A total of 1,428 unique individuals accessed the SCS between June 12 2018 and December 31 2019, with 248 unique clients (17.4% of all SCS users) accessing the PAIP. Of these 248 PAIP clients, 94 were injection recipients, 89 were injection providers, and 65 were both recipients and providers on at least one occasion. Just over half of PAIP clients identified as female (n=132, 53.2%), which was significantly higher than the 40.3% (n=575) of SCS clients identifying as female, χ2(1, N=248) = 17.22, p<.001). Three quarters (77.8%) of PAIP clients identified as Indigenous (First Nations, Métis or Inuit), which was significantly higher than general SCS clients, of whom 62.2% identified as Indigenous, χ2(1, N=248) = 25.858, p<.001).
A Mann-Whitney U test was conducted to test whether the average number of visits of PAIP clients (n=248) differed from the general SCS clientele (n=1180) between June 12, 2018 and December 31, 2019. Over that period, PAIP clients had an average of 1,007.98 (SD=1277.44; range=1-9073) visits to the SCS and non-PAIP clients had an average of 87.59 visits (SD=319.71; range=1-4,986). The mean rank of PAIP clients was significantly higher than non-PAIP clients, U=261,990.0, p<.001.Male PAIP clients were 3.5 times more likely (95% CI: 2.735, 4.48) to inject a female recipient than a male recipient, χ2(2, N=1445) = 104.529, p<.001.
Overdoses occurring following a peer-assisted injection comprised only 1.02% (n=28) of all site overdoses (n=2,758) between June 12 2018 and December 31 2019 . As is standard procedure at all SCS, all overdoses were reversed.
Themes
Three themes emerged from the qualitative data: Compassion and pragmatism versus reluctance; safety and risk aversion; and, social connections and the circle of trust. Participants also made suggestions for improving the PAIP. In this section, to indicate the role of the participant, we have provided three signifiers: either IP (injection provider), IR (injection recipient) or IP/R (both roles); the participant’s age; and, the participant’s gender (M or F).
Compassion and pragmatism versus reluctance
The participants 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” [IP/R 34 M]; ”wasting their drugs” [IP 30 M]; or causing tissue damage through fruitless and often dangerous attempts to find and then stabilize a vein. Injection providers 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 one participant , “and when they’re really dope sick, I know how that feels too, so then I’ll give them a hand” [IP 40 M]. Another injection provider 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” [IP 40 M]. Still others provided injections 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. As one participant stated: “You get him high, and get him over his [dope] sickness…and I’m happy; he’s happy” [IP/R 54 F].
The injection providers were highly pragmatic about their role, which they saw as unpleasant but necessary. One participant said, about injecting others, “I just don’t like doing it… It’s kind of annoying sometimes…They might OD, so it’s like, that’s always on my mind” [IP/R 34 M]. Some participants acknowledged having acquired reputations among their peers for expertise in venipuncture and owned the injection provider role willingly. The more sought-after injection providers explained they could “doctor them good” [IP 27 F], and find a vein on the first attempt. One participant who needed assistance to inject said she would permit only someone she thought had expertise—as determined by clients and staff—and who she trusted to inject her:
If one of the girls says, ‘I've been injecting so long, ever since they've been here,’ I was like alright. [But] then I kind of got scared so I didn’t really trust them. And then one of the [SCS] workers here [says] ‘She's been injecting a lot of people. I've been watching her.’ [IR 26 F]
Some injection providers 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. Injection providers 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 [IP/R 45 M]. “I tell them to watch me when I do it” [IP/R 34 M] and one participant said that the “best way [to learn] is to watch” [IP 40 M]. Skill at peer injecting may enhance self-esteem and provide a sense of purpose: “I feel good about succeeding at what I do,” remarked one participant [IP/R 54 F]. Another participant indicated that she encourages recipients to watch and learn:
“I wash my hands, go to them, tie their arm, feel the vein, show them where it is and if they’re comfortable with that part, then I’ll do it and I’ll say – if they don’t want to look at it or … you know, I’ll say, ‘Turn around and look’” [IP/R 43 F].
Attention to detail was frequently emphasized by injection providers, especially for recipients who did not grasp either the inherent risks or the nuances of injection that is acquired over time and practice: “You’ve got to be responsible if you’re going to do this shit, you know …[it’s] dangerous, you know—wrong move, wrong shit—you’ll be gone in a second” [IP/R 43 F]. Some participants described peers gaining the skills over time, reducing their workload as providers: “I haven’t really been injecting anyone lately because everyone pretty much knows how to do it now” [IP/R 24 F].
