Drug Abuse

THEORETICAL BASES FOR UNDERSTANDING DRUG USERS' ORGANISATIONS

Samuel R. Friedman, National Development and Research Institutes, Inc.

Drug users' organisations have worked to prevent the spread of HIV and other infections in many countries and have also provided a users' voice in public discussions and in policy formation. The structures of drug scenes affect what users' groups can do and how they can function. Dyadic relationships and large-scale sociometric risk networks among drug injectors can affect both the spread of HIV (and other infections) and attempts to influence behaviours. 'Core' areas of large networks can serve as centres for viral transmission (and high risk behaviours) but also as centres of AIDS education and user solidarity. Theories of 'primary relationships', with intellectual roots in social movement theory and in studies of workplace dynamics and struggles, can help users' groups apply network-basedinsights to build their strength and influence , and to prevent viral spread. Organisational forms also affect users' groups strength and efficacy. The relative value of more democratic versus more oligarchic forms of organisation may depend upon the nature of the local drug scenes, organisational goals and activities, and the prevalence of HIV, other infections, preexisting high-risk behaviours, and the content and enforcement by users themselves of norms about risk behaviours. Organising is a process that depends upon the structures and mixes of local drug scenes. It is crucial to consider what is not known : the drug scene in a city is too complex and rich even for 'insiders' to know the scene. The need to have information that lets the group influence all parts of different scenes can also shape the best organisation form. Finally, research needs on drug users' organisations are discussed.

FUNCTIONS OF DRUG USERS' ORGANISATIONS FOR HARM REDUCTION

As an introduction to understanding drug users' organisations and the issues they face, it is useful to start by considering what they have done. Their actions fall into several spheres. First in importance from the perspective of harm reduction is, perhaps, their contribution to preventing the spread of HIV and other infectious diseases. Here, they have taken the lead in many countries in promulgating information to drug injectors and, in many cases, in distributing risk-reduction supplies and performing syringe exchange services. They also work with other bodies who are concerned about HIV, such as other NG0s in the field (often including organisations of commercial sex workers and of gay people), public health authorities, hospitals and researchers. Very importantly, they provide these bodies with their knowledge of the drug scene and of society and with critiques of proposals or ideas presented by these other groups that might have negative impacts on drug users.

They also provide advice and useful critique to drug treatment organisations. On occasion, they have organised demonstrations for changes in treatment.

Similarly, they interact with the police. Their modes of doing so vary greatly from country to country. Often, they convey to the police ideas about why harm reduction policies are better for society, the police, and the users than are 'war on drugs' policies. Everywhere, in so far as 1 know, one of their messages to the police is to recognise the humanity of users and not to demonise them.

Likewise, they serve as a pressure group in society against the demonisation of users and in many cases to end the illegality of drugs. This has an important 'internal' side to it: They also serve to legitimate the humanity of users to users themselves and thus to help users deal with the attacks and stigmatisation they undergo.

Some drug users' organisations also function as consumer groups vis-a-vis the drug dealers. In the Netherlands, for example, they have put leaflets into the street that warn users of brands of drugs that can cause overdoses or otherwise make users sick.

Finally, in many cases, they provide informal counselling services, referral, or other crisis intervention for drug users who need such assistance. The extent of such activities can sometimes become nearly overwhelming to the group's staff or activists and thus come into conflict with the attainment of other group goals (Crofts and Herkr, 1995). Similarly, drug users' organisations provide a socially supportive environment for rug users and an opportunity to learn new skills and to perform socially valuable services for their community.

In this paper, I will look carefully at their natures both as service-providing organisations and as social movements. These concepts capture key aspects of what they can do to fight HIV in terms of the following: (a) providing educational and material HIV-related services; (b) changing the norms and structures of drug scenes to reduce HIV risk; and (c) influencing social policies that affect both the spread of HIV and the medical and social care provided for the sick.

COMMUNITY BASE ISSUES

Like all such organisations, drug users' organizations have to relate to their popular constituency as well as to funding agencies and to potentially hostile groups (like police and neighbours) in their environments. Here, we should think about the nature of their 'community base', i.e. of drug scenes.

Of course, drug scenes vary widely, and this means that different drug users' organisations face different environments and different problems. In New York, we have drug supermarket areas similar to that of the Bushwick section of Brooklyn in the early 1990s or to that of some sections of the Lower East Side at various times. We also have areas where drug selling is much more hidden. At various times, shooting galleries have been major parts of a neighbourhood like Bushwick, but then they became much more rare. In Flagstaff, Arizona, which has been studied by Trotter et al. ( 1995), the scene is much less public. It is variegated, with some parts being organised around families who inject together, while others tend more to be organised around relatively covert drug markets. Little is known about the networks of drug injectors in rural areas. Syringe exchanges in such areas in the United States and Spain either provide mobile deliveries or arrange for local users to act as secondary exchange volunteer staff.

