drug-using populations. Our findings illustrate how injection drug-using populations undergo a vicious cycle of emergency  140 department visits, hospitalizations, and departures that repeats itself and both increases the risk of death and overall burden on the health care system. Certainly, there is an urgent need to integrate evidence-based approaches that show promise in disrupting this cycle. Methadone maintenance treatment has shown some promise in mitigating departures from hospital prior to completing treatment among IDU (Chan et al., 2004), and efforts to increase access to opiate substitution therapies among hospitalized IDU are needed. Our findings underscore how this approach must be properly managed, and it is likely that increased addictions training among physicians and nurses will be necessary to accomplish this. However, it is worth noting that these approaches have limited effectiveness among IDU who are not motivated to receive treatment (Kelly, O'Grady, Mitchell, Brown, & Schwartz, 2011), and more comprehensive approaches environmental supports are, therefore, needed to address this continuing problem.  Over the past decade, considerable evidence has mounted highlighting the role of ?safer environment? interventions (e.g., syringe exchange programs, supervised drug consumption facilities) in reshaping the ?risk environment? of drug users (Rhodes et al., 2006). Within this context, supervised drug consumption facilities have been found to be particularly effective in fostering social, structural, and environmental conditions that enable harm reduction practices and facilitate access to health care services (Kerr, Small, Moore, & Wood, 2007; Krusi et al., 2009; Lloyd-Smith et al., 2009; Small, Van Borek, Fairbairn, Wood, & Kerr, 2009; Small et al., 2008). Moreover, preliminary evidence suggests that this harm reduction strategy has significant potential to reshape the social and structural-environmental contexts within health care settings (Krusi et al., 2009). In this regard, our findings lend support to the argument for integrating comprehensive harm reduction approaches that include supervised drug consumption services into hospital settings (Rachlis, Kerr,  141 Montaner, & Wood, 2009). While this approach is by no means a panacea, it is likely to minimize the deleterious effects of efforts to deter and limit drug use within hospital settings, and thus drug-related risks (e.g., injecting alone) and discharges from hospital against medical advice. Furthermore, this approach would allow nurses and physicians to shift their attention from policing drug use to more pressing patient concerns, and also minimize the conflicts occurring in hospital settings.  We acknowledge that this approach is likely to encounter opposition in many settings from those ?morally? opposed to harm reduction services (Buchanan, Shaw, Ford, & Singer, 2003), as well as health care professionals who view harm reduction as counter to ?curative? approaches to care (Pauly, 2008). In addition, drug legislation in some settings may preclude the adoption of comprehensive harm reduction approaches (Beletsky, Davis, Anderson, & Burris, 2008). It may, therefore, be instructive to position harm reduction as an ?ethical approach? intended to minimize harm as part of a broader strategy to ensure equitable access to hospital care (Pauly, 2008), and thereby locate it within the scope of health care practice. This approach has previously been used by an HIV/AIDS care facility in a Canadian setting to reposition supervised injection services as an issue of ethical health care practice (Wood, Zettel, & Stewart, 2003). This study has limitations that should be taken into consideration when interpreting its findings. Because our participants had been discharged against medical advice, their experiences in hospital may be negatively biased, and are not representative of those who completed treatment. Our findings are also specific to hospitals in the Vancouver area and, although they generate insights that may be relevant to other settings where hospital care is shaped by similar contextual forces, they cannot fully account for drug users? experiences in hospitals. In this regard, it is important to note that, whereas our participants were covered by universal, publicly- 142 funded health care insurance, IDU in other settings may face additional financial barriers to care that, in turn, have a broader impact on hospital care. Finally, it is important to note that, because we did not interview hospital staff or conduct participant-observation in hospital settings, our findings may be considered to represent only the perspectives of IDU. It is, therefore, possible that we overlooked some of the contextual forces that shaped specific aspects of care (e.g., pain management).  In conclusion, this study documents how hospitals constitute a ?risk environment? for IDU. Our findings demonstrate that contextual forces operating within hospital settings (e.g., policies and practices that prohibit drug use, negative stereotypes) foster social, structural, and environmental conditions that increase the potential for drug and health harms, including discharges against medical advice. Comprehensive harm reduction services, including supervised drug consumption services, have significant potential to promote health equity by reshaping the environmental context of hospital care, and thus warrant serious consideration.  