Smoking in the inhalation room was mentioned by eight participants as a viable alternative to injecting, when an IP could not be found, although the high was described as “different” by several participants and that an injected drug “hits you faster” [IR 32 M]. One participant believed that smoking presented considerable health risks: “I seen like when you smoke a pipe, that thing really gets black like and I wouldn’t want that shit in my lungs [chuckles]” [IP 30 M]. Two participants said they preferred smoking but found the inhalation rooms were often occupied, resulting in a wait list for the service: “I try and stick to smoking or snorting, but there’s [not enough space back there]…If there was more safe space, I think there’d be more smokers than injectors… people don’t like [to wait]” [IP/R 43 F]. Another participant said “The reason why I started injecting again is because the smoke room is always too hard to get into because of the [waitlist] and so that’s why I just go for an injection and that’s the reason why I started injecting again” [IP/R 49 F]. Reluctant injection providers would encourage would-be recipients to use the SCS inhalation room, where they could smoke their drugs instead: “I just tell them ‘Well if you can’t do it [inject], like why don’t you just smoke it?” [IP 34 M]. However, two participants indicated that rather than use the inhalation room, if an injection provider was not available, they would leave the SCS to pursue assistance off-site.
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…I just say no” [IP/R 34 M]. Reluctance to inject others was connected not with selfishness or indifference, but fear of causing harm; injection providers 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 injection providers only injected others in the SCS, where recipients could immediately receive medical treatment. Participants frequently articulated a fear of causing someone to overdose. One participant stated, “I’ve had a few OD on the shot that I’ve given them…Maybe they’ve mixed it wrong… it’s upsetting” [IP 51 F]. This hazard alone was enough to dissuade erstwhile injection providers from continuing the practice, professional supervision at the SCS notwithstanding. “Lately I’ve been trying not to do it for people, because when they OD on it, I’ll feel bad for it” [IP/R 34 M]. Even those injection providers 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 one participant [IP 40 M]. Another participant was more blunt: “What if they don’t make it through—they die right there? Then I’d feel like it was my fault” [IP/R 19 M].
There was some reluctance among recipients as well, who didn’t always like asking for help to inject. One participant stated that it was very hard to ask for help and “I didn’t like asking my friends [to] do it for me” and that “I'd rather do it myself now” [IR 32 M]. Recipients were grateful to those who would assist and inject them, because they either didn’t know how to inject properly, are “scared to do it by myself” [IR 26 F] or would just “rather get someone else to do it” [IR 26 F]. Recipients sometimes described wanting to learn how to inject themselves, but other times were content to have the help.
Safety and risk aversion
Injection providers were scrupulous about procedures and safety, regardless of the recipient or the locale. Much like health care workers adhering to universal precautions, injection providers proceeded on the assumption that everyone was HIV+/HBV+. Participants were asked to describe the steps they go through when injecting someone, and most narratives began with handwashing. Many injection providers wore gloves, provided they did not interfere with locating recipients’ veins: “You know, wash up if you’re at a place, otherwise you could use gloves; I just don’t like handling an injection with gloves” because of the difficulty of finding a vein [IP 51 F]. Several participants indicated that their injection assisting practices at the SCS were not substantially different from their practices off site, wanting to “try and make [recipients] as safe as I can” [IP 51 F].
Recipients prepared their own drugs, which is a program requirement. However, one participant indicated this was likely responsible for an overdose in a client she was assisting: “Maybe they’ve mixed it wrong… They have to mix their own drugs - that’s the-the law here - and then, well obviously they’ll give it to me” [IP 51 F]. Injection providers were required by SCS and PAIP policies to inject recipients prior to injecting themselves, lest they miss veins and cause tissue damage due to intoxication. They also refused to inject peers who were ‘tweaking’ (visibly high on methamphetamine), intoxicated from any substance, unable to sit still, ‘too needy,’ or otherwise at risk. For injection providers, these safety measures were an indicator of both SCS rules and their personal moral compass. “[Even] if I don’t like them, that doesn’t mean I want them to be hurt or anything,” said one participant [IP/R 43 F] with a laugh, “I’m not a hateful person.”
