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Official websites use. Share sensitive information only on official, secure websites. Understanding the experience of initiating injection drug use and its social contexts is crucial to inform efforts to prevent transitions into this mode of drug consumption and support harm reduction. We systematically reviewed and synthesized existing qualitative scientific literature to identify the socio-structural contexts for, and experiences of, the initiation of injection drug use. Peer-reviewed studies were included if they qualitatively explored experiences of or socio-structural contexts for injection drug use initiation. A thematic synthesis approach was used to identify descriptive and analytical themes across studies. From initial results, 41 studies reporting data from participants were included. We developed eight descriptive themes and two analytical higher order themes. The first analytical theme focused on injecting initiation resulting from a social process enabled and constrained by socio-structural factors: social networks and individual interactions, socialization into drug-using identities, and choices enabled and constrained by social context all combine to produce processes of injection initiation. The second analytical theme addressed pathways that explore varying meanings attached to injection initiation and how they link to social context: seeking pleasure, responses to increasing tolerance to drugs, securing belonging and identity, and coping with pain and trauma. Qualitative research shows that injection drug use initiation has varying and distinct meanings for individuals involved and is a dynamic process shaped by social and structural factors. Interventions should therefore respond to the socio-structural influences on injecting drug use initiation by seeking to modify the contexts for initiation, rather than solely prioritizing the reduction of individual harms through behavior change. Keywords: Systematic review, qualitative synthesis, thematic synthesis, injection drug use, injection initiation, drug use, trajectories, transitions. Twelve million people inject drugs globally 1 and, with limited access to harm reduction services 2 , face vulnerability to poor health and social outcomes 3 — 5. Patterns of drug injecting are evolving: injection drug use is increasing in some areas and populations that have historically reported low prevalence e. There has long been interest in preventing transitions to drug injecting 9 , 10 , though the effectiveness of interventions has been limited according to scientific evaluations conducted to date There is therefore a need to further develop understanding of injection drug use initiation to inform interventions and policy responses. Quantitative studies of injection drug use initiation have explored a range of factors linked to injection initiation, including shifts in the drug supply, drugs used, unemployment, family disruption, homelessness, incarceration and social networks 12 — Qualitative research offers unique complementary insights by enabling in-depth exploration of how injection initiation is experienced, for example: the meanings and identities it can bring, and how initiation is shaped by contextual factors A synthesis of this qualitative literature would help elucidate the frequently complex pathways by which individual experiences, discrete factors and contexts combine 21 , We aimed to systematically review and synthesize qualitative literature on the experience of, and social context for, injection initiation. What role do family, friends and others play in influencing the context of injection initiation? Thus, we understand injection initiation as arising from interactions between individual agency and the constraints and opportunities afforded within these overlapping environments 22 , which can vary across populations due to the intersection of individual characteristics and social-structural inequities. We used this overarching theoretical framing - of social and structural factors forming pathways with individual agency to produce injection initiation — to explore and elucidate the empirical findings of qualitative research in this area. We employed a thematic synthesis approach in order to develop concepts and theory of relevance to policy and intervention development 27 — We combined database and manual searches to ensure a comprehensive review see search record in supplementary file 2. Searches for relevant studies were conducted in March We manually searched selected journals to ensure recent publications were included, searched Google Scholar and hand-searched institutional webpages of key authors in the field, identified through our familiarity with the literature. For each included study, we also checked reference lists in other papers. Inclusion criteria were: scientific peer-reviewed literature; English language; analysis drawing on qualitative research design, including mixed-methods approaches; and analyses addressing the experiences, processes or contexts of injection initiation. Exclusion criteria included grey literature, quantitative research; opinion articles, commentaries, and editorials i. We reviewed the titles and abstracts for citations found in the database and manual searches. Full references were then checked against inclusion criteria. We assessed the quality of included studies to support interpretation and development of the analysis, rather than as the basis for inclusion. This approach is consistent with previous qualitative syntheses and debates on the merits of judging quality and the likelihood of lower quality studies contributing less to review results Thematic synthesis develops descriptive and analytical themes through coding of original studies. Descriptive themes translate the findings from original studies into one another to identify common areas of focus Analytical themes seek a novel synthesis of the literature and to explain and explore the descriptive themes After familiarizing ourselves with the included studies a coding framework was developed iteratively. We focused this process of translation on second order constructs i. We undertook this approach owing to the limitations on understanding the context of primary data presented in each study and the consequent risk of misinterpreting isolated data fragments. The coding and analysis process was iterative and ongoing, and focused on discussion across the team to refine our translation of concepts, comparing the coded data within codes, and grouping codes into categories. We used the theoretical framing discussed above to categorize the codes, using core areas of focus from the risk environment such as micro-social environment and agency 23 — Codes