143 CHAPTER 6: CONCLUSION 6.1 Summary of Findings This dissertation examined the role of contextual forces operating within the risk environment in shaping the socio-spatial relations of people who inject drugs (IDU) in relation to safer environment interventions and places associated with drug-related risks and harm in Vancouver, Canada. In Chapter 1, it was noted that, notwithstanding the improvements in population health produced by safer environment interventions, the current scope of interventions in Vancouver, as elsewhere, has proven insufficient in bringing about more comprehensive reductions in morbidity and mortality among IDU. This chapter argued that spatially-oriented research into safer environment interventions and high-risk settings was needed to document the limitations of current approaches, and develop recommendations to address social, structural, and environmental factors within the risk environment that constrain access to safer environment interventions, or otherwise produce harm among IDU.  In Chapter 2, a meta-synthesis approach was employed to synthesize the qualitative literature exploring IDUs? experiences in relation to safer environment interventions. While highlighting how safer environment interventions alter the social, structural, and environmental contexts of injection drug use to enable IDU to enact risk reduction, this meta-synthesis illustrated ?latent? functions of these interventions that were viewed by IDU to be equally important. Notably, safer environment interventions were viewed as critical environmental supports that enabled IDU to minimize their exposure to the ?structural? and ?everyday? violence that characterizes street-based drug scenes. Whereas the role of safer environment interventions in promoting physical safety was a common theme across studies, many also highlighted how these interventions promoted ?safety? from stigma, in that they  144 fostered social or physical settings in which IDU were not discriminated against on the basis of their injection drug use. Studies included in this meta-synthesis also illustrated how safer environment interventions facilitated access to diverse supports (e.g., social support, food and shelter, medical care) critical to the survival of IDU, and, as such, occupied a prominent place within IDUs? social geographies. However, meta-synthesis findings underscored how safer environment interventions operate within regulatory frameworks (e.g., drug criminalization, restrictive policies) that constrain access to these interventions, with street-policing identified as an ongoing barrier in many settings. Meta-synthesis findings set the stage for the ensuing chapters by focusing attention on the diverse functions of safer environment interventions, and factors that adversely impact their effectiveness. Drawing on qualitative interviews and mapping exercises with highly-vulnerable IDU, Chapter 3 examined the role of hegemonic forms of masculinity operating within the Downtown Eastside in perpetuating ?everyday? violence toward women and marginal men, and shaping their spatial practices. Women and marginal men were found to occupy lesser positions within the gendered hierarchy of power in the neighbourhood, which rendered them vulnerable to violence at the hands of ?dominant men? (e.g., drug dealers, gang members, ?boyfriends?). Diverse forms of violence were found to shape the spatial practices of women and marginal men, who spoke of how they avoided drug scene milieus where they had experienced violence or perceived to be ?dangerous?. Although some marginal men claimed that their spatial restrictions were driven by drug acquisition practices, their emphasis on violence experienced in drug scene milieus, in combination with their avoidance of these areas, suggested that this merely enabled them to resist ?marginalized? identities while enacting spatial strategies to promote safety. Within the context of gendered drug scene violence, the environmental supports available in some areas of the  145 neighbourhood enabled women and marginal men to negotiate geographies of survival. Whereas Chapter 2 emphasized the role of structural-environmental barriers in constraining access to safer environment interventions, this chapter demonstrated that drug scene violence is an under-examined social-environmental force that significantly impacts upon access to interventions (e.g., Insite) in areas perceived to be ?dangerous?.  