“Hooked on the needle”: Exploring the paradoxical attractions towards injecting drug use

Abstract

Injecting drug use is one of the leading risk factors for infections and drug-related deaths. Despite these risks, many people who inject drugs (PWID) continue to inject despite access to alternative intake methods. In this study, we explore this seemingly paradoxical attraction. We conducted 80 qualitative interviews with PWID, recruited from low threshold settings in five Norwegian cities, where we focus on the process of injection initiation and why PWID maintain such behaviour over time, despite associated negative consequences. The analysis shows how participants’ experiences evolved from a fear of the needle, to embracing it as a meaningful practice. First, this involved social interaction and learning from other PWID, second, appreciating the intensity and speed of the intoxication, third, the positive ritual aspect of injecting, and finally, a devaluation of other modes of use. The study thereby helps expand upon and provide new understandings of the interactional process and cultural context of drug use, in which the interplay of social factors influences individual actions and promotes injecting over other modes of use. Future interventions for reducing the number of PWID thus need to consider how various social contexts impinge on, or even encourage, injecting drug use.

Keywords:

• Injecting drug use
• social interaction
• risk
• qualitative interviews

Introduction

Injecting drug use is one of the leading risk factors for blood-borne infections, such as HIV and hepatitis C, and drug-related deaths (Degenhardt et al., 2011; Mathers et al., 2013). Despite these elevated risks, injection is still the preferred mode of use among many opioid and stimulant users (Degenhardt et al., 2017; EMCDDA, 2020), with an estimate of 11.3 million injecting drug users worldwide (UNODC., 2020). While epidemiological studies have provided a valuable overview of the practice and of the degree of associated risks (Rhodes et al., 2001), a growing body of qualitative literature shows that injecting drug use involves distinct meanings, shaped by social and structural factors (Guise et al., 2017). These perspectives offer an in-depth exploration of how injection initiation is experienced, the meanings and identities it can bring, and how initiation is shaped by contextual factors (Neale et al., 2005). Such perspectives also highlight the ‘normalization’ of drug injecting within particular social networks (Rhodes et al., 2011; Roy et al., 2008), which, over time, lead to new social roles and identities bound to injecting (Fitzgerald et al., 1999). These mechanisms may help explain the limited effectiveness of interventions that aim to prevent injecting drug use (Werb et al., 2013).

In addition to health risks, injecting drug use is also associated with an increased risk of abscesses and skin infections due to contaminated needles and incorrect injection routines (Phillips et al., 2012). Injecting drugs is also associated with a high degree of stigma which may contribute to economic and social problems, such as less access to employment, social exclusion and psychological problems (Lloyd, 2013; Simmonds & Coomber, 2009). Despite these well-known risks, the practice of injecting drug use may however be sustained by subjective logic that rationalizes risky behaviour (Mayock, 2005), by which PWID see injection as an acceptable, and even desirable, route of administration (Harocopos et al., 2009).

Following such a perspective, drug injecting also involves a certain level of autonomy, by which actors are attracted to such scenes by a desire for excitement, independence and belonging (Fast et al., 2009). As such, the individual trajectories towards injecting drug use unfold alongside dynamic and changing perceptions of risks that are relational and socially contingent (Mayock, 2005). These insights have led to an increasing focus on ecological approaches that seek to understand the ways in which structures, social processes and physical environments of drug scenes contribute to shaping risk among drug-using populations (Fast et al., 2009; Rhodes, 2002; Strathdee et al., 1997).

