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Int J Drug Policy. 2019 Jul;69:24-33. doi: 10.1016/j.drugpo.2019.04.004. Epub 2019 Apr 28.

Navigating social norms of injection initiation assistance during an overdose crisis: A qualitative study of the perspectives of people who inject drugs (PWID) in Vancouver, Canada.

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British Columbia Centre on Substance Use, Vancouver, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, Canada.
Division of Infectious Diseases & Global Health, University of California, San Diego, United States; Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada.
Kings College, Guy's Campus, London, United Kingdom; Division of Global Public Health, Department of Medicine, University of California, Los Angeles, United States.
British Columbia Centre on Substance Use, Vancouver, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada. Electronic address:


Despite the proliferation of fentanyl and fentanyl-adulterated opioids in North America, the impacts of this drug market change on injection initiation processes have not been examined. With the aim of informing structural interventions to address injection initiation and related harms, we explore how people who inject drugs (PWID) in Vancouver, Canada understand and navigate social norms of initiating others into injecting within the context of an overdose crisis. In-depth qualitative interviews were conducted with 19 PWID who reported helping someone inject for the first time. Participants were recruited from two cohort studies of PWID. Participants articulated moral dilemmas about assisting others with injecting. While participants described a 'moral code' prohibiting assisting injection-naïve individuals, this code was not the sole consideration shaping social action around injection initiation. Rather, PWID exercised agency about whether and how to assist novice injectors within the context of constraining and enabling social norms around practicing interpersonal responsibility. Changes to the drug market heightened feelings of moral culpability and criminal liability among PWID who assisted others into injection, given that injecting heightened initiates' risk of overdose. These concerns operated in tension with the aim of protecting novice injectors from harms associated with an increasingly potent and unpredictable drug supply by providing them with injection assistance, education and supervision. Our analysis of how PWID practice interpersonal responsibility helps conceptualise how 'moral codes' prohibiting initiation assistance are managed and negotiated amidst structural vulnerability. Structural interventions reducing the vulnerability of novice injectors should be prioritized, including the implementation of supervised injection sites allowing for assisted injection, Good Samaritan laws, and policy changes conducive to a safer drug supply.


Fentanyl; Injection drug use; Injection initiation; People who inject drugs

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