In drawing upon ethnographic fieldwork conducted at an ?unsanctioned? DCR operated by VANDU, Chapter 4 sought to characterize the risk environment of IDU who require help injecting, and examine how this had been impacted by the DCR which sought to accommodate assisted injecting among local IDU. Consistent with studies included in the meta-synthesis in Chapter 2 (Fairbairn et al., 2010; Small et al., 2011), findings underscored how rules prohibiting assisted injections at Insite were a structural-environmental barrier that constrained access to this facility, and outlined how this disproportionately impacted particular drug-using ?subjects? (e.g., women, older adults, those with disabilities). Furthermore, findings demonstrated that intersecting social (e.g., gender inequities), structural (e.g., constrained access to Insite), and environmental (e.g., unhygienic injecting settings) factors produced vulnerability to an array of harms when assisted injections were performed in drug scene venues. Of critical importance, this study demonstrated that providing assisted injections in a regulated environment and in accordance with a harm reduction policy mitigated these harms, and worked to establish safer injecting routines among highly-vulnerable IDU. Notably, assisted injections performed in this setting disrupted social practices that produce HIV and HCV risks (e.g., syringe switching) and reinforced overdose prevention messages (e.g., ?halving your hit?). Building upon findings in Chapter 2, this study also illustrated how this peer-run DCR provided IDU who  146 require help injecting with a legitimate place to occupy and thus escape from ?everyday? violence within the street-based drug scene.  Finally, Chapter 5 explored how contextual forces operating within hospital settings structured medical care and discharges from hospital against medical advice among IDU. In drawing on in-depth interviews with thirty IDU, this chapter examined how intersecting social (i.e., discrimination, stigmatization) and structural (i.e., abstinence-based drug policies) forces operating within hospitals produced vulnerability to diverse harms. Central to IDU narratives was an emphasis on the suffering produced by inadequate pain management, which was fuelled by narcotics control and negative stereotypes regarding drug-using populations (i.e., ?drug-seeking addicts?). Whereas many IDU sought to inject drugs to alleviate their pain or ?dopesickness? (i.e., opiate withdrawal), diverse forms of surveillance and regulation aimed at preventing drug use in hospital settings increased the potential for drug-related harm and discharges against medical advice. Within this context, the steps taken by IDU to conceal their drug use in hospital settings (e.g., injecting in bathrooms, hiding syringes) constrained their ability to enact risk reduction, and some were involuntary discharged for injecting drugs on hospital premises. Other IDU left hospital to inject drugs and were subsequently discharged against medical advice. Together, these findings illustrate how hospitals constituted a ?risk environment? whose social and structural conditions were critical in producing drug related harms and discharges against medical advice, and thus compromised the health of IDU.   6.2 Unique Contributions  The studies that comprise this dissertation make several unique contributions to the growing literature on the risk environment. Although these contributions are outlined in the individual chapters, there are three key contributions worth noting.   147 First, this dissertation underscored how spatially-oriented, ethno-epidemiological methods can be employed to generate insights into the role of contextual forces operating within the risk environment in shaping the socio-spatial relations of IDU in relation to safer environment interventions and other settings (e.g., hospitals). While ethno-epidemiological methods are increasingly prominent in studies of drug use risk environments (Lopez et al., 2013; Wagner et al., 2011), there have been few studies to date that have used these methods to examine the role of ?place? in structuring drug-related harm. Notably, the studies included in this dissertation demonstrate how diverse ethnographic methods, including participant-observation, in-depth interviews, and qualitative mapping exercises, can be combined to develop a nuanced understanding of the spatial practices and patterns of IDU. Specifically, Chapter 3 used in-depth interviews and qualitative mapping exercises to examine the role of violence in shaping the spatial practices of IDU in the Downtown Eastside. It was only through combining these methods to link experiences of violence to specific places in this neighbourhood, and document their impact on spatial patterns, that it was possible to identify a previously undocumented social-environmental barrier that constrained access to Insite.  Second, as noted in the introductory chapter, safer environment interventions have been under-conceptualized in the existing literature, and the overwhelming emphasis placed on ?risk reduction? has obscured other functions of these interventions. Chapter 2 represents the most comprehensive review of safer environment interventions to date, and makes an important contribution to the literature by outlining their diverse functions. Notably, this chapter underscored how the ?latent? functions of safer environment interventions are of equal importance to risk reduction when viewed within the context of the lived experiences of IDU. These latent functions (e.g., providing material and social support, access to regulated  148 indoor environments, and medical care and referrals) were identified