Injecting Alone. The Importance of Perceived Safety, Stigma and Pleasure for Solitary Injecting

• Published date: 01 January 2024
• DOI: http://doi.org/10.1177/00220426231151377
• Author: Kristin Hanoa,Ola Røed Bilgrei,Kristin Buvik
• Date: 01 January 2024
• Subject Matter: Articles

Article

Journal of Drug Issues

2024, Vol. 54(1) 74–89

© The Author(s) 2023

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DOI: 10.1177/00220426231151377

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Injecting Alone. The

Importance of Perceived Safety,

Stigma and Pleasure for Solitary

Injecting

Kristin Hanoa

1,2

, Ola Røed Bilgrei

1

, and Kristin Buvik

1

Abstract

Many people who inject drugs (PWID) inject when they are alone which increases the risk for

drug-related mortality, and the majority of overdose-related deaths occur among solitary users in

residential environments. Drawing on qualitative data from interviews with 80 PWID in Norway,

this study explores the complex practices of solitary injecting. The analysis illustrates that the risk

environments in which they participated involved high levels of distress, fear and stigma that made

them prefer solitary injecting. This involved a perceived notion of safety from an unpredictable

social environment. Stigma was described as causing additional harms and they therefore wanted

to hide their drug-using practices. Finally, injecting drug use involved contextual pleasures that

were maximised by injecting alone. The study illustrates how the risk environment the PWID

inhabited caused additional harms, by which solitary injections was rationalized, despite its in-

creased mortality risks. Future harm-reduction initiatives should ref‌lect this important aspect.

Keywords

injecting drug use, solitary injecting, risk, pleasure, stigma

Introduction

The burden of disease caused by drug use has continued to increase during the past decade

(UNODC, 2021). In Europe, drug overdose is the main cause of death among high-risk drug users

(EMCDDA, 2018,UNODC, 2021), of which drug injection is one of the leading risk factors

(Degenhardt et al., 2011;Mathers et al., 2013). Norway is one of the countries in Europe with a

high and stable overdose-related mortality rate (EMCDDA, 2020,EMCDDA, 2021;Gjersing,

2021). This is partly due to a persistent culture of injecting poly-drug use (Gjersing & Bretteville-

Jensen, 2014,2018), and the fact that many people inject drugs alone (Gjersing, 2017;Gjersing &

1

Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway

2

Agency for Social and Welfare Services, Oslo Municipality, Norway

Corresponding Author:

Kristin Hanoa, Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, PO Box 222 Skøyen,

0213 Oslo, Norway; and Agency for Social and Welfare Services, PO Box 30 Sentrum, 0101 Oslo, Norway.

Email: kristin.hanoa@fhi.no

Helle, 2021), which eliminates the opportunity to intervene in a timely manner (Papamihali et al.,

2020).

The number of people who inject drugs (PWID) in Norway is estimated to be between 7400 and

10 500 (Burdzovic & Amundsen, 2018). In order to reduce the drug-related mortality, the

Norwegian Government introduced a national overdose strategy in 2014. Several preventive

measures were implemented as part of the strategy, such as the “Switch”-campaign, which

encouraged PWID to switch from injecting to safer intake methods (e.g. smoking). PWID were

also encouraged to avoid poly-drug use, and to be aware of reduced tolerance after periods of

abstinence (Helsedirektoratet, 2019,Helsenorge, 2021). The use of harm reduction services was

also expanded, such as the take-home naloxone program, drug consumption rooms (DCR), which

now exist in two cities in Norway: Oslo and Bergen, and the establishment of heroin-assisted

treatment in 2022 (Edland-Gryt, 2018;Helsedirektoratet, 2019). Additionally, encouraging PWID

to inject together with peers has become a widespread overdose-prevention strategy aimed at

individual behavioural change (Helsedirektoratet, 2019;Winiker et al., 2020). However, minimal

research has been conducted to understand the reasons why PWID inject alone, despite the

elevated risks (Bardwell et al., 2019;Winiker et al., 2020). While harm-reduction strategies have

focused on individual-level behaviours, some studies show that the choice of drug-use envi-

ronments is shaped by factors such as perceptions of unsafety, shame or avoidance of legal

prosecution (Rhodes et al., 2007;Small, Moore, et al., 2012;Winiker et al., 2020). This may help

explain the limited effectiveness of interventions that aim to prevent solitary injections among

PWID (Winiker et al., 2020). To determine effective harm-reduction interventions, there is a need

to understand factors that inf‌luence the setting in which injections are performed and why many

PWID prefer to inject alone.

In this paper, we explore the complex practices of solitary injecting as expressed by a large

group of PWID. Based on qualitative data from interviews with 80 Norwegian PWID, the aim is to

study the meanings, perceptions and possible rationales associated with such a drug-using

practice. The qualitative approach is sensitive towards the lived experiences of those under

study and helps provide new understandings of solitary injecting drug use. This insight should

help inform future harm-reduction interventions.

Injecting Drug Use Environments

The setting where drugs are injected represents an important dimension in the production of drug-

related harms (Small, Moore, et al., 2012). Injecting in public places is associated with elevated

risks (Carlson, 2000), deriving from hasty injections due to fear of interruption or arrest. The

public exposure involved in such settings may also cause feelings of shame, leading PWID to

prefer private settings for their drug use (Hagan et al., 2007;Small et al., 2007). Public injections

are therefore described as a situational necessity, resulting from homelessness or withdrawal,

rather than an active choice among PWID (Rhodes et al., 2007).

Injecting alone may entail lower rates of risk behaviour by avoiding multiple use of drug

paraphernalia and thus preventing cross-contamination (Hagan et al., 2007). However, those who

inject alone experience elevated risks of mortality and morbidity (McCrae et al., 2020). For

example, naloxone programmes require another person present for administration. As such, the

majority of overdose-related deaths occur within residential environments (e.g. private residences,

supportive housing or shelters) and among those using alone (Bardwell et al., 2019;Papamihali

et al., 2020;Tsang et al., 2019).

Quantitative studies exploring solitary drug use (not exclusively injections) highlight factors

such as convenience, stigma, peer pressure to share injection equipment and the avoidance of legal

consequences or violence, as common denominators (Hagan et al., 2007;Papamihali et al., 2020).

Hanoa et al. 75