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Policing and injection drug users' health

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Title:
Policing and injection drug users' health the impact of law enforcement practice on drug users' risk behavior
Creator:
Kapral, Craig G
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English
Physical Description:
viii, 126 leaves : ; 28 cm

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Subjects / Keywords:
Drug addicts ( lcsh )
Intravenous drug abuse ( lcsh )
Risk-taking (Psychology) ( lcsh )
Drug control ( lcsh )
Law enforcement ( lcsh )
Drug addicts ( fast )
Drug control ( fast )
Intravenous drug abuse ( fast )
Law enforcement ( fast )
Risk-taking (Psychology) ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 120-126).
General Note:
Department of Anthropology
Statement of Responsibility:
by Craig G. Kapral.

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|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
62873367 ( OCLC )
ocm62873367
Classification:
LD1193.L43 2005m K36 ( lcc )

Full Text
POLICING AND INJECTION DRUG USERS HEALTH:
THE IMPACT OF LAW ENFORCEMENT PRACTICE ON DRUG USERS RISK
BEHAVIOR
by
Craig G. Kapral
B.A., State University of New York at Potsdam, 1992
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Anthropology
2005


This thesis for the Master of Arts
degree by
Craig G. Kapral
has been approved
by


Kapral, Craig G. (M. A. Anthropology)
Policing and Injection Drug Users Health: The Impact of Law Enforcement
Practice on Drug Users Risk Behavior
Thesis directed by Professor Stephen K. Koester
ABSTRACT
Injection drug use continues to be a dominant risk factor for transmission of
blood-borne diseases such as human immunodeficiency virus (HIV), hepatitis B
(HB V), and hepatitis C (HCV) and presents risk for other drug-related harm such
as drug overdose. Public health interventions designed to address these risks are
dominated by psychological models that focus on changing individual behavior.
Oftentimes, these models ignore or pay only lip service to the contextual factors
that influence behavior. Anthropological models resolve this shortcoming by
reintroducing context into the study of drug-related harm and serve to redirect
our focus to structural determinants that condition risk behavior. Law
enforcement acts as an integral influence on the everyday behaviors of drug
injectors. In response to policing agendas that target them for arrest, injection
drug users (IDUs), engage in behaviors that may simultaneously reduce their risk
for arrest while increasing their risk for drug-related harm. Research findings
include: vigorous policing agendas serve to create an atmosphere of fear and
uncertainty among IDUs and affect injection-related risk behavior in multiple
ways; police arrest of users serves to alter the composition of injection and social
networks, thereby increasing the drug-related risks faced by network members;
IDUs resort to behaviors that increase their risk for overdose and drug-related
harm as they attempt to avoid arrest and suppress the effects of physical
in


withdrawal after having been detained in jail. These findings demonstrate the
failure of policies criminalizing addictive drug use in view of a public health
crisis suggesting the need to change current policies and police practice as they
pertain to drug using populations.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.
Signed
Stephen K. Koest


DEDICATION
This thesis is dedicated to my wife Kristine M. Kapral for her unwavering love,
understanding, support, and encouragement. I am profoundly grateful for all that
you have given of yourself during the time that it took to complete this project.


ACKNOWLEDGEMENT
I would like to take this opportunity to thank Dr. Stephen K. Koester. Providing
me with the opportunity to access your qualitative database and sharing your
thoughts on the material that it contained made this thesis possible. Your
guidance and advice were crucial to the completion of this project. I would also
like to thank Dr. Jim Igoe and Dr. John Brett for their time and energy. You are
both an inspiration.
My parents have provided me with endless support and encouragement and have
instilled in me the drive to accomplish my goals, always making me feel like
anything was possible. Thanks for providing a source of motivation and
understanding that has been invaluable. Many thanks to my brother and sister for
always being there and listening.
A deep measure of gratitude goes out to Kris Kapral. Thanks for walking the
whole way with me. Youre the best.


CONTENTS
CHAPTER
1. INTRODUCTION................................................1
Drug Related Risk Behaviors...............................3
Thesis Organization.......................................4
2. THEORETICAL ORIENTATIONS....................................8
Ecological Theory.........................................9
Critical Medical Anthropology Perspective................10
Psychological Models: Stressing the Individual and
Ignoring Context.........................................11
The Theory of Reasoned Action: Research Application
and Inherent Flaws.......................................13
Anthropological Models: The Importance of Context........17
Law Enforcement and CMA..................................18
Drug Use in CMA Perspective: Policing as a Structural
Element and the Imbalance of Power between Law
Enforcement and IDUs.....................................20
3. REVIEW OF THE LITERATURE...................................24
IDUs: Behavior and Risk..................................24
Law on the Books and Law on the Streets: The
Foundation for a War on Drugs............................26
Policing and the Enforcement of Drug and Paraphernalia
Laws.....................................................29
Police Practice and the Effects on IDUs Risk Behaviors..31
Policing, High Rates of Incarceration, and the Health-
Related Dangers Posed to IDUs in Prison..................36
4. METHODOLOGY................................................40
Secondary Data Analysis..................................40
Denver Police Department Ride Along and Officer
Interview................................................43
Data Collection..........................................45
Sampling Procedures......................................47
Study Sample.............................................48
Data Analysis............................................49
Study Limitations........................................50
5. FINDINGS...................................................51
Findings 1...............................................52
Vll


Policing the Streets: The Constitution of an
Atmosphere of Fear and Uncertainty among EDUs........52
IDUs and Risky Injection Behavior: Responding to
the Pressure of Police Patrols.......................56
Policing and the Production of Violence among Drug
Market Participants..................................63
Findings II.............................................69
Policing and the Disruption of Stable User Networks:
Increasing the Risk for Blood-Borne Disease and
Drug Related Harm among IDUs.........................69
Findings III............................................83
Fear of Arrest and the Effects of Incarceration:
Overdose and Additional Risky Behaviors..............83
IDUs in Jail: Physical Withdrawal and Risky
Behaviors............................................87
6. A DENVER POLICE OFFICERS PERSPECTIVE.....................95
Hitting them Hard: Targeting the Drug User for Arrest.95
Enforcing the Law: Rigid Application of Drug Policy.....99
Moving Them Around and Not Giving In.................102
7. DISCUSSION...............................................106
8. CONCLUSIONS AND RECOMMENDATIONS.........................114
Recommendations........................................116
REFERENCES.........................................................120
vm


CHAPTER 1
INTRODUCTION
Injection drug use is currently related to more than one-third of acquired
immunodeficiency syndrome (AIDS) cases and more than one-half of hepatitis C
(HCV) cases in the United States, and continues to be the dominant risk factor for
new cases of both human immunodeficiency virus (HIV) and HCV (CDC 2000).
The transfer or sharing of non-sterile syringes and/or other injection-related
equipment such as cookers utilized in the preparation of drug solutions, during the
process of drug preparation or injection contributes to the efficient transmission of
these viruses. While direct participation in the injection process has proven to be an
important factor in the continuing evolution of these disease epidemics, injection
drug users (IDUs) contribute indirectly to new cases of disease as well, primarily
by transmitting the virus through unprotected sexual practices. Moreover, women
who become infected with HIV through sharing contaminated syringes or engaging
in sexual relations with an infected IDU can transmit the virus to their offspring
before or during birth or through breastfeeding (CDC 2000).
One strategy that is proven to effectively reduce the transmission of HIV
and other blood-borne pathogens is to encourage IDUs to use sterile syringes each
and every time they prepare and inject drugs (CDC 2000). In many areas, however,
access to sterile syringes is problematic because of contextual factors that create an
artificial scarcity of sterile syringes. These impediments include laws governing
syringe sales and possession, state pharmacy board regulations, and sales policies at
some pharmacies (Lewis et al. 2002). Limited legal access to sterile syringes may
force IDUs to engage in risky injection practices, thereby increasing transmission
of blood-bome-pathogens (CDC 2000; Koester 1994). In an effort to increase the
1


availability of sterile syringes, and thus reduce risky injection-related behaviors,
many cities have introduced needle exchange programs (NEPs) that operate
primarily on one for one exchange procedures. While NEPs have proven to be an
effective strategy for reducing the adverse health consequences associated with
injection drug use, they continue to lack federal funding and remain relatively
uncommon in the U.S. (Needle 1998a).
In recent years, research concerned with the health implications of injection
drug use has begun to focus on other factors that influence risk behavior among
IDUs, including how policing and law enforcement practices may contribute to the
spread of communicable disease and/or encourage other forms of drug-related harm
(Aitken et al. 2002; Beyer et al. 2002; Blankenship and Koester 2002; Bluthenthal
et al. 1999; Burris et al. 2004; Koester 1994; Maher and Dixon 1999; Midford et al.
2002; Rhodes et al. 2003). Much of this research is informed by an enduring
perspective among social scientists and public health specialists that considers how
social and physical elements in the environment play a crucial role in the
determination of a populations overall level and distribution of health. From this
viewpoint, law enforcement is held to be a mechanism through which ecological
conditions are transformed into risks and health-related outcomes (Burris et al.
2004). This strain of thinking ascribes to the view that daily interactions between
police officers and IDUs and the general social atmosphere created by law
enforcement practices are converted into risk behaviors and ultimately detrimental
health consequences for drug using populations.
This study is concerned with how vigorous policing practices and law
enforcement agendas acting in support of current drug policy encourage and
exacerbate risky behaviors among EDUs in Denver, Colorado, thereby intensifying
the health-related dangers associated with injection drug use. In Colorado, as in all
fifty states, police enforce federal narcotics laws banning the sale, purchase, or
possession of illicit substances such as heroin used by drug injectors. In addition,
2


both a state statute and a municipal ordinance define syringes and other
paraphernalia used for the purpose of injecting controlled substances into the body
as illegal. Possession of drug paraphernalia is a Class Two misdemeanor,
punishable by a maximum $100 fine. Denver police normally enforce a
complementary city ordinance outlawing injection devices, rather than the state
statute because it requires less paperwork. The penalty for violating the ordinance
is determined by the judge and may vary from a small fine to time in jail (Koester
1994). Possession of controlled substances carries felony charges for which the
penalty may include substantial fines and/or incarceration. In response to the
criminalization of drugs and injection-related devices they use on a regular basis,
IDUs must resort to behaviors that reduce their chances for being apprehended with
either. The purpose of this study was to gauge how policing practices and law
enforcement agendas influence the risk behaviors of Denver area IDUs according
to the attitudes, beliefs, and experiences of those who live and inject drugs in the
local metropolitan vicinity.
This research utilizes data from a study conducted through Urban Links.
Urban Links is a project within the Center for Health and Behavioral Sciences at
the University of Colorado at Denver and Health Sciences Center and is funded
through grants from the National Institute on Health (NIH), the Centers for Disease
Control (CDC), and the state of Colorado. The projects director and principal
investigator, Dr. Stephen Koester, has been funded to research interventions that
target individual and network components in the prevention of HIV among IDUs.
Drue-Related Risk Behaviors
There is a multitude of drug-related behaviors that place IDUs at risk for
transmission of blood-borne diseases such as HIV and HCV. These behaviors may
occur as part of the actual injection process or as part of the preparation or
3


distribution of drugs between injection episode participants. The sharing of
previously used or non-sterile syringes to inject a drug solution is one risk behavior
that has garnered a great deal of attention from both public health specialists and
social science researchers. There are however, other behaviors that place IDUs at
risk. These include the sharing of drug mixing containers, filters that remove
impurities from the drug solution, or water for drug preparation and/or syringe
rinsing. These behaviors often occur as part of a process that includes preparing and
allocating jointly purchased and shared drugs. In addition, high risk sexual
behaviors increase the risks faced by many IDUs. Both men and women drug
injectors are known to trade sex for drugs or money or engage in commercial sex to
generate income that pays for their habits and this increases their risk for
transmissible disease (CDC 2000). While there are numerous practices that place
drug users at risk, it must be recognized that transmission of blood-borne viruses is
due to behaviors that occur within social contexts. In comparison with infectious
diseases that are spread by casual contact, HIV is transmitted primarily by risk
behaviors that involve close contact between infectious and susceptible individuals
(Neaigus 1998).
Thesis Organization
The thesis I present challenges the theoretical assumptions put forth by
psychological models predominant in HIV prevention strategies among drug using
populations. By demonstrating the important influence contextual factors, in
particular policing, have on IDU risk behavior I call into question the efficacy of
current prevention models that emphasize individual behavior change. In Chapter
Two, I introduce my theoretical position and illustrate the shortcomings of current
prevention models that rely upon rational decision making theories to guide
intervention efforts. The chapter contains an explanation of why anthropological
4


models provide a more effective approach to understanding IDU risk behavior and
how law enforcement acts as a structural element in the daily lives of drug
injectors. The chapter concludes with a critical overview of how societal
perceptions of drug use have been shaped by changing political and economic
forces and the role that law enforcement has played in support of policies that
criminalize those who use illicit drugs.
Chapter Three provides a review of the literature focusing on IDUs risk
behavior and the contextual elements that influence it. The central theme
organizing this chapter is that research continually demonstrates the failure of
current legal policies criminalizing addiction in view of the public health crises of
HIV and HCV. This chapter seeks to illustrate that law is comprised of multiple
components and reveals how existing drug and paraphernalia laws, including their
enforcement on the street, act as detrimental elements to both IDUs well being and
the public health at large.
Chapter Four is a description of the methods utilized for data collection and
analysis. It includes a discussion of limitations inherent in the secondary data
analysis approach chosen for this project as well as an explanation of sampling
procedures. Demographic information of the subject population is provided as well
as explanation of the sources that provided raw data for analysis.
Data analysis revealed three central findings presented in Chapter Five. The
first comprises the multiple effects that law enforcement practices have on drug and
injection-related behavior as a result of EDUs fear of arrest and police interference.
The second depicts how police agendas targeting street-based drug injectors for
arrest serve to alter the composition of IDUs social and injection networks thereby
affecting how transmission of blood-borne disease takes place, including how risk
is contextualized for other forms of drug-related harm. The last finding
demonstrates how police practices influence the potential risk for drug overdose
among IDUs. This chapter aims to reveal how policing agendas have created an
5


environment in which IDUs perceive the threat of arrest or legal repercussion as
more serious than the consequences of overdose. It also reveals how frequent arrest
and time in jail functions to increase the risk for dangerous injection episodes and
overdose as addicts attempt to quickly alleviate the symptoms of withdrawal upon
release. Included in this chapter are data taken from an interview conducted with a
Denver police officer. These data serve to reinforce the central findings by
illustrating that Denver law enforcement has made concerted efforts to target and
arrest large numbers of street-level drug market participants. The interview also
serves to highlight the untenability of a wider policy criminalizing drug use as the
officer reveals his belief that regardless of law enforcements efforts, there will
always be illegal drugs and those who use them.
Chapter Six focuses on discussion of the central findings and argues that
legislation and enforcement policies criminalizing addiction are incompatible with
lessening the severity of a public health crisis fueled by injection drug use.
Included in this chapter is explanation of the theoretical merit of the
anthropological models chosen for analysis and description of why public health
models informed by psychological theory are inadequate for interventions focused
on drug-related harm among IDUs.
Chapter Seven concludes the thesis and emphasizes the need for both major
policy change and perhaps more immediate alterations of the policing agenda that
influences the environment in which drugs are used. While the problem of drug-
related harm among IDUs can ultimately be traced to the impact of structural
policies and enforcement practices criminalizing drug use and addiction, it would
be unfair to characterize all police departments and personnel as contributing to
drug-related harm. Nevertheless, political agendas, legislative policies, and societal
attitudes towards illicit drug use have been internalized in police culture resulting
in persistent negative attitudes towards illicit drugs and those who use them. Most
6


importantly, these pervasive attitudes influence the way patrol officers police drug
users and think about the way that society should deal with them.
7


CHAPTER 2
THEORETICAL ORIENTATIONS
For the purposes of this thesis, I employ midrange applied theory to the
problem of blood-borne disease transmission and drug-related harm among IDUs.
Midrange theory is what is utilized most frequently when addressing problems
from an applied anthropology perspective. Pelto and Pelto refer to midrange theory
as:
predictive generalizations arising from the time and space
immediacy of field data and linked to broader theoretical
approaches or paradigms such as structuralism; postmodernism;
ecological, or systems theories; and Marxist/materialist or
evolutionary theories (cited in Trotter and Schensul 1998:696).
While Trotter and Schensul agree with this definition, they provide clarity
and refinement by referring to midrange theories as approaches that have arisen
from research in anthropology that precede and guide research in local settings, and
where that research has direct applications (Trotter and Schensul 1998). This
refinement is appropriate and speaks directly to work being done within the field of
drug-related HIV/A1DS prevention in which I am primarily interested. It is
particularly important to recognize that midrange theories are locally situated.
These theoretical models describe, explain, and/or predict what is
going on in one or more cultural domains in a specific environment.
Such models are generated from prior knowledge and field
experience, are tested in the field, and are continually refined
(Trotter and Schensul 1998:696).
8


The theories that I utilize fit within a materialist perspective in that they
assume the existence of real, physical world elements or aspects of human society
set constraints for, and have significant impact on, human behavior (Barfield 1997).
The two theories most pertinent to the interests of this thesis are ecological theory
and the perspective of critical medical anthropology (CMA).
Ecological Theory
Ecological theory gives central importance to the concept of adaptation,
defined as behavioral or biological changes at either the individual or group level
that contribute to survival in a given environment (Baer et al. 1997). From this
theoretical perspective, the level of health of any particular social group is viewed
to be an expression of the relationships within a population, between neighboring
populations, and among the life forms and physical components of a habitat
(McElroy and Townsend 1985:2). Ecological perspectives emphasize that the total
environment is of concern when examining issues of health and disease. This
means that not only is the relationship between humans and their natural physical
environment important, but so too are the interactions between and among human
groups who exist in that environment. According to Brown, An ecological
approach to human health and illness emphasizes the fact that the environment and
its health risks are, to a significant extent, created by the culture (Brown 1998:4).
This statement underscores the important recognition that health risks are primarily
the product of human socio-cultural, political, and economic activities. In other
words, health risks are not simply a natural product of an external and independent
environment, but are deeply influenced by human endeavors and hierarchical social
structures (Baer et al. 1997). With regard to injection drug use, an ecological
perspective is particularly relevant because it allows examination of the behaviors
of drug injectors as adaptations or responses to environmental variables or
i

