Agency and exchange: an ethnography of a heroin marketplace

This thesis is concerned with the exchange of heroin in localised, street-based marketplaces. Commercial exchange of heroin in such sites has been a characteristic of the Australian heroin scene since the early 1990s. Although some qualitative investigations have been undertaken, the dominant approach to understanding these sites in Australia has been quantitative (primarily epidemiological and criminological). These efforts largely adopt a narrow and under-developed conception of 'markets' and much of this work adopts a narrow and circumscribed conception of the subjects who act within these sites. In contrast, this thesis is positioned within a long tradition of ethnographic accounts of drug users as active agents and of drug markets as embedded in particular social, cultural and economic contexts.In this thesis, I explore two related questions: 1) what are the social relations and processes constituting street-based drug markets, and 2) how do participants in these street-based drug markets express agency, given that, in public and research discourses, they are often understood and depicted either as lacking agency or as expressing agency only through profit-seeking, criminality or both. I explore these questions through an ethnographic examination of the everyday lives of Vietnamese heroin user/dealers who participate in a local heroin marketplace in the Melbourne suburb of Footscray. The key analytical concerns are the social relations through which this particular market is constituted, the social and cultural processes of exchange through which the market is produced and reproduced, and the ways in which participants in the market express agency, including the ways in which their agency might be constrained.My ethnography of the Footscray drug marketplace reveals that the marketplace is constituted by complex and dynamic social processes and relations. With a focus on drug user/dealers, my analysis condenses to two major themes - those of agency and exchange. Throughout the thesis, I show how, and in what ways, drug marketplace participants act on the world, achieve diverse outcomes (intended or otherwise, constrained or not) and, thus, express their agency. I also demonstrate the complexities of heroin exchange in the marketplace, revealing that heroin is exchanged in multiple ways (e.g. through trade, barter and gifts) for multiple purposes and according to multiple and fluid classifications of social relationships. My account shows the embeddedness of the Footscray drug marketplace - that it is shaped by its particular historical, social, cultural, political and economic context. I show also how market processes - such as exchange - are shaped by culturally patterned ideas about what is right, wrong and even conceivable. This thesis also problematises dominant constructions of drug user subjectivity. Such conceptions have ethical and political implications with regard to the ways in which drug users are understood, judged, regulated and governed. My analysis suggests that the subjectivity of Footscray dealers is ambiguous, contradictory and multiple, constituted not simply by instrumental rationality but by a complex of motivations and by the cultural and social formations which shape these motivations.This thesis provides an alternative to the dominant approaches to understanding Australian drug markets and marketplaces. Accounts of drug markets tend to privilege an etic view that is theoretically underpinned by neo-classical economic models of markets. Additionally, the quantitative methodological approaches that predominate in Australian drug market research tend to preclude considerations of process and temporality. In contrast, in this thesis I privilege an emic account of the drug marketplace. Influenced by theoretical frameworks drawn from anthropology, in my examination of the everyday lives of drug user/dealers, I stress the importance of the social, political and cultural dimensions of these people's lives and direct attention to the importance and creativity of personal agency.Drug users and dealers are widely stigmatised and demonised as 'other', juxtaposed against supposedly 'normal' non-drug users. Dominant representations of drug users are unidimensional and do not capture the complexity of drug user agency and subjectivity. This thesis demonstrates that the people who sell heroin in the Footscray marketplace actively engage in a range of exchanges, for a range of purposes - subsistence, the creation of identity, the pursuit of prestige, reciprocity, sociality, the production and reproduction of social relations, and profit-making. My account, therefore, repositions drug users, challenging their stigmatisation by revealing that, in their everyday lives, they struggle with many of the same challenges that confront us all

Grievable lives? Death by opioid overdose in Australian newspaper coverage

Opioid overdose deaths are increasing in Australia and around the world. Despite this, measures aimed at reducing these deaths such as safe injecting facilities and take-home naloxone continue to face obstacles to uptake. The reasons for this are manifold, but a key contributor is public discourse on opioid consumption and overdose. In this article we explore this public discourse using Judith Butler's work on ‘grievable lives’. The article analyses mainstream newspaper coverage of opioid overdose in Australia to map key articulations of overdose and to consider how public understandings of overdose are shaped. It then goes on to consider ways these understandings might be reshaped, looking at what have been called overdose ‘anti-memorials’ and a new website Livesofsubstance.org. In concluding we argue that until the lives of opioid consumers come to be considered grievable, the measures known to reduce overdose deaths may struggle to find public support

