The Growing Popularity of Prescription Opioid Injection in Downtown Montréal: New Challenges for Harm Reduction

Abstract

Starting in 2007, a 2-year study based on ethnographic methodology was carried out downtown Montréal, Canada. A thematic analysis of observational and interview-based notes was conducted. Illicit prescription opioid (PO) use was widespread among street-based participants. Injection was the main mode of PO administration observed among users. Some injection practices such as “doing a wash” could pose new challenges in terms of prevention of infections. More research is needed to examine the role of illicit PO use in the development of opiate addiction and to better understand drug-using contexts that put PO users at risk of infections. The study’s limitations are noted.

Prevalence and correlates of prescription opioid residue injection

“…For drug residue injection, it can be hypothesized that, compared to legal income sources, marginal or criminal sources of income likely produce more irregular or weak income streams, which could force PO injectors to fall back on PO residues. These results are consistent with prior ethnographic studies reporting that residue injection is mainly practiced by PWID with low-income sources or unsuccessful income-generating strategies (Bourgois, 1998;Bourgois and Schonberg, 2009;Roy et al, 2011).…”

“…Reports of PO injection have risen worldwide, including in the United States (Davis and Johnson, 2008;Young et al, 2010;Surrat et al, 2011;Lankenau et al, 2012;Black et al, 2013;MateuGelabert et al, 2015), Europe (Partanen et al, 2009;Keijzer and Imbert., 2011;Roux et al, 2011), South Asia (Larance et al, 2011) and Australia (Degenhardt et al, 2006). In Canada, over the past decade, PO injection has gained in popularity among drug users across the country (UHRI, 2013; Leclerc et al, 2013;Firestone and Fischer, 2008;Roy et al, 2011;Roy et al, 2013;Bruneau et al, 2012;Fischer et al, 2006;PHAC, 2014). Data from I-Track, a multisite surveillance system that monitors HIV and hepatitis C virus (HCV) infection rates and associated risk behaviors among persons who inject drugs (PWID) in Canada, revealed that hydromorphone, morphine and oxycodone, either in tablet or capsule form, were injected more often than heroin.…”

“…Now, it is generally acknowledged that injection practices may vary depending on the types of substances injected, resulting in more or less serious consequences for the health of users (Gordon and Lowy, 2005). The ethnographic work we carried out in downtown Montréal has allowed us to examine the injection techniques used by PWID to prepare PO tablets or capsules that are designed for oral use (Roy et al, 2011). The study findings showed that, due to the physical composition of the two most available forms of POs in the area (Dilaudid ® and Hydromorph Contin ® ), dissolution was complex and required large amounts of water.…”

“…The containers and filters were often kept for further use, a practice referred to by users as "doing a wash", as it implies rinsing the used equipment with water to extract the drug residues for injection. Washes were often shared among users who considered them valuable goods they could exchange or offer to other users (Roy et al, 2011).…”

“…Ethnographers observed that similar to some PO formulations, black tar heroin was not easily dissolvable and left significant amounts of residues in filters used for injection. Overall, ethnographic studies highlighted the vulnerability of PWID who inject residues, showing that this behaviour was mainly practiced by individuals who had unsuccessful income-generating strategies and, consequently had to rely on their own or others' drug residues to relieve opioid withdrawal symptoms (Bourgois, 1998;Bourgois and Schonberg, 2009;Roy et al, 2011).…”