Crofts and Herkt (1995) have suggested that Western Australia may provide an example of how the social structure of a drug scene can affect drug users' organisations: They suggest that the drug scene is organised around discrete social groups that 'homebake' their own drugs, and that this has made user groups harder to form than in locations where a drug market provides opportunities and necessities for wider interaction. Furthermore, they suggest, these differences have meant that organisational structures, ideas, and strategies that were appropriate for other Australian users' groups did not work in the Western Australia environment. Although this analysis has been challenged (David Burrows, personal communication; Annie Madden, personal communication), it suggests the need for more detailed information about both the structures of different drug-using communities and for analysis of how these structures affect drug users' organisations in these communities.

This variety in drug scenes probably means that drug users' organisations need to learn how to think about their local communities in ways that are useful to them and then how to test out their understanding.

One danger here is that of being complacent with understanding only part of the local scene. This can lead to a well-functioning organisation, but in the age of HIV, HBV and HCV epidemics, it also means that the overlooked social groups within the scene may become epicentres for viral spread not only within their own group but also, perhaps, back to those sectors of the scene that were already organised. Ofcourse, if the scene varies considerably, this may imply that separate organisations are needed to address different parts of the scene. Questions of how such organisations can collaborate need to be investigated.

Here, I want to provide some ideas about how to conceptualise drug scenes. These thoughts are based on my research into drug scenes in New York, but also on my work with collaborating researchers in the WHO Multi Center Study on Drug Injection and HIV, and on my work with drug users' organisations and their supporters around the world. It is also based on my activities, studies and research on communities, on workplace and union struggles, and on social movements before 1 became involved in issues associated with HIV. As such, this section of the paper looks at the structural roots that underlie previous articles such as my discussion on how drug users' organisations can organise their constituency (Friedman and Des jarlais, 1992), and this is discussed briefly in the following section.

There are three major empirical and theoretical foundations to this section of the paper. The first is our empirical studies of the nature of dyadic relationships between drug injectors in New York, along with our studies of which kinds of relationships are associated with high-risk behaviours. Second is our network studies of how these dyadic relationships are sociometrically structured in the wider drug scene, and thus includes consideration of which kinds of ties can spread viruses across a scene, and which can'spread social influence within a scene. Third, we will consider the studies by industrial sociologists into primary work groups (Blumberg, 1968; Mayo, 1933; Roethlisberger and Dickson, 1964; Weir, 197 2,1974; Whitehead, 1936), as well as social movement studies of primary groups in communities (Rude, 1980) and studies of how these primary groups are important building blocks for organisations and activities.

 

Dyadic relationships

In our Bushwick study (Friedman et al., in press), we asked participants to tell us about their relationships' with other drug injectors. We asked about how long they had known their network contacts, and also' about how close their relationship was. Of 1702 relationships we were told about between drug injectors, who were not sex partners, 21% were short-term relationships that had lasted less than 12 months; and 47% were long-term relationships that had lasted for 5 years or more. Of 617 people who had sexual partners, 16% of the relationships were with ....... drug injectors and 22% were with non-injectors in persons with short term relationships; and slightly over half of the friendships with sex partners who were either drug injectors or non-injectors were long-term relationships.

In general, we found that high-risk behaviours' are more frequent with persons whom they have known longer, with whom they have 'very close' relationships, and with whom they have multifaceted relationships (i.e. relationships that involve a number of spheres of activity). This is true for receptive syringe-sharing (Neaigus et al., 1995a), for distributive syringe-sharing by infected drug injectors (unpublished findings), and for unsafe sex, (Friedman et al., 1994).

Sociometric networks of relationships

The structure of sociometric networks in a drug scene can be Studied by examining the patterns of relation-:, ships among multiple pairs of drug injectors. These patterns have a dual nature: On the one hand, relationships that incorporate high-risk behaviours can be thought of as 'risk networks', and these are the paths along which HIV and other infections can travel through the community. On the other hand, to the extent that relationships involve communication, empathy, or even fear, they can be the paths along which social influence travels. One implication of this, as should be clear, is that as drug users' organisations form, and as new friendships grow up within and around them, these new relationships can be paths along which risk-reducing influence flows and/or paths through which infections flow.

