EXECUTIVE SUMMARY

This report focuses on drug using, specifically on injecting drug use. It takes as its starting point the functionality of much drug use, both injecting and other forms. The objective of the research is to provide details about functional users and users who do not come in contact with treatment agencies. Such details will assist in the development, design and delivery of educational material regarding HIV and clarify the terminology used to define users. The impact of HIV and AIDS on injecting drug use is examined within the contexts of functional drug use and the processes of its production.

The literature review (see section 2(a)) indicates a number of correlates of functionality which might differentiate those who can sustain a pattern of drug use not likely to lead to problems. These correlates include having friends and valued peers, varied leisure activities, having obligations to families and partners, work commitments, having access to sources of income, and satisfactory housing conditions, having a fairly stable pattern of values and feasible personal objectives, and having one's life at least partially mapped out in time sequences which produce a structuring of time and assorted routines.   Such correlates of functionality are equally applicable whether the individual is involved with drug taking or not. When applied to drug taking, additional considerations are suggested. These are having an accessible source of supply, having preferred drugs and the means of evaluating alternative drugs, and having, at least sometimes, autonomy over time and space.

To the extent to which most of these correlates are present, the drug user may be able to integrate the drug taking into other aspects of his/her life, and keep the drug taking in proportion according to a socially or individually defined regime of regulation. Such drug use may be said to functional. So long as the drug using has a stable meaning in relationship to some self sustaining set of values, social practices and feasible objectives, and the conditions for the reproduction of these are satisfied, then it is likely that a pattern of functionality can be sustained.

We had initially thought that functional users would be those injecting drug users who had not come into contact with treatment agencies and had not been in prison. The literature review, however, revealed that this definition was simplistic. Instead we defined functionality in terms of satisfaction with use, where injecting use was not a major lifestyle determinant. This definition guided our initial thinking and our selection of respondents but, as noted below, this definition was developed and refined by the findings of our research.

As noted in section 1 of the report, the project focused on producing in-depth data on a small sample of injecting drug users in order to provide an analysis of the social processes underlying the responses of functional injecting drug users to the HIV epidemic.

While the major purpose of the study was an investigation of functional drug use, the other major criterion for selecting the sample was heterogeneity - specifically with regard to gender, age, social class, and sexual preference. At the time of writing this report, 28 interviews had been completed. We were satisfied that a reasonable spread across these variables was achieved. Nineteen of the participants in the study were men and seven were women. Ages ranged from 22 to 45 years. Seventeen of the respondents had full-time and three had part-time work, with occupations ranging from a public servant, a small business owner and an engineer to a bank employee, a musician and a stores worker. Six people in the sample were unemployed, five men and one woman, one was a house worker, and one a student. All but one were from English speaking backgrounds and most came from inner Sydney.

The method chosen was theorised life history which allows the experience, injecting drug use, to be scrutinised for its underlying structure. The participants were interviewed using a semi-structured schedule. In the analysis, the processes of the construction of injecting drug use and the meanings of the practices associated with drug use are examined.

It is important to note that in the following discussion of the processes which constitute functional drug use, our interpretation is based on the data from a small number of interviews. These processes, as captured in our analysis and as outlined below, are social processes and are generalisable as such.

The sample of injecting drug users who were interviewed in conjunction with this study confirmed the existence of functional drug users. Our early working definition of functional injecting drug user was elaborated in response to the literature review and our empirical findings, as discussed in section 2(b). I n this report we define functionality as follows: a pattern of drug use which is stable or non-disruptive, and reproducible within a socially patterned mode of existence. The remainder of the executive summary concerns the processes which constitute functional drug use discussed in Sections 3, 4, 5 and Appendix 1.

The sample of drug users was remarkable because of its variety. The only two things that the individual drug users had in common were their drug use and their experience of stigma. There was considerable variation with respect to social background, family and occupational history; and sexual preference and practice. There was variety, too, in their general drug histories, although for most their initiation was in their teenage years. With regard to current usage, while for most there is a stable and sustainable pattern of use, there are some differences amongst the users. Some are dissatisfied with their drug use because of drug related problems such as fear of acquiring a habit, while others enjoy it and have no wish to change their pattern of use.

What is important to recognise is that functionality itself changes. The patterns of drug use change as life circumstances change. The data indicate that people move from functionality to dysfunctionality and back again. Among those who can be currently classified as having a stable and sustainable pattern of drug use, there are those who report previous periods on instability. Some drift between periods where everything seems to be under control to periods of states of disequilibrium. We have called these 'drifters'. Our sample also contains another category of user - the 'would-be abstainer'. These drug users have come to the view that the benefits of drug use do not justify the hassles involved. The sample also included some whose pattern of drug use did not appear to be sustainable without major problems--dysfunctional users.   1 n other words, the characteristics of a 'successful' or 'unsuccessful' user are not to be found in the user him or herself. Rather the characteristics of functionality or dysfunctionaiity are to be found in the social contexts of people's lives. Drug use is to be understood in social and structural terms.

