‘It’s more about the heroin’: injection drug users’
response to an overdose warning campaign in a
Thomas Kerr1,2, Will Small1,3, Elaine Hyshka1,4, Lisa Maher5& Kate Shannon1,2
British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada,1Department of Medicine, University of British Columbia, Vancouver, BC, Canada,2
Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada,3Addiction and Mental Health Research Lab, School of Public Health, University of
Alberta, Edmonton, AB, Canada4and The Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical Research), University of New South
Wales, Sydney, NSW, Australia5
regarding high-potency heroin and increases in fatal overdoses. Design
Vancouver, Canada. Participants
view guide focussing on heroin injectors’ perceptions of and responses to the overdose warning, including reasons for
failing to adhere to risk reduction recommendations. Findings
warning, their recollections of the message and the timing of its release were obscured by on-going social interactions
within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin
economic and structural forces that interacted with individual behaviour and undermined efforts to promote behav-
ioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available
heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering,
withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also under-
mined risk reduction messages. Conclusions
Among heroin injectors in British Columbia, a 2011 overdose warning
campaign appeared to be of limited effectiveness and also produced unintended negative consequences that
exacerbated overdose risk.
To assess heroin injectors’ perceptions of and responses to a warning issued by public health officials
Semi-structured qualitative interviews.
Semi-structured inter-Eighteen active heroin injectors. Measurements
Although nearly all participants were aware of the
Heroin, injection drug use, overdose, public health warning.
Correspondence to: Thomas Kerr, British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6.
Submitted 13 September 2012; initial review completed 20 November 2012; final version accepted 7 February 2013
The health sequelae of heroin use are severe, and include
fatal and non-fatal overdose . In most settings, the
primary public health response to heroin overdose has
been individually-focussed interventions that seek to
educate drug users about risks for overdose and promote
changes in behaviour . This over-reliance on
individually-focussed interventions persists despite the
known limitations of these approaches and growing
awareness that drug-related harm is shaped by an array
of physical, social and structural forces operating within
the broader risk environment surrounding drug use
One commonly applied, but understudied, overdose
prevention intervention involves issuing warnings to
drug users about adulterated or potent heroin, or
increases in fatal overdose [5–7]. Although many
municipalities issue overdose warnings, we know of only
one in-depth qualitative evaluation of this form of
intervention. Miller studied injection drug user (IDU)
responses to media stories about increases in heroin over-
60 IDU interviewed had communicated messages con-
tained in the stories to their peers, and that none had
changed their injecting practices or reduced the amount
ity of IDU reported actively seeking out the strong heroin
© 2013 Society for the Study of Addiction
described in the stories, leading Miller to conclude that
‘media reporting of killer batches of heroin has little
value as a public health strategy’. This latter finding is
also consistent with a quantitative study by Freeman
et al. , which found that 21% of drug users in New
Jersey, USA, had sought out fentanyl despite warnings of
a spike in overdoses associated with use of the drug.
Vancouver, Canada, has long been home to dual epi-
demics of heroin injection and heroin-related overdose
. In May 2011, local health authorities issued a
warning that there had been a recent increase in heroin-
related overdoses in Vancouver associated with ‘higher
Columbia [10,11]. As indicated in Fig. 1, local IDU
were encouraged not to use drugs alone, to call 911
and to use local services, including the supervised
We undertook a qualitative evaluation of this over-
dose warning initiative to examine IDU’s awareness of
the warning, their reactions to it and the impact of con-
textual factors on overdose prevention behaviours. In
doing so, we have endeavoured to complement and build
upon past work on this topic by exploring the reasons
why some IDU ignore such warnings and fail to modify
their drug use behaviour, as well as why many seek out
potent heroin despite the risks this may pose.
