Demographics
A total of 248 unique clients accessed the peer-assist program at the SCS, either as recipients (n = 159), injectors (n = 154), or both (n = 65, at least once) between June 12th, 2018 and December 31st, 2019 (Fig. 1). A total of 1,430 unique individuals accessed the SCS during the same timeframe, meaning peer-assisted injection was accessed by 17% of total SCS participants. Just over half of peer-assist clients identified as female (n = 132, 53.2%), in contrast to the 40% of total number of SCS clients identifying as female.
The mean age of peer-assist clients was 33 (range 18 to 60+) (Table 1), closely aligned with total SCS clients’ mean age of 34 (range 16–60+) during the same reporting period. Three quarters (77.8%) of clients in the peer-assist program identified as Indigenous (First Nations, Metis or Inuit) (Table 2). On this measure, both the total peer-assist clients and study sample skewed slightly higher than the total number of SCS clients during the same time period, of whom 63% identified as Indigenous.
From June 12, 2018 to December 31, 2019, the SCS was visited 353,331 times, with 1,469 visits involving peer-assisted injections (averaging 77 per month). A total of 2,758 overdoses were reversed at the SCS during this timeframe; among these, only 28 occurred as a result of peer-assistance, meaning the total frequency of peer-assist overdoses was 1.02%. None of the overdoses resulted in death.
Themes
Compassion and pragmatism versus reluctance
Within the interview data, clients repeatedly expressed compassion for their peers’ suffering, which moved them to help with injections. Participants described not wanting to see others ‘dope sick’ (experiencing withdrawal); struggling; hurt; ‘stabbing themselves’; ‘wasting their drugs’; or ‘marking’ (causing tissue damage) through fruitless and often dangerous attempts to find and then stabilize a vein. Injectors particularly empathized with those struggling through withdrawal or inability to locate veins, whether on account of skill or physiology, having themselves undergone these tribulations. “I don’t like to see them stab themselves so many times,” remarked Kyle, “and when they’re really dope sick, I know how that feels too, so then I’ll give them a hand.” Another injector, Tyson, was motivated by concern for his peers’ financial circumstances. “I feel bad that they miss every time and they [have] to keep going on. The drugs cost a lot of money; and if they lose [it], they waste it; [and] they’re going to have to try and go get more.” Still others injected for recipients whom they knew were afraid of needles. Common to all these responses was a willingness to give without recompense, beyond the gratification of providing relief to a fellow PWID in need. “You get him high, and get him over his [dope] sickness,” said Ashley, “and I’m happy; he’s happy.”
The injectors were highly pragmatic about their role, which they saw as unpleasant but necessary. Some acknowledged having acquired reputations among their peers for expertise in venipuncture, and owned the injector role willingly. The more sought-after injectors, such as Justine, explained they could ‘doctor’ their recipients well, and find a vein on the first attempt. These skills could even be connected with self esteem: “I feel good about succeeding at what I do,” remarked Ashley. Others did not always feel up to the task. “I’ll inject people here, [but] there’s a lot of times I just [don’t] feel like it,” said Steve; “I just say no.” Reluctant injectors could also send would-be recipients to the SCS inhalation room, where they could smoke their drugs instead.
Some injectors felt a strong moral imperative to build recipients’ self-reliance, through teaching and encouragement to gain the skills needed for self-injection. Teaching centred on the recipients’ immediate needs, before and during the time of active assistance. Injectors actively coached recipients on the techniques of finding a vein and injecting themselves. “I show them, and I tell them, and then I show them,” explained Steve. “I tell them to watch me when I do it.” Attention to detail was frequently emphasized, especially for recipients who did not grasp the inherent risks. “You’ve got to be responsible if you’re going to do this shit, you know,” Zoë (injector/recipient) chuckled. “That’s dangerous, you know—wrong move, wrong shit—you’ll be gone in a second.”
Reluctance to inject others was connected not with selfishness or indifference, but fear of causing harm; injectors were mindful of missing veins, creating abscesses or other injuries, or wasting recipients’ drugs. Fear of overdosing recipients, however, was paramount. For this reason, many injectors only injected others in the SCS, where they could immediate receive medical treatment. “I’ve had a few OD on the shot that I’ve given them,” recalled Victoria (injector). “Maybe they’ve mixed it wrong… it’s upsetting.” This hazard alone was enough to dissuade erstwhile injectors from continuing the practice, professional supervision notwithstanding. “Lately I’ve been trying not to do it for people,” said Steve, “because when they OD on it, I’ll feel bad for it.” Even those injectors with the skills and knowledge to safely administer a hit actively tried to dodge this responsibility, knowing that failure entailed potentially negative social and emotional consequences. “[The recipient] walks around hating you, because you missed it, and they don’t have no more drugs, or whatever,” explained Kyle. Tyson was more blunt: “What if they don’t make it through—they die right there? Then I’d feel like it was my fault.”