I
9


conditions that occur within specific and local contexts. One of these variables is
the institution and practice of law enforcement. While an ecological perspective is
highly informative when applied to the problem of disease transmission and drug-
related harm among IDUs, it alone is insufficient for achieving a more complete
understanding of how and why this population experiences elevated levels of drug-
related harm and what we can do to address this problem. Ecological perspectives
fail to fully account for the influence of power and the way that changing
hierarchical social structures effect an environment that bears certain risks for
specific segments of the population (Baer et al. 1997). As this thesis demonstrates,
the risky behaviors that IDUs engage in are often the result of a set of conditions
created by larger political and economic structures requiring a response on the part
of these marginalized individuals. Unfortunately, these responses often lead IDUs
to engage in behaviors that may compromise their well being. In order to address
the larger forces that shape the environment in which EDUs act, the perspective of
CMA is utilized.
Critical Medical Anthropology Perspective
CMA is an approach that:
understands health issues within the context of encompassing
political and economic forces including forces of institutional,
national, and global scale that pattern human relationships, shape
social behaviors, condition collective experiences, reorder local
ecologies, and situate cultural meanings (Baer et al. 1997:27).
This approach provides improvement over an exclusively ecological
perspective by refining our understanding of the forces that influence the
environment in which EDUs live. These forces are inherently political and
economic and are responsible for the creation of asymmetrical power differences
10


that shape social processes and condition human behaviors. CMA allows us to
place, center stage, the structural forces that constrain human agency and contribute
to the production of disease and illness in any given environmental context. The
core elements of this perspective can be seen in the work of
physician/anthropologist Paul Farmer. Farmer illustrates through his work on AIDS
and tuberculosis in Haiti, that infectious disease is not the product of cultural
differences that embody ritualistic and destructive behaviors, but rather the
outcome of broad and encompassing social inequalities and structural violence.
Structural violence refers to the way that historically driven, often political and
economic processes conspire to constrain individual agency (Farmer 1999). In his
analysis, Farmers critical perspective highlights the insight that certain groups are
rendered vulnerable to diseases like AIDS through social processes. These social
processes encompass economic and political forces that ultimately shape the
dynamics of HIV transmission (Farmer 1999). As this thesis demonstrates, law
enforcement practices are an integral structural influence on the health of IDUs,
serving to affect the behaviors of drug injectors in myriad deleterious ways. It is in
this sense that law enforcement becomes an expression of structural violence.
Psychological Models: Stressing the Individual and
Ignoring Context
An ecological foundation and CMA perspective are important to the
analysis of drug-related harm among IDUs because they highlight the important
contextual elements that influence risk behavior. Unfortunately, the predominant
models put forth for understanding and preventing HIV among drug users have
originated from within the field of psychology, and rather than acknowledging the
fundamental role of structural influences and environmental factors in the spread of
blood-bome disease, have stressed the individual by divorcing them from the
11


environment in which they act. In other words, these models have mistakenly
placed the burden of responsibility for behavior change on the individual, and in
doing so, have ignored the critical role that structural influences such as policing
play in disease transmission.
While the last two decades have witnessed a growing recognition on the
part of public health researchers and social scientists that individual and population
health is largely a product of social and environmental influences, public health
interventions among IDUs, particularly in western nations, have continued to focus
on individual risk behavior change as the unit of analysis.
In theoretical terms, rational decision-making theories dominate.
Emanating from the psychological concepts of health-beliefs
(Becker, 1974) and self-efficacy (Bandura 1977), these theories
promote a conception of risk as a product of cognitive health-beliefs
and reasoned risk assessments. Such theorizing assumes an overly
calculative and context-free vision of risk decision-making,
neglecting to capture how risks and their perception are context
dependent. At its crudest, individual action and decision-making
theories assume a shared, even single, rationality of risk avoidance,
wherein rational behavior is viewed as synonymous with risk
avoidance (Rhodes 2002:86).
I have chosen behavior change models theoretically informed by
psychology for critique because previous research and the data presented in this
thesis demonstrate the ineffectiveness of such approaches. While public health
outreach efforts have provided IDUs with considerable educational information
regarding ways to reduce their risk for communicable disease, injection drug use
continues to be either directly or indirectly responsible for high proportions of both
HIV and HCV cases. Two decades of research focusing on injection drug use and
the implications of behavior change for disease transmission have fallen short of
making a substantial impact on the perpetuation of HIV and HCV epidemics
among IDU populations. The continual use and propagation of unproductive
12


behavior change models warrants a renewal of their critique and a shift in focus
from the individual and their behavior to structural change.
The Theory of Reasoned Action: Research Application
and Inherent Flaws
One particularly prominent model that has served as a general guide for
public health interventions among drug users and which has dominated prevention
research within the field of HIV/AEDS is the psychology derived theory of
reasoned action.
The central premise of the theory of reasoned action is that people
make behavioral decisions on the basis of a reasoned consideration
of the available information. The theory can, therefore, be regarded
as a deliberative processing model, to the extent that behavioral
decisions are seen to be the consequence of the persons systematic
consideration and deliberation of the information available to him or
her (Terry et al. 1993:7).
The Theory of Reasoned Action posits that the causal agents of behavior are
comprised of a series of logical and sequential cognitions that encompass
individual intentions, attitudes, beliefs, and motivations (Terry et al. 1993). One of
the central assumptions of the theory is that a persons intention to perform a
certain behavior can only be considered an accurate predictor of whether they will
actually carry out that behavior in the event that the intention can be performed at
will (Terry et al. 1993). This means to say that if a persons intention to do
something is free from social influence or is completely independent of outside
resources, knowledge, or barriers, then it will be a good predictor of actual
behavior. The problem with this supposition is that it presumes human intentions
and behaviors occur as a result of individual perceptions or cognitions that exist
independent of encompassing social processes. Human behavior is a fundamentally
13


social phenomenon and occurs within a framework of social structures and
relations, not in a void of independent cognitions that lead to certain acts (Kippax
and Crawford 1993). In other words, human behavior does not occur in a vacuum,
but is motivated by the reality of shared social processes and outside influences.
Targeting the theory of reasoned action for critique, Kippax and Crawford expose
the flaws in this inherently individualistic model and argue that interventions based
upon such views hinder effective efforts because they ignore the essentially social
nature of human action (Kippax and Crawford 1993). The authors contend the
main problem for the theory of reasoned action is its reliance on cognitive
structure to explain behavior change. They state:
Our basic argument is that such a reliance means that the theory
ignores the connections between individuals, both the interpersonal
and social relations in which they act, and the broader social
structures which govern social practice. Social relations and
structures are important, for without them individual behaviors have
no meaning. Action is constituted with reference to shared meanings
(Kippax and Crawford 1993:255).
Needle and colleagues 1998 study examining drug acquisition and multi-
person use of paraphernalia, drugs, and syringes provides a useful illustration of
how an approach informed by this perspective focuses on identifying individual
risk factors in order to develop ways to help drug users modify their own behaviors.
Needle et al. demonstrate that in comparison to lower risk injection networks,
higher risk injection networks are characterized by larger size and pooling of
resources to buy drugs (Needle et al. 1998b). Concluding that behavioral
transactions linking members of injection networks in the processes of acquiring
and preparing drugs create the potential for HIV transmission, the authors
emphasize that prevention messages must be aimed at IDUs by encouraging them
to change their own risky behaviors. The authors maintain that the foremost
prevention messages should be, Do not reuse any injection equipment and Do
14


not use a syringe to transfer a shared drug solution (Needle et al. 1998b:2417). In
addition, they assert that users should be encouraged to divide drugs while in dry
form, so as to avoid the sharing of a jointly prepared drug solution (Needle et al.
1998b). Encouraging IDUs not to reuse drug preparation/injection equipment
places the onus entirely on the individual and reinforces the notion that it is their
sole responsibility to make the changes necessary to protect their health. Bourgois
has illustrated the inadequacy of these unrealistic public health messages, arguing
that standard public health outreach messages of bleach it, never share water,
cookers, cottons or needles, and always wear a condom insult dope fiends or
push them into defensive denial (Bourgois 1998:2233-34). As Bourgois explains,
public health researchers must reconceptualize their psychological behaviorist
paradigm of individual risk behaviors because the everyday pragmatics of income
generating strategies and the notions of respect, identity, and mutual dependence
make it impossible for street-based IDUs to heed these prevention messages
(Bourgois 1998:2323). Bourgois argument illuminates the flaws inherent in
reasoned action approaches by demonstrating that human behavior is not the
result of independent cognitions, but is dependent upon social relations with
intention informed by both negotiation and mutual dependence. While not
explicitly using the theory of reasoned action, Needle and colleagues study
incorporates the logic of the theory in distinct ways. First, it assumes that if
provided with adequate information (in the form of outreach messages) regarding
the risks associated with reusing drug preparation/injection equipment, IDUs will
make logical and reasoned judgments about the dangers and will subsequently
change their risky behaviors. Second, the authors assume that individual intent is
the primary focus in the effort to effect behavior change. Regardless of whether risk
behaviors occur within the context of injection and/or social networks, Needle et al.
presume that it is the individual drug user that must ultimately be educated about
dangerous behaviors. Moreover, their approach indicates that it is these individual
15


behaviors, as an accumulation of injection network practices that are responsible
for high risk among certain groups. Lost in their analysis and recommendations for
public health intervention is the recognition and appreciation for how structural
factors influence EDUs risk behavior by constraining their ability to carry out, in a
practical way, the advice contained in outreach messages. As Bourgois points out:
mainstream applied public health paradigms ignore power whether
it be the criminal justice system and laws governing controlled
substance and paraphernalia; the ideological and social structural
enforcement of social marginalization by institutions and
mainstream discourses; or the structuring of networks and
identities/practices of risk by race, class, gender, sexuality, and
geography. By focusing on changing individual behavior in a
vacuum, public health researchers obscure and ultimately reinforce
the power dynamics that shape risk (Bourgois 1998:2344).
The primary problem with models like the theory of reasoned action that
continue to inform behavioral understandings and intervention efforts associated
with HIV/AIDS, is that they neglect to confront the dynamics of power.
Psychological models applied to problems such as blood-borne disease
transmission and drug-related harm place the onus on the individual and fail to
account for the influence of structural and environmental determinants that shape
risk behaviors. The issue is not, however, one of EDUs simply reacting to external
stimuli, but rather one of dynamic social process where certain structural forces
such as drug laws and policing practices set up conditions requiring a response on
the part of marginalized individuals. It is this dynamic interplay between the
individual and their environment that ultimately sets the stage for certain risky
behaviors and which ultimately contributes to negative health-related outcomes.
16


Anthropological Models: The Importance of Context
Anthropological models offer valuable insight to public health efforts
targeting IDUs by serving to correct the epidemiologically based and
psychologically guided interventions whose focus of analysis is the individual. In
contrast to psychological models that give primacy to individual agency, ecological
theory in anthropological perspective recognizes that there are constraints inherent
in the environment that force individuals and populations to adapt and as a result,
behavior that may appear irrational from an outside perspective may have adaptive
value from an insiders point of view. Ecological models recognize that there may
be multiple independent variable domains that influence individual and group
behavior and that local context is important in determining how individuals
continuously adjust to environmental circumstances (Trotter and Schensul 1998).
Anthropological models are more effective and appropriate than psychological
approaches to the study of risk behavior associated with drug-related harm because
they incorporate context into their approach. In addition, anthropological models
and perspectives have embraced IDUs as a vulnerable population; something
individually focused intervention models have failed to do (Aral et al 2002; Baer et
al. 1997; Blankenship and Koester 2002; Bourgois 1997; Bourgois 1998; Burris et
al. 2004; Friedman et al. 2001; Koester 1994; Lazzarini and Klitzman 2002; Maher
2002; Rhodes 2002). This is important because it reinforces the understanding that
IDUs generally lack the essential resources necessary to effectively respond to
conditions that produce drug-related harm. As Rhodes points out, Vulnerability to
drug-related harm is closely associated with social, material, and health inequalities
more generally (Rhodes 2002:91-2). Bourgois clearly demonstrates how everyday
poverty faced by IDUs in San Francisco shooting encampments places them in a
compromised position that contributes to the adoption of risky behaviors. He
17


relates, In short, risky needle practices emerge out of the microstrategies that street
addicts utilize to avoid dopesickness, minimize risk of arrest, and construct
supportive social networks (Bourgois 1998:2331). In addition, Koester illustrates
how contextual factors, such as legal mandates restricting possession of syringes
and strategies employed by IDUs to acquire drugs, leave drug injectors vulnerable
to behaviors that increase their risk for blood-bome disease transmission (Koester
1994). Viewing IDUs from a perspective of vulnerability allows us to
conceptualize elements external to the individual that influence and wield power
over drug injectors behavior and life conditions. As members of society who
occupy disadvantaged and marginalized social positions, IDUs are more likely to
suffer elevated levels of harm because they lack access to essential resources that
allow for effective responses to structurally influenced environments of risk.
While structural conditions may render IDUs vulnerable to drug-related
harm, it is important to recognize that drug users may, in some circumstances, be
actively resisting the dominant conditions that envelop them (Bourgois 1995).
Actively participating in the illegal drug market offers some users an alternative
form of income and personal dignity that is in opposition to an exclusionary and
judgmental mainstream society. With this understanding in mind, IDUs may
actually be increasing their sense of agency when faced with oppressive economic
and social circumstances. While recognition of this sense of personal agency is
important, so too is awareness of the reality that active resistance may ultimately
result in the personal destruction of those who embrace it (Bourgois 1995).
Law Enforcement and CMA
With respect to the use of a broad ecological foundation that gives primacy
to the concept of adaptation or response in consideration of how individuals
interact with their environment, application of the CMA perspective assists in
18


achieving a more complete understanding of how drug-related risk behaviors are
contextualized within the specific environment of Denver, Colorado. In particular, I
look at policing practices and law enforcement agendas that exist in support of
current drug policy in an effort to reveal how they influence risk behaviors among
IDUs. Law enforcement and the practice of police officers can be situated within
the perspective of CMA in two ways. First, law enforcement must be understood as
a structural element that is part of a wider policy criminalizing drug use in the
United States. Second, interaction between police officers and IDUs demonstrates
the nature of a power imbalance that leaves drug injectors in a vulnerable and
oppressed position where they must respond to structurally imposed and enforced
conditions.
Sumartojo refers to HIV-related structural factors as ... barriers to, or
facilitators of, an individuals HIV-prevention behaviors. They directly or
indirectly affect an individuals ability to avoid exposure to HIV (Sumartojo
2000:S3). Law enforcement interacts with IDUs on a regular and intimate basis. In
doing so, it exerts strong influence upon multiple aspects of their behavior,
including that which is related to health risks posed by drug-related activity.
Representing the enforcement of state power, the police are the chief institution that
carries out the will of government, including its laws and wider agendas (Johns
1992). As Skolnick maintains, The police in democratic society are required to
maintain order and to do so under the rule of law. As functionaries charged with
maintaining order, they are part of the bureaucracy (Skolnick 1994:6). It is in this
sense that the police, as representatives of the state and part of the political
bureaucracy, are viewed to be a structural factor that influences the social
environment in which IDUs live and act.
19


Drug Use in CMA Perspective: Policing as a Structural
Element and the Imbalance of Power between
Law Enforcement and IDUs
CMA views illicit drug use within a historic and developmental framework
that considers the key political economic factors that have influenced drug using
behavior. This perspective emphasizes that drug use and its perception by society
has evolved as a result of changing political and socioeconomic circumstances. It is
these changing influences that have contributed to how drugs, and those who use
them, are policed in modem American culture.
While over the counter and prescription use of opiates during the colonial
period was widely embraced and considered normal by the medical community and
American public, certain forms of behavior, particularly opium smoking associated
with inner city minorities, were considered deviant and problematic (Baer et al.
1997). According to Baer et al. ... the real problem appears to have been racism.
The primary concern was not drug use but who was using the drugs (Baer et al.
1997:133). Intense concern over who was using drugs and politically fueled drug
panics have been used historically in this country as part of a larger war against
marginalized populations, designed to further marginalize them and legitimize their
oppression (Johns 1992:74). In the early part of the twentieth century the legal use
of drugs began to be questioned. As government authorities reevaluated
international relations and profits relating to the opium trade, concern over
competitive markets associated with the international drug trade led Congress to
construct and pass the Harrison Narcotic Act of 1914. Passage of this act served to
place restrictions on the sale of over the counter narcotic medications (Baer et al.
1997). The ultimate social effect of the new federal law was to label the drug user
a criminal. In the aftermath of this labeling, drug use came to be synonymous with
20


deviance, lack of control, violence, and moral decay (Baer et al. 1997:138).
According to Friedman et al., the hostility and stigma directed at drug users is, in
part, a reflection of the economic and social crisis that capitalism has experienced
(Friedman et al. 2001). Faced with varying periods of economic pressures and
inequalities, reduced government budgets allocated to education, health care, and
the poor, and popular resentment at daily problems and life conditions, power
holders have re-directed societal anger and resentment of worsening conditions
towards certain social groups such as drug users. The stigma and criminalization of
drug use has played a central part in this diversion as political leaders have aimed
to deflect attention away from the larger social ills that plague society (Johns
1992) . By utilizing drug users as a scapegoat, power holders have effectively
consolidated the middle and working class citizenry against a common adversary
(Friedman et al. 2001). The end result of criminalizing drug use and blaming
certain races and marginalized populations for the problems that society confronts,
has been that drug users have been labeled enemies of the purportedly good,
respectable, and worthy citizenry. Moreover, demonizing drug users has had the
effect of portraying the addict as a deviant who, when left unchallenged, would
commit horrendous crimes against society in order to obtain drugs (Waterston
1993) .
While physicians were initially exempt from the regulatory reaches of the
Harrison Act, the freedom to prescribe medicinal narcotics did not last. Growing
concern on the part of political and economic leaders that drug use would spread
from marginalized populations to higher social classes led to Supreme Court
decisions that banned physicians from prescribing narcotics as part of a cure (Baer
et al. 1997).
In the twelve years after passage of the Harrison Act, at least 25,000
physicians were arrested on narcotics-selling charges, and 3,000
served time in jail as a result ...By 1919, there were 1,000 addicts
21


brought up on federal drug charges. By 1925, there were 10,000
arrests per year (Baer et al. 1997:139).
These figures serve to illustrate that even during the early years of the War
on Drugs high arrest rates by police were a central part of the effort to control illicit
drug use in the United States.
Over the years, the War on Drugs has resulted in the United States
incarcerating a higher percentage of its citizens than any other country and has
substantially expanded the power of the police at all levels from federal to local
(Bluthenthal et al. 1999). As the institution charged with enforcement of federal
and state policy on local levels, police officers play a central role in the War on
Drugs because they are bestowed with the authority to ensure that public order is
maintained and policies instituted by law makers are followed. Law enforcement
operates on multiple socioeconomic and political levels. Through daily interaction
with the public, the police serve as key structural elements in the determination of
drug users health. As Waterston points out, relations between street addicts and the
police are clearly hostile as law enforcement considers the addict a destructive
threat to American society (Waterston 1993:150). The persistence of this
antagonistic view ensures that drug users will continue to be targeted by police.
As representatives of the state, police are granted with authority that gives
them almost absolute power over poor, marginalized IDUs. On the street, law
enforcement officials are empowered by their badges and their mandates to set out
upon a search for the relatively weak and powerless (yet bad) drug addict
(Waterston 1993:151). Many IDUs live in a state of impoverishment, often forced
to engage in temporary partnerships or illegal activities to obtain money for drugs
and other living expenses (Koester 1994). As a result of operating out in the open
and in often known drug buying places, IDUs are vulnerable to detection and
arrest by police officers. It is highly likely that IDUs who participate in the local
drug scene long enough will become known to the police and eventually be
22


apprehended. While police crackdowns on drug using populations are common,
they are usually ineffective in reducing local drug use and trafficking. As such,
these agendas may point to other factors that weigh on police decisions to pursue
such operations. Waterston suggests police initiatives serve the wider political and
economic interests of the community and that police actions against drug users
provide a symbolic demonstration to the general public that action is being taken
against criminals. Moreover, police crackdowns remind low-level, visible, and
vulnerable street addicts of their relative powerlessness (Waterston 1993:152).
IDUs are, for all meaningful purposes, powerless in comparison to law enforcement
agencies and the police. They are vulnerable to harassment, abuse, and arrest
because they lack the social and economic resources to effectively respond to
police actions taken against them. Furthermore, due to their impoverished and
stigmatized position in society, they are unable to mount the legitimate
representation required to gain power through confrontation of their marginalized
social status.
Throughout this section, I have critiqued behavior change models by using
the perspective of CMA. By looking at changing perspectives on drug use and
situating the police as an influential structural element carrying out a policy that
criminalizes the drug user, I utilize CMA to demonstrate the shortfalls of
psychology guided intervention models that focus only on the individual and
behavior. The perspective of CMA offers critical examination of the contextual
factors that affect IDUs and their risk behavior, and therefore provides a more
useful approach to understanding why IDUs engage in certain forms of drug-related
behavior, and where we must redirect our focus if we are to exact meaningful
change in current patterns of disease transmission and drug-related harm.
23