as critical in enabling IDU to negotiate survival within the context of drug criminalization and entrenched poverty. Accordingly, Chapter 2 demonstrates that safer environment interventions should be defined not only on the basis of their role in altering social, structural, and environmental factors to reduce risk, but in accordance with their broader functions. Finally, relatively little attention has been given to how drug-related harm is contingent upon the subject positions occupied by IDU. Collectively, the studies in this dissertation identified how these were central in structuring harm and access to safer environment interventions. Chapters 3 and 4 identified how IDUs? positions within gendered hierarchies of power (e.g., women and marginal men) and embodied subjectivities (e.g., IDU who had poor venous access or physical disabilities) rendering some more vulnerable to harm.  For example, Chapter 3 outlined how the lesser position accorded to women and marginal men within the street-based drug scene increased their exposure to violence and, in turn, impacted upon their access to Insite. Chapter 4 illustrated how the regulatory framework under which Insite operates (i.e., prohibition of assisted injections) constructed IDU as neoliberal subjects (i.e., autonomous, independent IDU who are capable of self-injecting), and thereby excluded IDU occupying alternate subject positions (e.g., those unable to self-inject due to disability or poor venous access). Furthermore, Chapter 5 illustrated how, within the context of hospital care, those labelled as ?drug users? received inadequate pain management and were subjected to surveillance. Together, these chapters demonstrate the heterogeneity within the injection drug-using population, and focus attention on how the risk environment is experienced as dependent upon an individual?s subject position.  149 6.3 Limitations  While the limitations of each study are described in detail in the individual chapters, several limitations spanning these studies warrant closer attention. Importantly, this dissertation reflects the contextual forces operating within the risk environment of injection drug-using populations in a specific geographic locale (Vancouver, Canada), and findings might not be transferable to other settings. In many regards, Vancouver is distinct from other geographic settings, in that: (i) a more comprehensive range of safer environment interventions operate in this city than elsewhere in North America and most other cities in the world; (ii) the high concentration of IDU within the Downtown Eastside is distinct from communities with smaller or more geographically dispersed injection drug-using populations; and, (iii) local police have prioritized arresting drug dealers over individual IDU and demonstrated support for local safer environment interventions (Debeck et al., 2008; Small et al, 2012). Although similar social, structural, and environmental factors may operate in some settings, the interactions among these contextual forces within the broader risk environment undoubtedly varies, and presents unique challenges and opportunities for risk reduction.    Furthermore, there are several methodological limitations that should be noted. First, dissertation findings reflect the perspectives only of these IDU participating in the individual studies, and cannot be viewed to be representative of the experiences of IDU in Vancouver or elsewhere. Second, because participants were recruited from among those who encountered social and structural barriers to accessing Insite or completing treatment in hospital, it is possible that study findings were negatively biased against these settings. Third, because participants were recruited from VANDU, it is possible that they may have exaggerated the benefits of the DCR, and in particular their experiences may not be representative of IDU who are less marginal  150 within the street-based drug scene. Fourth, as noted elsewhere (Bourgois, 2002), IDU have a tendency to give socially desirable responses regarding risk behaviours when participating in research, which potentially limits insights into these risks. Finally, in spite of the steps taken to mitigate the potential of poor recall of events, including limiting recruitment to participants who had recently been discharged against medical advice (Chapter 5) and triangulating multiple data sources (Chapters 3 and 4), the studies included in this dissertation nonetheless relied primarily upon self-reported data, and it is thus possible that specific events were reported inaccurately. 6.4 Recommendations  The collective work in this dissertation has important policy and practice implications and, while specific recommendations have been outlined in each chapter, there are several important recommendations worth highlighting.  