were grouped into descriptive themes representing large code categories e. The structural framework we used oriented the development of these descriptive and analytical themes towards understanding relationships between individual experiences and environmental factors. We identified unique articles through the search, of which 41 met inclusion criteria Figure 1 ; Table 1. Many papers we classified as medium rather than high quality owing to limitations in study reporting, primarily due to restrictions on article length and disciplinary conventions rather than weakness in study design. The included studies frequently addressed experiences of initiation in depth or the social contexts for this; fewer studies explored specific theoretical relationships between these experiences and their contexts. We therefore characterize the literature as frequently in-depth and conceptually diverse, although with less emphasis on developing theoretical relationships between constructs. We developed eight descriptive themes grouped into two analytical themes. The first analytical theme explores injection initiation as a dynamic process produced over time, involving individuals interacting with socio-structural factors. The second analytical theme then further delineates pathways to, and contexts of, injection initiation events. These pathways explore how individuals experience and ascribe meaning to injection initiation within specific social contexts Figure 2. The first injection of drugs is often embedded in long-term processes of change in self and identity within the context of social interactions and structural factors. Social connections and networks were reported as fundamental to drug injecting initiation. Friends 41 , 44 , 47 , 48 , 50 , 51 , 55 , 56 , 60 , 68 , 70 , 73 , 77 , family 41 , 43 , 44 , 51 , 52 , 55 , 68 , 70 — 73 , intimate partners 42 , 48 , 49 , 52 , 57 , 59 , 60 , 64 , 68 , 70 — 72 , 77 , acquaintances 37 , 43 , 77 , gang members 63 , elders 65 and drug dealers 41 , 42 were all described as influential. Different types of social interactions shaped injection initiation. Studies suggested that people who already inject may encourage injection initiation, enthusing about the benefits of drug injection linked to pleasure or cost-efficiency 37 , 47 , 48 , 51 , 52 , 70 , 72 , 73 e. Encouragement by people who already inject could extend to peer pressure 37 , 66 , 68 and more direct coercion 38 , 52 , By contrast, people who already inject drugs also actively discouraged potential injectors 43 , 66 , Studies suggested a strong reluctance or refusal to assist injection initiation, reflecting group norms on the unacceptability of facilitating injection initiation 51 , 53 , 66 , 71 , 72 , However, this convention to refuse the facilitation of first injection events was reportedly frequently ignored, for a range of logics, including the desire to reduce potential harms experienced by initiates or to access drugs 53 , 66 , 71 , 72 , Both those assisting and those seeking to inject described processes of help-seeking, extending to persistent and pressuring requests to be initiated 48 , 51 , 53 , 66 , 72 , This process was described as the erosion of social norms against drug injecting among individuals through their own actions and those of others. Injection initiation involved crossing boundaries of morality, stigma 50 , 66 or risk 61 , where fears or negative social norms are displaced or replaced 48 , 72 with new social roles and identities bound to injecting This shift can be influenced by other people 48 linking to the interactions described above and through increased participation in social networks centered around injection drug use 50 , 52 , 58 , This active role is also indicated in persistent requests for help, as described above. A core theme across studies, however, was of limited agency. This occurred whether through accounts of limited autonomy 42 or in how experiences of, and claims to, active choice and autonomy with respect to injection initiation that were, in fact, constrained and enabled by environmental factors 42 , 47 , 50 , 61 , 66 , 67 , Conversely, some people emphasized a dominant role for context in shaping their initiation of injecting drug use. Recognizing the potential for constraint on an individual from environmental factors also served to help individuals rebuild an identity in response to drug use, which they may regret or be seeking to overcome Meso-level environments i. Homelessness also led to an immersion in street scenes or shelters where injecting was visible and encouraged 38 , 44 , Linked to this concentrated disadvantage were constrained socio-economic opportunities stemming from structural vulnerability that amplify the risk of drug injection initiation: working in distributing or selling drugs leading to proximity to drugs 37 , 39 , 42 or unemployment leading to injecting drug use as a way to manage boredom 65 , gain prestige 63 or manage poverty and increasing tolerance Within prison environments, injection drug use is potentially visible and encouraged 58 , identified as a way to cope with misery 52 , or as a focus for coercion from others Changes in drug supply linked to intensive police action 47 or policy shifts in the specific context of prescription opioid availability 58 may increase the viability of injecting from an economic perspective, given contexts of poverty and economic survival 47 , 65 , or the potential for higher quality drugs 62 , Overarching economic changes, whether short-term cycles interacting with poverty and vulnerability to foster the economic appeal of injection 47 or long-term transitions linked to shifting norms and social ties around drug use 66 , 67 , are also linked to initiation. In this second analytical theme we explore four overlapping descriptive themes reflecting meanings associated with injection initiation, and delineate pathways linking these individual experiences to specific social and structural factors. Boredom and a need for excitement was also linked to a concern for pleasure and self-fulfillment 41 , Seeking pleasure is bound up within specific social-structural factors. An increased high associated with drug injecting was described as emerging from engagement in social networks that include people who already inject drugs 51 , 52 , 56 , 60 , 73 , where the high is witnessed 48 or encouraged 47 , 73 and curiosity generated 44 , Seeking pleasure can be enabled by such social environments 66 , whilst experiences of homelessness and marginalization can push people in to social networks and street scenes where injecting is witnessed and people become curious about its effects 42 , Shifts in the drug supply to purer or more easily injectable forms also create incentives for injecting