As Rhodes and colleagues (2011) argue, there is a large body of epidemiological research emphasizing individual-level factors in explaining initiation to injecting drug use, such as childhood and educational experience, early initiation to non-injecting drug use, and risk perceptions and practices. Without undermining the value of such epidemiological perspectives, they tend to highlight the importance of context, in which initiation to injecting drug use is also a process bound to social interactions (Rhodes et al., 2011). As such, the importance of peers and social networks is accentuated (Harocopos et al., 2009; Roy et al., 2008; Small et al., 2009), where the transition to injecting drug use involves a combination of social exposure, social influence and social learning (Sherman et al., 2002; Stillwell et al., 1999; Witteveen et al., 2006). These perspectives highlight how the paradoxical attractions towards injecting drug use are embedded within drug-using milieus, resulting from a social process enabled and constrained by socio-structural factors, in which the meanings associated with injections evolve through interaction (Guise et al., 2017). This invites further discussion of social interactionist theory and how it may inform an analysis of such drug-using behaviour.

A social interactionist perspective on injecting drug use

The concept of social interactionism places emphasis on the socially situated nature of individual action, and strives to describe the meanings and practices that persons produce when they do things together (Denzin, 1992). In his seminal conceptualization, Blumer (1969) argues that people act towards things on the basis of the meanings they apply to them. Importantly, such meanings are not ready-made, but rather derived from social interaction, in which actors modify and develop such meanings through an interpretive process (Blumer, 1969, p. 2). In its crudest form, the analytical focus of social interactionism is therefore to explore the processes by which individual behaviour is shaped through socialization (Battjes, 1984).

Following such a perspective, drug use may be viewed as a social behaviour that involves interactions such as buying and selling drugs, needles and paraphernalia, sharing injection equipment and using in places where other PWID gather (Kumar et al., 2016). This social context may thus influence and alter the perspectives of those involved, in which PWID learn important norms and rules, as well as acquire knowledge, which may be technical and practical, but also more emotionally anchored or embodied (Lalander, 2012; Richert, 2015). The initiation of the self into drug use is therefore a process derived from social interactions occurring in specific contexts (Rhodes et al., 2011). The identity transition associated with injecting drugs thus involves a process of becoming and constitutes a transition to a new symbolic identity (Järvinen & Ravn, 2011; Martin, 2010). The perspective of social interactionism thereby seeks to understand the social meanings, experiences and contexts of risk behaviour (Rhodes et al., 2001), and highlight the social environments and complex social negotiations that promote injecting drug use (Guise et al., 2017; Mayock, 2005; Sherman et al., 2002).

In this study, we employ such a social interactionist perspective and explore the narratives of a large group of PWID in Norway – a country in Europe with a relatively high and stable drug-induced death rate. In 2020 the rate was 6,1 per 100 000 inhabitants (EMCDDA, 2020; Gjersing, 2020). Our aim is to explore the various attractions towards injecting drug use, and how such practices are rationalized and sustained over time, despite the associated negative consequences. This study thereby provides not only insight in the complex trajectories towards injecting drug use, but also the various ways in which such behaviour is embedded with meaning and how it may help understand the seemingly paradoxical attractions towards injecting drug use. The intention of the paper is therefore not to explore the risks related to injecting drug use, but rather to understand the participant’s experiences of injecting. This knowledge should help inform future harm reduction interventions targeting PWID.

Methods

The study draws on qualitative interviews with 80 PWID, recruited from low-threshold services in five Norwegian cities. Interviewees were on average 45 years old (range 23–63) and 77% were males; the sample reflects the overall population of people who inject drugs in Norway (Gjersing & Bretteville‐Jensen, 2018). Majority of interviewees injected drugs on a daily basis. A total of 71% of the sample used multiple substances (mainly combinations of heroin, amphetamines and benzodiazepines), 19% mainly used amphetamines, and heroin was the main drug of choice for 10%.

Voluntary interviews were conducted during October 2019 and interviewees were recruited at low-threshold services such as health and social services, needle exchange programmes, homeless shelters, emergency food assistance programmes and drug consumption rooms. The services received information about the project in advance and informed PWID in order to motivate participation. Whilst most of the interviewees were recruited by service staff when researchers were present, some interviewees were recruited through snowball sampling or by the researchers themselves. Three researchers (first, second and third author) and two trained research assistants conducted the interviews. In order to create an atmosphere where the interviewees could talk freely and undisturbed, interviews were conducted in private spaces.

