Everyday Substance Insecurity Among Homeless Injection Drug Users in Israel’s Largest Open Drug Scene

Participants

Interviews were conducted with 11 HIDUs and professionals who work with this population. The HIDU participants included nine men and two women. Participant average age was approximately 42 years old (range 28-56). Participants regularly inject substances such as heroin and/or Hagigat and/or substitutes such as Subutex (Buprenorphine). All participants were addicted and use substances several times a day. All were homeless or had unstable housing, prompting their arrival at the First Step Center (FSC). All had tried rehab or were previously in substitution therapy. Table 1 shows demographic variables such as gender and age as well as substance use and patterns of obtaining money for drugs.

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Table 1.

HIDU Sample Characteristics, Including Substance Use and Patterns of Obtaining Money for Drugs (With Real Names Altered).

N	Name	Gender	Age	Substances use	How they obtain money for drugs?
1	Ohad	M	41	Heroin, cocaine, LSD, Suboxone, Hagigat	Drug dealer (until recently), beggar
2	Beny	M	29	Heroin, cocaine, Suboxone, Hagigat	Drug dealer (in the past), selling things and selling CDs and DVDs
3	Lilach	F	30	Heroin, cocaine, methadone, Subutex, Suboxone, Hagigat	Friends from the streets and normative friends
4	Yori	M	29	Hagigat, heroin; in the past: Subutex, Suboxone, MDMA, LSD	Collects plastic bottles for recycling; theft (especially bicycles), drug dealer of hashish (in the past). Occasionally works in construction
5	Israel	M	43	Hagigat, heroin, methadone	Loans, money from the family, money from National Insurance
6	Kori	M	28	Heroin, opiate tablets	Said it was personal and was not prepared to tell. But during interview said that “he was tired of stealing for drug trade”
7	Ami	M	+50	Heroin; in the past: Hagigat	Collects cans for recycling, collects iron, rummages in garbage
8	Yossef	M	+50	Subutex, Hagigat, in the past: everything	Money from National Insurance, seller of Subutex (he has a prescription), working in construction and iron
9	Shaul	M	56	Heroin, methadone	Did not answer question, only said that he had inherited a house
10	Pazit	F	+50	Heroin, cocaine	Having sex for drugs, obtaining money by false pretense: “I lost my wallet”
11	Yonny	M	52	“I am ‘drug pig’ the more the better . . .”	Did not answer question

Note. HIDU = Homeless Injection Drug Users; LSD = Lysergic acid diethylamide; MDMA = Methylene dioxy meth amphetamine.

The four professionals were three men and one woman who worked with the HIDU population. Two of them work in the FSC, while another is a social worker who works in methadone maintenance treatment (MMT) near the FSC. One works for the Tel Aviv Municipality and with the homeless and addicts in the area.

Study Setting

The study was conducted at the First Step Center (FSC), a product of a harm reduction initiative. One of the main reasons that HIDUs arrive at FSC is due to its syringe exchange program (SEP). SEP operates twice a week on Sunday and Thursday from 16:00 till 19:00. In addition, FSC offers HIDUs a safe place where they can eat a snack or receive some clothing. They can also shower and chat with volunteers in the center. For volunteers and staff, this is an opportunity to establish initial contact with homeless addicts in the area. In the mornings, the center refers HIDUs to needed services, including detox units, medication-based treatment, and a clinic for treating sexually transmitted diseases (STDs). On Wednesdays from 12:00 to 14:00, the center is open only for women.

Each year, about 200 homeless addicts pass through the doors of FSC. FSC collaborates with the Israel Anti-Drug Authority and the Ministry of Health’s Department of Addiction Treatment (Ezra, 2018).

The interviews were conducted in the primary office at FSC—a small and quiet room, mostly during the afternoon hours. Observations were made in the main room, a sort of gathering space that serves as a waiting area, where HIDUs can also eat and drink. Observations were also made in and around the Center.