CHAPTER 3
REVIEW OF THE LITERATURE
IDUs: Behavior and Risk
Interventions designed to prevent the transmission of blood-borne
pathogens have customarily focused on altering the individual behaviors that place
IDUs at risk for disease. These behaviors encompass not only the direct sharing of
syringes between injection-episode participants but may also include other, more
subtle behaviors that occur as part of both the preparation and actual injection
phases of drug use. Termed indirect sharing, these other behaviors occur when
drug injectors share injection paraphernalia other than syringes while preparing or
distributing a drug solution. Indirect sharing is used to distinguish between these
types of risk behaviors and those entailing the direct sharing of a common syringe
among two or more injectors. Paraphernalia used for injecting a drug solution
includes water used for rinsing syringes and/or mixing drugs, containers or
cookers used to hold and mix the drug solution, and filters or cottons used for
filtering out impurities or pieces of undissolved drug while the solution is being
drawn up into the needle. In addition to the sharing of these injection-related
paraphernalia, researchers have identified methods of transferring portions of the
drug solution from one syringe to another as potentially placing IDUs at risk for
infection (Koester and Hoffer 1994). Frontloading is one of these methods and
occurs when one syringe is used to transfer some of the drug solution to another
syringe by removing the needle of the receiving syringe and depositing the drug
directly into its hub. The other method, termed backloading, occurs when the
drug solution is transferred from one syringe to another by removing the plunger of
24


the receiving syringe and then squirting the drug solution from the donor syringe
directly into its barrel (Koester and Hoffer 1994). These practices occur as
intermediate steps in the drug preparation and injection process and rather than
being easily recognized by IDUs as potentially dangerous, as is the direct sharing
of syringes, remain largely misunderstood by most injectors (Koester 1996). Recent
research in Denver identified that indirect sharing practices were much more
common than the direct sharing of syringes. According to Koester and colleagues,
dividing the drug as a solution and the common use of a cooker, considered to be
proxies for the practice of drug sharing, occur as routine practices when IDUs inject
together (Koester et al. 2005).
Koester et al. maintain that the sharing of paraphernalia associated with the
injection process is only a component practice of sharing drugs; the real risk
behavior that places IDUs at danger for infection (Koester et al. 2005). Sharing
paraphernalia while preparing and injecting a shared drug solution occurs
frequently as the end result of a process in which IDUs have jointly purchased
drugs. While purchasing drugs together may be due to the reality that drug use is
for many a social activity, the formation of small partnerships for the purpose of
acquiring and then jointly preparing a drug solution is also a result of economic
hardships faced by many IDUs, the conditions of the local drug market, and the
illegal status of injection drug use (Koester et al. 2005). Moreover, many IDUs find
that preparing a jointly purchased drug into a common solution allows for more
accurate distribution of the drug to those who have contributed to its purchase.
Unfortunately, if a contaminated syringe or other paraphernalia is utilized for the
preparation or distribution of the drug solution, injectors face a heightened risk of
infection even when they do not share needles.
Research has demonstrated that a majority of IDUs are knowledgeable
about AIDS transmission and realize that sharing needles may result in blood-borne
disease infection (Caslyn et al. 1992). Injection drug use, however, continues to be
25


a major factor in the perpetuation of HIV and HCV. Ethnographic research has
refuted the proposition that drug users continue to share paraphernalia as a result of
adhering to rituals or subcultural codes governing injection drug use, showing
instead that lack of access to sterile needles and enforcement of policies outlawing
syringe and drug possession are critical to the perpetuation of sharing behaviors
(Kane and Mason 2001). It is these obstacles that contribute to the continuing
practice of paraphernalia sharing and which serve as formidable barriers to the
adoption of more safe injection-related behaviors by IDUs.
While it is important to continue outreach efforts that aim to inform and
educate IDUs about the nature of risk behaviors embedded in the process of drug
preparation and injection, it is crucial that public health strategies elucidate avenues
for structural change. Only by examining and altering the structural elements that
so heavily influence the ways in which drug use is negotiated will meaningful
decline in current risk behaviors associated with injection drug use be observed.
Law on the Books and Law on the Streets:
The Foundation for a War on Drugs
Law is a complex phenomenon comprised of multiple components. For
example, law does not only include the rules, regulations, statutes, and court
decisions that we often think of existing on the books, but is also comprised of
the institutions, agencies, and practices through which they are implemented in
daily fashion on the street (Burris et al. 2004). In terms of legal policies relating
to drug use and the influence that they have on health outcomes experienced by
IDUs, law can be perceived to consist of four distinct components: law on the
books; criminal justice management policies, standard operating procedures, and
training; practices, knowledge, attitudes, and beliefs of frontline police officers; and
the knowledge, attitudes, and beliefs of injection drug users (Burris et al. 2004).
26


With regard to criminal drug law, law on the books provides an extensive written
definition of what constitutes criminal acts and establishes the mission and powers
of various law enforcement agencies (Burris et al. 2004). Legislative action taken
by federal and state level lawmakers resulting in legal policies governing illicit
drugs and injection paraphernalia has provided law enforcement agencies with clear
directives in the stance toward drug use. For all intents and purposes, law
enforcement agencies consider addicts no different than those who produce,
distribute, and sell illegal drugs. While there are differences in legal charges
associated with the type of activity involved, both street-level addicts and large
scale traffickers are considered criminals by the police. Drug policy and formal
law on the books provide police with an institutionalized and socially approved
enforcement agenda that prioritizes locating illegal drug activity and arresting those
who participate in the drug market.
Since the beginning of the 1980s, the United States government has
undertaken an extremely costly and extensive War on Drugs that has operated on
the basis of a punish to deter approach. The belief behind this approach is that
fear of punishment will act as a deterrent by raising the risks of drug abuse and
will thus lead to less use and abuse (Bluthenthal et al. 1999:26). During the course
of the War on Drugs, penalties for possession and sales of drugs have increased
substantially and drug use has become justification for loss of employment and
denial of education, housing, and welfare assistance (Bluthenthal 1999). While
most observers contend that the War on Drugs has failed to eliminate or even
modestly affect the drug problem in the United States, political leaders and
policymakers at various levels continue to embrace and promote a course of action
that has promulgated a range of unintended and harmful consequences (Tonry
1995). Perhaps the most significant of these is the spread of drug injection-related
blood-borne disease. Prohibitionist policies regarding drugs and their attendant
paraphernalia have served to drive IDUs underground and away from essential
27


medical services, encouraged sharing of artificially scarce syringes, and promoted a
variety of dangerous and risky injection-related behaviors.
The street-level enforcement of drug and paraphernalia laws is a critical
component of the War on Drugs serving to demonstrate police authority and the
rule of current policies that criminalize drug use. Societal stigma of illicit drugs and
the addicts who rely upon them has become entrenched in the police function and
structures the way police perceive, approach, and handle drug users (Waterston
1993). Because police officers exercise a large amount of discretionary freedom in
the performance of their daily work, the enforcement choices they make can
sometimes reveal a loyalty to the criminal status of drug users even when the
intention of policy-makers is to assist the drug addict by decriminalizing possession
of injection equipment. (Beletsky et al. 2005 in press). Beletsky et al. demonstrate
that in the aftermath of legislative action taken in Rhode Island that effectively
decriminalized personal possession and over-the-counter sales of hypodermic
needles, police officers continued to treat the possession of syringes by IDUs as
illegal. Importantly, data from their study revealed that police officers used syringe
possession (even when treated as legal) as a tool in two ways that allowed for the
enhanced probability of finding further evidence which could then be used to
charge individuals with drug-related crimes. In the first instance, officers reported
using a recovered syringe as evidence of illegal activity, and by requesting that it be
tested for drug residue, were able to justify the arrest of IDUs pending test results.
Secondly, syringe possession was treated by officers as the rationale for a body,
vehicle, or premises search. Seventy one percent of the police participants in the
study explicitly stated that syringe possession is considered a sure sign of illicit
drug use (Beletsky et al. 2005 in press). These findings demonstrate that actual
enforcement procedures of frontline officers are as critical to how law affects the
public as are rules and regulations existing on the books. Furthermore, they reveal
that specific legal measures such as syringe decriminalization do not go far enough
28


because police are able to defer to an all encompassing drug policy that promotes
the arrest of those who possess or use illicit substances. Law on the books and law
on the streets are mutually reinforcing categories and serve to perpetuate the
criminalization of drug users even when lawmakers seemingly attempt to protect
the publics health by decriminalizing injection paraphernalia.
The War on Drugs is embedded in the socio-political fabric of the United
States and the written laws that serve as its primary doctrine have become ingrained
in the conscience and enforcement practices of law officers. Drug laws serve as a
type of legal resource providing police officers with the authority to intervene and
disrupt illicit drug markets, harass participants, and to make self-initiated arrests
(Maher and Dixon 1999). If police are able to circumvent specific legal measures
introduced to assist drug users by simply deferring to an overall policy outlawing
the use of illicit drugs, then written law exists as contradictory and unbeneficial to
those it aims to assist. Therefore, law on the books continues to serve law on the
streets as police pursue illicit drugs and those who are addicted to them.
Policing and the Enforcement of Drug and
Paraphernalia Laws
In recent times, researchers have paid increasing attention to how policing
and law enforcement practices influence the spread of communicable diseases
among IDUs (Aitken et al. 2002; Blankenship and Koester 2002; Bluthenthal et al.
1999; Burris et al. 2004; Koester 1994; Maher and Dixon 1999; Rhodes et al.
2003). Perhaps the most directly identifiable way that policing affects the risk
behaviors of IDUs is through the enforcement of laws that impact the availability of
paraphernalia, including sterile syringes and other injection equipment necessary to
protect against HIV and other forms of blood-borne disease. The enforcement of
paraphernalia laws not only affects the availability of these items, but also
29


contributes to how their use is negotiated when IDUs possess them. It is widely
understood among public health professionals and social science researchers that
IDU access to sterile syringes is an important, if not critical, component in the
effort to reduce blood-bome disease transmission among this population.
Importantly, it has been clearly demonstrated that making sterile syringes available
to IDUs does not increase injection drug use among non-using populations (CDC
2000). Access to sterile syringes is important because the transfer of previously
used or infected syringes between injection episode participants can lead to blood-
bome disease transmission (CDC 2000). While several structural impediments
affect IDU access to sterile syringes, significant among these are paraphernalia
laws that restrict the sale and/or possession of specific equipment used for injecting
illicit drugs.
In 1979, the U.S. Drug Enforcement Agency developed the Model
Drug Paraphernalia Act, which provided a comprehensive definition
of drug paraphernalia that enabled states and municipalities to
standardize their laws controlling the sale and use of these items.
Included as drug paraphernalia are hypodermic syringes, needles
and other objects used, intended for use, or designed for use in
parenterally injecting controlled substances into the body (Koester
1994:289).
For IDUs on the street, being caught with a syringe is to be avoided at all
costs. Being apprehended with a syringe identifies the offender as a drug injector to
the police, resulting in a court appearance and fine, and can lead to incarceration. In
addition, a paraphernalia violation goes on the users record, compromising the
ability with which the individual can plead not guilty to future drug-related charges.
As IDUs have explained, receiving a citation for a paraphernalia offense can make
it difficult to convince a judge of their innocence should they be apprehended and
charged for more serious drug-related transgressions in the future (Koester 1994).
30


Koester contends that in comparison to Dayton and Columbus, Ohio, in
which enforcement of laws prohibiting the possession of syringes is situational, and
Seattle, Washington, where possession of injection equipment leads to mild
harassment but not arrest, sanctions against needle possession in Denver appear to
be more rigidly enforced (Koester 1994). This leads to elevated caution among
IDUs concerning carrying syringes and results in many injectors being without
syringes when they need them. The rigid enforcement of laws prohibiting syringe
possession by IDUs can elevate the normal risks associated with the use of
injection drugs. As IDUs become fearful and anxious about the potential for arrest,
they resort to behaviors that put themselves and others at risk for blood-borne
disease and/or other forms of drug-related harm.
Police Practice and the Effects on IDUs Risk Behaviors
There are numerous effects that drug laws and police enforcement practices
have on IDUs injection-related risk behavior. Several authors have identified the
unwillingness of IDUs to carry syringes and/or other drug-related paraphernalia for
fear of being stopped by the police and how this may lead to increased syringe
sharing, re-use, and/or stashing (Aitken et al. 2002; Bluthenthal et al. 1999;
Bourgois 1999; Claris et al. 1998; Koester 1994; Maher and Dixon 1999). In their
study sample of 1257 IDUs, Bluthenthal et al. found that 404 (32%) were
concerned about arrest while carrying drug paraphernalia. Most importantly, their
results demonstrated that IDUs who were concerned about arrest while carrying
drug paraphernalia were more likely to share syringes (23.1 vs. 12.4%) and other
injection equipment (57.6 vs. 36.2%) than those not concerned (Bluthenthal et al.
1999). These results are particularly significant because they illustrate that
injection-related risk behaviors are directly associated with IDUs fear of arrest by
police while carrying syringes. Numerous ethnographic studies support such
31


findings and demonstrate that IDUs will go to great lengths to avoid being arrested
while carrying drugs or drug paraphernalia (Aitken et al. 2002; Blankenship and
Koester 2002; Bourgois 1998; Burris et al. 2004; Maher and Dixon 1999; Koester
1994; Rhodes et al. 2003).
In research conducted on the effects of police campaigns targeting the
Cabramatta heroin market in Sydney, Australia, Maher and Dixon found that
intense law enforcement encouraged market participants to resort to the oral and
nasal storage and transfer of heroin in order to avoid detection (Maher and Dixon
1999). A natural extension of the nasal and oral storage of heroin is the behavioral
tactic of swallowing drugs when users face the possibility of police confrontation.
Research demonstrates that users may experience increased instances of drug
overdose as they attempt to avoid the legal repercussions associated with
possession of illicit drugs (Blankenship and Koester 2002; Maher and Dixon 1999).
Swallowing drugs as a means of concealing evidence is dangerous because
unregulated drugs are consumed all at once thereby placing the user at risk for an
episode of overdose if the drug is unrecoverable. Maher and Dixon reveal evidence
that swallowing drugs to avoid detection by the police led to a number of near-fatal
overdoses in their study population (Maher and Dixon 1999). While this particular
method is employed by IDUs in the effort to avoid drug detection by police, it is
not the only risk behavior that may lead to dangerous episodes of overdose.
Blankenship and Koester argue that IDUs frequently choose not to report medical
crises due to fear that doing so will result in legal charges and potential
incarceration (Blankenship and Koester 2002). The failure to report medical
emergencies such as overdose plainly affects the health of IDUs and serves to
reinforce their marginalized social position by driving them away from crucial
health-related services. Overdose and the potential danger it poses for IDUs health
is often the result of behavioral responses that users employ due to fear of
discovery and arrest by police. Unfortunately, rather than acting as a deterrent to
32


drug use, the fear and apprehension that law enforcement incites increases the
possibility for negative health outcomes among IDU populations.
Police practices that target IDUs for arrest can also serve to affect how drug
and paraphernalia use is negotiated. Numerous studies indicate how fear of police
arrest structures the injection-related behaviors of IDUs (Aitken et al. 2002;
Blankenship and Koester 2002; Bourgois 1998; Burris et al. 2004; Maher and
Dixon 1999; Koester 1994; Rhodes et al. 2003). Qualitative data show that when
injectors experience a lack of privacy, heightening the possibility for police
interference and arrest, they become extremely wary and prefer to have as little
paraphernalia around as necessary. In such circumstances, IDUs are encouraged to
prepare and inject drugs as quickly as possible to avoid detection and charges of
possession by police. This may mean that adequate cookers, rinse water, and/or
syringes are not present or in sufficient quantity to ensure safe injection episodes.
Regrettably, when multiple IDUs prepare and distribute portions of a drug solution
through the use of a contaminated syringe they are not simply reducing their
chances for potential legal difficulties, for they may be simultaneously increasing
their risk for disease infection (Blankenship and Koester 2002).
Police interference with needle exchange services can also function to
structure the risk behaviors that IDUs ultimately engage in. In research detailing the
effects of a police crackdown on a drug markets organization in Melbourne,
Australia, Aitken et al. describe how police presence near the local needle exchange
deters drug users from utilizing this protective service. As one user described in
their study, he ended up using a friends previously used and unbleached syringe
due to the discouraging presence of police at the needle exchange (Aitken et al.
2002). Police interference with patrons of needle exchange services has been
documented at great length by leading researchers of the HIV/AIDS program of the
Human Rights Watch Organization (Human Rights Watch 2003 2B; 2G; 4D).
Needle exchange, which has proven to be an effective intervention strategy for
33


preventing transmission of HIV and other blood-bome pathogens among injection
drug users, is legal in Canada and often funded through government resources
(Human Rights Watch 2003 2B). According to data gathered by researchers in
Vancouver, syringes provided to users by the Vancouver Area Network of Drug
Users (VANDU) dropped by over 30% due to police crackdowns in the area.
Researchers talking to needle exchange volunteers documented several instances in
which volunteers witnessed returned needles held together by tape or that were very
dull due to repeated use, indicating that users are hesitant about frequenting the
exchange more than absolutely necessary. Moreover, volunteers reported to
researchers that many injectors expressed fear over carrying the clean needles they
had been given by the exchange, thereby leaving them unprepared when they were
ready to inject (Human Rights Watch 2003 2B). In consideration of the
crackdowns role in driving IDUs away from exchange services, volunteers
expressed concern that fear of arrest was driving IDUs into unsafe injection
practices with one veteran of the program commenting with regard to police
interference, This is not harm reduction its harm production (Human Rights
Watch 2003 2B). In Togliatti City, Russia, the availability of syringes was
considered good by most IDUs with most pharmacies openly selling new syringes.
However, vigorous police patrols targeting IDUs served to influence the extent that
pharmacies were utilized for purchasing syringes. According to Rhodes et al,
... one of the most commonly mentioned factors said to influence the extent to
which injecting equipment was exchanged or purchased was a fear of being stopped
or detained by the police (Rhodes et al. 2003:49). Police interference with needle
exchange services can lead IDUs to resort to risky behaviors they would not
normally engage in. Out of fear of arrest or harassment by law enforcement, many
users choose to stay away from exchange programs when police are present,
instead being encouraged to share or use old, previously used injection equipment
that may pose significant health risks.
34