It is the social structuring which provides the means by which users maintain a stable pattern of use, that is, remain functional users. The majority of functional users could be distinguished from a minority who were experiencing difficulties in terms of the social context of their drug use, and those with problems related to drug use were much more likely to inject alone.

For most of the respondents drug use is integrated into a range of subcultural practices.   Most of the expressed motives for using relate to typical experiential features of the lives of users and non-users alike: the desire for fun and recreation, the need to be able to relax, cope with work, or have a good sex life. Drugs are used for having fun at parties, to wind down after a weeks work with a close friend, with a lover to enhance sexual excitement.

Initiation typically takes place within a friendship group or network, in a context of trust.   Almost all of the respondents were initiated after a prior history of other drug taking involving considerable experimentation with a range of drugs. With all of them their injecting use occurred as a result of social contacts with other users. Injecting successfully requires tuition from others already experienced in the rituals of drug preparation and the use of needle and syringe. There is a great deal of trust placed by the initiate in those carrying out the tuition. They learn the rules and rituals which, in general, make for 'safe' procurement, drug administration and use, and disposal.

Knowledge associated with drug use includes knowledge of HIV transmission. No one in the sample was ignorant of the prohibition of sharing needles. In situations where sharing occurred, other rules which minimised harm to self and others came into effect. Needles were cleaned and those few in the sample who were HIV antibody positive claimed always to use last. On the other hand, there was a tendency to rely on the safety of the people one knew, and few in the sample practised safe sex.

While stressing the importance of subcultural practices and the social structuring of drug use, it is important to recognise that there is not a_ functional drug sub-culture or, for that matter, any number of functional drug sub-cultures. Most in our sample have non-using friends and they are involved in overlapping subcultures. The geographical location of our sample indicates small pockets of friendship networks whose interconnections are, in terms of face-to-face encounters, minimal. Only networks of dealers connect them but these are often invisible to most users. There is also little evidence that the subcultures, to which our respondents individually belong, are articulated to broader structures of community affiliation.

These same social structures provide for individual safety and support via a collective responsibility for drug taking. There is safety in the social structuring of regulations and rituals which enable and to some degree, constitute injecting drug use.

Injecting drug use is risky, and risky in a number of ways. Danger is associated with injecting drug use. Not only is it deemed illegal, but its use is related to playing with the unfamiliar and the unpredictable, transcending the ordinary, and to some degree letting go of personal control. The impact of any particular drug depends, to some degree, on the context in which it is used far more than the specific pharmacological properties of the drug itself. The impact of the drug and the meaning of the experience to the user is socially constructed.

Ritualised and regulated practice allows for loss of personal control, for flirting with danger, within a safety net of support. Respondents in the sample provided a great deal of evidence of rule following and planning behaviour. A central theme through the data was a desire to remain in control and not let their drug use get out of hand or take over the user's life.

Those who seemed to have most control applied a wide range of rules and control strategies. Users' rules centred around general issues such that the following responsibilities were met and life patterns maintained:
- financial commitments
- work schedules
- relationships with friends
- relationships with partner and family.

Rules and rituals applied also to drug use. Rules focused on the frequency of use, physical location, social context of use, procurement of syringes, disposal of equipment and ways of approaching dealers. Still other rules applied to actual administration, and these were the most highly ritualised. These were:
- procedures to test drug quality - rituals to avoid overdosing
- rituals to avoid drug ingestion difficulties - rules for dealing with emergencies
- the mechanics of drug preparation
- rules regarding tidying up of equipment
- the order in which users inject
- status hierarchies among participants
- appropriate roles for those of HIV status

Rules are sometimes broken. This depends on a variety of factors: the spontaneity of the moment or excessive desire for the drugs, an atmosphere of light hearted conviviality, polydrug use and its effect on dropping one's guard, or some chance happening which prohibits forward precautions. But the occasional rule breakage does not detract from an obvious desire to adhere to the rules and the recognition that not to do so is foolish and likely to precipitate a downward slide into drug dependency.

Clearly injecting drug use is not an unstructured affair, but a highly complex patterned and regulated institutionalised set of practices. The very lack of structure in the experience of drug use demands a highly structured context. One which is intensely social.

Our discussion of rules and planning behaviour recognises that most in the sample are already engaged in risk reduction behaviour. Harm reduction and the construction of a hierarchy of risks with respect to drug use in education campaigns, however, may result in stigmatising the injecting drug user and may delegitimate his/her own knowledge regarding the satisfactions of safe using. Both harm minimisation and risk reduction are concepts suffuse with negativity.