Safety and risk aversion
Injectors were scrupulous about procedures and safety, regardless of the recipient or the locale. Much like health care workers adhering to universal precautions, injectors proceeded on the assumption that everyone was HIV+/HBV+. Intravascular injections usually began with hand washing, and many injectors wore gloves, provided they did not interfere with locating recipients’ veins. Recipients prepared their own drugs. Injectors invariably saw to recipients’ injections before their own, lest they miss veins and cause tissue damage through intoxication. They also refused to inject peers who were ‘tweaking’ (visibly high on methamphetamine), drunk, unable to sit still, ‘too needy,’ or otherwise at risk. For injectors, these safety measures were yet another measure of personal moral compass. “[Even] if I don’t like them, that doesn’t mean I want them to be hurt or anything,” said Zoë with a laugh. “I’m not a hateful person.”
Despite their engagement in an intrinsically risky practice, injectors were fundamentally risk-averse. Supervised injections at the SCS, while time consuming, were far preferable to the offsite alternatives, where PWID were vulnerable to overdose, contamination, infection, violence, theft, arrest, and social stigma. Some participants had entirely confined their usage to the SCS since its opening in February, 2018. “I really don’t like doing it on the street, because it’s something that you don’t want to show to the whole world,” Zoë admitted. In the participants’ view, SCS safety culture played a significant role in their wellbeing. Nurses and paramedics, on hand to teach safe injection techniques and aftercare, boosted the knowledge base and self-reliance of clients, who in turn paid these benefits forward to their peers.
While the SCS and the peer assistance pilot were felt to be transformational for many clients’ safety and self-reliance, participants pointed out a at least two drawbacks with the program. At the time of the study, Health Canada and the Canadian criminal code defined any transfer of drugs between individuals as trafficking, thereby forcing SCS clients to share and divide their drugs offsite. This application of the law, reviled as arbitrary and unfair, created an unwelcome speed bump in the peer assistance process. “Sometimes I’m really sick, and then that just takes more time of me having to torture myself, walking over there just to give my friend something, and then coming back,” said Justine (injector), who went on to point out that sharing and dividing drugs in the street effectively negated the protection of the SCS from arrest or self-harm. Meanwhile, onsite inhalation rooms in the SCS—a first in North America—represented a safer alternative to many clients reluctant to administer or receive injections, yet the demand for this service far exceeded the capacity of the site. “I try and stick to smoking or snorting, but there’s [not enough space back there],” remarked Zoë. “If there was more safe space, I think there’d be more smokers than injectors… people don’t like [to wait].”
Social connections and the circle of trust
Of the 16 participants interviewed, only two injectors acknowledged intimate relationships with their recipients. The rest characterized their peer injection networks as circles of trust, underlain by kinship or kinship-like bonds. These clients saw their peers not just as fellow travellers, but as friends and family. The emphasis on kinship amongst Indigenous clients—whether by family or band affiliation—was a significant contributor to this social order, but street life entailed its own loyalties and attachments. Familiarity, mutuality and reciprocity were key factors of the injector/recipient dyads—far outweighing gender, which mattered only to the extent that female injectors were more likely to help female recipients. Injectors would not “say yes to just anyone,” and recipients in turn only sought the assistance of injectors with whom they had a strong social connection. This principle resulted in a semipermeable boundary around the peer network of injectors and recipients.
Injector-recipient relationships were characterized by normative, mutual support—Danny (recipient) felt it was “common courtesy to give someone a hit”—but also tacitly understood as transactional. Injectors helped recipients, knowing certain, unspoken benefits would accrue: social capital, goodwill, and respect, as well as tangibles such as gifts of drugs and other goods. Compensation was a fluid concept; help might be given one day and repaid in a different form on another day. Identity also influenced participants’ attitudes to reciprocity. Gord (injector), who identified as First Nations, remarked he neither expected nor declined recompense from recipients, because “[in] my culture you can’t deny an offer, or else they’ll take it as [if] I’m dissing them.” Amongst the participants, injector-recipient reciprocity amounted to a tacit social contract, based on mutuality and trust rather than power.