IDUs frequently stash or hide syringes due to fear of being apprehended
while in their possession. In research conducted in the shooting encampments of
heroin addicts in San Francisco, Bourgois documents how IDUs frequently stash
their syringes near where they sleep at night as a result of anticipation of police
searches. Unfortunately, IDUs may have to select formerly used syringes for
injection because other addicts steal stashed supplies for resale or their own
personal use (Bourgois 1998). Bourgois contends that:
The puritanical paranoia that curbs needle exchange programs
converts syringes into a scarce commodity that artificially inflates
their monetary value on the street and logistically encourages
addicts to share them and/or steal them (Bourgois 1998:2236).
IDUs stash syringes because doing so reduces their chances of being
caught carrying them, but also because hidden supplies offer readily available
means for drug injection after drugs are procured. Aitken et al. demonstrate that
due to the fear associated with getting caught with used needles and syringes, IDUs
dispose of their equipment with less care which means that, contrary to the
objectives of law enforcement, the visible evidence of drug use may actually be
increased (Aitken et al. 2002). Increased visible evidence of drug use is not the
only problem associated with unsafe disposal however, for discarded syringes pose
a public health risk, and needles discarded in public places like recreational parks
serve as a source of injury and anxiety to individuals employed in the waste
disposal and recycling industries (Burris et al. 2002).
Policing and law enforcement practices have multiple effects on the
injection-related risk behaviors of IDUs. While some of the influences may be
direct, such as confiscation of injection-related equipment that encourages episodes
of syringe sharing or reuse among IDUs, others are more subtle, such as the fear
induced failure of drug users to contact appropriate medical personnel in the event
of drug-related emergencies. Practices that discourage EDUs from carrying syringes
35


and/or other essential injection-related equipment or from utilizing legally
sanctioned syringe exchange services are clearly negative outcomes of police
activities. IDUs are fearful of police intervention and the legal repercussions
associated with using illicit substances and injection related paraphernalia. As a
result, they respond by using drugs quickly, sharing paraphernalia, and choosing
not to contact medical personnel in the event of overdose. These responses place
IDUs in danger for drug-related harm and must be understood, in part, as pragmatic
replies to an environment that has criminalized addiction and the possession and
use of drug paraphernalia.
Policing. High Rates of Incarceration, and the
Health-Related Dangers Posed to IDUs in Prison
As a result of participating in the sale, purchase, and possession of illicit
drugs and paraphernalia, which are deemed criminal acts by law, and because they
are targeted by police campaigns and law enforcement agendas, IDUs have
experienced high rates of arrest and incarceration (CDC 2000). While crime has
decreased overall in the United States over the past several years, drug arrests and
convictions have climbed steadily (Gray 2001). Legal policies outlawing the
possession of certain drugs and paraphernalia have created conditions that
encourage crime as poor users attempt to obtain the resources necessary to purchase
drugs. For users who have been jailed and then paroled on the condition that they
not possess or use any illegal drugs, future violation is almost certain to occur. As
many drugs remain detectable in the body for considerable amounts of time, addicts
have little chance for meeting parole testing requirements. Likewise, if users fail to
show for urine analysis testing, as is so often the case, they will be found in
violation as well. The result of these types of policies is the creation of lifetime
prisoners out of a nonviolent underclass of drug using and addicted individuals and
36


unusually high rates of arrest and imprisonment of the unorganized and non violent
participants in the drug market (Gray 2001).
In 1996, an estimated 250,000 inmates incarcerated in state prisons had
injected drugs, including 120,000 who had reportedly shared needles. Moreover, in
the federal prison system, it is estimated that some 14,000 inmates had injected
drugs, including 6,000 who have shared needles (CDC 2000). Drug users are
overrepresented in the prison system and the prevalence rates of HTV and viral
hepatitis are higher among incarcerated populations than among members of the
outside community (Nelles et al. 1998). At the end of 1996 the rate of confirmed
cases of AIDS in federal and state prisons was six times higher than that seen in the
total U.S. population. About 54 out of every 10,000 inmates were reported to have
AIDS compared to about 9 out of every 10,000 in the total U.S. population
(Hammet et al. 1999). Risk behaviors such as syringe sharing and unprotected
sexual contact are responsible for the transmission of HIV and other blood-borne
pathogens among inmates. Given the large numbers of DDUs that are incarcerated
in both state and federal prison systems and the large numbers of at-risk or infected
individuals, prison plays a pivotal role in the spread of HIV and viral hepatitis. The
risks involved with large numbers of incarcerated IDUs are not just contained
within the walls of the penitentiary however, for there is a constant flow of
individuals in and out of the system, with the vast majority of inmates returning to
the community (Nelles et al. 1998). This revolving current of incarcerated
individuals disperses the risk for blood-borne disease serving to threaten wider
community populations that do not use injection drugs. In other words, the elevated
levels of disease that prison populations experience, particularly the segment that
inject drugs, can translate into increased risks assumed by the public. Implementing
harm reduction measures in prison must be considered an essential part of public
health policy (Nelles et al. 1998).
37


While prevention services currently offered to incarcerated populations vary
widely across state, county, and city jails and prisons, the implementation of risk
reduction strategies have not been widely adopted in U.S. correctional institutions
(Hammet et al. 1999). The possession of needles in U.S. prisons and jails is a
violation of federal law and/or correctional institution regulations. While IDUs are
at significant risk of disease simply because of their membership in the incarcerated
population, the danger they face for blood-borne disease transmission is
exacerbated because they must find ways to inject when confronted with severe
limitations on injection equipment. Such limitations naturally lead to episodes of
sharing. Research conducted at Hindelbank prison in Switzerland came upon
evidence that sharing of syringes among IDU inmates was exceptionally high.
Faced with this high risk setting and the possibility for increased transmission of
blood-borne disease, the health service of the prison requested an experimental
introduction of syringe distribution among inmates. Upon analysis of program
impact, researchers found that after introduction of needle distribution, the sharing
of used syringes among inmates virtually disappeared. At the outset, eight of 19
IDUs reported sharing syringes with others in the past month spent in prison, two
of them with more than one person. After three months, only five of 18 reported
sharing and at six months two of 11 users reported sharing episodes. At the
conclusion of the project, only one individual reported sharing a syringe in prison
(Nelles et al. 1998). The study not only provided confirmation that drug abuse
continues in prison with 85% (45/53) of respondents reporting heroin or cocaine
use while incarcerated, but revealed that most (37/45) took drugs by intravenous
injection (Nelles et al. 1998). The use of syringe distribution in prison is not
sanctioned in the U.S., and therefore leaves both IDUs and the public at risk for
unnecessarily elevated levels of blood-borne disease.
The War on Drugs has targeted large numbers of street-level drug market
participants resulting in an overburdened criminal justice system. At midyear 1998,
38


more than 1.8 million people were incarcerated in state and federal prisons, with six
million more under some form of criminal justice supervision such as probation
(Hammett et al. 1999). While incarcerated populations suffer higher levels of
infectious disease, IDUs may be at particular risk due to multi-person sharing of
injection equipment in prison systems that make it especially difficult to obtain
these items. Police enforcement of drug and paraphernalia laws targets vulnerable
street-based IDUs and places them at increased risk for disease should they be
arrested and sent to jail or prison. These practices call into serious question the
effectiveness of such campaigns if serving the publics interest is considered part of
the police function.
39


CHAPTER 4
METHODOLOGY
Secondary Data Analysis
The methods employed in this research endeavor are, in part, somewhat
different from that of traditional thesis projects in that the majority of data utilized
for analysis come from an information base previously collected by a diverse team
of researchers. This database was compiled over a five year period by a team
consisting of professional researchers and fully trained research assistants who
conducted interviews under the direction and oversight of Dr. Stephen K. Koester;
affiliated with both the Program in Health and Behavioral Sciences and the
Department of Anthropology at the University of Colorado at Denver and Health
Sciences Center. As part of an ongoing research project funded by the National
Institute on Drug Abuse (Grant # DA0923297), Koesters study was designed to
further develop knowledge of the injection process and evaluate its implications for
HIV transmission, and to increase understanding of the social organization of IDUs
by developing a typology of injection networks that sought to identify and describe
the association between network dynamics and the injection process. In addition,
the project aimed to test two specific intervention models designed to address
injection-related risks among members of ego-centered (personal) injection
networks. The bulk of data used for analysis in this thesis is taken from a portion of
the transcribed qualitative interviews conducted with Denver area IDUs that
resulted from the efforts of this study.
The method of utilizing previously collected data for the purpose of a new
research agenda is often referred to as secondary data analysis. Secondary data
40


analysis involves the utilization of existing data, collected for the purposes of a
prior study, in order to pursue a research interest which is distinct from that of the
original work (Heaton 2004:1). My work falls under what Heaton refers to as a
new perspective/conceptual focus. This particular use of previously collected
data is defined as, the retrospective analysis of the whole or part of a data set
from a different perspective, to examine concepts which were not central to the
original research (Heaton 2004:3). While the secondary data analysis approach has
not been widely adopted in anthropology to date, there is growing interest in re-
using qualitative data due to limited opportunities for conducting primary research,
the introduction of new software to aid in the coding, retrieval, and analysis of
qualitative data, convincing arguments that the approach can be used to generate
new knowledge, hypotheses, and/or support for existing theories, and the
recognition that secondary analysis reduces the burdens placed on respondents by
negating the need to recruit further subjects and that it allows wider use of data
from rare or inaccessible respondents (Heaton 2004). In addition, Heaton points out
that some researchers have suggested that secondary analysis is a more convenient
and appropriate approach for particular researchers, notably students.
Despite even the most careful and sensitive utilization of formerly collected
data, there are inherent limitations imposed upon one who undertakes a secondary
analysis of qualitative data. I was not present for the primary data gathering
process, and as a result, my research lacks information that, as Waterston describes
comes from an array of communication modes: how people act, feel, and look and
what they say and do in actual situations (Waterston 1993:xiii). This limitation,
however, may be relegated to minor issues of contextualization as I was primarily
interested in the actual words of informants as they related to issues of law
enforcement, rather than the implications of personal traits or characteristics.
Perhaps a more important consideration is that in using this approach I was
constrained by the research agenda and strategies of the original project. During the
41


course of my analysis, there was numerous times in which I felt a certain frustration
because the interviewer did not probe further when opportunities came up or did
not ask questions, which with the benefit of hindsight, would have seemed
particularly appropriate or enlightening. In addition, although it may seem obvious
and summon comments such as well what do you expect when doing a secondary
data analysis, I had to make due with the agenda of each interviewer as they
investigated topics that, in many instances, were peripheral to my particular
interests. As Waterston points out, these types of issues raise questions about the
reliability of social-science research in general, not just this type of methodology.
The methods that I have employed in this thesis project underscore the recognition
that qualitative approaches are inherently based upon subjective representation of
the data. With respect to this understanding, I do not claim to present an unbiased
or objective report. Rather, this analysis should be seen as an examination of data
that was collected by different researchers for different purposes. Despite these
limitations, I believe that by allowing the data to speak for itself and taking every
care to represent the words of those who I have drawn from truthfully, this project
makes an important contribution to understanding the intersection of policing and
EDUs health by prioritizing the experiences and perspectives of those addicts
whose voices are heard in interviews and read in the pages of this thesis.
A prime example of the value of secondary data analysis as a
methodological approach and the insight that it can generate is found in Alisse
Waterstons Street Addicts in the Political Economy. Using secondary data analysis
exclusively, Waterston utilizes ethnographic data collected by a multi-disciplinary
team of social science researchers to present an account of New York City street
addicts lives from their perspective. In her analysis, she reveals the socio-political,
economic, and ideological influences that structure addicts daily life while
challenging the idea that poor drug users are simply a marginalized and deviant
subgroup existing on the outskirts of society. Connecting micro-level data with
42


macro-level insights into the political economy, Waterston seeks to portray street
addicts as members of the poor, working class that emerged as a result of economic
transformation, changing class relations, and the power of social institutions to
reproduce dominant ideologies. Waterstons use of thousands of pages of
previously collected and transcribed interview data to analyze street addict life and
the position that they occupy in the social structure holds credence among
anthropologists and sociologists alike. Moreover, the efforts of her work are widely
considered to have resulted in one of the seminal books to be published on the
political economy of drug use in the last fifteen years.
Denver Police Department Ride Along and Officer Interview
In addition to the utilization of previously collected qualitative interview
transcripts that focused on the perspectives and knowledge of Denver area IDUs, a
ride along with a Denver police officer and a semi-structured interview with
another Denver police officer provided valuable data. Ride along privileges are
open to the public and offer a way for civilians to see the working atmosphere and
operational duties of patrol officers. In order to participate in a ride along, you must
submit a request, on a DPD 8 Authorization to Ride in a Denver Police Car Form,
to the district station of your choice. As part of this process, applicants undergo a
criminal history background evaluation, and in order to meet approval, must be free
of felony convictions. Authorization is granted to individuals only once each
calendar year and to those 21 years of age or older. As part of the official
agreement to participate in a ride along with the Denver Police, no photos or
recordings are permitted unless authorized by a Division Chief. During my ride
along, the officer did, however, allow me to take written notes. The ride along
served as a way to familiarize myself with the nature of police work and with those
who patrol the streets in Denver. It also allowed me to observe firsthand how police
43


interact with civilians while on duty. The ride along opportunity provided my
research with a measure of context with which to understand policing and law
enforcement practice.
As a result of participating in the ride along, I had the good fortune of
meeting a Denver police officer who has considerable knowledge and experience
with drug law enforcement. The officer with whom I rode admitted that he did not
have detailed knowledge of the drug scene in Denver and only responded to calls
from the central dispatcher concerning drug activity. It was my good fortune that
the officer with whom I rode introduced me to the officer who I would eventually
interview. Getting police officers to grant an interview regarding drug use is not
always easy. Many officers are reluctant to provide information on sensitive topics
such as the enforcement of illicit drug use and remain wary of outsiders who seek
this type of information. After my initial introduction, I spent several weeks trying
to contact the officer and then a couple more attempting to set a time and date for
the interview. This was despite the fact that he gave me his personal cell phone
number for me to contact him. During the course of repeatedly attempting to obtain
a return phone call from the officer and securing informed consent, I entertained
doubts that he was ever interested in talking to me at all. Nonetheless, with dogged
persistence, I was able to obtain written consent and the participation of a
knowledgeable and willing Denver police officer.
Speaking with police officers is an essential but missing component of most
research focused on the effects of policing on public health. The majority of
research considering health outcomes resulting from the interaction between law
enforcement and IDUs chooses to formulate conclusions based upon data collected
exclusively from the perspective of drug users or from participant observation
activities conducted in social proximity to this population. Despite the integral role
police officers play in the implementation and enforcement of policy among drug
using populations, very little is known of their knowledge, attitudes, and beliefs
44


regarding drug users and the role that police play in the enforcement of illicit drug
markets. The contact that frontline officers have with drug users on a daily basis
and their importance in the implementation of drug policy underscores the need for
increased efforts to understand police attitudes and behavior from their perspective.
Such an understanding is central to the development of a fully informed
appreciation of the factors that influence practice among both drug users and
police. In addition, it can contribute to the formulation of effective interventions
that consider both the health status of IDUs and the working agenda of police
officers.
Data Collection
For the purposes of data collection regarding IDUs perspectives, transcripts
that were coded using Folioviews 3.1, a text management program, were drawn
upon. Text material relating to the code law enforcement were identified,
reviewed, and analyzed for emergent themes relating to the thesis topic. It is
important to note that all interview transcriptions chosen, for which the code law
enforcement identified relevant text material, were printed in full and contained in
their entirety the content of the original interviews. Maintaining and analyzing the
full length of each interview is essential so as to preserve, as much as possible, the
context of the dialogue and the subtle variations in communicative direction that
each interview takes. While I participated in a focus group discussion with
Professor Koester and three IDUs at the Boulder County outreach program The
Works, and spoke informally with 15 Denver area IDUs at a dinner sponsored by
the Harm Reduction Coalition, some of whom are represented in the transcribed
interviews, I learned about the lives and perspectives of various IDUs primarily by
reading and re-reading written dialogue between interviewers and Denver-based
addicts. As part of the data collection process, I initially spent a considerable
45


