Although there are many similarities among older drug users who live in suburban environments and inner-city neighborhoods, here we focused on their differences in risk behaviors. These differences were related to their social context and their awareness of behaviors that increase their risk of contracting infectious diseases. The social context of the inner-city presented greater challenges for older drug users in terms of social violence and vulnerability to being incarcerated, which increased their risk for infectious diseases, but living in the city also provided drug users with greater awareness of risks and more access to harm reduction paraphernalia that were unavailable to suburban users. Both urban and suburban users who were incarcerated reported a lack of access to condoms while in jail or prison, but those who lived in the city reported more time incarcerated than those who lived in the suburbs.
Differences were also found regarding when and how users in the different environments became aware of the risks for communicable diseases. Suburban older users appeared to have been informed earlier in their lives regarding the transmission of communicable diseases, specifically those who attended college, whereas older drug users in the city learned later in their drug use trajectories about behaviors to prevent and reduce risk—for some too late. Regardless of when they learned about the risks of unsafe sexual and drug use practices, access to harm reduction paraphernalia was a problem.
The Urban Harm Reduction Center was the primary mode of obtaining clean syringes and other harm reduction paraphernalia (e.g., condoms, cotton, clean water) for urban users. In contrast, the majority of older drug users living in the suburbs relied on relatives or friends who had diabetes to supply clean syringes. Others learned how to ask for syringes in pharmacies without arousing suspicion. Few suburban users had heard of the Urban Harm Reduction Center, and if they did, they often lacked transportation to the city to use its services.
A significant risk behavior for both suburban and city older drug users was found among those who engaged in sex work or sex for drugs. Both urban and suburban users reported engaging in multiple sex relations for work, money, or drugs without using condoms. City drug users appeared to have more access to sexual clients and, therefore, more sexual partners.
While those who had insurance reported no problems accessing healthcare, the majority of older drug users we interviewed did not have health insurance. Those who had Medicaid could obtain free or reduced-cost health services, but they needed to have access to medical facilities. City users could use public transportation to access healthcare clinics, and for emergencies many were given rides to clinics by staff from the Urban Harm Reduction Center and other non-profit organizations who were familiar with the health issues of drug users. Suburban users without a car were more isolated, and many reported a dire lack of public healthcare due to transportation issues. Moreover, they reported that few suburban healthcare workers were aware of the specific issues associated with injection drug use, and harm reduction strategies were rarely discussed with suburban healthcare staff.
Limitations and Future Research
The major limitation of this study is that it is not representative of all older drug users. As an exploratory qualitative study, a probability sample was not required. The goal was to gain a better understanding of older drug users' risk behaviors, specifically a comparison of those living in the city and those in the suburbs, and for this aim a small sample was sufficient. The themes and implications proposed here need to be further examined and verified in future studies with larger samples.