In May 2011, 2 weeks after the overdose warning was
issued, we conducted 18 in-depth qualitative interviews
over a 10-day period with regular heroin injectors
recruited from Vancouver’s Downtown Eastside—a
neighbourhood characterised by a large open drug and
sex-work scene, a network of single-room occupancy
hotels, and longstanding epidemics of HIV infection
and fatal overdose . A research assistant, who was a
member of the Vancouver Area Network of Drug Users,
approached IDU known to be regular heroin injectors.
Efforts were made to ensure adequate representation of
lished behaviours, we sought to recruit experienced,
rather than novice, heroin injectors.
Potential participants were invited to visit the study
Figure 1 The overdose warning flyer cir-
culated by the British Columbia Coroners
Service in May 2011
Thomas Kerr et al.
© 2013 Society for the Study of Addiction
they provided written informed consent to participate in
the study. Details concerning the age, gender and length
of injecting were self-reported by participants and are
presented in the following. A semi-structured interview
guide was used to facilitate discussion of the overdose
warning, including behavioural responses and the
impact of contextual factors on overdose prevention
behaviours. The guide was adapted from previous quali-
tative work on overdose among IDU in Vancouver ,
and was modified to include a number of questions and
related prompts specific to the objectives of our study.
After the first two interviews, the interview team met to
discuss ways of improving upon the existing guide,
although no changes were deemed necessary. After 16
interviews, no new information was forthcoming.There-
data saturation had been reached. Interviews lasted
30–80 minutes, were audio-recorded and transcribed
verbatim. There were no refusals to participate and no
dropouts during the interview process. All participants
received a CA$20 honorarium. The study received
institutional ethical approval from the Providence
Health Care/University of British Columbia Research
Our analysis was informed by Rhodes’ Risk Environ-
ment framework [4,13,14], which posits that drug-
related harm is shaped by forces operating within the
physical, social, political and economic environments.
Analysis began early in the data collection process and
continued as interviews were completed. Emergent
thematic analyses of early interviews were discussed
among the three interviewers (TK, WS and EH) and
served to inform the focus of subsequent interviews, as
well as ongoing analyses. The coding framework
employed a priori codes derived from the topics used
to structure the interview guide, as well as emergent
codes based upon the content of the transcripts. All
interview data were reviewed, and text segments related
to each individual code were categorised/classified. Sub-
sequent coding passes (i.e. continued efforts to apply our
coding framework) were used to refine and expand
code categories, and to identify instances of negative
The 18 individuals participating in qualitative interviews
included 8 female and 10 male IDU. The median age of
participants was 45 years (range: 26–60 years), the
median length of injecting career was 21 years, and all
participants confirmed that they were regular heroin
injectors upon recruitment.
Awareness and timing
Although many of participants were aware of the over-
dose warning that had been issued 2 weeks prior to the
2 days, while others reported hearing about it weeks or
The disparity in responses regarding the timing of the
warning appeared to reflect ongoing discussions among
social interactions focussed on the quality of the heroin:
[What were people saying?] That there was some
strong heroin. But there’s always, there’s always
messages going around. (Respondent #7: male, age
46, injecting for approximately 20 years)
When asked to describe the warning, many participants
noted that discussions on the street among IDU were
focussed first and foremost on heroin quality and not the
recent rise in overdose deaths:
I mean, there’s not really a lot to discuss, you know.
Whether if it’s good [heroin] or not, you know? . . .
It’s more about the heroin. (Respondent #2: male,
age 44, injecting for over 20 years)
Other participants pointed out that dealers were con-
stantly telling IDU that the heroin they were selling was
particularly strong. This ‘selling tactic’ was said to be so
pervasive that most IDU simply ignored it:
[P]eople say “That’s really good stuff, be careful.” So
many people say that so you’ll buy it. That, that’s
bullshit. Nobody even listens to that any more.
(Respondent #9: female, age 43, injecting for
approximately 20 years)
The Reaction: People don’t go “warning, warning”.