In general, those in our sample may be distinguished from non-drug users in two ways.   The first thing that distinguishes them is that drug use helps them to achieve their ends - relationships, recreation, work,

relaxation, etc. For some it is injecting drugs, for others alcohol which serves a similar purpose.

Alcohol use, however, is not illegal. The second thing that distinguishes drug users from others in our society is the stigma attached to such use. All participants in our study are affected by the illicit nature of their activity.

Illegality does not only affect the respondents directly in the sense that they fear encounters with the law.   It produces secondary consequences in that choices regarding the conditions under which drugs are procured and used are affected. The overall outcome works against safe use; stigma imposes strains on the conditions of use, the social patterns of people's lives in which drug use is situated and integrated. Stigmatisation has an uncanny tendency to be internalised, affecting self image, motivation and disrupting social skews the conditions under which injecting occurs such that unsafe using becomes more likely.

The financial as well as the psychological costs of illegality are high. Supply restrictions force up the price of drugs, leaving our users dependent not only on artificially inflated prices but on possibly contaminated supplies, often dubious business practices and the fear of the law.

Respondents in the sample comment on the need to use in physical locations away from the eyes of disapproving others. There is an overwhelming preference for sites defined as safe where there is control over the circumstances of use. Unsafe use, however, does occur. Unsafe injecting locations are not frequently individually chosen, they come about as a result of social negotiation and are a function of the social milieu of the user as well as of the spontaneous social pressures emergent in each specific situation.   Unpreparedness often means no ample supply of needles, no facilities for cleaning, and an atmosphere not conducive to safety.

Although ease of needle procurement has increased safe use, obtaining needles is bedevilled by the illicit nature of the practice. Pharmacists are preferred by the less regular user; pharmacies are seen as more anonymous and less stigmatising than the needle exchange. Some respondents complained of what they see as too many gatekeepers at the needle exchanges. A few complained of the difficulties of procuring clean needles at night.

Illegality prohibits the transmission of honest, scientifically accurate, explicit information about drugs and safe drug use. It leads to counterproductive educational messages being transmitted particularly in schools--the most urgent locale for AIDS education, given the age at which drug and sexual practice is initiated.

The stigma attached to illegal use inhibits those who need and seek help. All the respondents define 'junkies', the addict, in negative terms, even those who admit to the term themselves. Most, however, reject the term applying the 'junkie' label to those whose lives are seen as having been taken over by drugs, to those who are no longer seen as capable of acting responsibly.

Decriminalisation is long overdue. Drug abuse and not drug ingestion is the problem.   This is the single most important challenge.

Recommendations:

1.   The evidence from this research project supports the recommendation of the National AIDS Strategy for changes to the legal regulation of injecting drug use. The continuing illegality of injecting drug use is counterproductive, among other things, to the prevention of H I V transmission.

2.   The dominant conceptualisation in this society of drug use as 'dysfunctional' is not borne out by this research. Recognition of functional drug use is crucial to the reformulation of policy and programs in the drug use area. Such recognition will reduce stigmatisation which inhibits the reach of programs to functional drug users in particular. We recommend the targeting of education programs directly to functional drug users.

3.    Treatment programs and agencies require training to sensitise them to the existence and nature of functional drug use in order for them to develop appropriate programs.

4.   Research indicates that functional drug use is socially constituted through a variety of practices, relationships, rituals and symbols. It is important for drug programs to pursue a 'normalisation' of the social dynamics of injecting drug use in order to create a climate in which educational messages can be effective.

5.    Intervention programs should exploit the ritualistic components of functional injecting drug use in the design of educational messages.

6.    Within such 'normalisation', educational programs for school-aged youth are vital. These programs need to present drug use in the light of the existence of functional drug use.

7.    I n addition to the above, educational messages about needle sharing and safe use should exploit the interpersonal relationships of functional injecting drug use. The relationship between safe needle and syringe use and safe sex needs to be emphasised - with casual and regular partners.

8.   Our research also indicates that 'petty dealers' may be useful in providing informal HIV prevention education among their own networks and in their own areas. We recommend the trialing of a program of mobilising these dealers as AIDS prevention agents.

9.   Patterns of needle and syringe procurement among functional drug users indicate that procurement needs to be made more ordinary, subject to less scrutiny and easier to access, for example, the use of automatic dispensers and more varied disposal methods should be tried. These initiatives, however, should not be a substitute for effective education programs.

10.   We recommend that needle and syringe manufacturers be approached to produce simple colour-coded syringes for easy identification of individual user's equipment.

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