Tools and Procedure

Data were gathered through open in-depth and open-ended interviews between July and December of 2014. A general interview guide was devised in advance, including topics and talking points. This served as a backup for cases in which open discussion did not elicit all research topics. The guide was also intended to assist if the conversation was interrupted or stopped. The opening question was, “Can you tell me about life on the streets?” The subsequent questions were based on dialogue constructed from interviews and were designed to generate descriptions of individual experiences. Interview guides included a range of topics. For instance, experiences from life on the street and its effects on drugs, violence, lodging, and food. Another topic was substance use—which ones, how were they obtained, how injected, and what did users need to consume them? Others included survival strategies on the street surrounding basic needs and characteristics related to norms in the streets. Yet another was reference to childhood and family. Finally, HIDUs could be asked what they think of the authorities and harm reduction services. Most of the topics arose from earlier ethnographic research conducted by the first author. However, in-depth interviews in the current study enabled further exploration of these issues.

All interviews were conducted by the first author in the FSC main office. As noted, the interviews were accompanied by observations in and around the Center as well as by informal conversations in the open drug scene until 2015. Center observations were made during the opening afternoon hours, when IDUs gather there for syringe exchanges. External observations were mostly made accompanied by professionals working with IDUs.

Ethics approval was obtained in accordance with the ethical standards of the Institutional Review Board (IRB) of the author’s institutions. Permission to conduct interviews and make observations in FSC was obtained from the Israel Anti-Drug Authority.

Participants were asked to volunteer for the interview and did not receive compensation. Thus, the research process relied on participant goodwill. Initially, it was very challenging to find participants who consented to be interviewed. The researcher revisited FSC multiple times during opening hours, interacting with and making observations of HIDUs and volunteers. Only then did they grow accustomed to the presence of the researcher. With development of trust followed expressions of willingness to be interviewed, but not recorded. According to the HIDUs, the fact that the researcher was female made interviewees more receptive and less intimidated to research participation. Participants provided written informed consent prior to their interviews. The interviews lasted 45 min to 120 min each and interviewees were promised anonymity. They were assured that they could leave the interview at any stage or choose not to answer any question. The interviews were conducted in Hebrew. The professionals who work at FSC constituted the safety net and a source of consultation for both interviewees and researcher.

The interviews and observations were analyzed in two stages. First, handwritten observations and reflections were recorded based on research topics in the interview guide during and directly following the interviews. Additional written insights and reflections on the interviews were made by the first author who carried out the interviews. Second, after interview transcription, coding of data was carried out according to salient topics. In this stage, we formulated subcategories and established the main themes. Coding was initially performed by the first author, followed by the second author who served as an external reader offering an additional critical perspective. All coding and data analysis occurred in the context of continuous dialogue and discussion between the two authors. The field observations provided information from an additional perspective and enabled triangulation of the findings for more accurate research validity. In the results section, a “thick” description of quotations from participants is included, translated from Hebrew.

Everyday Substance Need Caused Fear and Anxiety

Participants experienced a continuous need to consume substances (mostly illegal ones) at least several times a day. For HIDUs participants, the need for obtaining drugs or money for drugs is a constant restless feeling. Mostly impoverished, living on the streets, and unemployed, their ability to purchase these substances in socially acceptable ways is very low. To secure drug money, they use creative means, some of which are deviant and criminal: theft, drug-dealing, begging, garbage digging, collecting recyclable materials, prostitution, and more (e.g., see Table 1). HIDUs are quite aware of their state of desperation. As Shaol said,

It’s such a cruel system . . . If you don’t have the cash, you can remain dope sick and collapse. (Shaol, male)

Ami was another participant who elaborated on the ceaseless wandering created by drug dependency and deprivation:

You only sleep every four days. When you go wandering around you’re constantly looking for something—for food, gold, silver, bottles that will bring the [money for the ] next day . . . [always] looking. (Ami, male)

The emotional toll of this grim daily routine is often despair and exhaustion. For instance, Kori was asked about his eating and sleeping habits, and how he acquires drugs on the streets:

Of all the participants, only Joseph showed no fear of not being able to obtain illegal drugs. However, he could rely on a prescription supply of Subutex tablets. Some were sold for money to buy Hagigat used as a Subutex “booster”:

I take Subutex. It’s pleasant to me. As a street addict, it’s pleasant to me—because I never get dope sick. I’m not stuck in dope sickness. I’m not familiar with the term, dope sick. I have two weeks of drugs. (Joseph, male)

Substance Need for HIDUs partly revolves around uncertainty of the quality of the illegal substances. Participants repeatedly mentioned pervasive substance impurity. They often used the expression, “We buy poison drugs.” However, they emphasized that their priority was more drug access and obtainment than substance quality. With little money, heroin was essentially priced out of reach. They reported being compelled to use other cheaper and more dangerous drugs such as Hagigat.