given the decreased pleasure associated with less potent drugs or a greater difficulty in purchasing drugs 62 , Accounts referenced increasing tolerance to a drug 37 , 40 , 41 , 47 , 48 , 52 , 55 , 58 , 60 , 68 , 70 , 71 , 76 , withdrawals 47 , 48 , 56 , 58 , 61 , 70 and economic pressures or recognition of the economic efficiency of injecting 37 , 41 , 46 — 48 , 51 , 52 , 55 , 58 , 60 — 63 , 65 , 68 , 70 — 73 , 76 , 77 as linked to injection initiation. A recognition of the increased efficiency of injection drug use can occur within social networks of people already injecting who can encourage this understanding 47 , 48 , 52 or be a rationale for coercing others in to injecting 77 , and thereby reflect economic pressures generated by poverty, marginalization 47 , 61 , and shifts in drug supply Injection initiation can secure belonging to particular groups and identities. I saw them enjoying drugs and I felt lonely and always left out. A need to belong or adopt certain identities was structured by gender. Drug injecting can function to manage, or respond to, violence, abuse or neglect. Injection initiation was identified as a response to grief, misery and stress 37 , 52 ; as an aid in coping with mental illness including depression 46 , 50 , 55 , or to manage physical pain I went through the windshield. Injecting was also described as a response to the stress of deportation 64 , guilt 68 and assault and rape 39 , 41 , The nature of crises and trauma and the capacity to manage them can be bound up in social and structural factors. Specific neighbourhoods and street scenes for drug use can be a place people seek refuge in after traumatic experiences 69 , or be settings in which crises are more prevalent, for example violence in poor neighbourhoods 71 , and where social contacts that can enable drug injection are present 50 , This qualitative systematic review synthesized concepts, experiences and pathways linked to injection initiation. Using a socio-structural framework 22 , we developed two analytical themes that comprise eight descriptive themes: injection initiation as a dynamic process produced over time, involving individuals interacting with social-structural factors; and, injection initiation stemming from specific pathways to and contexts of injection initiation events. In seeking to bring clarity to a large qualitative literature through our theoretical framing, we have demonstrated the extensive empirical evidence for injection initiation as a multi-dimensional phenomenon involving individual, social and structural factors. We have also highlighted the importance of concepts of socialization, identity and an approach exploring dynamic pathways of enacted and constrained individual agency occurring in relation to environmental contexts framed by larger structural vulnerabilities. We consider these concepts and pathways potentially generalizable to a range of contexts, although more study is needed to fully support this. The review provides insight into the range of pathways by which socio-structural contexts shape individual and group capacities and behaviors. There is also need to further elaborate the theoretical relationships by which agency interacts with specific contextual factors 22 ; as we noted, studies often provided insight to meanings and experiences or to contextual factors, although there is less emphasis on exploring specific theoretical relationships between factors. Future research should respond to this multi-dimensional understanding of injection initiation and develop more insight in to the specific pathways shaping injecting initiation in diverse contexts, building on the conceptual clarity developed in this review. Future research should address the underrepresentation of experiences of particular ethnic, sexual, and gender identities in current research; the role of particular drugs; and identify additional specific pathways linking social and structural factors to individual experiences of injection initiation Policy and interventions to address the needs of people who use drugs and respond to injection drug use should orientate to a dynamic, multi-level understanding of injection initiation. Recent emphasis on structural approaches to reduce the risk of initiation 78 has built on lessons gained from individual level approaches seeking to alter behavior, which may be constrained in their capacity to effectively reduce the potential for initiation This review seeks to develop this emphasis further and we, therefore, explored the emergence of injecting within constraining and enabling contexts. Recognizing this, interventions and policy should seek to create socio-structural environments in which vulnerable individuals have alternative, attractive choices to initiating injection drug use 42 , rather than solely prioritizing the reduction of individual harms through behavior change. Whilst implementing and scaling up such structural approaches to health carry challenges, our recommendations respond to evidence for how discrete structural modifications such as supervised consumption facilities can change social environments and so disrupt specific harmful drug-using practices 79 — Such socio-structural approaches would need to respond to the multiple meanings attached to injection initiation and its multiple contexts, whether someone injecting under pressure from an intimate partner 57 or driven by curiosity and pleasure The centrality of pleasure in our analysis, commonly not highlighted in drug policy research 82 , also has implications for considering the feasibility and acceptability of strategies to prevent individuals from initiating injection drug use, as it suggests that currently conceptualized prevention efforts have limits and that allied efforts to support safer injecting are needed This review has limitations. First, we were limited to English language studies, explaining the dominance of North American, Western European and Australian literature on our findings although the search did not return any non-English language studies. Second, the methodology of thematic synthesis has been criticized for decontextualizing findings, which is often understood as the foundation and inherent value of qualitative research However, thematic synthesis is valuable in its capacity to highlight broad themes in the literature that can be developed and explored for their relevance to policy or intervention development Third, all qualitative research, including the products of a thematic synthesis, have limits on generalizability; the findings from this review should therefore be understood as potentially theoretically generalizable to other contexts 84 , with future research needed to further explore the relevance of these concepts and refine their applicability in specific contexts. We reviewed the existing qualitative literature to delineate experiences and contexts for drug injection initiation. The available qualitative literature suggests injection initiation has varying and distinct meanings and is a dynamic process shaped by social and structural factors. Research and interventions need to adapt to this multi-dimensional understanding of injection initiation as both behavioral and social, and should seek to understand and target socio-structural change. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Published in final edited form as: Addiction. Find articles by Andy Guise. Find articles by Danielle Horyniak. Find articles by Jason Melo. Find articles by Ryan McNeill. Find articles by Dan Werb. Issue date Dec. PMC Copyright notice. The publisher's version of this article is available at Addiction. Open in a new tab. Medium 2 Briggs et al. UK: London and Bristol In-depth interviews. Medium 3 Carbone-Lopez et al. USA: Missouri In-depth interviews. High 4 Dertadian et al. Australia: Sydney Life history interviews. Low 5 Draus et al. High 6 Fast et al. Canada: Vancouver, Downtown district with long-established drug market In-depth interviews and ethnographic observation. High 7 Finlinson et al. Puerto Rico: Bayamon In-depth interviews. Medium 8 Firestone et al. Canada: Toronto Qualitative study using in-depth interviews. Medium 9 Fitzgerald et al. Australia Qualitative study using semi-structured interviews. High 10 Giddings et al. UK Qualitative study using in-depth interviews. Low 11 Guise et al. Kenya: Nairobi and coastal region Qualitative studies using in-depth interviews, observation and ethnographic interviews. Medium 12 Harocopos et al. Medium 13 Higgs et al. Australia: Melbourne Qualitative study using semi-structured interviews. Medium 14 Horyniak et al. Australia: Melbourne Semi-structured interviews. High 15 Kermode et al. India: Nagaland and Manipur, northeastern states with proximity to Golden Triangle Semi-structured interviews. High 16 Khobzi et al. High 17 Kolla et al. Canada: Toronto Semi-structured interviews. High 18 Lankenau et al. Medium 19 Lankenau et al. Medium 20 Lankenau et al. High 21 Lazuardi et al. Medium 22 Mars et al. High 23 Martin 59 Explore social conditions under which women become vulnerable to injecting initiation. Australia: Melbourne In-depth interviews. Medium 24 Mateu-Gelabert et al. Ireland: Dublin, poor inner city community Longitudinal ethnography with interviews, focus groups and participation. Medium 26 McCurdy et al. Tanzania: Dar es Salaam Semi-structured interviews. Medium 27 Nasir et al. Indonesia: Makassar, slums In-depth interviews. High 28 Ojeda et al. Mexico: Tijuana In-depth interviews. Medium 29 Razani et al. Iran: Tehran Focus groups and key informant interviews. Medium 30 Rhodes et al. Moldova: Balti Semi-structured interviews. High 31 Rhodes et al. High 32 Robertson et al. Medium 33 Roy et al. Canada: Montreal In-depth interviews. High 34 Sherman et al. USA: Baltimore In-depth interviews. High 35 Simmons et al. Medium 36 Small et al. High 37 Tuchman 73 Explore the social, contextual, and behavioral dimensions of injecting practices of women who inject drugs. Low 38 Wagner et al. Low 39 Wenger et al. Medium 40 Witteveen et al. The Netherlands: Amsterdam In-depth interviews. Medium 41 Wright et al. Declarations of competing interest: We have no competing interests. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Andrade et al. Explore shifts in New York heroin markets, and impacts on non-injecting heroin users. Briggs et al. Within a study on speedball injection, aims to explore how homeless hostel environments shape injecting drug use and related harms. Carbone-Lopez et al. Dertadian et al. Draus et al. Describes contextual factors contributing to heroin injection initiation. Fast et al. Canada: Vancouver, Downtown district with long-established drug market. In-depth interviews and ethnographic observation. Finlinson et al. Explores polydrug use history of recent initiators of drug injecting. Firestone et al. Responding to prescription opioid and crack use amongst street drug users, aims to describe behaviors and preferences as well as social and structural contexts for use of these drugs. Fitzgerald et al. Qualitative study using semi-structured interviews. Giddings et al. Explores what differentiates drug injecting from other methods. Guise et al. Combines studies to explore the social context for transitions to injecting heroin. Qualitative studies using in-depth interviews, observation and ethnographic interviews. Harocopos et al. Describes social contexts for injecting initiation. Longitudinal qualitative study using repeated in-depth interviews. Higgs et al. Horyniak et al. Understand injecting drug use exposure and preferences among young people from culturally diverse backgrounds. Kermode et al. Increase understanding of contextual factors associated with initiation to injection drug use. India: Nagaland and Manipur, northeastern states with proximity to Golden Triangle. Khobzi et al. Exploration of biological, psychosocial, socio-cultural and socio-structural processes in injection initiation. Kolla et al. Examine initiation events from the perspective of the initiators, in order to understand their roles and motivations. Lankenau et al. Describe the circumstances surrounding the first injection of Ketamine. Describes how drug type used at first injection relates to characteristics of the initiate, risk behaviors, and future drug use trajectories. Survey integrating qualitative data collection. Describe initiation in to prescription opioid misuse. Lazuardi et al. Mars et al. Understand process by which heroin injectors had initiated heroin use and injecting. Martin Explore social conditions under which women become vulnerable to injecting initiation. Mateu-Gelabert et al. Explores drug use and sexual risks of non-medical prescription opioid users. Mayock Longitudinal ethnography with interviews, focus groups and participation. McCurdy et al. Explore the rules and organization of drug use. Nasir et al. Examines the influence of the social context on initiation of injecting drug use in slum areas. Ojeda et al. Describes illicit drug use behaviors in diverse settings of Mexican born deportees from the USA. Razani et al. Explore risk behaviors of people using drugs in context of harm reduction efforts. Rhodes et al. Explore accounts of people who inject drugs who initiate others in to drug injecting. Explores how narratives of drug transitions relate to broader social and economic transitions. Robertson et al. Examine the correlates and contexts of US injection initiation among undocumented migrants. Roy et al. Examine social contexts and processes influencing transition to drug injection among street youth. Sherman et al. Explores the influences on the transition from sniffing to injecting heroin. Simmons et al. Explore the interpersonal and structural dynamics that shape injection initiation within intimate partnerships. Small et al. Investigate the initiation of injection drug use among street involved youth. Tuchman Explore the social, contextual, and behavioral dimensions of injecting practices of women who inject drugs. Wagner et al. Wenger et al. Examine the injection initiation process from the perspective of established people who inject drugs. Witteveen et al. Elucidate injection initiation and risky injection practices among young drug users. Wright et al. Explore women drug users experiences of abuse from intimate partners when being injected with illicit drugs.