Qualitative research interviews were chosen in order to understand the lived experiences of PWID themselves. The interviews were semi-structured and open-ended, and we used an interview guide in order to ensure that key topics were covered. This guide included questions about topics such as thoughts on injections before injection initiation, positive and negative experiences with injecting drug use as well as experiences with other intake methods. The interviews lasted between 25–60 min, with an average of 45 min. Prior to gaining informed consent, we assessed individuals’ level of intoxication, including their potential to provide informed consent and participate. We terminated two interviews, however, because we deemed it would be inappropriate and unethical to proceed, given the participants’ heavy intoxication or poor mental health.

The interviews were recorded and transcribed verbatim. The analytic software tool HyperRESEARCH was used to systematically code the data. In total, 25% of the interviews were coded by two researchers to ensure sound interpretation and shared understanding of the data. Transcripts from the interviews were thematically coded and included a broad range of codes, such as reflections and narratives on injection initiation, risk and risk-prevention strategies and perceptions on injecting drug use, as well as other modes of use. Topics that emerged from the fine reading of the interviews were supplemented to the code list, finally consisting of 34 codes in total. As the topic of interest in the current study involved an investigation of the possible attractions towards injecting drug use, we focused the further analysis on the stories that were relevant to understand their prolonged careers as PWID, such as memories of their first injections, positive and negative drug effects, as well as detailed descriptions and how they prepared and injected drugs. All quotes in the relevant codes were then reanalysed, and helped identify common themes that led to the classification into the four main categories presented in the results: social interaction and learning from other PWID, appreciating the intensity and speed of the intoxication, the positive ritual aspects of injecting, and devaluation of other modes of use.

The project was approved by the Regional Committee for Medical and Health Research Ethics in Norway (REK). All interviewees were reimbursed NOK 200 (approximately 20 €) for their time, any identifiable information has been anonymized and the interviewees are referred to by pseudonyms.

Results

The analyses revealed a process in which participants evolved from being afraid of injecting drug use, to embracing it as their preferred mode of use. This process involved social interaction with more experienced peers and transfer of knowledge, an acquired appreciation of the rapid and intense sensation following drug injection, development of positive rituals involved in the injecting behaviour, as well as negative experiences or perceptions with other modes of use. The analysis thereby highlights the paradoxical attractions associated with injecting drug use and why PWID sustain such behaviour over time, despite the associated negative consequences.

Social interaction and learning from other PWID

Most interviewees described having had negative attitudes towards injecting drug use prior to their first injection. They associated it with uncleanliness, diseases and overdoses, and perceived that injections could lead to greater addiction and make it increasingly difficult to quit. Several also spoke of a fear of needles. In these narratives, they expressed deep concerns about injecting, about the breaking of barriers required to transition to injecting, and described it as a practice they would never initiate. Karl explained:

I was afraid of everything that could go wrong. To push something in and maybe get acute blood poisoning – in a flash you’re so ill that you can’t account for yourself. I was afraid to do it.

Despite their initial fears, the interviewees spent time in social milieus where injecting drug use was widespread. Drugs were prepared, injected and the effects were observed, communicated and vividly described among their peers. Over time, by observing and interacting with other people using drugs, the interviewees described how they successively learned technical as well as practical skills for injecting. Kari, who used multiple substances, spoke of an initial fear of needles. Yet, by watching her friend inject, she described how she acquired practical knowledge – a process that helped diminish her fears:

I actually had a fear of needles. Everyone said “you, who had a fear of needles, ended up as an injecting drug addict!” But it’s different when you do it yourself. I kept a close eye on what my friend did, how he prepped it and stuff, and what he did when he was shooting. So, I sat alone, and there was no trouble, just boom and I made it on the first try.