Our studies in New York have found a somewhat paradoxical picture (Friedmanet al., in press; Neaigus et al., 1995b). The 'cores' and 'high centrality' areas of large connected components of networks are, first, characterised by considerable discussion of HIV and AIDS, and by the perception that friends support norms that mandate condom use and forbid syringe sharing. They also, however, are characterised by relatively large proportions of members who engage in needle-sharing and other high-risk behaviour, -and by having greater seroprevalence both of HIV infection and of the markers for having been infected with hepatitis B. Intellectually, this can be understood if we think of the core, or high -centrality, section of a drug injection network as being composed of persons with relatively strong needs to take their drugs but with relatively low resource bases with which to buy drugs, syringes, and the private space in which to use them. Thus, core members interact greatly, and are important as a force in promulgating norms, both among themselves and to other drug injectors who come into contact with them. On the other hand, their intensity of interaction in drug markets, shooting galleries, outdoor injection settings, and the like mean that they are vulnerable to being asked to 'share a taste' or share a syringe with another member of the scene who lacks resources to stave off withdrawal. The very sense of community, altruism, and empathy with other users that supports the promulgation of risk-reducing norms, then, can also lead to high-risk injection practices if members of the core lack the resources to provide needy members of the scene with syringes and drugs when required.

In practice, this paradox poses a challenge to drug users' organisations and to public health officials. To change norms and to build a community strong enough to enforce them, drug users' organisations need to build empathy, interrelationships, altruism, and solidarity in the core sections of the drug scene. At the same time, these same relationships and orientations can lead to 'sharing' when resources are lacking. Thus, for drug users' organisations, this paradox requires building very strong norms (and ways to enforce them) against highrisk behaviours but also requires finding ways to safely provide the 'needy' with the supplies they need when they need them.

Primary relationships

These implications of our observations about the duration of dyadic relationships and about the structure of social networks can be strengthened if they are put into a context of an important insight into the dynamics of social struggles-that the nature and strength of primary groups varies, but that it is the small groups of people who regularly interact on a day-to-day basis who provide the strength behind group norms and the potential activism in group struggles (Weir, 1972, 1974). Primary work groups were described as one of the important discoveries of the Hawthorne experiments (Mayo, 1933; Roethlisberger and Dickson, 1964; Whitehead, 1936; see also Blumberg, 1968). Rude (1980) has shown that pre-industrial popular movements were shaped by the primary groups that small owners, workers, artisans, and housewives formed in their daily interaction patterns.

The implications of the theory of primary relationships are several. First, to the extent that different drug scenes vary in the extent to which there are primary groups within them-or vary in the extent to which primary relationships connect persons who are in different parts of the scene (such as connecting drug injectors with crack smokers)-there may be differential potentials for self-organisation in drug users' organisations and/or for the creation of effectively binding norms against high-risk behaviour.

Second, different patterns of primary interaction may imply different approaches to organising users. For example, to the extent that drug injectors are integrated into the rest of the local community, attempts to organise them either have to involve separating them out from their neighbours or, alternatively, creating organisations in which non-using friends and family members will be both welcome and able to contribute. (Drug injectors seem to be more integrated in their communities in Glasgow (McKeganey and Barnard, 1992), for example, than in much of New York City.)

Third, patterns of recruitment of drug injectors into a drug users' organisation and/or into the broader activities sponsored by the organisation should build upon the concept of recruiting primary groups and not just individuals.

Fourth, to the extent that loyalties remain heavily oriented towards the primary group, then the threat posed by HIV, or by police practices, to the welfare of the group and its members can be a powerful motivating force in mobilising drug users on behalf of organizational activities and/or group protective risk reduction. Here, it may be important to distinguish between the widespread 'vocabulary of motives' (Mills, 1940) expressed by drug users in saying that they 'have no friends, only acquaintances' and the findings that, when asked about specific relationships, most drug injectors seem to have long term relationships, which they describe as being 'very close', with other injectors.

Fifth, it is important to take full account of the findings that syringe-sharing and unprotected sex are more common in very close relationships than in more casual relationships. This means that, to some extent, the members of a primary group are likely to share similar fates in an epidemic like that of HIV. If one of them becomes infected (particularly if she or he does not quickly know it), then infection may spread relatively rapidly to other members of the. primary group. This, in turn, may mean that episodic or short-term relationships, as well as injecting in high risk sites like shooting galleries, are of considerable epidemiologic importance as they pose the threat of transmitting an infectious agent into a group that otherwise might be protected. On the other hand, it is also possible to prevent spread within primary groups if the norms against high-risk behaviour are strong enough, and ways to develop such strong norms need to be devised.

Finally, in both research and in the daily process of organising and working with drug users' organisations, it will be useful to understand better how primary groups of drug injectors are structured in a given locality; how and why they change over time; and whether and how the structure of primary groups and the sociometric structures of drug injectors are related to each other.