Participants Beny and Kori were familiar with these “fake” and “dangerous” drugs:

8-10 years ago the drugs were good, and now they’re fake. The most [common street drugs are] Hagigat and Nice Guy [a kind of NPS]. They [the drug dealers] spray all kinds of things [on the drugs]. In the streets, they prefer it because it’s cheaper. A little money feels like a bomb. Drugs for the poor! (Beny, male)

The most dangerous drug, most retarded drug is Hagigat. This is something. . . and God forbid what it does to people. People start to go crazy in front of your eyes. (Kori, male)

Some participants described avoiding Hagigat due to its lethal reputation. They said that it is known on the streets that most “mad” and “damaged” people are Hagigat users.

In addition, Substance Need is manifested as insecurity over safety of consumption equipment. Regardless of the syringe exchange program, which operates on a twice-weekly basis, many IDU participants reported reusing someone else’s injection equipment. They also reported the existence of a thriving street syringe trade. Thus, new syringes from SEP were often sold to buy drugs. In addition, constant deception surrounding drugs injection equipment was widespread on the streets. Users were known to steal empty and drug-filled syringes from each other. Ami described one such deception:

My syringe is ready. If someone says turn around, I’ll inject you in the leg [addicts are sometimes injected by other addicts due to the difficulty in locating a vein]. He gives his friend my syringe, replaces it with a syringe with water, and gives it to me. (Ami, male)

As noted, HIDU participants experienced everyday fear and anxiety caused by Substance Need.

For IDUs, drug consumption can be necessary for avoiding withdrawal symptoms. However, it is also needed to avoid physical, mental, and psychological pain. The risk of experiencing pain from substance deprivation can grow into fear—one they attempt to avoid at almost any cost.

Abraham, a drug treatment professional and recovering addict, described this fear:

Someone who is “normative” will not get it. I can’t describe the internal paranoia, thoughts, feelings, and terrible fears that arise in you and don’t leave during dope sickness [withdrawal syndrome]. It’s unbelievable—their fear of getting dope sick. This is physical and mental pain, a paranoia attack. It’s loss of physical, mental, and spiritual control. [It’s like] coming into an attack, a crazy panic . . . the most crazy panic. It’s the sharpest pain, as a panic attack. I can’t describe it in words. (Abraham, male)

This aspect of “dope sickness” due to an extended period without a substance was also recounted by Kori:

It’s always fear that [you] don’t get it [the fix]. And it’s fear of getting caught [by the police]. If you “break into dope sickness” and get taken into [police] custody. It’s scary. I very much want to sleep—but am afraid to if I get dope sick. I’ll have to get organized [to obtain drugs]. (Kori, male)

Fear of withdrawal symptoms was also noted in our interview with Pazit, a female participant. She asked to stop the interview after 40 min due to her anxiety over the approaching withdrawal. This interview was conducted in the afternoon, while her last consumption of heroin was at 10 a.m. She claimed to need heroin twice a day (morning and evening), so she had to use commercial sex as a means to secure cash to buy more drugs.

For participants, illegal substances are not prescription pain killer medicine, and they live with everyday fear and anxiety over absence of their “medicine.” This attitude of illegal drugs as a “medicine” was exhibited by participants Israel and Ami:

I’m addicted to opium. This is my medicine. I must consume it. (Israel, male)

A junkie is an ill person and drug addiction is a disease. It’s a fact that a drug addict will do everything to get [drugs]. (Ami, male)

The everyday fear and anxiety was experienced in the shadow of death on the street, a grim reality of the HIDU condition as described by Yonny:

The people who inject look like death. Many people were dying near me—not one, two, or three. Some died near me because of lack of nutrition, injuries, open sores, lack of hygiene. The immune system is collapsing. This is something that I see: death in the eyes. And I say: When you want, take me! I was afraid to die and there were moments when I really wanted to die. (Yonny, male)

Substance Need Experienced as More Urgent Than Basic Survival Needs

As noted, Substance Need is often felt as more urgent and intense than other basic survival needs such as food, sleep, physical security, and health. Many participants fear sleeping because they are afraid to awaken with withdrawal symptoms. They thus feel compelled to scrounge, beg, and steal money for their next dose of heroin. As such, they reported not worrying about food or a place to sleep. This ordering of need-based priorities was noted by Yory:

Food we have. There’s no lack of food in the country. A place to sleep is not [a problem] to find because it’s a hot country, so it’s possible on a bench. That’s not a problem. (Yory, male)

In the area around Tel Aviv’s largest open drug scene, where HIDUs gather, available food from NGOs, donations, or from digging through restaurant garbage cans can be found. As Ami said,

When you’re looking for food, you find half and quarter liter drinking bottles and you take them. Vegetables and fruits you take. Some eat in certain restaurants that provide food free of charge. Do you know how much food is thrown in the garbage? (Ami, male)

Even the basic need for sleep is not as urgent for HIDUs as the craving for drugs, with most interviewees reporting severe lack of sleep. In addition, an effect of stimulants such as Hagigat is extended periods of sleeplessness and hunger suppression. As we have seen, HIDUs participant generally considered food and a place to sleep to be more or less readily available, with the real challenge that of acquiring illegal substances. Yamit, a professional who works closely with HIDUs, summarized the physiological reality of drug dependency:

Sleep—they don’t sleep. They can be 3-4 days awake until they faint somewhere on a bench. Sleep, eating, and all the basic needs are moved aside since they aren’t hungry or thirsty.

Thus, pervasive participant neglect of health is quite common. In fact, if unable to secure their next dose, many HIDUs do not even come to the FSC. Many participants reported not being afraid of disease infection, including HIV and hepatitis. Some also confided to not fearing death. On the contrary, they often wanted to die as an escape from everyday intolerable pain and Sisyphean life on the streets.

HIDU Attribution of Misunderstanding and Denial of Substance Need to the Authorities

HIDU participants typically reported that authorities do not understand them, much less their needs. Many participants complained about police, health, and welfare authorities. They fear police brutality and often felt that the police simply want them to die.

Ami elaborated on this grave sense of despair aggravated by lack of police sensitivity:

The police want addicts to die. On the street, wherever the [IDU] is going they drive after him. He [the IDU], with his paranoia, sees police everywhere. He’s afraid, walks for kilometers . . . Why us? It’s not enough that you’re paranoid and anxious about an injection. The police took the syringe out of his hand, don’t give a damn. They want that the substance will enter his body and what will be after that? There should be a social worker that if a person gets into trouble, they have someone to talk to. On the street, there’s no one to talk to. Go to a secretary at the Police station? [Tell him] I want to commit suicide? Having someone to talk to about mental help 24 hours a day. Police want junkies to die. This is the unequivocal position: Leave us here to die. Why should I like this? They treat you like crap, treat us like air, just like a junkie. [But] no one knows what he’s suffering. (Ami, male)

Participants often displayed intense emotions during interviews because of their dire predicaments. Ami shed tears and confided that some interview questions irritated him because they made him think about his difficult situation and how society treats him “like dirt.” Nevertheless, he said it was important for him to be interviewed, that finally someone was willing to really listen to what he had to say and was interested in his problems.

Participants complained that authorities do not consider them sick people suffering from addiction disease. As a result, they are not given substances. Even in the case of substitutions like Methadone, many difficulties exist in securing them without extra complications of conditions or money. For instance, one participant, Israel, showed us a prescription form for Methadone. However, it expired the next day and required him to pay 350 NIS. Many HIDUs participants and treatment professionals note serious problems with the drug substitute program such as lack of continuous financial support. They also reported that service hours of the FSC and SEP were relatively scarce (twice a week for 3 hr each time). In fact, the FSC only contains a single shower—and thus a long queue typically forms.