amount of time reading from dozens of interviews to begin to develop a sense of
what the database contained in general, and later, to identify in the hundreds of
interviews what was of particular relevance to my research interests. The codes
contained in the database proved critical to my efforts for they allowed me to
identify specific material relating to the topics of policing and law enforcement.
These codes enabled me to identify excerpts of text in specific interviews in a
database that contains vast amounts of qualitative data.
The interview conducted with a Denver police officer used a semi-
structured format. Semi-structured interviews utilize a set of outlined topics and/or
questions to guide the exploration of certain key issues, thereby helping to focus
the available time for an interview session. They also have the advantage of leaving
the interviewer free to probe specific topics as they arise during the course of the
interview (Patton 2002). For this interview, a question guide was formulated with
the input of Dr. Koester, who serves as the director of this thesis. The question
guide was formulated to elicit information regarding several areas of interest
regarding the policing of illicit drugs and IDUs. The guide contained questions that
pertained to three domains of interest:
1. Perception of Denver drug scene and general law enforcement practices
2. Use of discretion in drug policing activities
3. Police perception of drug users
Each of these domains contained a few questions designed to allow the
officer to answer at length while allowing the interviewer to probe for further
information as necessary. The interest of the semi-structured interview was to
initiate conversation about certain topics rather than directing the participant to
answer specific questions as seen in more structured or pre-arranged interview
formats. The officer was informed about the purpose of the research and signed
46


consent was obtained. The interview was conducted in an office at the District # 6
station in Denver and was recorded.
Sampling Procedures
The interview transcripts selected from the qualitative database were chosen
with a purposive sampling strategy in mind. The logic and power of this strategy lie
in the researchers intent to select information-rich cases for study. Studying
information-rich cases yields valuable insights and in-depth understanding rather
than empirical generalizations (Patton 2002). The 39 full length interview
transcripts that were utilized for further analysis, and which ultimately became the
foundation for this thesis, were chosen in part because of the highly relevant nature
of the coded material they contained, and also out of practicality due to the vast size
of the database constructed under Dr. Koesters direction. All of the interview
transcripts chosen offered exceptionally rich information on individual EDUs
experiences and perspectives regarding Denver policing practices and law
enforcement agendas. By no means do they represent an exhaustive collection of
material in the database relating to the code law enforcement. They do, however,
represent information-rich cases in which IDUs offered their perspectives on law
enforcement and relayed to interviewers their personal experiences with Denver
police.
The District # 6 station was selected for the ride along because it is
responsible for an area of Northeast Denver that has previously been identified to
be high in drug activity (Koester 1994). In addition, calls placed to several districts
in an attempt to choose a location revealed that Denver police officers considered
the chosen area to be particularly active with regard to current drug law
enforcement practices. District # 6 is located at 1566 Washington Street and patrols
an area bounded by 38th Street on the North, 6th Avenue on the South, York Street
47


on the East, and the Platte River on the West. Within this area is a particularly well
known and active drug market neighborhood referred to as Five Points. The
areas moniker refers to the intersection of five primary streets in this Northeast
Denver neighborhood.
The officer selected for the semi-structured interview was the result of a
snowball sample provided by information elicited from the patrolman who
conducted the ride along. Snowball or chain samples are part of a purposive
sampling approach and occur as the result of talking to people who know others
that would be good interview participants and/or willing and able to provide
information-rich data (Patton 2002). In this case, the officer that was interviewed
was the only participant that was located through this method. The single police
interview was added to achieve an understanding of the police perspective with
regard to drug use and drug enforcement in Denver. This interview should not be
considered representative of the general views of police officers in the Denver area
or of law enforcement personnel in general. Due to the single police interview
obtained for this thesis, the information provided should be considered for
perspective purposes only and cannot be generalized to other context specific
findings.
Study Sample
The 39 interviews utilized for this thesis were comprised of 532 pages of
transcribed text and represent 13 individuals (10 men and 3 women). The
racial/ethnic composition of this sub-sample is 54% African American, 23% white,
and 23% Hispanic. With the exception of the three white individuals represented in
this study, two of whom are in their mid twenties and the other in his late thirties,
all of the other individuals are in their late forties or older. While this sample may
not be representative of the original studys demographic composition, the
48


constraints of sampling are due to limitations inherent to secondary data analysis.
In order to obtain useful and information-rich data relating to the code law
enforcement, interviews had to be chosen based upon the quality of their content
rather than on the basis of other criteria. This reveals further limitations of using
secondary data analysis. It should be emphasized that while the sample reflects the
limitations of the methodological approach chosen, it still provides useful and
highly relevant information concerning IDUs perspectives on policing and law
enforcement practices.
Data Analysis
Once all of the selected qualitative database interviews had been printed in
their entirety, the process of coding began. This was accomplished by thoroughly
reading and re-reading each of the interviews and identifying re-current concepts
and themes that related to the topics of policing and IDU risk behavior and health.
Each of the interviews was numbered for organizational purposes and codes were
written down as headings on a separate document. Written underneath each code
were the specific numbers of interviews that referred to that code along with notes
about the individual interview participants. Some of the codes were pre-identifled
by the researcher according to topics uncovered by other researchers or authors that
have previously published work on this topic.
The interview conducted with the Denver police officer was transcribed in
full and read thoroughly to ensure accuracy. The transcripts were then analyzed for
significant themes and concepts as they related to the researchers knowledge
regarding the interaction of police and JDUs. Upon identifying these themes,
excerpts were chosen for further analysis based upon the information-rich data they
contained. All of the information chosen was selected because it spoke directly to
the topic of interest and represented the views of this particular officer. Careful
49


consideration was given to the context of the interview conversation and every
effort was made to accurately depict the words of the officer.
Study Limitations
As with utilization of any particular set of research methodologies, it should
be noted that there are limitations associated with the methods employed in this
thesis project. In addition to the shortcomings inherent to the secondary data
analysis approach mentioned above, there are other constraints that deserve
attention. The context specific data and sample size utilized for analysis hinders the
generalizability of any findings to other context specific drug use and policing
environments. In addition, due to the fact that the majority of data utilized for this
project was collected several years ago, some of the descriptions of people,
systems, and events may seem overly static. While I would argue that this is an
inevitable consequence of any attempt to capture and describe the ethnographic
moment, it is important to note that people and the social circumstances that affect
their lives are ever changing.
An obvious limitation of this project was the acquisition of only one
interview with the Denver Police. Ideally, multiple police interviews would
enhance the findings of this research and allow for more analysis regarding the
nature and impact of law enforcement practice on IDUs risk behaviors. Moreover,
due to the fact that I was constrained by the research agenda and strategies of the
original project, a major limitation appears to be a possible overemphasis on the
negative aspects and effects of police practice on IDUs and their behavior. This
concern, however, is alleviated to some degree as other accounts of addicts
experiences and perceptions reveal that this may reflect common conditions rather
than any bias on the part of my analysis.
50


CHAPTER 5
FINDINGS
Data analysis revealed three primary findings associated with policing and
the effects it has on IDUs and their risk behaviors. The first finding is that fear of
the police and the potential for arrest and incarceration dominates the way IDUs
conduct their daily lives and has significant effects on their injection-related risk
behavior. It affects where, when, and how they obtain and inject drugs and
structures relationships between drug market participants. In some instances, fear
and suspicion increases the likelihood for dangerous episodes of violence as dealers
and users become suspicious and ever more fearful of being apprehended.
The second finding describes how policing campaigns targeting street-based
IDUs for arrest can serve to disrupt stable drug user social and injection networks,
thereby promoting increased risk for blood-bome disease transmission and other
forms of drug- related harm among IDUs. In response to the arrest and jailing of
their social network partners, drug users may be encouraged to resort to new
relationships and living conditions in order to meet financial, emotional, and social
needs. Unfortunately, these new relationships may prove dangerous as injectors
frequently resort to risky behaviors with individuals they previously did not
associate with. This forced mixing of individuals can have serious implications
for the spread of blood-bome disease and may present social circumstances in
which violence and other forms of drug-related harm are increased.
The last finding reveals how fear of arrest and actual time in jail can lead to
dangerous behaviors that increase the risk for drug overdose and injection-related
harm. IDUs attempting to avoid being caught with illegal drugs may resort to
51


swallowing them. This behavior can result in dangerous drug overdose and could
lead to death. In addition, as a result of police arresting and detaining drug users in
jail, many IDUs experience symptoms of withdrawal while they are in custody. As
they become desperate to alleviate the symptoms associated with withdrawal,
addicts often resort to dangerous drug using and injection-related behaviors that
place them at increased risk for drug-related harm and damaging health outcomes.
Findings I
Policing the Streets: The Constitution of an Atmosphere
of Fear and Uncertainty among IDUs
IDUs in Denver do what they can to avoid contact with the police. For
IDUs, contact with the police is a primary reason for many of their daily fears
including the potential for unforeseen hassles or arrest. For Denver area IDUs,
witnessing law enforcement officers patrolling the neighborhoods where they live,
work, and buy, sell, and use drugs is a daily occurrence and makes clear the ever
present reality that life lived, in part, as a drug addict carries constant legal threats.
The possibility for arrest, physical or psychological abuse, and incarceration are
never far away for the drug user. Fear of the police and the potential legal
consequences associated with being arrested for illicit drug use, or the often times
illegal hustling strategies that IDUs employ to meet their daily living
requirements, structures the ways in which drug users perceive the police and may
directly or indirectly influence a multitude of their behaviors, including those that
position them at increased risk for HIV, viral hepatitis, or other drug-related harm.
This apprehension also forms the intimate basis for the ways in which legal
policies, law enforcement agendas, and drug laws criminalizing the addict carry out
penetrating forms of structural violence in the personal lives of IDUs.
52


Fear and loathing of the police is felt by many IDUs. These emotions are
part of everyday life and often exist in an intensity that is related to other situational
or circumstantial factors. In the following passage, Gail exemplifies this reality.
Gail is an African American heroin injector who also smokes crack cocaine. She
was identified to be 44 years old at the time of the interview and has lived in
Denver for most of her life. She is homeless but usually stays at local shelters,
motels, or acquaintances apartments rather than on the streets. In the context of a
discussion centered on having been recently cleared of all outstanding warrants for
her arrest, Gail describes what it means to her now that such a burden has been
lifted from her daily worries and directly relates her usual state of emotion when in
proximity to the police.
Gail: ... Its been a pretty good day. I have no more warrants.
Researcher: No more warrants?
Gail: No more. Im Code 4.1 even cussed the police out. Im like,
Im Code 4. Mother fucking police, they can kiss my ass.
Researcher: So what does that mean for you out on the street, that
now you dont have any other warrants?
Gail: That means that Im not scared to go by the police.
Basically.... just not be scared ....
This quotation demonstrates both Gails fear and loathing of the police and serves
to illustrate how they are inextricably linked. When she feels free of any obvious
legal debts (warrants), she plainly expresses her contempt for police officers and
declares feeling liberated from the repressive fear of law enforcement she normally
experiences out on the street.
For another IDU named Paul, the presence of law enforcement has been
such a constant throughout his life that it has ultimately contributed to how he
perceives himself and the world around him. Paul is African American and injects
heroin and smokes crack on a regular basis. He is homeless and in an intimate
relationship with Gail. He is a longtime Denver resident and is approximately 55
53


years old. For Paul, perpetual contact with the police and the arrests that it brings is
a product of who he is and what he does. In essence, he has embodied the feeling
that the inability to avoid legal trouble is his fault rather than the product of various
situational factors, legal policies, and policing agendas. As the following excerpt
illustrates, law enforcement can be pervasive in the lives of street-based IDUs, and
as a result, they may internalize the constant interactions they have with police.
Researcher: Im curious now, Paul, like this whole police thing, its
like ever present in your life. Does it affect you? I mean, are you
always aware of that or no?
Paul: Pretty much so. But its not something I fight, I tend to avoid
it, you know. And thats part of my problem because I dont
necessarily avoid contact with it.
Researcher: Well, just on average, how many contacts would you
say youve had with cops one way or the other?
Paul: Its down now. Actually over the past six months I think I
might have had three, two or three.
Researcher: Thats it.
Paul: Yeah. Its down now.
Researcher: But you could just walk down the street and have them
stop you.
Paul: Uh, huh (yes).
Researcher: Thats not bad?
Paul: But thats what Im saying, I have contact and Im not doing
anything at all to warrant the contact. It just seems like something
that flows from me.
Researcher: In the past, did you have more contact with them?
Paul: Yeah, because I was in the thing that put me in that position,
see. Well Id be walking around with the persons _____ goods or
trying to sell something to someone. Or I have all kinds of
paraphernalia or this, that, and the other, you know, bam! Or be
doing something, be somewhere in an area where I shouldnt be, you
know.
In yet another passage that describes the effects of policing activities on
street-based IDUs, an informant describes how overwhelming fear has affected the
habits of a user/dealer named Carl. Carl is an older heroin addict that sells drugs to
54


feed his own addiction. He is considered by many IDUs to be one of the main
sources of drugs in the Five Points neighborhood. According to the informant,
Carls apprehension and fear of the Denver police has led him to reduce his drug-
related activities. This fear is often internalized in such a way that drug users
attempt to alter their behavioral routines in the hopes of avoiding arrest.
Informant: You could walk down this block, you could walk down
that block .... Now its hard as hell. Carl, he comes out on the
weekends now. Thats the only time he comes out.....
Researcher: Why doesnt he come out... .he just doesnt need to
come out everyday or he ....?
Informant: I think hes more scared. And see the same police are
on during the week as they are during the weekends. So I think hes
just more scared. And hes on his way to the penitentiary. Oh he is.
Researcher: No wonder hes scared.
Informant: Oh, hes scared to death. Hes too old .... I mean, hes
in his 50s. That man is too old to be going to the penitentiary.
According to this informant, Carl is clearly afraid to participate in the local drug
scene during certain times. The fear of arrest and incarceration is powerful among
IDUs and lends itself to the creation of an environment where the risk for drug-
related injury is increased. Burris makes clear, Investigations by nongovernment
organizations have repeatedly identified police interactions with IDUs as
potentially worsening the risks of HIV transmission (Burris et al. 2004:132).
Research has clearly demonstrated that law enforcement practices targeting street-
based users encourage risky drug-related behaviors among IDUs (Aitken et al.
2002; Beyer et al. 2002; Blankenship and Koester 2002; Bluthenthal et al. 1999;
Bourgois 1997; Burris et al. 2004; Des Jarlais 2000; Human Rights Watch 2003
(2B, 4D, 2G); Koester 1994a; Koester 1994b; Maher and Dixon 1999; Rhodes
2002; Rhodes et al. 2003; Sumartojo 2000; Weeks et al. 2003). Ultimately, the fear
and uncertainty that IDUs feel as a result of law enforcement agendas that target
them for information and arrest create responses on the part of these individuals
55


that may contribute to negative health outcomes. In addition to the threat of
increased levels of HIV and hepatitis transmission, law enforcement agendas may
also elevate the risk of other drug-related harm such as individual and community
violence and drug user overdose.
IDUs and Risky Injection Behavior: Responding to the
Pressure of Police Patrols
As IDUs attempt to carry out the various steps associated with the injection
process, they must remain vigilant so as to avoid unexpected interruption by
patrolling police. Intrusion by law enforcement could mean the loss of valued drugs
and paraphernalia while presenting the potential for arrest and incarceration. This is
especially true if drugs are injected outside in public settings such as parks and
underpasses or in semi-private locations such as cars and abandoned buildings.
Blankenship and Koester maintain that the fear and reality of arrest shape many of
the health-related activities of IDUs and that their visibility makes many users
particularly vulnerable when purchasing and using drugs in outdoor locations
(Blankenship and Koester 2002:551). Speaking from within this context of fear and
suspicion of law enforcement, Gail explains why she chooses to do drugs with a
particular IDU named Jerry.
Researcher: Say it again. Why do you have to get down with Jerry?
Gail: Because I go to his house and its safe. Nobody else has a
house. ... You know what Im saying? I mean, you know, we could
do it in the car, but I feel safe at the house.
In essence, Gail is commenting on the fear of arrest and vulnerability to detection
by police she feels when she has to inject drugs outside or in less secure places
such as a car. In the following passage, Lenny expresses this same sentiment.
56


Researcher: ... Oh, I want to ask you this, where do you get high
with some of these people? What are some of the kinds of places?
Do you ever get high outside with someone?
Lenny: No. Not me. I always go like ... usually I go to my crib. Not
my house, my apartment. And every now and then, we might take
off in the car. But, no, like in an alley or something? No way Jose.
Researcher: Really.
Lenny: Ill never do that. I got to be inside somewhere.
Researcher: What do you think of the rest of these people?
Lenny: The same. None of them are going to be out in alleys, too.
You know, that kind of exposure, the way police are riding around
and shit, you know, youll get busted trying to shoot dope in an
alley. Especially, if youre hard to hit, you know, you need some
place where it is light and in some kind of enclosed, you know ...
But none of them people there would not get down in an alley or
outdoors. Theyre going to find some place. Public bathroom or
something like that, in the car...
Researcher: ... cars arent so safe.
Lenny: No. You got to be real careful even then, you know, staying
there and the police turn the comer.
As the above passages illustrate, when IDUs are in unsecure locations such as
cars or other public places like underpasses, the potential disruption of injection
activities by police and the fear of arrest for possession of paraphernalia or drugs
creates circumstances that may lead to risky and unnecessarily hurried injection
behavior. It is important to note, however, that Lennys comments also indicate that
policing may confer positive effects on injection-related behavior in some
instances. Assuming that some injectors have a safe place to go, police presence
may encourage them to conduct injection activities inside and in a more careful
way. Injecting chugs indoors may provide better opportunities for the use of clean
water and sanitation practices such as injection site preparation and syringe
disinfection. Unfortunately, all too often IDUs are in a rush to use the illicit chugs
they possess, and in doing so, may neglect to practice safe injection methods. As
Lenny adds in the following comments, once IDUs purchase drugs, the primary
concern is to use them as quickly as possible so as to avoid getting caught by the
57


police and arrested for possession. Importantly, Lenny conveys that avoiding
carrying syringes is also wise if IDUs want to avoid legal trouble.
Lenny: .... Once you get the drugs, the issue then is how fast can
we get this in us..Thats one of the things I really hate about, you
know, the syringe laws, you know, because it puts you in that I dont
care type mode. I cant keep these drugs on me long because I dont
want to get caught. I dont want to carry syringes cause I dont
want to get caught with them. So I stash them in all kinds of unclean
and unsanitary places.
Paraphernalia laws criminalizing syringe possession and vigorous policing
activities encourage risky injection practices and, as a result, foster a drug using
environment in which transmission of blood-borne disease is elevated. As
researchers have pointed out, overt police presence and vigorous policing agendas
exacerbate the incidence of high risk injection episodes (Maher and Dixon 1999;
Bluthenthal et al. 1999; Koester 1994). Maher and Dixon suggest that users who
inject outside and in public settings are at increased risk of being interrupted by the
police either during preparation of the drug or actual administration (Maher and
Dixon 1999).
The most obvious consequence of this increased risk of being
busted is that some users are reluctant to carry injection
equipment. This means that, when they go to inject, they are less
likely to have clean equipment. Some stash their fits (syringes) in
nearby bushes, houses, or local flats, which may result in them being
used by others (Maher and Dixon 1999:497).
Users who inject in public or semi-public settings are anxious to get
on and get out. This can mean using any syringe that is available
if they do not have one: either borrowing one or picking one up off
the ground. Users are also less likely to have a taste first or to
measure their dose. Because they are fearful of interruption and
anxious to get rid of the evidence, IDUs typically administer the
drug in one dose, increasing the risk of overdose (Maher and Dixon
1999:499).
58