They go “good dope!” (Respondent #11: male, age 48,
injecting for approximately 30 years)
Given the variable quality of heroin and the need to
avoid opiate withdrawal on a daily basis in the context of
long-term dependency, some participants welcomed the
news that strong heroin was available. These factors
appeared to contribute to IDU’s desire to seek the potent
heroin described in the warning:
It would probably make me think . . . I do a point [a
tenth of a gram, 0.1 g] now, and I barely feel it so
yeah . . . maybe I will look for this stuff . . . maybe it
will be better . . . you know, better high . . .
(Respondent #14: male, age 46, injecting for
© 2013 Society for the Study of Addiction
of street-based heroin injectors. Within a context where
scarce resources, engagement in high-risk income-
purchase of low-quality heroin may precipitate opiate
They’re glad that there’s something out there worth
buying.Yeah, you know how disappointed someone
is when they’re sick [experiencing opiate
withdrawal], they go out there, they spend their
hard-earned money on dope and they’re sick after
that? (Respondent #11: male, age 48, injecting for
approximately 30 years)
Nearly all participants noted that information about
suggested that many heroin users would actively and
repeatedly seek the strong heroin once aware of it:
I know a lot people that would turn around and go
from here to the . . . far reaches of the earth to try
and find it . . . the better it is the less that they do,
but the better it is the more they want it.
(Respondent #4: male, age 39, injecting for 23
Injecting Routines: “I just pretty much do like I do every
day” (Respondent 12: female, age 43, injecting for
Although the warning contained specific messages
about various strategies to minimise risks (e.g. don’t
inject alone, etc.), nearly all participants reported that
they injected heroin according to established routines.
Many also offered the view that this was the case for
others as well:
A lot of times they just, they just fix like it’s their
usual, you know what I mean, like as if it was the
usual hit they did. A lot of people they don’t . . . take
precautions. (Respondent #14: male, age 46,
injecting for 32 years)
Some noted that these routines have been established for
years and are not particularly amenable to change:
[O]nce they get into a routine and they get used to
the routine that they do, they do it every day for
years and years on end. They won’t, it won’t change
the way they do it. (Respondent #4: male, age 39,
injecting for 23 years)
Invincibility: “Yeah, there’s no nervousness . . . it does
not bother me.” (Respondent #2: male, age 44, injecting
for over 20 years)
As indicated above, several individuals reported that
while they actively sought the potent heroin, they did not
alter their injecting behaviour in accordance with over-
dose risk reduction messages. Within the accounts of
these participants was a narrative about a lack of fear
and a sense of invincibility:
[People are a little bit sceptical about the warning?]
Yeah. [And why do you think that is?] I don’t know,
they think they’re invincible I guess . . . they think
they can handle it. (Respondent #1: female, age 44,
injecting for 15 years)
Some participants reported that continued survival and
the relative infrequency of severe overdose events in the
face of ongoing injecting rendered fatal overdose an
unlikely and remote risk to many IDU:
A lot of these people have been doing this for years
and if one day they say “well, now the heroin is
supposed to be strong . . .You do a point [a tenth of
a gram] and you might just drop to your knees and
that’ll be the end of it”. A lot of the times that never
happens . . . [I]n five years I’ve been injecting, I think
it happened once that I did a little bit too much and
not that I was dying but I was kind of on a nod . . .
You figure well, if it’s gonna happen, then what are
my chances, right? . . . So these people are probably
thinking, “Well you know, I’ve been shooting this
long for this many years and I’m still here today
. . .”(Respondent #12: female, age 43, injecting for
“Everyone wants to get high”: the desire for intense
accounts was the desire for intense heroin intoxication.
This desire was offered as an explanation for both the
eagerness to acquire strong heroin and the avoidance of
recommended overdose prevention strategies:
Sometimes they’re just pigs and they like to get that
nod. I know a fistful of people that that’s what their
goal is. (Respondent #15: female, age 42, injecting
for 15 years)
I hear from kids every day, right . . . they’re always
asking if it’s really strong and so you know that tells
you that . . . they’re looking for the ultimate high.