OLIGARCHY AND DEMOCRACY IN DRUG USERS' ORGANISATIONS

One of the fundamental theories of sociology and political science is the 'iron law of oligarchy'. This theory holds that all organisations come to be led by a small group of leaders, and that the extent of membership control over their actions becomes extremely limited. It is argued, furthermore, that bureaucratic leadership is the most efficient kind for groups that are engaged in social conflict (Michels, 1962) as well as for organisations that produce goods administer governmental functions, or provide services (Weber, 1957, 1958). We have previously suggested that the 'normalisation' of syringe exchange organisations in New York City that occurred when they switched from being underground organisations to being legal, funded organisations has provided the opportunity for distributing syringes on a much more massive scale and also for also providing a host of useful auxiliary services (Kochems et al., in press; Paone et al., 1995). Nonetheless, for drug users' organisations, it is by no means clear that bureaucratic modes of organisation are superior to forms in which drug users can democratically control their organisation and its activities. Friedman ( 1982, 1985) found that rank - and-file democracy is possible both in unions and in workers' opposition movements and, furthermore, that it leads to more effective outcomes than bureaucratic or oligarchic organisational forms. For drug users' organisations ' participatory and democratic forms would seem to have several advantages:

1. A major function that drug users' organisations need to perform is helping the norms of drug scenes become supportive of forbidding the sharing of syringes, backloading or other forms of syringe - mediated drug sharing with potentially contaminated equipment, unsafe sex, and other forms of high-risk behaviour. To the extent this can be accomplished, the precise forms of the norms, and the mechanisms through which these norms can be enforced, cannot be imposed on users by anybody, much less by a drug users' organisation. Drug users, after all, are experts in avoiding and defying behavioural prohibitions. Open, democratic decision making holds out the possibility both of developing norms and enforcement mechanisms that make sense to drug users and also of winning legitimacy for these norms and mechanisms in the eyes of most of the primary groups of drug users in a locality.

2. Drug users are the targets of widespread stigmatization, derision, and repression. Drug users' organizations are formed, in part, to resist these attacks and to defend the dignity and other rights of users. Bureaucratic or oligarchic organisational forms, even in the most well-meaning organisations with the most 'non-judgemental' staff, create distinctions between the insiders and the outsiders. These distinctions can become the basis for stratifying users into higher and lower categories, and can lead to resentments and hostilities between staff (even if they are volunteers) and other users. Although democracy is by no means perfect as a way to prevent this from occurring, it does put some degree of power in the hands of users who may need to use the organisation's services.

3. Democracy and participation can make it easier for users to become involved in the organisation and to contribute dearly needed ideas and creativity.

On the other hand, it can be argued that participatory democracy may be inappropriate for drug users' organisations. The strongest argument for this may be that, to the extent the users' group is primarily a service - provider (for example, as the operator of syringe exchange services, of outreach education, or of lay counselling services), continuity and professionalisation of these services is best provided through a traditional, bureaucratic service -delivery ode of organisation. Certainly, such an organisational form is normally the kind most acceptable to government agencies or to non-profit organizations that provide the funding by which the users' group provides such services.

Here, I want to pose this issue as a question for both scientific research and for practical experimentation. It seems likely that the best organisational form for a drug users' organisation will be a function )f two (and perhaps three) sets of variables: (1) The nature of the specific local 'community base', as was discussed above; (2) the goals and activities of the specific organisation; and perhaps (3) the extent to which HIV and similar potentially fatal infectious agents are present among drug injectors and others in he locality, together with the prior extent of high risk behaviour and the content and enforcement by drug injectors themselves of norms against high-risk behaviour.

ORGANISING AS A PROCESS

Previously we (Friedmanand DesJarlais, 1992) have suggested that it is useful to think of creating drug users' organisations that are composed of a highly dedicated core of persons who are committed to making the organisation work (and which may include some paid staff, but also needs committed volunteers); that contain other members or 'regulars' with a lesser level of dedication; and that have a periphery of other users who come to occasional meetings and/or help out with various tasks. All of these categories are important to a well-functioning organisation. Of considerable importance, for promoting risk-reduction norms such as never sharing syringes, avoiding unsafe sex, and never backloading or engaging in other forms of syringe-mediated drug injection (Jose et al., 1993; Grund et al., 1996), a drug users' organisation would usually engage in activities such as (1) holding 'town meetings' to determine the appropriate norms and to discuss how they could be implemented and/or (2) producing and distributing newsletters or media events to provoke, discuss, and win influence within the broader drug scene. In such activities, the contributions of members and peripheries would usually be essential in making them successful. (That is, there are few ways in which a core group or a paid staff, alone, can win over the scene to embrace and to enforce such norms.) Here, 1 want to put this earlier discussion in the context of the above discussion, namely the variety of drug scenes and the importance of considering the nature of dyadic ties, networks and primary groups in planning strategy. The first point is that the actual work of organising is extremely specific; discussions about 'drugs scenes in general' tend to miss most of what is essential in daily practice. Second, this very lack of ability to generalise means that organisers of drug users' organisations need to consider several issues very seriously:

