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Qualitative study using semistructured interviews.
4 drug treatment agencies in south Wales, UK.
24 participants (mean age 33 y, 83% men) who were drug users (mean duration of illicit drug use 15.3 y, mean duration of injecting drugs 11.6 y). 62% of participants had injected drugs within the previous month.
Participants were asked open ended questions in an interview about their injecting behaviours. They were also asked predetermined prompt questions to elicit ideas about aspects of needle fixation identified in the literature. Interviews were recorded and transcribed into an Atlas/ti database. The content of interviews was analysed for categories and themes by 1 researcher and then reviewed for validity by another researcher. Final categories and coding were then determined.
Participants talked about their initiation to injection and social role. Many participants shared that they had had a persistent aversion to needles. Participants talked about how the pharmacology of injecting psychoactive drugs was instrumental in needle use. The quick response of drug effects was the primary reason for injection. The experience of injection was described in phases. Before the injection: ritual characterised the setting up of the right equipment to begin the injecting, and some participants found that this provided as much of a rush as the drug itself. The injection itself involved discussion about the penetration of the skin and the first sight of blood upon entering a vein. Participants talked about their skill at injecting, which was viewed as an accomplishment that increased self esteem as well as role and social standing among other drug users. Participants also described injecting for the sake of injecting: substituting other drugs and water to divide drugs into smaller hits or to obtain a rush. Participants described their responses to pain, which was part of the injecting process. Some participants said they enjoyed the pain, and others suggested that the process of injecting might be indicative of an underlying tendency to self injury. Participants also talked about having no veins and persevering in attempting to find one. The relation between sex and injecting was expressed using 3 associations: the sexual analogy of injection, the use of injecting as an acceptable reason for intimacy, and the attribution of sexual pleasure to partners when injecting together. Participants' views on needle fixation included scepticism that it existed, the recognition of it in others but not in oneself, the theory that needle fixation is pursuit of the first ever or early injecting experiences, and the fact that it's difficult to disentangle the drug from the act of injection.
Substance users who injected drugs described experiences that matched concepts of needle fixation found in the literature. 1 aspect not identified in earlier work was the aversion to needles. Results from this study suggest that needle fixation constitutes a range of conditioned responses and a chaining of responses leading to secondary gain.
The behaviours associated with injection drug use (IDU) are unique and have always been an enigma. The rituals associated with drug use, and injection use in particular, have been alluded to in the literature.1 McBride et al, in this breakthrough study, have brought to the fore some novel perspectives of IDU. It would seem appropriate to credit the rekindling to Al-Adwani's letter to Addiction in February 2001,2 and also to the increasing HIV, hepatitis B, and hepatitis C infections in needle users. The current study, however, raises the issues related to IDU from anecdotal coffee room tales to serious scientific discussion.3
In eliciting the experiences relating to IDU the authors have done elegant and comprehensive qualitative research using indepth interviews in a group of active and dormant injection drug users. The use of computer assisted qualitative data analysis software (Atlas/ti) is appropriate for this simple design of single group interviews.4 Inclusion of interviews with professionals who deal with such individuals would have added to the merit by highlighting the treatment perspective. The core phenomenon of “needle fixation” was, however, noted to be not a ubiquitous one, and some participants reported it in others but not in themselves. Studies should be done to estimate prevalence of the phenomenon in IDU.
The authors' reference to conditioning processes in developing an explanatory model is most suitable because it allows testable hypotheses to be formulated and interventions to be developed. Dynamic aetiologies are inherently attractive but difficult to test as scientific hypothesis.
When treating injection drug users it is important to simultaneously assess needle fixation because this would influence the treatment outcome in a condition that otherwise has serious health implications. Understanding needle fixation as deliberate self harm can encourage testing pharmacological interventions in addition to behavioural therapies.
Source of funding: not stated.
For correspondence: Dr A J McBride, Community Addiction Unit, House 56, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 0S2, UK. Fax +44 (0)292 046 1768.
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