The association between socio-economic marginalisation in urban poor neighbourhoods and the prevalence of violence, crime, drug use and drug dealing has.
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Official websites use. Share sensitive information only on official, secure websites. This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author s have been asserted. The everyday lives of contemporary youths are awash with drugs to boost pleasure, moods, sexual performance, vitality, appearance and health. The research for this paper was conducted among male, female and transgender male to female, so-called waria sex workers in Makassar, Indonesia. The paper outlines how these experimental practices differ from those that have become the gold standard in biomedicine. The everyday lives of contemporary youths are awash with drugs to boost pleasure, moods, sexual performance, vitality, appearance and health Hardon, Idrus, and Hymans Hurwitz ; McCabe et al. Many of these studies have focused on the abuse of prescription drugs — painkillers, cognitive enhancement drugs and other substances with psycho-active properties — which circulate freely through youth networks alongside illegal drugs such as amphetamines and cocaine. It is noteworthy that prescription drugs are often seen by youths and adults to be safer and less addictive than illegal narcotics. Cognitive enhancement drugs such as Ritalin are widely used by college students to stay awake and to aid concentration and memory McCabe, Teter, and Boyd ; DeSantis, Webb, and Noar , high school girls are turning to antidepressants to provide energy and relief Knudsen, Hansen, and Eskildsen , and the imperative to socialize is fuelling the use of analgesics meant to treat headaches Hansen, Hansen, and Holstein At first glance, all this seems to confirm the state of modernity described by Nicholas Rose: one in which we no longer see biology as destiny, but seek to endlessly modulate, adjust, and enhance our neurochemical and somatic selves Rose and Novas ; Rose Scholars have traced this medicalization of everyday life to three broad developments: 1 governments, confronted with burgeoning expenditures for healthcare, are encouraging citizens to take responsibility for their own long-term health; 2 biomedicine produces novel understandings of health, which provide new opportunities for intervention; and 3 pharmaceutical firms use new and disconcerting health facts to promote disease awareness and consumption of their blockbuster drugs Medawar and Hardon ; Rose and Novas ; Rose ; Dumit Whereas medicine previously focused on treating pathology, we have come to see ourselves as inherently ill and in need of constant treatment Nichter and Vuckovic But something different seems to be going on with youth, who are inclined to ignore government health messages and are rarely concerned with their longevity or possible future ill-health. Franke, Lieb, and Hildt , for example, show that students do not differentiate between taking drugs such as Ritalin and drinking coffee. And as McKinney and Greenfield have argued, too much emphasis on governmentality and biopower ignores the symbolic and social dimensions of drug use among youths, where we see a pervasive trend towards the experimental use of prescription drugs for purposes other than what they were originally intended for. In a very different context, how young people appropriate pharmaceuticals for their own aims can be seen in how transgender youths use hormones to transform their bodies to align with their desired gender identities Kulick ; Sanabria , Sanabria has shown how Brazilian travestis use informally obtained oral contraceptive pills, hormone replacement therapies, and hormonal contraceptive injections as part of their projects of bodily transformation. Both groups use pharmaceuticals for effects that are not biomedically sanctioned. How does their collective experimentation construct knowledge on pharmaceutical efficacy? How do they develop their own modes of administration? How does information on drugs and practices circulate? We suggest that it is useful to examine how youth craft and assess drug effects in relation to their situated needs and desires, and how their experimental practices differ from those that have become the gold standard in biomedicine. Makassar, the provincial capital and largest city in South Sulawesi population 1. As youths migrate to such urban centres, they encounter consumer products and messages from around the world Nilan and Feixa ; Hansen Youth in Makassar have limited internet access; smart phones are generally too expensive for them while internet access remains slow and cumbersome. The most important health resources for Makassar's youth are thus the omnipresent street corner apotek pharmacies , which sell a broad range of ostensibly prescription drugs without prescriptions, and information that circulates via word of mouth within youth networks. Poverty is the most significant factor influencing entry into the sex trade in contemporary Indonesia Hull, Jones, and Sulistyaningsih ; Ford and Lyons Indonesian social and moral codes require that children, particularly female children, financially support their families Ford and Lyons ; earnings from sex work allow women and men from poor backgrounds to fulfil their social obligation of supporting their parents, siblings, or children until they are themselves married. The informants were all aged between 18 and Most had finished high school. The research in Makassar was part of the larger ChemicalYouth project, which examines the pervasive use of chemicals by youths in France, the Netherlands, the Philippines and Indonesia. The fieldwork in Makassar was conducted in two phases. The findings of this initial grand tour have been published elsewhere Hardon, Idrus, and Hymans In these interviews youths were asked which chemicals they applied to their