(Respondent #12: female, age 43, injecting for
Some individuals linked the desire for intense intoxica-
tion to the emotional suffering experienced by many
heroin users. For these individuals, accessing strong
Thomas Kerr et al.
© 2013 Society for the Study of Addiction
heroin was a means to escaping painful memories and
the everyday suffering experienced by IDU within the
local drug scene, and overdose risks are likely to be a
secondary consideration when seeking to get ‘out of it’:
[E]veryone wants to get high and they want to get
out of it. Like they want to get, as much as they can,
out of their life.You know everybody’s here to
escape reality. (Respondent #9: female, age 51,
injecting for 35 years)
Other barriers to the adoption of overdose prevention
strategies included the pervasive poverty experienced by
many IDU and the high cost of illegal drugs. Although
nearly all participants expressed awareness that it
was safer to inject with someone else, most said that
their heavy dependence and limited financial resources
meant they were unable to adhere to cultural norms
dictating that one should share their drugs when with
. . . people aren’t gonna sit there and watch you do a
hit without you sharing, ok? It’s really difficult to
watch someone get high and not use. (Respondent
#9: female, age 51, injecting for 35 years)
Opiate withdrawal was also said to serve as a barrier
to adopting overdose prevention strategies, including
recommendations to inject in smaller amounts:
When you’re sick, though, you just want to get it in
you. (Respondent #15: female, age 42, injecting for
Regular dealers as overdose prevention
Finally, a few participants stated that they did not need to
not perceive themselves to be at risk because they always
purchased heroin from the same source:
I only deal with two people for heroin, right, and I’ve
been dealing with them for so long I don’t deal with
anybody else. And that’s because they don’t . . .
screw around with their heroin the way everybody
else does. (Respondent #4: male, age 39, injecting
for 23 years)
This examination of an overdose warning initiative
revealed that although authorities were able to reach
many local IDU with messages about potent heroin, this
warning had limited impact in terms of mitigating over-
dose risks, as well as some unintended negative effects.
Consistent with the risk environment framework , a
diverse set of social, economic and structural forces
appeared to interact with individual perceptions and
behaviours to overwhelm the messages advocating risk
reduction contained in the warning.
Previous research has generated mixed results con-
cerning how quickly overdose warnings penetrate IDU
networks [6,8]. In the present study, while the overdose
warning reached nearly all of the participants inter-
viewed, perceptions of the warning and its content were
obscured by ongoing social interactions within the drug
scene that focussed on heroin quality. A growing body of
within drug scenes shape understandings of risk and
associated practices among IDU [4,15,16]. Although
many IDU in this study were talking about the warning,
these discussions focussed primarily on the quality of the
heroin that was available and where it could be pur-
chased, rather than the elevated risk of overdose it
presented. Further, common sales tactics of dealers pro-
to have led at least a small number of IDU to ignore
messages about overdose risks.
Consistent with the work of Miller and Freeman et al.
[6,8], many heroin injectors interviewed viewed the
arrival of potent heroin on the local scene as a positive
development, and many reported seeking and finding it.
However, unique to this study are findings that shed light
on why individual IDU seek potent heroin when they are
encouraged to avoid it, and why they do not employ risk
reduction recommendations promoted by public health
officials. Considered within the broader criminalised risk
environment and alongside the situated risk perceptions
of IDU, the opportunity to obtain potent heroin appeared
to outweigh concerns regarding overdose risks. Ethno-
graphic research suggests that IDU’s risk perceptions are
based upon socially and culturally situated knowledge
relation to other ‘everyday risks’ that characterise the
daily lives of injectors, including the potential for arrest
or incarceration, losing drugs to police, opiate with-
drawal and interpersonal violence [15,17].The opportu-
nity to acquire higher quality heroin could, therefore, be
construed as advantageous, as it mediates these other
competing forms of risk . The data presented herein
also suggest that efforts to acquire higher potency heroin
can also be understood as active responses to variations
in heroin availability, quality and price, which are deter-
mined largely by macro-level structural forces (e.g. poli-
Also unique to our study is the identification of a
number of individual-level factors that appear to shape
© 2013 Society for the Study of Addiction
responses to overdose warnings. For example, the
warning recommended reducing the risk of overdose by
altering individual behaviour, including avoiding inject-
ing alone. However, consistent with the work of Miller
, while some participants reported reductions in over-
dose risk behaviour, upon further questioning about
specific practices it became apparent that nearly all
respondents continued to inject heroin in the same way
as they had for years. As in the present study, previous
research has emphasised the importance of drug-using
routines and the meanings ascribed to such routines
[21,22], although this has not been studied widely in
relation to overdose risks. Efforts to alter risk behaviour
misunderstandingof thedruguseras‘capableof rational
decision-making and self-regulation in keeping with
risk-avoidance campaigns’ .