In Kari’s account, the informal process, in which she observed peers who injected, was an effective way of learning the necessary techniques to control her fears. As such, her everyday interactions among PWID facilitated a social platform for learning, in which the practical knowledge associated with injections was passed on. Others spoke of a similar process, and Asbjørn, who injected amphetamines on a daily basis, described how injecting was the norm within their social environment with drug-using peers:

I was one of the boys and had joined the gang. It was a bit like, if you were going to use drugs, you had to inject it. You were told, that’s the way to do it. There was only one way.

Asbjørn’s quote illustrates how injections were taken for granted within the drug scenes. Karl expressed it similarly and recounted the stories he was told when he initially entered the milieu: ‘Well, it was the typical story, you know, that you get a kick out of it and that it’s a lot stronger’. As such, the shared valuation of the effects was vividly described as well as explicitly recommended by peers. Similarly, Stig was told that: ‘You have to try this!’ Thus, norms of use and shared knowledge about the drugs’ effects were communicated within the participants’ environments. In this way, injecting drug use was normalized and can be described as habituated within the users’ social relations.

As well as verbal communication from drug using peers who explicitly expressed the benefits of injecting, the interviewees also described a more emotional and embodied communication stemming from the observable effects of injections. By spending time in an environment where injecting drug use was widespread, they grew curious about the effects. Mona explained: ‘Everyone told me how good it was, and I had seen others shoot. It looked like they felt good.’

Although the effects of injecting had been observed and described to them by other PWID, the effect was not immediately apparent. As such, the interviewees said that they needed to learn how to interpret the effects in order to value and experience them in ‘the right way’. Mathias recounted that he was disappointed after his first injection. However, after spending time with PWID, he described how he learned to recognize and enjoy the effects:

I had expectations that something great would happen, that I would get very high. I just didn’t quite understand it. But I did eventually, though.

Mathias’s story exemplifies the importance of expectations in the PWID’s initiations to injecting. Their observations and daily encounters with peers created a basis for anticipation, in which the effects of injecting were presented as pleasurable. However, this also involved learning how to interpret the effects and how to value injections as opposed to other modes of drug use.

The narratives presented among the interviewees indicate how their perceptions of injecting drug use evolved through social interaction. From deep concerns about the possible negative effects, they successively learned how to value injecting as pleasurable. These benefits were learned by interaction and illustrate the users’ socialization into a culture of drug use where drug injections were the preferred method of use. As such, their stories highlight the importance of the social context of drug use, and how it may influence and alter the perspectives of those involved.

The rapid and intense sensations of the high

The stories presented by the interviewees were not only related to the social contexts of drug use, but also highlighted the importance of the pleasurable effects stemming from injections. Oscar had injected drugs since his early teens and described the beneficial sensations of injecting: ‘It’s nothing positive besides the high – it’s just so damn good. That’s why I am unable to stop.’ As such, the stories of the immediate and intense effects that were initially conveyed when the interviewees first entered the scenes were increasingly embodied through their own injecting experiences.

Hanne had injected drugs for over 15 years and still vividly described the attractions injections had for her:

It’s the immediate effect. You get it right away, as quick as possible. I’ve been screaming out: “OOOH, that’s GREAT! This is better than an orgasm!” So, I would say that an orgasm is second place, a good shot of heroin is always number one [laughs].

Similar to Hanne’s account, the interviewees spoke of injecting as a way to maximize the effects from the drugs, usually described in terms of a kick, euphoria, rush, orgasm or intensity. Oyvind explained:

I only inject drugs. The rush comes right away. It takes 7-10-12 seconds and then you feel the kick. That’s the main reason: the kick.

Several interviewees emphasized the intense effects of injections. However, after years of injecting drug use, the participants described difficulties finding a vein for injection, as well as increased tolerance and withdrawal symptoms. Although some interviewees explained that they still felt and desired the intense rush, injecting drugs was also an immediate means to relieve withdrawal symptoms and ‘get well’. Hakon explained: ‘It’s the fact that it works in an instant. That you get well right away.’