The preoccupation with using drugs in a hurried manner may lead to
dangerous over-consumption of unregulated substances in an effort to eliminate
evidence. In addition, refusing to carry syringes may lead to risky sharing practices
including unsafe disposal of needles or other paraphernalia.
While drug users have become increasingly aware of the risks associated
with syringe sharing and have changed their behavior accordingly, the sharing of
other equipment used during preparation and injection episodes holds risks that
IDUs may be less aware of (Blankenship and Koester 2002). The following
interview extract further demonstrates how policing practices create an atmosphere
in which drug users engage in risky injection behavior and paraphernalia use,
thereby compromising their future health.
Researcher: Could I just have you do, since we missed that early
part of the tape, can you go back and just describe what we said
about the cookers? Describe that injection scene last night where
you and Melanie and ...
Informant: Yeah, it was four of us ...
Researcher: In the car...
Informant: In the car and I had a half a gram of dope. So what I did
was ... okay, I broke the guy that went in half with me on a half a
gram, I broke him half of the half gram, right? Okay he had his own
cooker. Melanie went to get it for us. She has to go as the go
between in order to get it. Okay so the normal pay for someone
going to cop for you, especially a quantity, is to give them a pill.
Rather than giving Melanie a separate pill, what I did was include
Melanies shot in ... put it in the cooker with mine and_. As
a convenience, you know, not to have three cookers in, you know,
the thing and then you have to remember also, theres a safety spot.
You dont want to have all this stuff where you cant get rid of it. So
if youve got a bunch a cookers gathered around, you know, and
something come down, you know, you cant lose it.
Researcher: You cant hide it.
Informant: Yeah, you can hide one or two, maybe. But, you know,
if youve got three or four cookers and youre trying to stuff in your
... or sail them across the room, so you know, theres also a safety
59


clause for as how you use cookers, how many cookers you use. ...
Like I said, for convenience sake at the time, were in the car and,
you know, you dont have a lot of room or a lot of time because you
want to get this done as fast as you can so that you can get on out of
the area or put this stuff up.
Researcher: That makes sense.
Informant: But like I said, that cooker issue is like I said, thats a
safety factor. It has a lot to do with how many cookers you have.
You do not want a lot of cookers in your purse, you know.
Sharing drugs as a solution and utilizing a common cooker during the process can
contribute to elevated risks for disease transmission.
Several studies have reported injection-associated practices in
addition to the direct transfer of a contaminated syringe that may
contribute to the transmission of HIV among drug injectors.
... Behaviors included are the common use of injection-associated
paraphernalia (water, cookers, or drug mixing containers, and cotton
filters) and the use of one syringe to mix, divide, and distribute
shared or jointly purchased drugs. In these practices the syringe is
not shared; its contents are shared (Koester 1996:135).
As the informant points out, this behavior occurs as the result of concern over
potential police interruption and the problems it can cause. In addition to hurried
drug use and the potential risks this poses, paraphernalia laws and policing agendas
can undermine the use of items contained in safe injection kits handed out by
some HIV intervention projects. Even when IDUs know the risks associated with
injection activities, the threat of police contact and legal retribution can disrupt
helpful and well intentioned efforts (Blankenship and Koester 2002).
Gail: And the police know whats going on.... Thats basically why
we dont get them kits, cause if you get stopped, they know what
its for.
Paul: Sure. And the first thing theyre going to claim, Ill give you
a ticket for paraphernalia.
Researcher: Yeah.
Paul: Just for having the bag.
60


Gail: Just for having the bag. You dont have to have the syringe...
Researcher: Are you sure? Are they giving people tickets for the
kits? No, Im serious. Theyre not supposed to be.
Paul: Well, they are.
Gail: Tickets for the Kits.
Researcher: Thats terrible.
Paul: Because you see ... I dont know. Do you still include the
cookers in your kits?
Researcher: Yeah.
Gail: Thats why.
Paul: Okay, that cooker is paraphernalia.
Researcher: So they think if they take it away, youre not going to
do it?
Paul: No, they just give you a ticket.
Gail: No, they just give you a ticket.
Paul: You get a ticket for paraphernalia.
Researcher: How much is a ticket?
Paul: It can be one day in jail.
Researcher: 100 bucks ...
Gail: It can be seven days in jail. They gave me seven days for a
syringe.
Paul: Okay, well like I said, they characterize cookers as
paraphernalia and they will give you a ticket if they can get enough
residue off of it, they will give you a possession case. So thats
another reason why you dont carry a lot of cookers... Like I said,
even if theres three or four, you might have to wait, rather than
everybody carry a cooker. Everybody has to carry their own outfit
[syringe], but no one wants to carry around their own cooker.
Gail: And then most people take outfits and hiding them
somewhere.
Paul: Right, they take them off their person and hide them. But the
cookers, theyre not very easy to dispose of, especially if youre
carrying a can. You know, you cant hide it or throw it very far, you
know.
For IDUs operating on the streets, the possibility of getting arrested and put
in jail, or at the very least, being issued a fine that they may not be able to pay, is
very real and may discourage the use of items that provide protective benefit.
Carrying cookers is problematic for addicts as it makes them vulnerable to citations
61


for paraphernalia possession or arrest. Pauls description of wanting to get this
done as fast as you can so you can get on out of the area or put this stuff up speaks
directly to the pressure that IDUs feel when injecting in places that leave them
vulnerable to police discovery. As Blankenship and Koester argue, the real danger
of blood-borne disease transmission in such an episode is not from sharing
cookers, but from mixing and distributing three of the four injectors drug solution
using one of the participants previously used syringes (Blankenship and Koester
2002). The pressure to prepare and inject drugs quickly is of primary concern in
such a situation and may influence IDUs to mix drug shares together using a
common cooker and then to distribute them through a single syringe. Sharing
drugs, mixing them all at once, and then distributing them through a participants
syringe is an efficient but dangerous way to expedite the injection process
(Blankenship and Koester 2002:552).
Police pressure and the strategies used by law enforcement agencies to
apprehend and convict IDUs forces users to inject quickly and to practice injection-
related behaviors that may be unsafe. The above passage demonstrates that policing
agendas may induce individuals to hide drug paraphernalia in unsanitary places.
Stashing previously used syringes may lead to episodes of re-use by others who
find them. This can be dangerous and contribute to the transmission of disease if
these syringes are not properly disinfected. As Maher and Dixon reveal, pressure
from law enforcement contributes to the stashing of used syringes that may be
used by others.
Such fear and uncertainty are not conducive to safe injection
practices. Our research suggests that street-based injectors are now
less likely to use sterile injection equipment and more likely to
engage in unsafe drug preparation and division procedures,
including needle sharing and the use of discarded needles, and to
practice unsafe disposal (Maher and Dixon 1999:500).
62


Policing and the Production of Violence among
Drug Market Participants
Fear of police contact infiltrates the lives of drug users and dealers alike and
may cause elevated levels of risk, not only in relation to behaviors associated with
transmission of blood-borne disease, but also with respect to physical violence. The
misgivings that drug users and dealers harbor are ever present, and more often than
not, directly related to the tactics employed by law enforcement agencies to elicit
information from street-based users. Blankenship and Koester point out police use
multiple strategies when seeking to manipulate drug users perceptions of one
another including the use of arrest, informant derived information, and harassment
techniques (Blankenship and Koester 2002). They contend that in doing so police
may:
create mistrust and undermine social cohesion among peers. For
example, IDUs become suspicious when another EDU appears to get
off easily after an arrest, especially if others caught in the same bust
are treated differently. These events can lead a user to get a jacket
- a reputation on the street as a snitch a label that can result in
serious consequences including death or physical punishment
(Blankenship and Koester 2002:552).
In the next selection, two Denver-based IDUs describe how suspicion and
fear of police strategies can extend to other users.
Informant #1: .... Im scared of half of these people. You got four
people that go to jail, got dope on them and theyre out the next day.
Informant #2: Thats another thing you got to be really leery of.
Researcher: For good behavior.
Informant #2: Yeah, right. Uh, huh, yeah. A lot of times .... Youll
tell on anything.
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These individuals are referring to how users who have been arrested will
sometimes provide information to the police in an effort to be released. If the police
get what they want, they may let users go on the condition that they will continue to
provide drug-related information to the police. In a separate but related excerpt,
Informant #2 describes how he was put in physical jeopardy after he was arrested
by Denver police for introducing a buyer to a seller.
Informant: Im not going to testify against him [dealer]. And see,
what they [police] did was, they put me in jeopardy.
Researcher: Sure, sure.
Informant: Because Ive never had a reputation as a snitch. And
these are young gang members that are holding these drugs and the
only reason I didnt get beat up while I was in jail or whatever, was
because they respect me for previously being in the hood and, you
know, everyone knows I have my own money. I usually buy this,
that and the other and I dont go that route.
Researcher: You lucked out, you know.
Informant: The guy told me, he says, if it had been anyone else,
other than me, he or some of his friends would have had a contract
to beat me up or whatever and take me out of the game.
The above passage serves to illustrate the ways in which law enforcement agendas
can contribute to user harm outside of injection-related risk. The fear that
penetrates drug users and dealers lives as a result of police operations is invasive.
In the concluding passage that follows, an DDU couple describe a rather distressing
situation in which a dealing episode has gone awry, giving clear indication how
penetrating this fear and paranoia can be. Martha is a twenty three year old white
female who injects heroin and smokes marijuana. Her boyfriend Darren is white,
twenty two years old, and also injects heroin and smokes marijuana. At the time of
the interview, Martha and Darren had been in Denver for about one year having
moved here from outside of New York City. They are homeless but have found
other drug users to stay with on a temporary basis.
64


Martha: Oh my god__________, fuckin Barry put a gun to my head.
Researcher: What happened?
Martha: Did we tell you this?
Researcher: What happened?
Martha: O.K. Darren and I, one morning I worked like 11 at night
until 7 in the morning. And we were really sick and really fucking
tired.
Researcher: And it was really cold outside.
Martha: It was super fucking cold outside. And so Darren just
paged like every dealer that we know and we were just gonna go to
whoever showed up first. ... And he went to Conoco to wait for
Julio, and we called Barry, Vinny, and Juan.
Researcher: Yeah
Martha: We havent seen them in like 2-3 months... And we called
them and he acted kinda funny over the phone.
Researcher: Barry you mean?
Martha: Yeah... And I was waiting at 7-11 for Barry. Barry pulled
up into the alley and I grabbed both the backpacks that I had and I
got in the back of the car and he just fucking took off down the
alley. I didnt even have my door shut yet and he fucking took off.
... Darren was standing at the end of the alley by where Conoco is ...
Researcher: Yeah.
Martha: And I was gone for like 20 minutes. And they usually, they
like, you get in the car and youll drive up around the block and let
you out.
Darren: She was gone for like a fucking half hour.
Martha:... he fucking gunned it man, and he just kept on driving.
And I was like, Oh my god, what the fuck.
Researcher: Was he saying anything
Martha: No, he didnt say nothing at first. And finally he looked at
me and he goes, You Rata? And I was like, What? And he was
like, You Rata? You Police, you snitch?
Researcher: Oh
Martha: And I was like No. I was like, What the fuck are you
talking about Barry?... He said Mitchell and Lucy, and like he
started naming off all these people that I dont even know ... And he
was saying that all these people were telling him that Darren and I
were snitches.
Darren: And that people were getting busted and shit.
Martha: He pulled over, he fucking went up my shirt, went up my
back, and made me pull my pants down, made me take my shoes
65


and socks off. ... I had this visor on, and he was feeling up
underneath the visor and he ripped it off my head... And he started
going through my hair, and he went through both backpacks that I
had, all my pockets, everything...
Researcher: Oh my god.
Martha:... like looking for a wire.
Researcher: You must have been so fucking scared.
Martha: Yeah, he stuck a fucking gun to my head. He turned
around and he was like, You Rata, you snitch.
Researcher: What did you do?
Martha: I said, I dont know what the fuck youre talking about.
... But after Barry went through me and he like dumped both my
backpacks and went through everything he gave me my backpacks.
And after he realized I didnt have a wire on me or nothing he
finally told the kid to give the balloon [drugs], and he didnt even
have it in his mouth, when I got in the car he had it in his hand. And
I looked at Barry, I was like, Is this O.K.? and he looked at me.
And I was like, Am I gonna fucking do this and die? You know, I
was like what the fuck. And he was like, You Rata. And I was
like, you know, just give me my fucking money back, Ill go to
fucking somebody else.
In this particular instance, fear of the police and the possibility of arrest have
transcended the users immediate personal experience and have created a
confusing, and potentially dangerous situation as the dealer attempts to reassure
himself that Martha and Darren pose no threat. While the aggressive threat and
invasive body search served to calm the dealer and alleviate his worries, the
physical assault and potentially deadly encounter contributed to extreme confusion
and anxiety on Marthas part. Her concern over whether she would do this [drug]
and die? speaks to the tactics that drug market participants may resort to when
faced with serious threats to their livelihood. Referred to as a hot shot, dealers
will sometimes purposely provide dangerous combinations of drugs to people that
they dont trust. This passage illustrates that police operations can cause
widespread mistrust and anxiety among individuals participating in the drug
66


economy. Unfortunately, episodes like the one above may not always end in such a
benign fashion.
As the foundation for a reciprocal relationship of mistrust, antagonism, and
at times violence between police and IDUs and between users themselves, fear is an
extremely invasive element that influences the ways IDUs interact and go about
their daily lives. Fear of the police and potential arrest influences the micro-level
risk environment of IDUs in multiple ways by shaping the risk behaviors that place
IDUs in danger for blood-borne disease or other drug-related harm. The structural
determinants of criminal drug law and policing practices affect the risk-related
behaviors of IDUs in both direct and indirect ways. For example, if a police cruiser
rapidly approaches a car that is occupied by IDUs who may be in possession of
heroin, causing the occupants to swallow large quantities of drugs to avoid arrest
and potential incarceration, then this influence can be seen as direct. If however, the
arrest and jailing of a user creates circumstances in which that individuals partners
or social network members must now take new and dangerous risks to survive,
police practices can be perceived to be more indirectly related to drug user risk
behavior.
The pressure placed upon IDUs by policing activities results in decision
making and drug-related behaviors that place IDUs at increased risk for negative
health outcomes. In an effort to avoid detection, IDUs use drugs as quickly as
possible after purchase. Drug consumption in an environment conditioned by heavy
police surveillance induces fear and encourages hurried injection practices not
conducive to safe drug use. Multiple risky injection-related activities occur as a
result of the apprehension IDUs feel, including sharing of syringes or other drug
paraphernalia, unsafe disposal of injection related equipment, overconsumption of
drugs in an effort to eliminate evidence, and unsafe stashing of injection devices to
avoid arrest for possession. Furthermore, law enforcement practices that create an
atmosphere of fear and uncertainty contribute to how relationships are negotiated
67


on the street. If users become highly suspicious of each other, as they sometimes
do, physical violence may ensue. The practices that IDUs employ in response to the
conditions created by law enforcement not only diminish their chances for police
detection and arrest, but also serve to increase their risk for negative health-related
outcomes.
68