Despite their engagement in what is arguably an intrinsically risky practice (injecting substances), injection providers were fundamentally risk averse. Assisted injections at the SCS, while time consuming because of required protocols, were far preferable to the offsite alternatives, where participants were vulnerable to overdose, contamination, infection, violence, theft, arrest, and social stigma. One participant stated his preference for being assisted in the SCS, because there, “we don’t have to worry about people watching us or the cops pulling in” [IP/R 49 F]. In the participants’ view, SCS safety culture played a significant role in their wellbeing, particularly when it came to peer assistance, which prior to being permitted was characterized by haste and considerable risk in the outdoor environment. Participants described how the SCS staff would teach safe injection techniques and aftercare, which boosted the knowledge base and self-reliance of injectors, who in turn paid these benefits forward to those they helped. “They’re good peoples,” one participant said of the SCS nurses who worked in the PAIP [IR 32 M]. One participant described how SCS staff “know what they’re doing, I know that. A few times I needed help and I was really sick…and if I’m gonna do it myself and they tell me, ‘Right here’s your band. Like put it right here…’” [IP/R 54 F].
Due to current Canadian drug laws, drugs must be obtained and divided outside the SCS, which one participant described as logistically challenging because they had to carry out the tasks of drug use into two different places: “I’d get our stuff ready there and then we’ll do our shot here… so then we don’t cut it wherever we’re going” [IP/R 49 F]. Another participant said “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” [IP/R 24 F]. Participants pointed out that sharing and dividing drugs in the street effectively negated the protection of the SCS from arrest or self-harm: “It would be better if they just like let us do it here instead of out there because then the cops come and arrest us if they see us or – and then it makes us more angry and want to hurt ourself because we’re so sick” [IP/R 24 F]. One participant said that the PAIP would be better “if we didn’t have to get our drugs offsite or walk away just to give our friend a half of our drug…but all in all it’s pretty good here” [IP/R 24 F].
Additionally, participants found the conditions challenging outside the site: “It’s like a hard time, you know, I never do it outside, because I never get it [the vein], because it’s in the cold… [Then] we just go inside and it’s like no problem” [IP/R 19 M]. Recipients also indicated greater difficulty with being helped adequately “on the street” as opposed to in the SCS and often required more help to inject in that environment [IR 32 M].
Social connections and the circle of trust
Of the 16 participants interviewed, only two injection providers acknowledged intimate relationships with their recipients at any time. The rest characterized their peer injection networks as circles of trust, underlain by kinship or kinship-like bonds. These participants saw their peers not just as fellow travellers, but as friends and family. One participant, when asked what their relationships were like with the people they helped, said: “We’re family” [IP/R 19 M]. Several participants described the relationship as being “like family” and at a minimum, friends: “friends, good friends, they’re like family.” [IP/R 27 F].
The emphasis on kinship amongst Indigenous clients—whether by family or band affiliation— contributed to this social order, but street life necessitated unique loyalties and attachments. Familiarity, mutuality and reciprocity were key factors of the injection provider/recipient dyads. All five injection providers invariably described injecting both males and females, regardless of whether the recipient was the same gender; similarly, the four recipients invariably stated they were injected by both males and females. The seven participants who were both injection providers and recipients were similarly open to either gender, with two of these participants indicating they preferred injecting with their same-sex friends. Only one participant indicated that their current intimate partner injected them.
Injection providers were, however, selective about who they helped, and recipients in turn only sought the assistance of injection providers with whom they had a strong social connection. Similarly, recipients described needing to trust the person who was assisting them, and that trust was earned slowly over time. One participant described a trajectory of trust, from starting out as “I don't really trust anybody around the area” to beginning the peer assist relationship as starting “as friends” [IR 32 M] in the injection provider/recipient relationship.
Injection provider-recipient relationships were characterized by normative, mutual support and reciprocity. One participant felt it was “common courtesy to give someone a hit” of the drug [IR 48 M]—but also tacitly understood it was purely transactional. Injection providers helped recipients, knowing that certain unspoken benefits would accrue: social capital, goodwill, and respect, as well as tangibles such as gifts of drugs (most commonly mentioned) and other goods. As one participant said, “Sometimes it’s smokes, sometimes it’s drugs” and “sometimes I just do it for free” [IP/R 27 F]. 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. One Indigenous participant 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” [IP 30 M].