Similarly, Roger explained that he consumed drugs both orally and by injections. Although he believed that the level of intoxication could be the same, he preferred injections to ‘get well’ and explained it by the speed of the effect:

You get well a lot faster. So [when taking the drugs orally], you have to wait 15 min, or half an hour. The best about injecting… It’s just the immediate effect if you’re sick.

Stories about being ‘sick’ and ‘getting well’ were repeated during the interviews, and implied injecting in order to stabilize and relieve withdrawal symptoms. Marie described an overwhelming feeling of comfort when she experienced withdrawal symptoms and injected drugs:

It’s a joy. The euphoria when you’re standing there [in front of the stove boiling pills with water], and get it into your veins and you get well. You get a kick and…oooh, it feels so good when you’re sick!

As well as withdrawal symptoms, injecting drugs was also perceived to relieve other types of discomfort or pains. These kinds of pains were often related to physical or emotional discomfort. Thomas struggled with physical pain from an accident some years ago. Although he had previously consumed painkillers orally, he explained his attraction towards injecting due to its instant pain-relieving effects. Others expressed the instant relief of emotional pain in terms of peace, numbness or protection from emotions. Arne described it as follows: ‘I don’t want to overdose, but to get the best high you almost have to tip over to an overdose’. This was usually referred to as ‘the head on the table’ and implied a level of intoxication in which they were heavily asleep, almost on the edge of an overdose. Oscar elaborated:

Preferably right on the edge of overdose, where you sit and you’re almost dying. Then you’re comfortably numb. Everything is comfortable, you’re good and warm and relaxed. There are no stress factors in the universe. You just withdraw into yourself, and then you’re just in a cotton bubble.

To sum up, the interviewees highlighted the rapid onset, the effective and intense sensations, as well as the pleasurable relief associated with injecting the drugs. Whether to feel the intense euphoria of the kick, or the pleasure and relief of discomfort or pain, the speed and the intensity of the effect were presented as key to understanding the users’ continued injecting practices. Accordingly, the narratives that initially influenced their initiation to injecting were increasingly embodied and served to explain their prolonged careers as PWID.

The ritual aspects of injecting

The pleasures associated with injections were however not limited to their intoxicating effects. During interviews, the importance of rituals emerged when participants spoke about their injecting practices. This involved specific ways of organizing the injecting ritual, and they were usually detailed and covered numerous steps that served to maximize the drug’s effects. Oyvind described his routine as follows:

I have a ritual. First, I drink one litre of water. Then I eat a good bowl of oatmeal, and everything is clean and nice around me. Then I put the equipment there, and then I put the drugs there. At that point I have complete peace.

The quote illustrates how the use of drugs was performed in a fixed and ordered manner, both in terms of the administration of the drug as well as selection of the physical and private setting for use; peace and concentration, secluded from the outside world. Einar described it similarly:

I went to the pharmacy and picked up Dolcontin [prescription opioid], and then I went home to cook it. If you cook it long enough, it turns yellow, then it turns a little greenish, and then you put the Dolcontin in and boil it and make sure everything is just right. Not too much water and not too little. A little ritual, every morning, almost like a kind of breakfast.

The latter quote indicates an instrumental function of the ritual; by preparing and administering the drug in certain ways, it maximized the benefit. Although some interviewees described rituals as personalized, like Hanne: ‘It’s your thing. Or if we’re together, it’s our thing’, rituals were in general perceived to be common among the interviewees, mastered through practice as well as by observing and learning from experienced PWID.

The interviewees believed rituals to be a central aspect of injecting, mainly described in positive terms such as expectations, joy, peace or excitement. Mathias explained: ‘A part of the enjoyment is the rituals’. Some interviewees described the whole ritual as being a meaningful part of injecting drugs, while others highlighted different parts of the injecting process as important. They highlighted the peaceful surroundings which promoted being calm and concentrated, the cooking and preparation of the drugs, as well as observing the blood mixing with the drug in the syringe, indicating that they had hit a vein, usually referred to as ‘the answer’ as Fredrik explained:

When you inject, you get the answer when you stick the needle into a vein and you see the blood coming into the syringe – that’s a kick in itself. I’m not the only one saying that.

