”It’s like dancing with the Devil.” Exploring perspectives on risk, pleasure and overdose among people who inject drugs

Abstract

Drug use is a significant health problem worldwide, and people who use drugs often suffer from impairments in daily life in terms of loss of healthy years, and premature deaths. This also affects the person’s family, as well as communities and societies. In Europe, drug overdose is the main cause of death among high-risk drug users, for whom drug injection is one of the main risk factors. Despite the implementation of several preventive measures, Norway is one of the countries in Europe with a high and stable overdose-related mortality rate. However, little is known about the views and opinions of the people themselves who inject drugs. In this thesis, I study injecting drug use and the risk of overdose from the perspective of people who inject drugs (PWID). The aim is to increase our understanding of injecting drug use, and the social meanings of risk and overdose, within the contexts of PWID’s everyday lives.

Based on qualitative interviews with 80 PWID, this thesis helps to provide understandings of PWID’s complex, and even contradictory perceptions and experiences of injecting drug use, risk, pleasure and overdose. In the three published articles, I show how PWID’s perceptions of their drug use practices entail multiple social meanings and experiences developed in social interaction and in the context of their everyday lives in the risk environment. The study shows a complex range of attractions towards injecting drug use and how participants’ experiences evolved from a fear of the needle, to embracing it as a meaningful practice. This highlights how perceptions of injecting and risk are relational and socially contingent. The thesis also demonstrates that PWID participate in risk environments which involve high levels of distress, fear and stigma. Despite the elevated risk of overdose death, these contextual factors made them prefer solitary injecting, involving a perceived notion of safety from an unpredictable environment, as well as contextual pleasures that were maximised by injecting alone. This highlights the competing priorities among PWID, and that solitary injection should be understood as an adaptive strategy. The thesis also highlights the complexity of overdoses, and challenges assumptions about the relationship between knowledge of risk and risk avoidance. PWID did not always personalise the risk, or they considered it to be part of their high-risk lifestyle. They also expressed an indifference towards survival whereby avoiding death, the main rationale of overdose interventions, was viewed with indifference. This is important for understanding the complexity of overdose mortality and should be reflected in future harm-reduction initiatives.

Overall, I have offered a contribution to the field of harm reduction regarding the need for increased knowledge about PWID’s own experiences and perceptions of injecting drug use. The key arguments are that contexts and the individual’s overall life situation need to be addressed in the overdose prevention work. PWID live their everyday lives in social environments that influence their perceptions of risk and survival. This illustrates the importance of a person-in-context understanding, and of addressing the reasons behind the interviewees’ ambivalence towards survival, and not only individual behavioural change, which may further contribute to the marginalisation of PWID.