Defying the Dominant Paradigm: A typology of low-frequency heroin injectors

1. Defying the Dominant Paradigm: A typology of low-frequency heroin injectors Lynn D. Wenger1, Philippe Bourgois2,Martin Y. Iguchi3 Alex H. Kral1,4 1RTI International,2University of Pennsylvania, 3University of California Los Angeles, 4 University of California San Francisco 8th National Harm Reduction Conference, Austin, TX, November 2010 Funding Source: NIDA

2. Objective • To gain an in-depth understanding of the experiences and needs of out-of-treatment injection drug users (IDUs) who inject heroin 10 or less times per month

3. Background Heroin has been described as an addictive drug that cannot be used occasionally Heroin injectors must inject daily to stave off withdrawal symptoms Norman Zinberg (1970s -1980s) conducted research on the topic of “controlled” heroin use He described patterns of heroin use among middle class heroin users that defied the dominant paradigm of daily heroin use In our epidemiological study of street-recruited IDUs, we found that 15% of heroin users were low-frequency heroin injectors (Low-FHI)

4. Methods - Recruitment • 602 IDUs were screened for eligibility between January-November 2008 • Eligibility criteria • Injection heroin use for a minimum of 5 years • Low-FHI • Heroin injection (alone or in combination with other drugs) 10 or less times in the past 30 days • No methadone or buprenorphine treatment in the past 30 days • High-FHI • Heroin injection 30 or more times in the past 30 days • Eligible participants (N=63) were encouraged to enroll in 2-year qualitative cohort study

5. Methods • Qualitative study • In-depth interviews; baseline, change of status, 1- and 2-year follow-up interviews • Digitally recorded, transcribed verbatim • Administration of two modules of the MINI International Neuropsychiatric Interview • Assesses addiction and/or dependence to alcohol, opiates, and other substances. • Monthly check-in appointments • Enhance retention • Monitor changes over time • Transcripts were coded for salient themes and categories

6. General Characteristics of Low-FHI (N=28) • All had previous experience with daily heroin use • Motivations to use at low levels • Economics • Competing priorities (e.g., supporting children, paying for stable housing) • “hassle of the hustle” • Family • Improving relationships • Death/overdose of family member • Fear • Overdosing • Abscesses, flesh eating bacteria • Withdrawal – always dealing with being dope sick • High levels of heroin use increased levels of criminal activity • incarceration

7. General Characteristics of Low-FHI (con’t) And I know that’s what’ll put me right back in the penitentiary real quick…I won’t make it a year without (going back), once I start on it and start getting that habit going and forget it, it’s on… then the other side of, me comes out. Thievery…whatever it takes 44 year old Latino, male

8. Interviewer: “How do you keep it [heroin use] under control?” Participant: “A little bit of fear, a little bit of knowledge and a little bit of just hope…hope, hope for something better.” 37 year old white, male General Characteristics of Low-FHI (cont.)

9. Typology of Low-FHI

10. Circumstantial Low-FHI • Poly-substance users • Primary drugs were crack, methamphetamines, and alcohol • Living with chronic health problems • HIV, liver disease, heart disease, diabetes • Homeless or marginally housed • Socially isolated • Situations when they use heroin • Celebrations • Heroin became readily available • Social or sexual situations where others are using

11. “I shouldn’t even be doing it once in a while. But you know, sometimes I get lonely and I want some companionship, I want to connect with somebody, and those girls that come, (laughs) they’s pretty strung out.” 48 year old white, male Circumstantial Low-FHI (cont.)

12. Transitioning Low-FHIs • Low-FHIs transitioning to daily use • Recent experience with incarceration • Intention to stay low-FHI • Social environment – easy access to heroin • Coping Strategies • Return to daily use • Entered methadone treatment

13. Transitioning Low-FHIs (con’t) “Influence, a friend of mine…he got out of prison and he had a big old dope bag and bam…I really didn’t start using that much, but I was handling it for him, you know what I mean…If you are around it you will eventually use..I got on methadone because I knew it was a matter of time…I don’t want to go through that addiction. Takes the fun out of it. It makes you miserable. 66 year old African American, male

14. Transitioning Low-FHIs (con’t) • Low-FHIs transitioning away from daily use • Tired of lifestyle and hopeful about the future • Coping strategies • Self-reliance • Smoking marijuana • Faith • Keeping occupied – art, music, family, exercise, work • Avoiding drug-using friends and environments • Support from family (partners, parents, children) “The weed helps, you know. The weed helps energize me to where I can get out and do things to keep my mind off the heroin.” 47 year old white, male

15. Transitioning Low-FHIs (con’t) • I’m not gonna be living in the area where that’s happening. You know what I mean? I’ll stay with mom…That’s my option. I’m gonna go to work. I’m gonna find something….Because, you know, at my mom’s house, you know, I keep it totally respectful. I’m out. I go in the mornings, I jog over to the park…I’ll go into the basketball court before all the mothers bring their kids… So I’ll, I’ll do my exercise early in the morning…You know and, and it makes me feel good….to keep that routine going. 51 year old Latino, male

16. Maintenance Low-FHI • Motivations for continued use • To take the edge off meth or crack • Stress relief • Self medication • Chronic pain • Anxiety, depression Participant: I use heroin when I just can’t hustle (for meth) anymore. I can stop for ten or fifteen hour…It’s like getting off a treadmill. It’s just ‘whoo, let it stop… so I can shut down any time I want to. 44 year old white, male

17. Maintenance Low-FHI (con’t) Interviewer: “Let me ask you…so how often are you fixing now?” Participant: “Well, basically, when I, when I go through my depression – which is probably every 3 or 4 days, or something like that…” 47 year old African American, male

18. Maintenance Low-FHI (cont.) • Coping strategies to maintain low-FHI status • Consciously limiting the number of days of heroin use • Use of other drugs (crack, marijuana, alcohol) • Prioritizing staying housed – paying rent before copping drugs • Avoiding drug-using friends and/or environments Participant: “You know, and, I’m very careful now as far as association; you know, as long as I’m not out there looking for the drugs…I’m not out there making friends with somebody that you know, I’m gonna have to give half of my stuff to and that’s my buddy from now on. So that’s what keeps me okay.” 54 year old white, female

19. Summary • Patterns of heroin injection vary, a small proportion of heroin users are low-FHIs • Differences exist among low-FHI • Circumstantial low-FHI are often dealing with issues related to poly-substance use – needs may have nothing to do with their heroin use. • Transitioning low-FHI may need traditional substance abuse treatment and/or supportive aftercare services • Maintenance low-FHI may need treatment for mental health problems, chronic pain, and assistance accessing appropriate prescription medications • When working with heroin injectors, it is important to assess their drug use patterns and trajectories in order to best understand their needs

20. Acknowledgments • National Institutes on Drug Abuse (R01 DA021627-01A1): Program Official Elizabeth Lambert • Urban Health Program staff: Sonya Arreola, Cindy Changar, Allison Futeral, Andrea Lopez, Jennifer Lorvick, Alix Lutnick, Askia Muhammad, Jeff Schonberg, and Michele Thorsen • Study participants without whom we would be unable to conduct this research