Findings II
Policing and the Disruption of Stable User Networks:
Increasing the Risk for Blood-Bome Disease and
Drug-Related Harm among IDUs
Understanding the risks associated with injection drug use requires, in part,
an understanding of the social networks within which injection activities take place.
Understanding the social context within which drugs are used allows for a greater
appreciation of how disease is transmitted between IDUs and how it may spread to
larger community populations. Social networks are:
groups of users linked by various relationships and bonds. Networks
differ based on the number of members and how stable the
relationships are, the types of relationships among members, the
degree to which the group is open to including new members, the
kind of social activity that occurs within it, and the types of drug
used and how they are used. ... The nature of the relationships
among members and the interpersonal and group dynamics of the
network directly affects a members drug use and sexual behaviors
and therefore are highly influential in determining that persons risk
of infection (CDC 2000:6).
Some networks may be small, consisting of only two drug using or sex partners,
while other networks may be much larger and defined by more open membership.
Regardless of size, networks and the risks they assume are partially identified by
the level and types of risk behaviors its members engage in, and are affected by the
settings in which drugs are consumed, including the closeness of the intimate bonds
that unite those members.
A member who has close links with other drug injectors in the
network is more likely to engage in high-risk practices, such as
69


sharing syringes or injecting in shooting galleries, than are drug
injectors who are only peripherally connected to other network
members... Social networks are a critically important context for
understanding drug use and its intersection with the transmission of
HIV and other blood-borne pathogens because of their role in
maintaining an epidemic within the group and in providing a starting
point for rapid transmission beyond the group (CDC 2000:7).
Law enforcement agendas that target IDUs for arrest and incarceration can
have immediate impact upon the risk behavior of network members. Policing
practices may affect the structure and overall composition of IDU networks and can
therefore contribute to how the transmission of blood-borne pathogens takes place.
According to Burris et al.:
Networks of injectors who share injection equipment only with the
other people in their network may, in theory, be retarding factors in
the spread of HIV, even if other networks become saturated with the
virus. However, high arrest and incarceration rates or other police
practices that encourage injection sharing may disrupt stable
networks and lead to reconstitution of seromixed networks that
facilitate the spread of HTV. Indeed, differences in the intensity of
police activity and the attendant disruption of networks could be a
factor in the substantial variance in HIV rates exhibited within and
across nations with large numbers of injection drug users (Burris et
al. 2004:133).
As police efforts to curb drug use and dealing activities result in the
continual arrest of street-based users, the network members associated with those
arrested may be placed in situations that compromise their well being. In response
to the absence of their normal injection partner(s) and social contacts, IDUs may
have to resort to behaviors and substitute relationships that place them at increased
risk for transmissible disease or other forms of drug-related harm. The following
analysis of two Denver-based IDUs illustrates how arrest and incarceration may in
fact elevate risky behaviors among network members.
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Gail and Paul are a married couple who inject heroin and smoke crack
cocaine. As previously mentioned, both informants are African American and
homeless. Together they represent a stable user network for they both claim to
inject primarily with each other or with one or two other users they know. Paul and
Gail have an intimate relationship and spend the majority of their time with each
other. Together, they form a team that employs certain hustling strategies to obtain
the money they require to purchase drugs. Police presence has been predominant in
both of their lives and time in jail for one or the other has contributed to how,
where, and with whom they use drugs. The disruption of this stable and intimate
network due to recurring patterns of arrest by the Denver police has created an
environment of risk that puts Gail, in particular, in a position that increases her
chances for blood-bome disease infection, for she must survive and tend to her
addiction without the usual aid of Paul, who is primarily responsible for obtaining
the financial resources that are used to purchase drugs. While both participate in
income generating strategies, Pauls techniques are by far the most reliable. It is
also Paul that generally mixes and divides the drugs for consumption. When Paul is
incarcerated, Gail must resort to relationships, activities, and risky behaviors that
she would not normally engage in, thereby increasing her risks for blood-bome
disease transmission and violence or other forms of drug-related harm. The
following excerpts are taken from a series of interviews conducted with Gail during
a period when Paul was detained in jail.
Researcher: But whats basically the difference for you when Paul
is out? I dont mean in terms of, Well, yeah, I got my man with
me. I mean, in terms of say, every day, how you hustle, the quality
of the dope, etc. The difference from when Paul is out, when hes
here or when hes in? Just day to day, how is your life...
Gail: I dont have to worry about being sick. Never. Cause hes
going to go out and make some money. I dont never have to worry
about being sick. Thats the biggest thing. I dont never have to
worry about being sick. Dont never have to worry about being
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broke when hes out. But now that hes in... .and he worries about
me. Where am I going to be staying and, you know?
The answer given by Gail to the researchers question must be considered carefully,
for her response emphasizes a critical condition in the life of all IDUs that must
constantly be avoided; being dope sick. For IDUs, the term dope sick means
being in the throes of physical withdrawal. The use of heroin on a regular basis
creates a powerful physical addiction that must be attended to if the addict is to
remain physically and psychologically stable. The opiates, which include heroin,
have an analgesic effect in that they inhibit the perception of physical pain.
Continued use produces tolerance, so that increased doses must be
administered to achieve the initial euphoria. The best known
consequence of continued use is the development of physiological
dependence or addiction. Once a user is dependent, consumption is
driven primarily by the desire to avoid withdrawal symptoms such
as chills, cramps, and sweats (Baer et al. 1997:130).
For Gail, like most addicts, being dope sick is serious and completely
destroys any possibility of conducting her normal routine.
Researcher: So how sick did you get?
Gail: Oh, God, I felt sick.
Researcher: From withdrawal? Tell me about that.
Gail: Oh, I couldnt even get out of bed. And when I did, it was to
throw up.
Researcher: For how many days, all five?
Gail: All five days.
Researcher: Then you came out clean, right?
Gail: Yeah, but I was still sick. See, Ive been doing this so long, it
takes more than... I mean, it only takes three or four days for your
body to get back together, supposedly. But as long as Ive been
doing it, theres a part of me that takes me longer to feel absolutely
normal. It would take me like actually a month for me to actually
feel normal normal, because Ive been doing it so long.
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For another IDU named Lewis, being dope sick is very serious and makes him feel
as though nothing could be worse.
Researcher: Why do you think you use it? I mean, besides, you
know, saying. Okay, maybe Im addicted to it. What does it do for
you?
Lewis: You know, I still like the high, but most of all, you know, I
dont want to be sick. You know Im addicted to it. My body craves
it and for me thats the bottom line, you know. If I could do it the
rest of my life and not have all the money problems, the being sick,
you know, that would suit me just fine. But once I reach the point
where Im waking up feeling like a piece of shit, you know, then the
highs not even important. Its just getting normal where I can have
the energy, strength in my legs, no cramps in my stomach, no
diarrhea, you know, for me its just not being sick and I fear that
more than I do death, itself. If you gave me a choice, youd say,
You can be dope sick for the next two days or you can die, right
now. Id choose death.
Researcher: Seriously.
Lewis: Im serious. I would choose death.
The following description by Martha further illustrates what it may feel like for an
IDU to be dope sick. Her description echoes the seriousness of Lewis depiction.
Martha: ...But like when your muscles are kind of stiff and with
Tar [black tar heroin] it feels like, God it feels like youre fucking
dying. Your bones hurt so bad, you cant eat, you cant go to the
bathroom.
Researcher: How sick are you now?
Martha: My stomach hurts so bad. And my nose always gets stuffy
and my back feels like its broken and my mouth gets like all pasty
and ... And its so crazy, cause its like as soon as we fix, like
within a minute, everything just completely goes away.
As this quotation illustrates, being dope sick creates a situation in which IDUs
might resort to desperate and hurried behaviors to get well. For as Martha
describes, as soon as drugs are obtained and injected, within a minute, everything
just completely goes away. Undertaking hurried and urgent behaviors to subdue
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the effects of being dope sick can result in risky injection practices that may
ultimately contribute to the transmission of blood-borne disease. For Gail, being
dope sick when Paul is not around is an ever present reality. In the following
passage, Gail describes what she does when Paul is in jail and the hurried behavior
that injectors engage in to avoid the symptoms of withdrawal.
Researcher: Okay, when Paul was in jail, you got dope sick then
sometimes.
Gail: Uh, huh (yes). But, you know, basically thats when I was
finding people to go half with me on a pill and stuff like that and I
was selling little papers and stuff and I was hustling with Mickey.
Researcher: And thats how you turn off getting sick...
Gail: Uh, huh (yes). Ill get some money from somebody to get me
some dope. If I have to go to my son.
Researcher: One of the things Im going to try to do is try to
compare heroin injection with methamphetamine injection and since
methamphetamine users dont get sick ... I mean, whatever it is they
get, its more psychological. One of the things we noticed with some
of the interviews we do with some of the methamphetamine people
is that they very carefully plan their needle injection. I mean, they
can get it down to, you know, we had these guys that laid out all
their different needles and had everything arranged and they can do
this meticulous sort of planning, right? And that seems to go with
the fact that theyre not dope sick. But I would think that with
heroin, youre not going to be going on that kind of trip.
Gail: Uh, um (no). Youre going to get your dope, youre going to
put it in the cooker, youre going to put your water on it, youre
going to heat it up as fast as you can, youre going to stir it up,
youre going to draw it up and youre going to get some dope in
you. You may not cook it all up. Theres times we havent cooked it
all up just to get some dope in us.
Obtaining drugs and injecting as quickly as possible is a primary objective when
someone is dope sick. Gails response demonstrates that she must resort to
alternative relationships to procure and use drugs. In doing so, she may be at
increased risk if she engages in dangerous injection practices. As Gail shares in the
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next passage, perhaps unwittingly, when she is injecting with others risky behavior
does indeed take place.
Researcher: Since the last time we talked, how many people would
you say youve got high with?
Gail: Since the last time?
Researcher: Say in the last week.
Gail: Belinda and Rory.
Researcher: When you get down with them, you share the dope,
right?
Gail: Uh, huh (yes).
Researcher: So you mix it up together ....
Gail: Uh, huh (yes) And then we backload it.
Researcher: And thats pretty much the way .... Thats pretty much
the way you get high with any of those people? .... The way they
would get high would be by sharing the dope and then backloading
or putting it back in the spoon?
Gail: No, just in the syringe.
Researcher: Not even squirting it back into the cooker.
Gail: Uh, um (no). Just straight into the syringe.
Researcher: Just on average, how many times do you think you use
a syringe?
Gail: Ill use mine until it dont go no more.
Researcher: So you got one now? How many times have you used
it?
Gail: The one I have now, Ive used it about four times.
As mentioned at the outset, the process of backloading involves distributing
shares of the prepared drug solution from a single syringe by squirting it directly
into the barrels of other syringes (Koester 1996). According to Koester:
Some IDUs prefer this [latter] method ... .because it saves time and
eliminates the need to draw the drug through the cotton filter a
second time, a step that may result in the loss of some of the drug.
During this procedure HIV can be passed to other IDUs syringes if
the syringe used for measuring shares of the drug solution is
contaminated with bioburden. The virus may be transferred if
bioburden is flushed out of the needle when the drug solution is
75


discharged into the mixing container or directly into other IDUs
syringes (Koester 1996:138).
By injecting with individuals outside of her stable network, and doing so by
using the method of backloading, Gail is at increased risk for disease infection.
Gails declaration of using her syringe four times is troubling and may indicate a
pattern that others in her temporary injection network also follow.
As mentioned above, Paul and Gail can be considered a stable user network
or part of a small network that might include another person at times. As Gail
describes below, they usually hang out with one other user, forming a trio that
comprises the basis of their drug using relationship.
Researcher: What do you mean by the expression everybody runs
in threes? What is that?
Gail: All our little groups are like three. Theres three people.
Researcher: Explain that to me.
Gail: Like there was one time, when Jared was with Walter, it was
Walter, Aaron, and Jared. And then Mickey, Darnell, and Jared.
Look, everybodys in jail now. Aint nobody out. Then at one time,
it was me, Paul and Maggie...
While these three people networks are intimate in size, they may represent only one
particular arrangement in time. Gail and Paul may, in fact, spend time and
participate in injection activities with many different people over the course of
various time periods. Nonetheless, while Paul is in jail Gail must resort to new
relationships in order to make money, obtain and use drugs, and find places to stay.
When Gail is asked who she has shot up with in the last thirty days, her response is
somewhat different than her description of the previous relationships that
encompass primarily Paul and one other person. In Pauls absence, due to arrest
and time in jail, Gail admits to spending time and injecting with several other
individuals.
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Researcher: So since hes [Paul] gone back to jail, since then, how
many nights have you slept outside? Have you ever slept outside
since hes been gone?
Gail: Uh, um (no).
Researcher: How many different places have you stayed at?
Gail: Debbie, Tim, Andy,.... Five.
Researcher: So where have you stayed at?
Gail: Debbies, Tims, Andys, the shelter, and Treys.
Researcher: And you got down with Debbie, Tim....
Gail: I didnt get down with Tim. I got down with Debbie because I
bought the dope. I got down with Andy a couple of times.
Researcher: ...But I mean, two months from now, youll be
somewhere and Lenny will be there and youll end up getting high
together.
Gail: Right. Lenny and I have gotten high this past summer. Walter
told me. I just havent done it. Walter told me, Gail, be up at
Safeway between 9:00 and 10:00, and you wont have to worry
about being sick. While your mans in jail, Ill get you high. Ill fix
you every day...
In the previous two descriptions Gail admits to getting down with at least five
different individuals. In terms of injection risk, her chance for contracting a blood-
borne disease is dramatically increased in comparison with the normal routine of
getting high on a regular basis with only Paul or with Paul and another individual.
Importantly, the disruption of Gails normal injection relationship, due to the arrest
of her stable partner, increases her incidence of injections with others.
The increased frequency of injecting with other addicts, however, is not the
only behavioral pattern that Gail may be forced into as the result of the disruption
of her stable network. Her options for living conditions also seem to be somewhat
limited and less secure than when Paul is with her and free from incarceration.
When they are together, Gail and Paul stay at various places. When Paul is
removed from this relationship, Gail must resort to other means in an effort to
secure a place to stay. The following excerpt illustrates the type of decisions Gail
may be forced into making.
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Researcher: And wheres Paul now?
Gail: In jail
Researcher: And what did they charge him with?
Gail: I dont know, I havent been able to get in touch with the jail
to see what hes charged with. I went to the bond ...
Researcher: How long ago was that?
Gail: It happened Thursday. And Ive been sick and stuff...
Researcher: So you need a place to stay ... What do you think is
going to happen to you now?
Gail: I dont know. This guy said hes going to pay my rent [at a
hotel], but I dont think so. Thats why I told you I needed the $20
cause I have some stashed. So if he dont pay it, then I can just go
on and pay the rent for tonight. But then he said he was going to pay
it for a week.
Researcher: Whos this guy?
Gail: Uh, just a guy I know. A Caucasian as well as a.... Hes a nice
guy though. But hes an alcoholic.
Researcher: Whered you meet him?
Gail: On the 16th Street mall.... He closes on his house Friday and
he told me I could come live with him. So he gave me his address
and all that kind of stuff and he spent the night. And when
somebody spends the night, they have to pay like $18, right?
Researcher: At the Standish [hotel]?
Gail: Uh, huh (yes). So he spent the night twice and he paid for
hisself, but I mean he wasnt helping me and Im not giving up
nothing. Okay? You going to get some sex on a promise? I dont
think so. Now if you do pay my room for me, Ill think about it.
Well he did try to pay it Saturday, but they dont take checks or
credit cards, so he said he had to wait until today so he could go to
his bank. He said he was going to have the lady he rooms with take
him to the bank and he would get the money and hed pay my rent.
As Gail describes above, without Paul she is confronted with a situation in which
she must hope that someone will help her out. Otherwise, she may have to help
herself by engaging in risky [sexual] behaviors. While she may have enough money
to pay for one night at the hotel, her interest is in securing more nights for the
future. As her comments demonstrate, she may be willing to engage in sexual
relations with someone if they pay for a place for her to stay. Actually doing so
78


may mean that Gail is increasing her risks for disease in order to meet simple living
expenses. In the following passage, Gail describes a different man that she hustles
and stays with while Paul is in jail. In this scenario, Gail leads us to believe that
while she does not consider this person to be her man, she may be, on occasion,
having sex with him.
Researcher: Now how long do you think this hustles going to
work?
Gail: Until Paul gets out, I hope.
Researcher: So where did you meet this guy?
Gail: On the street. Would you believe it? On the street. ... So we
actually stay together. And I keep telling people hes not... and
check this out. I say hes not my man, we just sleep together. Okay,
thats because we sleep in the same room. Every now and then if I
get the urge ... .but I cant wait till Paul gets out. Ive been praying.
Oh man, I cant wait until my baby gets out. Im just so tired of this
bullshit.
In the next interview segment, Gail leaves no doubt about the behaviors she must
occasionally resort to while Paul is in jail.
Gail: I have been a bad girl because I have never, ever done this in
my life. When I was a teenager, I didnt do this.
Researcher: Do what?
Gail: Prostitute. I did not do it. I would rob people, I never sold my
body. Yesterday, actually yesterday was the second time I sold my
body within a month.
Researcher: So what happened the other day when you were
prostituting?
Gail: I was just walking down the street....
Researcher: Where?
Gail: It was on the same street except one was in the day time and
one was in the night. I was just walking down the street and .... this
guy stopped me.
Researcher: You were alone?
Gail: I was by myself. He said, I believe in free enterprise. Ive got
this amount of money and I believe you need this amount of money
79


and Im going to give it to you. And I said, Okay, well, where are
we going? And he said, Well, I can find somewhere to park. So
he stops and were parking and we, you know, and I got my money
and I was gone.
Researcher: What about Paul... How is it going to get better when
he gets out?
Gail: .... So when he gets out hell have some place to go and I
wont be out on the street and I wont be running the streets, I wont
have to deal with all these fools out here ....
For Gail, these behaviors are part of what she must do to survive while Paul is
incarcerated. She clearly expresses guilt for turning to prostitution but made the
choice in consideration of her financial needs, part of which are to pay for a place
to stay and drugs to keep her well. As the following selection reveals, in the
absence of her stable partner Gail is surrounded by risky behaviors as she attempts
to deal with life as a homeless heroin addict.
Researcher: So where are you staying now?
Gail: Oh, man!
Researcher: At the crack house, basically?
Gail: Well, it is a crack house. I mean, the building .... its a crack
building, is what it is. I dont know what any mother fucker does
there. If they do, all fine and good. If they dont, I dont give a
damn, okay? (Crying).
Researcher: Im sorry.
Gail: I went over to (unintelligible because of crying). Okay. D
says, Okay Gail. You can come stay with me. I say, Okay. So
Im out boosting [stealing] and shit. You know I cant steal, but we
go out to Aurora Mall. Im the only one that gets anything, right?
And the only person in the car that doesnt boost, is the only person
that gets something. So I was doing little things to get some money
to get high, right? (Crying harder). Ill kill somebody. Anyway, one
day I didnt have any money. ... Run into a guy, the guy I was
hanging with the last time Paul went to jail. He tells me, Gail, you
can come stay with me. I said, Okay. ... Boy, but where hes
staying is a mad house. Man, they got Crack going on 24/7. Base
heads, oooo Father, I aint seen nothing like it. Oooo, they got
bitches in the kitchen giving head and fucking and giving head on
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credit and aint getting paid and its fucking me up. Up until
yesterday, I had been sick for four days and when they tell you that
you can kick heroin in three days, thats bullshit. ... (Crying) I
couldnt take it no more. ... Okay, I went to the psychiatrist Friday,
okay?
Researcher: At Stout street?
Gail: Uh, huh (yes). Stout Street and she asked me if I was suicidal
and I told her, No. Im homicidal. And she goes, Are you going
to kill somebody? I say, Yeah. She said, You know who youre
going to kill? I said Yeah. She said. Well who is it? I said, My
payee. I say, Cause if she fucks with my thing [money] Im going
to kill her. Okay? She goes, Well, Gail, I think we ought to
hospitalize you. Do what you feel is best, but if the bitch fucks the
money up, Im going to kill her.
As Gail feels the pressure of her living situation and the frustration of not receiving
her SSI (Social Security Income) check from her [payee], she becomes desperate
and vocalizes her predilection for homicidal behavior. The living situation in which
Gail has found herself exposes her to an environment of risk. Desperate and
perhaps unprotected sex for drugs, constant physical withdrawal, and surroundings
racked by the ever present possibility of violence now comprise Gails world.
The disruption of stable injection networks by law enforcement practices
can create desperate circumstances for those left without their usual partners.
Individual IDUs that rely upon their injection partners to generate income, obtain
and use drugs, and locate suitable shelter, may be at a loss when that partner is
removed due to police action.
To overcome the economic uncertainty that pervades their lives,
IDUs employ extensive and opportunistic strategies based upon a
variety of legal, quasi-legal, and illegal activities, none of which are
particularly secure or financially rewarding. As a result, injectors
develop ways to obtain drugs even though they are short of cash.
Among the most reliable are: (1) form temporary partnerships,
combine resources, and jointly purchase a drug; (2) perform a
service in exchange for a drug; and (3) rely on the kindness of others
for a taste of a drug. All three of these methods are regularly
81


