Identifying risks: Drugs and their contexts

As we have heard from Dr Magdalena Harris (Step 1.14) the health risks related to drug use are shaped by the ‘contexts’ and the ‘environments’ in which drug use happens. She introduced two ways to think about drugs and their contexts. Let us summarise these here.

Drug, Set and Setting

First, she noted the work of psychiatrist Norman Zinberg. Zinberg distinguished between ‘drug’, ‘set’ and ‘setting’. This work highlighted the importance of how ‘setting’ influences people’s beliefs and expectations about drugs and their effects (‘set’), in addition to the properties of the ‘drug’ itself.

Can you think of an example where the ‘setting’ might shape people’s expectations of drug effects, how drugs might be used, and their effects?

All drug use is quite ‘context-based’ in one way or another. A clear example here is recreational drug use, where the use of drugs, and the effects derived from this use, is very much linked to the social settings where this drug use takes place.

We can think of ‘setting’ in various ways. What different types of setting do you think might be important in shaping how drugs are used and the harms of drug use?

This is leading us to a second way of thinking about drugs and their contexts, also mentioned by Dr Magdalena Harris. This is the concept of ‘risk environment’.

Risk environment

The ‘risk environment framework’ was introduced by Professor Tim Rhodes, in 2002, as a harm reduction approach which takes account of the importance of setting and environment.

The risk environment framework helps us think about how drug harms are shaped by environments, including:

• Physical environment, such as geography and drug use settings
• Policy environment, such as drug laws, access to care and human rights
• Social environment, such as stigma, media, community attitudes
• Economic environment, such as poverty and income opportunity

Can you think of some of the different ways that each of these different forms of environment – physical, policy, social and economic – might shape drug harms? And what might be the harm reduction interventions in response?

Let us take the example of the physical environment. There are many ways the physical environment affects drug harms. We could think of prisons, and how these might produce risk when access to clean injecting equipment becomes impossible. Or we could think of the street or public settings where people use drugs, and where drugs get used more quickly and less safely for fear of police arrest.

This helps us to identify what the ‘context-based’ harm reduction responses might be. For instance, in the case of prisons, what interventions can we develop to create safer prison environments? And in the case of drug use settings, how can we make these safer?

The risk environment framework is described here. We have attached a downloadable copy at the end of this page.

You will hear throughout the course various examples of harm reduction intervention which seek to create ‘enabling environments’ for harm reduction through policy, legal, social, community and economic change. The key point is that drug harms may relate less to the drug itself, or the person taking it, or their beliefs and expectations, but more to the setting and environment. And we therefore need to focus our harm reduction efforts on changing or modifying the environment.

An exercise using photographs

To explore these ideas of risk environment, let us focus a little more on the example of the physical environment, and specifically, the public or semi-public settings where injecting drug use can happen. We are going to look at three photographs.

Our first image is a previously published photograph taken by the late social-documentary photographer John Ranard. It is an image of an outside location, near Odessa in Ukraine, where people congregate to buy and use drugs. Most people here are using a form of home-produced liquid opiate extracted from poppy straw, and many, at the time, would receive their dose squirted into their syringe directly from the dealer’s donor syringe. Access to clean syringes and water are not available at this site. People have to buy, receive and use their drugs quickly because this site is heavily policed by militia.

If you can imagine yourself in this setting, what do you think the risks are that you might be facing?

Our second image is also a previously published photograph taken by John Ranard. It depicts the same drug use setting. What do you notice about the picture?

In the picture, you can see someone urinating into a syringe in an effort to clean a dirty syringe in the absence of clean equipment or water being available. To the left is an outreach worker who comes to the site to distribute needles and syringes as a harm reduction effort.

Using the ‘risk environment’ framework, can you think of what might be done to help make this environment safer? There are some immediate practical things, such as distributing clean injecting equipment, but also sterile water, which people can use in an effort to keep their injecting equipment clean. But a major challenge of this environment is that people are purchasing their drugs already mixed and receiving it from a donor syringe, also in the context of a heavy presence of local militia. There is very little control over the potential blood-borne infection risks associated with the indirect sharing of the equipment (see the next image).

Our third image is a photograph taken during fieldwork in London (UK) linked to a research project led by Professor Tim Rhodes. This image depicts a practice known as ‘front-loading’, where the needle is removed from the front of one syringe in order to receive the pre-mixed drug solution (here heroin) from the donor syringe. This enables the solution to be split equally and quickly, but as we have noted above, increases risks of viral transmission, including for instance, hepatitis C.

Optional

If you are interested in reading about the risk environment framework, with examples of how it relates to harm reduction, there are various publications in the International Journal of Drug Policy, including by Tim Rhodes (2002, 2009), but also by others, for example, on the risk environment of opioid overdose (Cooper et al., 2020; Kolak et al., 2020; Fadanelli et al., 2020; Green et al., 2009), access to harm reduction in Iran (Bastini et al., 2018), drug doping in sport (Henning et al., 2020), using synthetic drugs (Elliott et al., 2018), and drug dealing (Fitzgerald, 2009).