Some explained how they perceived themselves to be addicted to the ritual as well as the drugs. Synne had consumed drugs by several modes of use, such as smoking heroin, but preferred injecting. When asked about her perceptions of injecting, she mentioned the speed of the effect, but also described how she felt addicted to the process of preparing the drugs for injection. She perceived the effect of the drugs as diminished without performing what she referred to as a ritual. Her reflection indicates how the ritual symbolized a positive outcome of the injection process:

It’s not the same when you get something that’s already prepared. I guess it has something to do with my expectations, you know, it kind of builds up and I’m thinking “now I’m going to do it”. I’m almost playing myself up a bit.

Synne’s story exemplifies the importance of rituals for injecting drug use, in which the meaning of the ritual and the emotions it gave rise to seemed just as important as the drug itself. This further illustrates how experiences of the effects were influenced by expectations and pharmacology, where rituals served as a blend of both instrumental and symbolic meanings.

However, the interviewees described the use of needles to be the most important part of their ritual and perceived themselves to be addicted to the needle, referred to by the interviewees as ‘hooked on the needle’. Einar explained:

It turns into a ritual that you get addicted to. You get really needle-horny. You want to consume everything with a needle.

After years of injecting, Trygve had increasing difficulties finding veins. Yet, he found it difficult to consume drugs by other modes of use and explained it by being addicted to the needle as well as the drugs. If he was without access to needles, he said that he would save the drug rather than consume it by another method:

If I don’t have any equipment, I don’t bother to sniff it. I can have half a gram for a day or two, until I get hold of the equipment. If I don’t have any equipment, I’m less likely to use drugs.

Several interviewees echoed Trygve’s experiences. Hege said that she preferred to inject pills and heroin separately, in order to perform two injections instead of one. Others described how they would happily inject water if they did not have access to drugs, in order to experience the act of injecting. Mathias explained:

You almost get addicted to the needle. You can inject water just to get a shot. It feels like an itch in the veins, that you have to have it now. I have injected water 2–3 times and I’m not the only one.

Overall, the ritual aspect of injecting, as has been highlighted above, seemed to be a central part of the participants’ practices. The ritual as a whole, or different parts of it, were described as an addiction in its own right, mainly in relation to the needle, in terms of satisfaction, calmness and concentration, indicating how the ritual symbolized a positive outcome of the injection process. As such, the interviewees described the ritual aspects of injecting drugs as addictive in themselves, influenced by perceptions, representations and the anticipation of injecting drugs.

Devaluation of other modes of use

Although injection was the preferred method of use among the interviewees, they had still consumed drugs by other modes of use, such as sniffing, smoking, drinking or by taking it orally. This was either prior to their injection initiation or if they had difficulties finding veins. However, amongst these participants, they all went back to injecting. Their narratives usually involved a devaluation of other modes of use.

A central factor expressed was the perception of injecting as more cost-effective compared to other modes of use. Bjorn had both smoked and injected heroin. When asked if he had considered switching from injecting to smoking, he explained the cost-effectiveness of injecting over smoking: ‘You need a lot more [drugs] and it’s more expensive. I can use 0.1 grams, and it makes me well. If I smoke it, I would have to use a lot more.’ Some interviewees recounted they were advised by peers about the cost-effectiveness of injecting. Although injecting involved more frequent use, it was perceived to be more economical in terms of lack of waste. Gunnar said that he had tried smoking heroin, but perceived it to literally ‘go up in smoke’. He explained:

It’s about the small amounts. 0.25 [grams], that’s quite a small amount, and if you smoke it, a lot of it disappears in smoke. But, when you throw it all [the ingredients for preparing heroin for injection] in a cooker with water to boil it, then all of it stays there. So, there’s all of these factors that make you prefer injections.