employed by drug injectors, and each one sets up conditions that
lead to indirect sharing (Koester 1996:141).
Unfortunately, employing the third method is inadequate and often
unreliable for IDUs dealing with a significant heroin habit. For Gail, strategies
number one and two are much more common. As she forms temporary
relationships with IDUs that she may not normally hang out with, her risks for drug
related harm are increased, particularly in light of regular injection episodes that
utilize the process of backloading to distribute shares of jointly purchased drugs. In
addition, Gail must occasionally resort to prostitution in order to obtain the money
and drugs she needs to live when she is without the aid of her stable partner,
increasing her risk for blood-borne disease transmission and violence. Policing
agendas that disturb stable user injection networks are contributing to much more
than the breakdown of social cohesion among this vulnerable population, for they
may be creating conditions of personal existence in which drug users are forced to
respond with risky behaviors in order to survive.
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Findings III
Fear of Arrest and the Effects of Incarceration:
Overdose and Additional Risky Behaviors
Participation in purchasing, measuring, and injection of illicit drugs makes
episodes of overdose that may result in death an ever present risk and part of
everyday reality for IDUs. While the potential for drug overdose is a readily
apparent consequence of using unregulated and illicit drugs, policing activities and
the fear of arrest and incarceration that they provoke also have negative influences
on IDUs decision-making and behavioral patterns, leading to increased levels of
drug-related harm. Overdose is a term that is used to describe the excessive
consumption of drugs that leads to negative health consequences, including death
(Alexandrova 2002:295). In their study of the consequences of saturation policing
on Cabramatta heroin market participants in Australia, Maher and Dixon reveal that
dealers and users have resorted to oral and nasal storage of heroin in order to
minimize police discovery. Maintaining that drug users frequently swallow heroin
in the attempt to avoid arrest by approaching police, the authors emphasize that
such behavior has resulted in a number of near-fatal overdoses (Maher and Dixon
1999). In this heavily patrolled and strictly enforced drug market, these behavioral
responses have the potential to result in harmful consequences to market
participants. The climate of fear and uncertainty that contributes to these behaviors
also exists among IDUs in Denver and has similar influences on their decision
making and behavioral patterns. For some street-based users, swallowing drugs or
refusing to submit to help from health care workers or emergency medical
personnel in the event of an overdose is standard, despite the potentially lethal
consequences. As the following quote illustrates, regardless of the potential ill
83


effects associated with overdose, some IDUs refuse to entertain the thought of
contacting emergency medical personnel for fear of going to jail.
Informant: And they told him as long as Im breathing, dont call
911. Thats the same way I feel. As long as Im breathing, dont call
911. Dont call the police cause if they take me to the hospital, Im
going to jail. Fuck that. Dont call them.
This particular quote clearly demonstrates that for some IDUs, calling emergency
help in the event of an overdose carries more serious and unwanted consequences
than does the possibility of life threatening and dangerous circumstances. As this
individual has pointed out, calling for help may lead to contact with the police and
possible legal charges. It is important to note however, that while fear of arrest is
ever present among IDUs and may influence their decisions regarding what to do in
the event of an overdose, police contact does not always lead to harmful
consequences, and in fact, may serve to protect IDUs health in some situations. As
the following selection demonstrates, law enforcement does not always pursue
agendas that lead to arrest and incarceration of drug users.
Informant: I said, If I ever go out and Im breathing, do not call
911,1 will be okay. Okay? Cause Ive shot dope, Ive gone out,
been by myself, three hours later I came to. If Im still breathing,
Im alright, just watch me. Dont call 911. So I fixed the dope up, I
gave her some, I split it in half and I put a syringe in my purse. So I
shot the first half. When I come to, Im looking at the police.
Researcher: Oh, no. And you had the other half....
Informant: Im looking at the police with my syringe laying next to
him full of dope.
Researcher: Laying next to the cop.
Informant: Laying next to the cop. Hes looking at my syringe.
Researcher: And this was the syringe that was in your ....
Informant: That was in my purse. So the first thing come to my
head, Im going to jail, I got dope. So they took me to the
ambulance... So they took me over to St. Anthonys. Right? Well I
got to St. Anthonys, the cop ... he came into the room, he said
84


_________what have you been arrested for? And I said, Basically,
paraphernalia. He goes, Have you ever had a dope charge? I said,
Yeah Which I have. I said, But that was like 1991. He said,
Well what happened? I said, Well, they gave me two years
probation. He said, Well you know what? Youre 43 years old and
you are too old to be going to the penitentiary. So Im not going to
give you a dope case and Im not going to give you a paraphernalia
ticket. Everybody at the shelter really likes you. All I want you to do
is just slow down because youre too old to be doing this. And I
thanked him and said, Okay.
While the police may actually serve to help users in some cases of
overdose, there are many instances where their mere presence influences users
behavior in potentially dangerous ways. As Maher and Dixon have pointed out, a
primary consideration for IDUs is to avoid being caught with illicit drugs. It is in
this regard that swallowing heroin or other illegal substances is ultimately viewed
to be less problematic than actually being apprehended by law enforcement.
Swallowing illicit drugs is dangerous and poses a direct health threat to those who
choose to employ this behavior. As one individual describes, swallowing drugs is
one way to avoid being arrested for possession, [albeit a very dangerous one], in
the event that patrolling police officers attempt to make contact.
Informant: The Police is on bicycles. Theyre trying to fuck
everything up. Cause were not hurting nobody. Were just trying
to get well.
Researcher: At any given time, they probably know when people
have just copped, right? There must be times when cops go, Fuck
it. I dont want to .... I mean, it must be a pain in the ass for ....
Informant: Cause there was one where I had just copped the pill
and he seen it and I swallowed the pill, but he thought it was Crack,
okay? And he swore up and down I had just bought some Crack or
just tried to sell some Crack, And you just swallowed it. And I
finally told him, Yeah I did swallow it. So he found a pipe on me,
okay? He was like, Well, wheres your pipe. Cause if I have to
look for it, Im taking you to jail. If you tell me where it is, Ill just
write you a ticket. So I told him where it was, okay? And then he
85


comes and he tells me, Well, you know you couldve got a
possession case. I said, Yeah, thats why I swallowed it. Which I
did. When he took__________to jail, I stuck my finger down my
throat and I brought the pill back up. Okay, so I still had the dope.
In a similar scenario, another individual describes swallowing heroin in
response to the police approaching after having witnessed the drug deal that was
taking place. Again, the police seem to have assumed that it was a crack deal taking
place, when according to the participant, the drug was really heroin.
Informant: I was making a drug deal, I got some drugs from where
the police .... we didnt see the police. He gave it to me. I looked at
my hand. The man thinks its a Rock. I put it in my mouth and I
swallow it and shit. You know he thought it was a crack deal when it
was a heroin deal. ... I heard that car drive off, I stuck my finger
down my throat and fucking throwed it back up. I was too sick for
that bullshit. I mean I do bad things, but God, I got a guardian angel.
I have been so blessed and I kept thinking I could be in sitting in jail
right now because I ODd in the damn shelter.
While neither of these particular interactions appears to have resulted in any serious
immediate physical harm to the individuals sharing their stories, one can imagine a
different outcome that entails the dire consequences of drug overdose and perhaps
death. In a separate interview taken from field notes, an IDU named Damon
mentions to the interviewer how he witnessed a dealer with a bunch of balloons of
heroin in his mouth, swallow all of them in response to approaching police. This
behavioral reaction to the presence of law enforcement and the threat of arrest is
easy to understand in terms of individuals who are simply doing whatever is
necessary to avoid being arrested and perhaps sent to prison for possession of
illegal substances.
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IDUs in Jail: Physical Withdrawal and Risky Behaviors
Fear and uncertainty associated with being apprehended with illicit drugs is
not the only condition that leads to risky behaviors. In many instances of drug user
and police interaction, IDUs are actually arrested and taken to jail. Time spent in
jail usually means that the user will be without opportunity to obtain and inject
drugs, and therefore will become at least minimally dope sick. As explained
previously, the physical symptoms of withdrawal can be powerful and may lead
IDUs to engage in risky behaviors such as sharing previously used injection
paraphernalia or unnecessarily hurried drug use that may result in the over-
consumption of unregulated substances. When IDUs are detained in jail,
particularly for lengthy periods of time (several days to several weeks or months),
they begin to lose their physical tolerance for the effects of drugs such as heroin as
the substance leaves their body. Upon release however, addicts are often concerned
with only one thing: finding and injecting drugs as quickly as possible in the effort
to relieve the suffering associated with the physical symptoms of withdrawal
(Wakefield 1963). The criminalization of street-based IDUs that results in their
frequent arrest and time in jail creates circumstances in which drug users are
placed in situations of limited agency. The responses that IDUs employ when
faced with these circumstances may ultimately lead to risky injection practices and
the increased likelihood of episodes of drug using that result in dangerous
overdoses.
In the following vignette, the interviewee describes both the tactical
behavior of swallowing drugs to avoid arrest and the negative influence that jail
time may have on IDUs risk behavior as a result of being in the throes of physical
withdrawal.
Informant: I was sure I was going to get busted that day, you know.
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Researcher: So youre walking down the alley .... and the guy sees
you, the cop....
Informant: The cop saw me and he just hit his brakes and started to
get out of his car. And you know, they were just like ready to, you
know .... I knew if I got caught with dope again thats .... Im not
getting caught.
Researcher: So you swallowed it.
Informant: Swallowed it and started hitting fences running. You
know, I held onto it as long as long as I could before I swallowed it
but, you know, as soon as I realized, Hey, hes got me.
Researcher: And then what did you do when he got you?
Informant: I was just like, Hey evading arrest. Give me three
days, I care. You aint got me for shit.
Researcher: Did they give you three days?
Informant: Yeah, three days in jail. I was like, Fuck it. Oh, well,
you can be sick for three days. ....
Researcher: What did they get you for, anything?
Informant: Nothing.
Researcher: Well, let me ask you .... so you come out of there,
three days into withdrawal, but the first thing you want to do is
shoot up, right?
Informant: First thing youre going to do is get well.
Researcher: Youre not going to use that as a little start?
Informant: From the county, I called the dope man. I said, Come
pick me up, man. You know, I still had cash in my pocket. Hey,
come pick me up and bring me a rig [syringe]. And sure enough ....
As this individual clearly describes, when addicts are released from jail their
primary interest is to get well. It is particularly noteworthy that in addition to
calling the dealer for a ride, this individual requested that the dealer also bring a
syringe for immediate use. In the unmistakable haste to subdue the symptoms of
withdrawal, IDUs may be unconcerned with the possibility that a syringe has
previously been used by someone else. As this next excerpt patently illustrates,
being dope sick may contribute to users taking elevated injection-related risks.
Researcher: I was reading a book about this the other day, that if
youre really Jonesing, if youre really sick, like everything else
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goes out the window, you just want to get your hit. You dont care
how you get it.
Informant: Thats true.
Researcher: Like if you dont have a rig, youll just do it wherever
you find one.
Informant: Thats true. Most.... not most.... Id say 45% of the
junkies do that. You know, they throw all the morals and everything
out the window, you know, they dont care. They just want to get
that sickness up off of them. So theyll do it. Theyll use somebody
elses point. Theyll rinse it, you know ....
Researcher: With water?
Informant: Yeah. 99% of the time theyll rinse it, but you find
some junkies that just dont care. But, anyway, theyll rinse it and do
it, you know, forget the Clorox, forget everything. They just want to
get well.
Researcher: Well, its hard. If youre shooting here you might have
Clorox here, but if youre like in an alleyway or something, you
might not have it with you.
Informant: Yeah, thats true. But, like I said, if theyre real sick,
they dont care. They just want to get that sickness up off of them.
Researcher: So even if you had the bleach sitting there, they dont
care if theyre sick?
Informant: They wouldnt take the time to do it, you know, cause
being dope sick is very irritable. Its a very ugly feeling. Everybody
has their own way of describing it, you know, cause its different to
everybody. Me, I dont like the cramping and I dont like the
sneezing. Other people, it could be they got water in their eyes, their
nose, you know.
As this individual explains, being dope sick is to be avoided at all costs. When
IDUs do get sick, the primary concern for many is to inject quickly to remove the
physical symptoms of being sick, regardless of the potential consequences of using
previously used syringes or other drug-related paraphernalia. As Koester explains,
To suppress withdrawal symptoms, heroin injectors waste little time between
acquiring their drug and injecting it, and they must carefully calculate the dose
necessary to get well (Koester 1996:142). For some IDUs, being detained in jail
and getting dope sick is absolutely unthinkable. As this next passage reveals, some
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DDUs will do whatever it takes to avoid being jailed and without the ability to inject
desperately needed drugs.
Informant: Cause, you know, anything can happen,________,
especially the biggest fear is, you know .... especially if you wind
up in jail with nothing on hand. You know, you got to lay up in there
and kick that, oh God forbid. I wont imagine me doing that. I
already know that I would .... Yeah, I would take my life because I
wouldnt go through that again.
Researcher: Okay, so you go into county. You get busted tomorrow
noon, you know, what are they going to give you?
Informant: Nothing.
Researcher: Nothing?
Informant: Nothing. They might give you some stuff to calm you
down. Something like that to lower your blood pressure.And the
idea of being locked up in that little box downtown with any kind of
habit, you know. Thats why I wouldnt do nothing to break the law
to put myself in a position of going to jail when Im strung out. I
dont want to be in jail anyway, but I definitely dont want to go
with no kind of [habit],.. I wont do anything to place myself in
jeopardy, you know, as far as doing something wrong where I know
I could be caught and me going to jail. Im not going there.
Arrest and incarceration of street-level drug users creates circumstances in
which EDUs get dope sick because they are unable to obtain the drugs they need to
stave off the physical and psychological symptoms of withdrawal while in jail. The
following passage reinforces how time spent in jail contributes to the onset of
physical withdrawal and how this can affect risk behavior.
Informant: ... The last time I went to jail, I was shooting over a
gram and a half of dope a day and when I went to jail, I went for 10
days, so I got really sick. ... But if Ive got five or six days to do in
jail, yeah I get sick ... I dont feel like doing shit. Im irritable as
hell and, you know, Im going to have the runs or something, you
know. ... You can walk out of that damn jail and havent sniffed
within four days and the closer you get to these Points [Five Points
Neighborhood], the more your nose is running, the more your eyes
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will run and you become dope sick. ... and the urge gets stronger
and stronger.
Researcher: Do you think theres a connection between being dope
sick and taking more risks when youre injecting?
Informant: Well, I find for me, myself, the only time I really get
careless and get busted or take risks that I dont have to is when Im
sick and I dont have the money compared to when Im sick and I
got the money. But the average person thats really dope sick cant
function as far as going out there getting no money. Whatever hes
going to do, hes really going to fuck it up.
Researcher: What about when youre taking risks injecting, like say
if youre going to do something like share a fit or something? Is that
more likely to happen when somebodys dope sick and trying to get
well, than when you try to get high? Do you think or not?
Informant: I think it would happen more likely when youre both
trying to get well because anybody ... Well, anybody thats trying to
get well, should always carry a fit with you. ... But then you have
guys that are scared to carry a fit, but they are going out there with
pockets full of dope. ... So if a fit isnt relatively close, he can take
risks that he probably wouldnt normally take where if youre well,
you can afford to wait, you know, to where you need to get the
things you need to be a little more safer. If hes sick, man, hes
thinking about getting hisself off the ground. So the risk into play,
like you say, it comes into play.
Suffering from withdrawal may also contribute to drug using episodes that
lead to overdose as IDUs make judgment errors relating to either the quality of
drugs available, or the quantity required in order to make them feel better. As they
hastily and desperately proceed to inject unregulated drugs into their systems, they
are often at risk of overdose. This risk is influenced by time spent in jail and the
corresponding interruption of more regular injections. The next selection speaks to
this particular scenario and further illustrates how being dope sick in jail can
contribute to harm when a user gets released.
Informant #1: Well, see, thats the thing right there. A lot of people
doing it dont realize, I guess, theyre letting their system get clean
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and then turn around there and figure they can shoot drugs just like
they did when their system was dirty. And you cannot do that.
Informant #2: Thats what you did.
Informant #1:1 know. Thats what caused me to go out [overdose].
And I went out on a bare minimum amount of drugs.
Researcher: Yeah, right.
Informant #1: So, you know. And see, youve got a lot of people
that are doing that, you know. They go to jail for three, four, five
days or a week or two, you know, and they come right back out and
its like, I can still do this. Oh thats just like whatcha-call-em
was telling me, a dude was telling me yesterday when I went up
there,________was getting ready to shoot a half a gram of drugs
... .the whole half a gram. Hed have been gone.
As these informants explain, when users spend time in jail, they may lose their
physical tolerance for drugs. As a result, their risk for drug overdose may be
increased upon release because they think that they can use the same amount or
quality of drugs as they did before their tolerance was interrupted. The
overwhelming desire to get well or subdue the feelings of withdrawal can lead
IDUs to inject excessive quantities of drugs upon release from jail that may
contribute to overdose or death.
As the last passage reveals, overdose is a constant reality for some IDUs.
Of particular importance is the informants recognition that even when warned by a
close acquaintance, he paid little attention to the possibility of overdose because he
was feeling sick and simply wanted to inject some drugs.
Researcher: So why .... A dumb question, but why do you want to
kick now? What are the reasons?
Informant: Ive overdosed three times in less than a year, you
know, wound up in the hospital twice. They didnt find me in my
room. I was passed out for three days. The last time they found me, I
was like, No, I cant do this no more. .... And the last one, I was
out in Lakewood and the dude I get my dope from, he told me, ....
Its really good. Be careful. And I was sick and I wasnt paying no
attention to him, man, I was just being stupid.I woke up in the
back of the ambulance getting hit with Narcan ....
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