1. What they do not know about the drug scene. Every 'insider' has a tendency to focus on what he or she knows that outsiders do not know. Non-users like the author of this article are indeed ignorant of most of the specifics that are important in daily practice. However, that Said, it is also true that most insiders know less thart they think. They may well know their own primary group reasonably well (although who really can be sure of what her or his steady sex partner does when they are not together?); and have a degree of knowledge of their own broader network and its social environment. They are likely to assume that much of the rest of the scene is similar-a belief that tends to be supported by the tendency of 'strangers' to try to blend in with their environment when visiting the organisers' section of the scene. Thus, what 1 am suggesting is that it is important to consider what is falsely presumed to be 'known' and to consider what one still needs to learn in order to work with other parts of the scene and with other 'scenes'.

2. Such information is not easy to come by. Attracting new members to the users' group who are part of different networks or scenes is one essential part of this process, as is getting them to discuss with the other members how their pairs of the drug world are different from (as well as similar to) those parts where other members hang out. Methodologically, it is necessary to get them to resist trying to 'blend in' so as to fit in, i.e. the reality and value of difference needs to be acknowledged in practice. If this ii difficult, friendly research anthropologists or sociological field workers might be able to assist. More systematically, as a drug users' group gains influence in one part of the scene, it may well develop that other parts of the scene come to resist the normative, risk-reducing innovations that the users' group is 'pushing'. Here, the need is to find ways to learn about these other sections of the scene, to open up communication with them, and to discuss the ways in which there are different barriers to risk-reduction in the 'other' scene-without being seduced into reducing barriers to high-risk activities in those parts of the scene where they are feasible.

3. When reaching out to people in the periphery of the group, and even more so when trying to reach and work with other parts of the given scene, with other scenes, and with 'hidden users', it is probably important to consider variations in the nature of local social environments. It is also important to remember, and to operate with the understanding, that a drug users' organisation is trying to gain influence in drug scenes and to attract members from different parts of the scene. Usually, this is best done by remembering that users, like others, live in social environments that are primary groups and networks. Recruitment to an event, to membership, or to acceptance of a norm usually needs to consider users as parts of primary groups and networks rather than simply as atomised individuals. If you can get a peer group leader to come to an event, and to try to bring the other members of her or his peer group to it too, this is more likely to be effective than if you approach individuals in ignorance of their friendship patterns.

4. As a final point on this, organisational openness, activity-focus and democracy are usually conducive to making it possible to get this information and to act on it. Organisational forms, however, may be more or less effective in different community contexts and for different goals and strategies. Thus, although the value of organisational traditions should not lightly be,~ cast aside, it is probably realistic to anticipate a need to discuss organisational structure and 1 function every year or two; and it is important, during such discussions, to consider issues of goals, strategies, and how needs vary, depending on the part of the drug world the users' group is operating within; and whether changes in the drug scene(s) itself, considered as the community context for the organisation, have necessitated changes in the organisation.

RESEARCH ON DRUG USERS' ORGANISATIONS

Previously, 1 have suggested that evaluations of drug users' organisations' impact on high-risk behaviours are a major priority (Friedman et al., 1993). Such research is, of course, extremely difficult, because drug users' organisations form as the result of users' own initiatives, rather than being an experimental condition that can randomly be assigned to occur or not to occur in a given locality. Furthermore, given the expense of impact evaluations and the current budgetary stringencies of potential research-funding sources-and the, at most, limited extent to which the formation of drug users' organisations depends upon the actions of the likely readers of impact evaluations-it may be more appropriate to focus research on other issues than the behavioural impact of users' groups. Two such research issues are:

1. Organisational studies of how the community characteristics of a drug scene and its environment affect the formation, growth, and optimal strategies and organisational forms of a drug users' organisation.

2. Studies of the variety of social structures in different drug scenes. Such research might fruitfully be carried out as a collaboration between professional researchers and users' groups (where they exist), and could examine the nature of drug injectors' dyadic relationships, networks. and primary groups; and if and how these community characteristics shape risk behaviours and/or cultural patterns of drug users.

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