Another devaluating factor concerned negative experiences of other modes of use, particularly heroin smoking or snorting amphetamine. Interviewees associated smoking heroin with nausea from the smell or taste, and thus preferred injections. Synne explained: ‘Some people smoke it. I almost get nauseous just by the taste and smell of it.’ Others described dental problems or nasal ulcers associated with frequent amphetamine snorting. In combination with advice from peers, they described harms from other modes of use to be one of the main reasons for continuing to inject. Dag used to snort amphetamine but switched to injecting due to the negative effects from snorting: ‘I noticed that after I had sniffed a lot, my nose, throat and stomach got ruined.’ Whilst some of the devaluating narratives were described as personal experiences, others were based on information from other PWID. Stig explained: ‘I know people who have had stomach ulcers and ulcers in the intestines and stuff. So, I don’t think it’s any better.’ Hege elaborated similarly:

Smoking, yuck. I’ve never tried it, but I couldn’t imagine it, either. Because of the taste. I started sniffing and it ruined my nose. I just got wounds and a lot of shit, so I stopped. I was afraid that I was going to get a stomach ulcer. So, the cleanest and best thing is to take it intravenously. That’s what they say.

Hege’s story further illustrates the assumptions of the interviewees. Based on information from other PWID, injecting drug use was perceived to be the cleanest, in terms of avoiding bacteria and impurities in the drugs with subsequent health harms. Thus, injecting was not perceived as more harmful than other modes of use.

Additionally, the interviewees who devaluated other modes of use highlighted their lack of skills, especially related to smoking heroin. Although some spoke of the positive effects of smoking heroin, such as less stigmatization and a high that enabled them to appear more ‘normal’, they had lower skills in smoking compared to injecting. The latter was, to a large degree, associated with self-confidence and status. Petter explained:

I’ve never had the patience to learn the technique properly. I see that there’s many who master it properly. If you learn to do it, it’s probably a good way to do it.

Interviewees highlighted the practical knowledge needed to consume drugs and explained their long-term injecting drug use partly by lack of skills in other modes of use, such as smoking heroin. Trygve said:

I’ve used heroin for 30 years and I’ve hardly smoked, it’s crazy. I can’t make it flow properly. It shouldn’t be that hard. You just put a little bit on top there and then you just [inhale] (…) It’s not out of the question [to smoke], I guess you just have to learn it.

To sum up, the interviewees spoke negatively about other modes of use and upheld positive views about injecting. Although most of them had less experience with other modes of use, they relied on the socially circulating stories within the drug scenes when denoting the negative consequences of smoking or sniffing drugs. This perspective was fuelled by their sensitivity to economic factors and lack of skills in these alternative methods of consumption, which caused a fear of not maximizing the effects of the drugs they bought. Importantly, these stories were intrinsically bound to their socialization within a user culture that favoured drug injection over other modes of use, highlighting the embodied knowledge, cultural norms and practical skills that guided their ways of doing drugs. As such, the social processes and physical environments of the drug scenes contributed to shaping their risk behaviour, by which they viewed injection as an acceptable and desirable route of administration.

Discussion

This study highlights the complex range of attractions towards injecting drug use. Based on an extensive number of interviews with PWID, the analyses show how these attractions involved social interaction and learning from other PWID, appreciating the rapid and intense sensation of injecting, a positive ritual aspect, as well as devaluation of other modes of use. However, the interviewees’ accounts illustrated how their perceptions had evolved over time. They described having had feelings of anxiety and negative beliefs associated with injecting when they first started. After a while, they increasingly perceived injecting as constructive and valued. Whilst the participants accounted for a variety of social and physical harms due to their drug-using practices, the analysis demonstrates the paradoxical attractions of injecting drug use, in which the interviewees evolved from fearing the needle, to embracing it as a valued mode of use.