Public injecting and public amenity in an inner-city suburb of Melbourne, Australia

Background: Public drug markets and injecting impose significant burden on individuals and the community. This study aimed to document public injecting and amenity in North Richmond, an inner-city suburb of Melbourne, Australia. Methods: A rapid assessment methodology was employed. Data comprised: secondary data on drug use indicators, structured observations and interviews with key stakeholders. Primary data were collected from May to October 2012. Quantitative data are summarised using descriptive statistics. Basic content analysis was performed on interview transcripts. Results: An average of 1843 needle–syringes (NS) were collected per month from syringe disposal bins and street-sweeps in the period January–December 2012. Discarded NS and other injecting paraphernalia were observed in a variety of locations. Stakeholder interviews indicated substantial concerns over the presence of NS and witnessing injecting and overdose. Discussion: Public injecting is widespread, frequent, and highly visible in North Richmond and has a substantial negative effect on public amenity. The research identified two main priorities: (1) enhance access to harm reduction services and materials; and (2) improve public amenity. Among other responses, the study findings support the introduction of a supervised injecting facility (SIF) as a viable component of a comprehensive harm reduction response to illicit drug use in this area

Measurement of Epstein-Barr virus DNA load using a novel quantification standard containing two EBV DNA targets and SYBR Green I dye

BACKGROUND Reactivation of Epstein-Barr virus (EBV) infection may cause serious, life-threatening complications in immunocompromised individuals. EBV DNA is often detected in EBV-associated disease states, with viral load believed to be a reflection of virus activity. Two separate real-time quantitative polymerase chain reaction (QPCR) assays using SYBR Green I dye and a single quantification standard containing two EBV genes, Epstein-Barr nuclear antigen-1 (EBNA-1) and BamHI fragment H rightward open reading frame-1 (BHRF-1), were developed to detect and measure absolute EBV DNA load in patients with various EBV-associated diseases. EBV DNA loads and viral capsid antigen (VCA) IgG antibody titres were also quantified on a population sample. RESULTS EBV DNA was measurable in ethylenediaminetetraacetic acid (EDTA) whole blood, peripheral blood mononuclear cells (PBMCs), plasma and cerebrospinal fluid (CSF) samples. EBV DNA loads were detectable from 8.0 × 10² to 1.3 × 10⁸ copies/ml in post-transplant lymphoproliferative disease (n = 5), 1.5 × 10³ to 2.0 × 10⁵ copies/ml in infectious mononucleosis (n = 7), 7.5 × 10⁴ to 1.1 × 10⁵ copies/ml in EBV-associated haemophagocytic syndrome (n = 1), 2.0 × 10² to 5.6 × 10³ copies/ml in HIV-infected patients (n = 12), and 2.0 × 10² to 9.1 × 10⁴ copies/ml in the population sample (n = 218). EBNA-1 and BHRF-1 DNA were detected in 11.0% and 21.6% of the population sample respectively. There was a modest correlation between VCA IgG antibody titre and BHRF-1 DNA load (rho = 0.13, p = 0.05) but not EBNA-1 DNA load (rho = 0.11, p = 0.11). CONCLUSION Two sensitive and specific real-time PCR assays using SYBR Green I dye and a single quantification standard containing two EBV DNA targets, were developed for the detection and measurement of EBV DNA load in a variety of clinical samples. These assays have application in the investigation of EBV-related illnesses in immunocompromised individuals.The Ausimmune Study is funded by the National Multiple Sclerosis Society of the USA, the National Health & Medical Research Council (Project Grant 316901) and Multiple Sclerosis Research Australia

Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis

We aim to quantitatively synthesise available epidemiological evidence on the prevalence rates of workplace violence (WPV) by patients and visitors against healthcare workers. We systematically searched PubMed, Embase and Web of Science from their inception to October 2018, as well as the reference lists of all included studies. Two authors independently assessed studies for inclusion. Data were double-extracted and discrepancies were resolved by discussion. The overall percentage of healthcare worker encounters resulting in the experience of WPV was estimated using random-effects meta-analysis. The heterogeneity was assessed using the I2 statistic. Differences by study-level characteristics were estimated using subgroup analysis and meta-regression. We included 253 eligible studies (with a total of 331 544 participants). Of these participants, 61.9% (95% CI 56.1% to 67.6%) reported exposure to any form of WPV, 42.5% (95% CI 38.9% to 46.0%) reported exposure to non-physical violence, and 24.4% (95% CI 22.4% to 26.4%) reported experiencing physical violence in the past year. Verbal abuse (57.6%; 95% CI 51.8% to 63.4%) was the most common form of non-physical violence, followed by threats (33.2%; 95% CI 27.5% to 38.9%) and sexual harassment (12.4%; 95% CI 10.6% to 14.2%). The proportion of WPV exposure differed greatly across countries, study location, practice settings, work schedules and occupation. In this systematic review, the prevalence of WPV against healthcare workers is high, especially in Asian and North American countries, psychiatric and emergency department settings, and among nurses and physicians. There is a need for governments, policymakers and health institutions to take actions to address WPV towards healthcare professionals globally

How prepared are pharmacists to provide over-the-counter naloxone? The role of previous education and new training opportunities

and Aims: Opioid overdose can be reversed with timely administration of naloxone. In Australia, naloxone was rescheduled from prescription only (S4) to pharmacist only over-the-counter (OTC, S3) in February 2016, increasing access for the general public. A key barrier to naloxone supply by pharmacists is a lack of knowledge, highlighting the role of pharmacist education. Community pharmacists' education, experience, and training preferences related to naloxone provision, overdose, and substance use disorder were examined.Online survey data from a national sample of Australian pharmacists on their educational preferences regarding naloxone and overdose prevention, and prior training on substance use disorder (n = 595) was analyzed using bivariate and multivariate regression analysis. Data from qualitative semi-structured telephone interviews with pharmacists about OTC naloxone provision (n = 21) was analyzed using thematic analysis.Most pharmacists (81%, n = 479) were willing to be trained in opioid overdose prevention, with greater willingness to attend training associated with younger age, being female, fewer years of practice, not having attended previous education on substance use disorder, and higher confidence in issues relating to substance use disorder. Qualitative interviews confirmed community pharmacists' willingness to attend training but analysis revealed low awareness, knowledge, and confidence about naloxone and preventing opioid overdose. Most pharmacists preferred online training or webinars.Most community pharmacists in Australia are willing to attend training on providing naloxone and preventing opioid overdose. There are opportunities to develop and expand the online presence of training, guidelines, and education materials to facilitate the expanded supply of OTC naloxone

Benefits and barriers to expanding the availability of take-home naloxone in Australia: A qualitative interview study with service providers

Aims: To investigate the perspectives and experiences of service providers regarding provision of take-home naloxone to people who use opioids in Victoria, Australia. Methods: Content analysis of qualitative semi-structured interviews with 15 service providers who are either involved with take-home naloxone programs or whose work brings them in contact with people who use opioids. Findings: Statements about take-home naloxone were universally positive. Both direct and indirect benefits of take-home naloxone were described. Alongside potential reductions in opioid overdose-related harms, service providers highlighted the empowering effects of providing people who use opioids with take-home naloxone. No significant risks were described. Service providers supported the expansion of naloxone availability, but also identified several intertwined barriers to doing so. Key among these were costs, current regulations and scheduling, availability of prescribers and stigma related to illicit and injecting drug use. Conclusions: Expanding the availability of naloxone is a key component of strategies to reduce harms associated with opioid overdose. Our article provides Australian evidence of the successful operational implementation of peer-to-peer THN delivery within a range of drug primary health services and needle syringe programs. Further research is required to better understand the implications of and impediments to scale-up of this potentially life-saving public health intervention