hair, eyes, face, lips, teeth, and so on, over their entire bodies, ending with their toenails. In individual and group interviews, more general themes were also pursued such as their future aspirations. The interviews took place in cafes, bars, and other places where youths regularly met, depending on where they felt most comfortable talking about their use of chemicals. Sex workers, however, were not the only ones who admitted to the off-label use of Somadril. Students, waiters, waitresses and shop attendants reported taking Somadril to help them socialize and to increase their libido. But as it made them feel dizzy and drunk, a condition hardly conducive for them to study or work, they took only one or two and at most three pills a day. The intravenous drug users who were interviewed made frequent mention of Somadril, but for them it was a second-choice drug; they preferred Calmlet a drug containing the tranquilizer alprazolam and Suboxone containing the heroin-replacement drug buprenorphine. And while the transgendered informants also often mentioned Somadril, they were clearly much more interested in hormones to transform their physical bodies. The second phase of the project involved focused ethnographies of chemical practices that emerged as central in the everyday lives of specific subgroups of youth, including the use of Somadril by sex workers and the use of contraceptive hormones by transgender youths. The focused ethnographies involved participant observation in the sites where the interlocutors work and socialize, focus group discussions, and feedback and validation sessions. The informants work freelance and live in a nocturnal peer group that shares everything, helping each other gain customers and sharing in the proceeds. If one has a customer, they use the proceeds to buy Somadril for all. It is recommended in the Indonesian Informasi Specialite Obat ISO Indonesia pharmaceutical compendium for lower back pain, muscle spasms, tension headache, painful menstruation, and other ailments such as chronic arthritis. The active component of Somadril sold under the Soma brand in the USA is carisoprodol, which entered the global market as a muscle relaxant more than 50 years ago. Developed by Wallace Laboratories, Soma was thought to have superior muscle relaxing properties and less potential for abuse than Milltown containing meprobamate , the drug it replaced Berger et al. The s and s witnessed growing concern over the abuse of Soma in the USA, with clinical researchers reporting withdrawal symptoms such as insomnia, vomiting, tremors, muscle twitching, anxiety and hallucinations among patients who ceased taking it SAMHSA ; DEA This eventually led to carisoprodol being listed as a Class IV drug i. In Europe, evidence on the abuse potential of carisoprodol has led to its withdrawal from the market EMEA They repeatedly stated that it made them feel pede confident , enak delicious, a term used for food but also for sex and senang happy. The informants at Losari Beach used different techniques to enhance the effects of Somadril. Some chewed the pills; others took them with Sprite a soft drink commonly used as a solvent for drugs in Indonesia. Some mixed Somadril with whisky or vodka. Reflecting underlying hot-cold notions of chemical efficacy, the informants told the authors they buy pedas hot food, which makes them sweat and which enhances the high. They also wore warm jackets and avoided cold drinks and the wind, which they said weakened Somadril's effects. In discussions, the informants routinely pointed to differences in how their peers used the drug and the effects they experienced. These recalls revealed that their consumption of Somadril often far exceeded the recommended maximum dosage of four pills mg of carisoprodol per day ISO Indonesia It was noticed that men who took higher dosages of Somadril reported more side-effects and more often nausea and vomiting than women, who more often complained about feeling dizzy. All but one of the informants reported suffering on days when they did not take Somadril. But both Dextro and LL are not very strong, according to the informants. Over time, the authors came to realize that the lion's share of the informants' income was going to support their Somadril habit. The authors wondered whether the drug facilitated the work of their informants, or whether they were now working to buy Somadril. For most of them, it seemed more important than food; indeed many of them admitted to being addicted. Bodily presentation thus appears more important than sexual acts in asserting femininity Boellstorff Lacking access to sex reversal surgery — for those who may have wanted it — they resorted to the off-label use of contraceptive hormones both pills and injections , the most important chemicals in their daily lives. Dress, voice and how they walk are significant aspects of their desired femininity, as is having well-formed breasts. To attain this latter goal, the informants used high dosages of hormonal contraceptive pills and injections. They proudly showed the authors their breasts, squeezing them and asking the authors to do so too to show that they contain batu hard tissue. Hard tissue in the breasts, they explained, is a prerequisite for breasts to grow and an assurance that if the dosage of hormones is lowered, the breasts will not disappear. But hard tissue alone is not enough. The hormones also need to form a dasar base for the breasts to make sure that they will grow in the right place. To grow breasts in the right place with hard tissue inside, the waria informants in their self-treatment experimented with hormonal combinations that are cocok compatible with their individual bodies. All the respondents had long stories to tell about how they tried different brands of contraceptive pills and injections to see if they were cocok for them. Twenty-two-year-old Mince described how she switched from Andalan pills to Cyclofem injections and then to Marvelon pills. Andalan made her feel dizzy, sick and lazy. She gained weight and therefore felt less attractive as a sex worker. She switched to the contraceptive injection Cyclofem, taking one shot in each arm every week, which worked very well. Her breasts were beautiful; she had thinner muscles and a sexy behind. Having formed her breasts, she switched back to contraceptive pills, this time Marvelon, which she says causes muscular pain. But the pains are tolerable, she says, because they do not interfere with her appearance. This combination had been advised to one of them by a private doctor in Surabaya, Indonesia's second largest city. All three were very pleased with the results. They stressed that the place of the injections was very important. If you did not inject in the