First, this dissertation underscores the urgent need to scale-up supervised injection services in the Downtown Eastside and elsewhere in Vancouver. The findings in Chapters 3 and 4 add to the argument that the current scope of supervised injection services cannot fully address the needs of IDU (Marshall et al., 2011; Kerr, Montaner & Wood, 2008). Furthermore, although VANDU has expanded access to supervised injection services, the legal status of the current DCR (i.e., lack of an exemption to the CDSA) and organization?s limited resources make this a stopgap measure at best. Against this backdrop, there are several immediate steps that can be taken to improve access to supervised injection services. Notably, it is recommended that efforts be made to build upon VANDU's current DCR by increasing the number of injecting booths, and providing increased funding support to increase the organization's stability and operating capacity (i.e., hours of operation, peer-based supports). While this would not resolve concerns regarding the legal status of the current DCR, an application could be made for an exception to the CDSA and, barring  151 that, strategic litigation could be undertaken to pre-empt its closure (Small, 2010). Furthermore, supervised injection services should be expanded into other areas in the Downtown Eastside and elsewhere with established drug scenes (e.g., Downtown South, Kingsway Corridor) by situating these services in relation to the socio-spatial relations of IDU currently unable to access VANDU or Insite (e.g., integrating supervised injection services into emergency shelters, supportive housing, drop-in centres, and health clinics).  Second, there is a need to reorient the operating procedures of safer environment interventions to maximize access among injection drug-using populations, and in particular those disproportionately vulnerable to harm (e.g., IDU who require help injecting). Chapters 2 and 4 demonstrated that existing regulatory frameworks in some settings limit the impact of safer environment interventions, notably legal frameworks that require SEPs to operate on the basis of one-to-one exchange and those that prohibit assisted injection at supervised injection facilities. Whereas these regulatory frameworks are intended to allay community concerns regarding publicly-discarded syringes (Des Jarlais, 2000), or limit potential criminal and legal liabilities of service providers (Pearshouse et al., 2007), they instead have the effect of not only undermining access to these interventions, but of amplifying an array of drug and health harms. Accordingly, regulatory changes are needed to minimize structural-environmental barriers to these services to the greatest extent possible. In the local context, the rules prohibiting assisted injections within supervised injection facilities are particularly harmful and should be immediately changed. Furthermore, as outlined in Chapter 4, these changes may in fact be necessary to comply with Canadian human rights legislation given that the current regulations effectively serve to deny services to vulnerable individuals, including women and those with physical disabilities.   152 Third, this dissertation provides evidence to support the extension of safer environment approaches, including supervised injection services, into health care settings. Importantly, as outlined in Chapter 5, abstinence-based drug approaches in hospital settings negatively impact IDU, and produce discharges against medical advice. There is an urgent need to examine the potential of integrating supervised injection services into hospital settings in minimizing discharges against medical advice. This approach has tremendous potential to alter the social and structural contexts of care, and thus foster environmental conditions that are more amenable to the care and treatment of IDU. As noted in Chapter 5, existing regulatory frameworks (e.g., drug criminalization) may hinder efforts to adopt this approach in some settings (Beletsky et al., 2008), and it is likely to encounter opposition from health care professionals who consider harm reduction to be incompatible with ?curative? care (Pauly, 2008). However, given that existing abstinence-based approaches produce considerable suffering, it may be possible to position supervised injection services as an ?ethical? clinical strategy for mitigating harm and ensuring equitable access to hospital care. Finally, consistent with the growing literature on the social-structural production of drug-related harm (Rhodes et al., 2005; Strathdee et al., 2010), this dissertation emphasizes the role of current regulatory approaches to injection drug use (i.e., drug criminalization) in driving drug-related harm, and thus lends further support to the argument for comprehensive drug policy reforms (Global Commission on Drug Policy, 2012; Wood et al., 2010). Whereas meta-synthesis findings in Chapter 2 outlined how drug law enforcement constrained access to safer environment interventions, Chapters 4 and 5 underscored how current regulatory approaches within Insite (e.g., rules prohibiting assisted injections) and hospital settings (e.g., abstinence-based approaches) led to devastating harms among IDU. Taken together,  153 these findings underscore how drug policy changes are needed to maximize the benefits of safer environment interventions, as well as minimize barriers to care. In this regard, there is an urgent need to reorient the societal response to injection drug use away from drug law enforcement and toward risk reduction. 