for intense intoxication.This desire was linked frequently
to emotional suffering and the desire to ‘escape reality’.
These findings further underscore a flawed assumption
underlying conventional overdose interventions ,
which assume that IDU will minimise risk at the expense
of a stronger ‘high’. While previous research has high-
ambivalence towards death , unique to our study
was the finding that, because of a perceived sense of
invincibility, some participants viewed fatal overdose as
something that would not happen to them.
reported efforts to manage their risk of overdose. Among
the strategies most commonly cited by this group was
buying drugs from the same dealer. It is important to
[14,23] and active responses to real contextual con-
straints . Although accessing heroin via the same
dealer was viewed by our participants as a way of man-
aging overdose risk, the effectiveness of this strategy is
unknown, and it is unlikely that street-level dealers
provide a consistent, unadulterated product, given the
complexity of supply chains and the unregulated nature
of illicit drug markets .
and interventions. Dietze et al. have urged caution when
implementing strategies focussed on individual overdose
risk behaviours , as these may produce unintended
negative effects. Indeed, they suggest that strategies
should focus on informing drug users about responses
that reduce the likelihood of fatal overdose. The findings
of the present study resonate with these suggestions.
Other authors working in our setting have called for the
implementation of elaborate overdose warning strategies
that include use of peer networks to disseminate such
warnings . However, given the findings presented here
and by others, the true value of such a system is unclear,
and, if implemented, it should be subjected to rigorous
evaluation. Also potentially problematic is the focus on
potent and adulterated heroin contained in such warn-
ings, as past evidence suggests that these factors may not
contribute greatly to heroin-related overdose [1,26].
Our findings also point to the need to address the
social, structural, economic and physical dimensions of
the broader risk environment that produce overdose risk.
Supervised injection facilities have been shown to be
effective in reducing overdose fatalities [12,27]. However,
these interventions tend to be limited by low coverage
resulting from limited opening hours, political con-
straints, and restrictive operating policies [28,29]. Other
approaches include creating low-threshold employment
opportunities as a means of addressing poverty and the
reliance on high-risk income-generating activities, such
as drug dealing and sex for drugs exchanges [30,31]
among IDU. Evidence concerning the positive impacts of
take-home naloxone for the reversal of opiate overdose is
increasing [32,33], and the potential of this approach
merits further implementation and evaluation. Lastly,
there is growing consensus that the criminalisation of
drug use has produced an array of unintended negative
consequences, including dramatically inflating the price
of drugs.Agrowingnumberof countriesareexperi-
menting with alternative models of decriminalisation
and regulation [34,35], and our data suggest that these
models should be further explored and evaluated in the
North American context and elsewhere.
This study identifies important limitations and signifi-
cant unintended consequences of a public health
warning regarding high potency heroin and increases in
overdose, and documents how a diverse set of individual,
social, structural and economic factors undermined the
impact of this public health intervention. While addi-
tional research is needed to inform the development of
novel overdose interventions, efforts to move beyond
individually-focussed strategies towards interventions
that address the contextual drivers of overdose risk are
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