upper arms, you would not get a dasar in the right place. A fourth informant, whose mother had warned her of the dangers, had stopped taking hormones altogether. A fifth informant, who runs her own beauty salon, recommended going to Surabaya for silicone injections. She had done so two years ago when she was sick and tired of the side-effects of hormones. She proudly showed the authors her remarkably well-formed breasts. Waria not only take hormones to fulfil their gender-bending desires; they also want to transform their bodies to increase their earning capacity. The informants often referred to the sexual desires of their customers when discussing the effects and side-effects of their drug use. For example, they experimented with different hormone dosages to maintain their capacity to penetrate their clients. While they share their experiential knowledge on the effects of various self-treatments, they do not pool their resources to sustain their chemical use. When asked about the longer-term effects of their practices and their future aspirations, many admitted they were worried. One informant, who had recently shifted to injections, told about a friend who had died because her body could not absorb the heavy dose of contraceptive pills. Another stressed that the hormones can cause breast cancer; a third said she had heard pills can affect your heart. Although the informant with silicone breasts was not worried about any longer-term effects, others refrained from using silicone as they had heard it can spread in the body causing damage. How will they bury us? Outreach workers had warned them about the risks of contracting HIV, providing them with condoms and advising them to get tested at the local community health centre. Their use of condoms, however, remained haphazard. Many clients want sex without condoms, while the informants, high on Somadril, often forget to use them. These fieldwork vignettes reveal the creativity of young male, female and transgender sex workers in trying out — referred to as coba — adjusting dosages and mixing substances to achieve their desired bodily and mental states. The sex workers at Losari Beach ingest high doses of Somadril to become confident and happy, mixing it with drinks, pills and hot food to enhance their combined effects. The leading concern of the transgender waria is to grow breasts — both to fulfil their gender-bending desires and to attract male customers. They first try to generate hard tissue and create a base for their breasts with relatively high levels of injectable hormones, after which they switch to maintenance therapy with lower dosages of pills. The waria informants suffered a range of side-effects from taking high dosages of hormones. But each time they lowered the dosage, their breasts shrank again. The sex workers at Losari Beach suffered headaches and pains when they could not afford Somadril in large quantities. As both groups earn their livings by providing sexual services, side-effects that interfere with their capacity to earn are avoided. For the sex workers at Losari Beach, this means that they avoid other psycho-active drugs that blur their vision or make them lose control. They tolerate the sickness that comes with taking too much Somadril because they value the confidence and sexual pleasure that the drug provides. The waria seek to avoid side-effects that make them less attractive to their male customers, such as pimples and gaining too much weight, while tolerating others such as nausea that do not affect their capacity to earn a living. They do so, she argues, because something potent resides in the drug, something that makes them not want to think about harm. The authors indeed found their interlocutors to be well aware of the side effects of drugs. The informants sought to optimize their good effects and minimize their bad ones by experimenting with different dosages, with different forms of administration injecting or swallowing, with or without food and with different drug combinations. The relational notion of cocok — compatibility — was a term that came up time and time again when youths described their experiences with drugs. If side-effects occurred, the substance and its form of administration were said to be not cocok. Both in individual interviews and informal group discussions, the informants generally talked about the effects of drugs and their practices of self-medication with enthusiasm. But over time, the authors came to hear more about their concerns. They talked of friends who had died due to overdoses and reflected on their own lives. None expected to live long. This was part and parcel of the economic reality of their lives: the feeling that they were trapped, that they needed to use drugs to earn a living, was pervasive. How did the sex workers at Losari Beach — who do not have access to the internet where information on the off-label use of Somadril circulates — find out that this unadvertised drug for muscle pain makes them happy and confident? How did the waria learn that they first need to form hard tissue with injectable hormones before they can lower the dosage and take pills as maintenance therapy? In the focus group discussions where the authors asked about the lived effects of drugs, youths invariably referred to the experiences of their peers — a veritable storehouse of experiential knowledge. Indeed, youths primarily learned about the beneficial effects of drugs through word of mouth dari mulut ke mulut. This informal circulation of knowledge reflects the off-label use of these substances. While the drugs are not illegal, the interlocutors were well aware that they officially need prescriptions to obtain them. They were reluctant to give the authors information on the sources of drugs, and the authors did not push them to do so. But as their trust was won over time, many informants mentioned friends who work as pharmacists and pharmacy clerks as their sources. All knew about the several apotek that seem to specialize in selling psycho-active prescription drugs over the counter, apparently without repercussions. Although the sex workers at Losari Beach do not fall within this group, they learn about the latest trends in mood-modification from their more experienced boy friends. The private doctor in Surabaya, referred to above, prescribed the now-popular cocktail of two shots of Cyclofem weekly and two pills of Marvelon daily. The cocktail's beneficial effects, as observed by one of the informants, led others to try out the same regime, and with excellent results. Waria do not need prescriptions to obtain contraceptives. They simply ask for them at the pharmacy and seek a friend who can inject the drugs. What role did pharmacists play in the off-label use of