8.5 Future Research The studies that comprise this dissertation have several important implications for drug use research. Of particular importance, this dissertation highlights the important role of spatially-oriented ethno-epidemiological methods (e.g., qualitative mapping exercises) in generating unique insights into how contextual forces operating within the risk environment structure the socio-spatial relations of IDU and, in turn, how these shape drug-related risks and harm. Despite acknowledgement that ?place? is a central determinant of drug-related harm, there remains an insufficient understanding regarding how ?place? structures risk and harm. Within this context, there is a need for large-scale projects to map, over time, the evolving socio-spatial relations of injection drug-using populations within street-based drug scenes to identify spatial patterns linked to specific risks (e.g., avoidance of particular areas, high-risk injection settings) so as to inform the development of environmental interventions. Moreover, targeted studies that use spatial methods, including but not limited to qualitative mapping exercises, to examine how the socio-spatial dynamics within specific high-risk settings (e.g., shooting galleries, alleyways) may enable researchers to identify previously undocumented factors shaping risk and thus inform environmental interventions.  Another important area for future research lies in the examination of how the various subject positions occupied by IDU shape the distribution of risk and harm. The collective findings of this dissertation caution against homogenizing IDU, in that categories commonly used in epidemiological and qualitative studies (e.g., gender  154 binaries) overlook the greater diversity within these ?categories? of IDU. In this regard, there are several important considerations that should guide future research. First, future studies among injection drug-using populations would benefit from closer attention to how hegemonic gender constructs (e.g., socially and culturally-situated constructs of ?masculinity? and ?femininity?) shape interactions among IDU and associated risks and harms (e.g., interpersonal violence and injecting practices). While these powerful social forces are most easily examined within ethnographic studies, the potential of ethno-epidemiological approaches to identify sub-characteristics linked with harm and determine their impact at the population-level may provide evidence to refine existing, and develop targeted, interventions. Second, given the disproportionate harm and unique barriers to safer environment interventions experienced by IDU with disabilities, additional research is urgently needed to generate more complete understandings of the risk environments experienced by these populations. To date, these have been almost entirely overlooked in the drug use literature, and evidence is needed to inform targeted interventions. Finally, future research into safer environment interventions would be strengthened by closer attention to the subject positions that their operating procedures inscribe onto these interventions. Whereas there is evidence that these interventions construct neoliberal drug using subjects, it is possible that other such constructs embedded within safer environment interventions pose unique barriers to particular IDU.  Finally, it would be remiss not to mention that, given the potential opposition to the abovementioned recommendations, it is important that pilot interventional studies be pursued to provide evidence in support of safer environment interventions and approaches, and thus drive broader policy and programmatic reforms. In this regard, the previous evaluation of Insite is instructive, in that the original legal exemption allowing the implementation of this intervention was linked to a pilot  155 evaluation and the resulting evidence was critical in supporting the successful legal argument that led to its permanent establishment. The further pursuit of pilot interventions linked with the abovementioned recommendations that employ ethno-epidemiological approaches to determine their impacts on the distribution of risk and harm, and how these are shaped by contextual forces operating with the risk environment, is needed. As an initial step, a pilot evaluation of the integration of supervised injection services into a hospital setting that frequently provides care to injection drug-using populations (e.g., urban teaching hospitals in Vancouver) is urgently needed to examine the potential impacts of this approach on hospitalization outcomes among IDU, including discharges against medical advice. 8.6 Conclusion This dissertation has underscored how contextual forces operating within the risk environment shape the socio-spatial relations of IDU, and how these are critical determinants of access to and engagement with safer environment interventions and health care services. The research emerging from this dissertation demonstrated that social and structural factors shape the spatial practices of IDU, and thus constrain access to these services and produce devastating health harms. 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