These evolving attitudes highlight the importance of social influences in PWID perceptions and negotiations of risks. While most of the interviewees acknowledged the dangers associated with their injecting practices, they were still heavily influenced by peers when addressing their initial trajectories and describing the pleasures they associated with injecting. As such, they had learned how to value injecting, despite their initial fears, and their interactions with drug-using peers enabled the acquisition of both technical skills and a more embodied knowledge that influenced their perceptions of risks and pleasure.

Similarly, Lalander (2001) describes drug use as a social process where experience and knowledge are internalized through social networks and embodied experiences, emphasizing the importance of a common habitus. Small et al. (2009) also demonstrate how injecting is heavily influenced by socially constructed perceptions, developed through social relationships with other PWID rather than a rational calculation of risks. Perceptions of risks are therefore relational and socially contingent, fuelled by subjective logic that rationalizes risky behaviour (Mayock, 2005). The paradoxical attractions of injecting drug use are thus highly embedded in the social processes and physical environments of drug scenes, which contribute to shaping risk among drug-using populations (Fast et al., 2009; Rhodes, 2002; Strathdee et al., 1997). Such ecological perspectives thereby shift the unit of focus from individual risk factors, to social, political, and economic factors, as well as the importance of physical environments and how they interact with personal characteristics to determine health (Burris et al., 2004; Rhodes et al., 2005). As Duff (2007) argues, this is not to ignore the significance of choice and responsibility, but rather to emphasise how drug use behaviours are also shaped and transformed by contextual factors, and not least how they are rooted within shared social and symbolic meanings.

Findings highlight the participants’ appreciation of the immediate and intense effects produced by injecting and this appeared to be key to understanding their sustained injecting careers. Similar associations have also been found in several other studies (Crofts et al., 1996; Fitzgerald et al., 1999; Goldsamt et al., 2010; Stillwell et al., 1999), and it is suggested that the promise and experience of a rush are particularly important for initiation to injecting drug use (Fitzgerald et al., 1999). We found that participants’ stories of the immediate and intense effects that were initially conveyed when the PWID first entered the scenes were increasingly embodied through their own descriptions. Accordingly, the shared perspectives on the attractiveness of the effects, and the stories that sustained them, helped provide narratives and contributed to shaping conceptions of injecting as meaningful and pleasurable (Khobzi et al., 2009; Lalander, 2001).

However, the attractive effects of injections had not been immediately apparent among the interviewees and some expressed a need to learn how to interpret these effects in ‘the right way’. Similar findings have been suggested by several scholars, arguing that shared perspectives and social norms contribute to perceptions on how drug effects are valued, expressed and interpreted among PWID (Becker, 1953; Lalander, 2001; Richert, 2014; Svensson, 2007). This highlights the importance of the interactional processes between experienced and novice PWID in defining effects as pleasurable (Harocopos et al., 2009; Khobzi et al., 2009), and further demonstrates the value of ecological perspectives in explaining the seemingly paradoxical attractions towards injecting drug use.

As we have demonstrated in this study, the pleasures associated with injecting drug use were bound to interactions, through which the interviewees learned both practical and technical skills, as well as to interpret the effects as pleasurable. Over time, the embodiment of this cultural knowledge was displayed by their narratives that sustained such pleasures and through their ritualized practices, which ultimately made them reject other modes of drug use. Despite the interviewees’ risks of health harms, overdoses and ambivalence towards injecting drug use, these stories drifted within their social networks of PWID, and displays how the paradoxical attractions of injecting were embodied in making it a meaningful and rational practice. As such, the study shows the complexity of injecting drugs and how the practice of injecting is contingent on the cultural context of drug use, in which the interplay of social factors influences individual actions and help explain the prolonged careers of injecting drug use. If interventions are to encourage reductions in injecting drug use, there is a need to understand how different social situations and contexts impinge on and encourage such risky practises among PWID.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was funded by the Norwegian Directorate of Health, the Norwegian Institute of Public Health and the Agency for Social and Welfare Services, Oslo Municipality.