pharmaceuticals by the interlocutors? The reality in Makassar is that most pharmacies are run by assistants, who simply sell the drugs. They do not see it as their role to educate customers. Somadril, for which there is a high demand in the evening and at night, has become a street drug. The informants have the telephone numbers of dealers who they can call when in need of the product. They explained that some of the street vendors sell counterfeit Somadril. The interlocutors check for authenticity of the product by bending the aluminium foil of the strip. If it is stiff, the strip of pills is probably fake. These observations show that knowledge on the use of drugs and the drugs themselves travels across the boundaries of formal and informal sectors in unexpected ways cf. Lovell ; Sanabria and Benguigui ; Wentzell Doctors sell prescriptions for the off-label use of drugs; midwives give advice to transgender persons on how to use contraceptives to grow breasts. Whereas doctors and regulators in Europe and the US are well aware of the serious adverse effects of Somadril, this knowledge has apparently not reached the pharmacy assistants who sell Somadril in Makassar. And while the contraceptive pills used by the waria interlocutors were accompanied by package inserts, these were seen to be directed at women. Instead, the informants learnt about the harmful effects of specific drugs through experimentation — that is, by experiencing for themselves and by exchanging notes with peers about what drugs do in and to their bodies. This method, while effective in revealing the immediate and common adverse effects of drugs, leaves much to be desired — most obviously concerning the longer-term effects of addictive substances. Such experimentation is not unique to the sex workers at Losari Beach and the waria at Karebosi. The ethnographic fieldwork in Makassar revealed similar patterns of experimentation among other groups of youths. Construction workers mixed energy drinks and potency products; hard-core drug users injected a veritable cocktail into their veins in search of new highs. Students were also found to use Somadril in all kinds of different mixtures, but only on weekends and mainly to enhance sexual pleasure Hardon, Idrus, and Hymans How does the accumulation of knowledge by youth through trial and error differ from knowledge production in biomedicine? There are five main differences: first, biomedical experiments have pre-defined endpoints. The group receiving the inert substance is called the control group Goldstein The endpoints are specific to their everyday needs and desires. The waria informants want to feminize their bodies; freelance sex workers need to be confident to approach clients. The youth-led experiments differ from biomedical research in how they apprehend a drug's adverse effects. Biomedical researchers a priori define adverse effects and then measure them in trials. Safety and efficacy data are submitted to regulatory agencies, which then weigh the drug's benefits and risks for market approval. It is well known in pharmacology that unexpected side-effects can occur once the drug is used in routine medical practice. In contrast, youths in this study appeared unconcerned about side-effects before trying a drug for the first time. They simply tried it and observed what happens. A fourth difference between how youth experiment with drugs and biomedical research pertains to how drugs are administered. Drugs in laboratory experiments are tested in isolation, in fixed dosages to allow for the standardized measurement of effects. Finally, in the biomedical measurement of drug effects, efficacy is situated in the drug's active pharmaceutical content — if substance A is proven to be effective in population B, it is assumed to work identically in population C as well. In assessing the positive and negative effects of substances in their bodies, youths in this study time and again made use of the relational notion of cocok. A comparable personification of efficacy can be seen in the biomedical discipline of pharmaco-genomics, which shows how drug effects vary depending on individual genetic makeup. Such knowledge, however, still has no place in standard clinical experiments on new drugs which are generally funded by pharmaceutical companies; too much diversity would limit the market for specific drugs. This comparison of how youths in this study and biomedicine generate knowledge suggests that youth — in Makassar, and most likely in many other places — do not subject themselves to biomedical understandings of their bodies, as has been suggested by influential scholars such as Rose and Dumit They develop their own understandings of drug efficacy through practice — by trying out drugs, mixing them with food and drinks, and experimenting with dosage and administration — using the knowledge gained from these experiments in their quest to achieve their desired bodily and mental states. This ethnographic study has shown how pharmaceutical practices emerge out of and fuel social life. Experiential knowledge is generated through joint experimentation, by sharing knowledge and pooling resources to buy drugs. In this collective process, youths seek what works best for their individual bodies and minds — they try out and mix products until they have achieved their cocok. The authors thank the interlocutors for the stories they shared. The authors hope that the interlocutors feel they also gained from the dialogues. The authors are indebted to Takeo David Hymans for his rigorous editing and his refusal to accept vague concepts. Ethics approval was received from the ethics committee of the University of Amsterdam Faculty for Social and Behavioural Studies. To ensure anonymity all identifying information names, birthdates, etc. Fieldwork conducted in the summer of in Makassar was funded by the University of Amsterdam. More detailed ethnographic accounts of Somadril use by sex workers Hardon and Ihsan n. The analysis here shows that youths creatively appropriate medicines in their quest for better lives. As a library, NLM provides access to scientific literature. Anthropol Med. Find articles by Anita Hardon. Find articles by Nurul Ilmi Idrus. Email: a. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. 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Buy Cocaine Makassar
The term Narcotic in Indonesia refers to the abbreviation of Narcotics and. Dangerous Drugs. In addition, other terms are also known which in the medical world.
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This study investigated the relationship between the social environment and drug use among young men in slum areas (lorong) in Makassar, Indonesia.
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