Most of the interviewees (n = 36) were male (see Table ). The average age of interviewees was 28.1 years old (range 15–51 years). All interviewees had used heroin within the past week and most reported that their main 'drug of choice' was heroin. Over half (53%) of interviewees were not currently in treatment and 30% were in methadone maintenance treatment (MMT).
Overdose experiences and prevention
Over half of the 60 interviewees (n = 35, 58%) report having previously overdosed, with an average of 4 (SD = 3.79) previous overdoses. Thirty two percent (n = 19) of interviewees reported doing nothing to prevent overdose.
BBV experience and risk behaviours
Interviewee behaviour regarding testing and risk behaviour around BBVs can be seen as possible indicators of the behaviours are able to engage in if they are not ambivalent towards their own fate, as well as a measure of the harm they have already experienced. A substantial proportion of interviewees were unaware of their HIV or HCV serostatus (13% and 10% respectively). Over half (54%, n = 32) were HCV positive and none were HIV positive. Around one in five of the interviewees in this study self-reported both ever borrowing someone else's needle (18%) and lending their needle to someone else (22%).
Attitudes towards Death
Two questions about death were asked. The first question asked the participant whether or not they ever talked about death with their peers. Most (84%, n = 50) reported that they never talked about death, although 3% (n = 2) reported that they often discussed death as a possible consequence of their heroin use. Interviewees were also asked how they felt about death and whether they were afraid of dying. The vast majority (82%, n = 49) stated that they were never afraid of dying, 12% (n = 7) said that they were afraid of dying from some causes other than heroin use (i.e. car accident) and 3% (n = 2) of the interviewees reported that they were often afraid of dying. Narrative responses showed that almost half of the interviewees (n = 28) were either indifferent or fatalistic about death.
Wayne, 51 yrs, Well, I surely don't want to die, but it doesn't make me not want to use. If it did I wouldn't use any more, because I've dropped a few times. It hasn't frightened me off enough. I know if I die, I'll just go to sleep any way, I just don't wake up.
Wayne's narrative provides an example where overdose death is perceived to be a comparatively pleasant experience. This attitude can be seen in its extreme form in the following narrative.
Casey, 15 yrs, I reckon that was the best feeling, overdosing. The best feeling ever. The first time I ever felt so stoned. It was just the best feeling ever. There was a time when I was apparently dead. It was grouse, I felt like a was asleep and I was just going through this full trippyness. It was the best feeling.
Casey's narrative holds a number of insights into both the motivation for risky heroin use, but also could be an example of the bravado expressed by a young person discussing a frightening experience. In the context of a research interview, and the complexities of such a social interaction, it is probable that both elements are at play. Ten interviewees also reported indifference towards both life and death.
Peter, 28 yrs, ...sometimes it gets too much. You're broke all the time. You haven't got a roof over your head or you haven't got money for food. You just get sick of the lifestyle. It's a real bugger because it's something you love but you get discriminated against. You know, the way people treat you, even your family. It [heroin overdose] would be a good way to go, better than cancer.
Peter's narrative points to many factors related to poverty and urban deprivation, in addition to dependence on heroin. Peter is also clear that the consequences he identifies are primarily social or societal in their origin, including a lack of accommodation, the lack of money or food, and more general discrimination, which are also mostly out of the control of the individual IDU. Such narratives suggest that poverty and urban deprivation play a role in IDUs attitude towards life, death and risk.
Another major theme to arise from the narratives (n = 8) was that death was an occupational hazard of heroin use.
Frank, 24 yrs, I think that people who use accept that as one of the risks. You just cop it on the chin.
Joe, 31 yrs, nearly every time, I know its Russian roulette. Sometimes pills. Also some speed, usually hammer first, then speed. Dropping is really an occupational hazard. When your number's up, your number's up. Why worry about it. It's just as likely that you'll have a good whack and then walk across the road and get hit by a truck.
Finally, not all interviewees exhibited the above-described attitudes towards death and three interviewees reported that they were not indifferent towards death and did their utmost to avoid death.
Bruce, 23 yrs, I mean, you talk about friends that have died and that, but I don't really have any sympathy for them. It sounds a bit harsh, but like I say, I've had a lot of friends that have died from one way or the other, you know, but if it's through the choices they made then that's their own business, you know what I mean. I don't want my daughter to know her whole life that her dad died a junkie.
David, 35 yrs, it is out of control in one sense but I don't break into houses or anything like that. The only control I have is to throw myself into an area where it's impossible to get heroin. The best I can do is one day without. There use an element of control I suppose, but it's not enough to break free. I don't want to die. Either that or fail heroicly.
Interviewees were also asked what they believed would be the worst consequence of experiencing an overdose. The interviewees were then read a list of four possible alternatives and asked to nominate one (death, brain damage, police involvement or being woken up). The order of consequences was randomly altered. Interviewees were also able to identify other consequences from which three more responses were identified (nothing, all and wasted money).
Whilst thirteen interviewees reported that death was the worst consequence of overdose, the majority (58%, n = 35) of interviewees identified brain damage as the worst possible consequence of an overdose. Other responses included 'Being woken up' (n = 5, 8.3%) and 'Police Involvement' (n = 3, 5.0%). Whilst this finding is similar to responses from non-IDU populations [39
], it does demonstrate that the majority of these interviewees clearly identified that there was something worse than death. For example:
Lisa, 25 yrs, I knew a guy who overdosed and ended up with brain damage and he ended up brain dead and they turned the machines off. That was pretty sad really. With my partner, I think about it: is it bad for him to be here brain-dead or with brain damage. I think I'd prefer them to die than have brain damage, but then it's the people that they leave behind. I think a lot of families go through a lot of shit. I mean, it's hard to say. Here I am saying "these families go through a lot of shit", but then I'll go and risk killing myself. For me in an overdose, I'd prefer to die, than have fucking brain damage.
The next most common response was 'being woken up'.
Damian, 29 yrs, Coming back with a fucking Narcan headache. That's worse than anything I've ever had. I'd definitely rather be dead than brain damaged. It's part of the game isn't it, guaranteed, you're born to die.
Debbie, 22 yrs, for me it was just waking up, that was the pits. For the person overdosing the worst consequence is waking up straight. If you've got people with you, you shouldn't get brain damage. All they're concerned about is the drugs and getting drugs and being stoned.