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Addiction, Treatment
Written by Gavin Daker White   

WHO KNOWS WHERE THE DRUG USERS ARE?

Gavin Daker White, Lydia Department of Genitourinary Medicine, St Thomas’ Hospital, London, UK

INTRODUCTION: NEED AND DRUGS SERVICE PROVISION

This article reports the results of an ethnographic study of drugs service provision at the district level. The prevalence of illicit drug use was a widely articulated ‘need’ for drugs services. However, in in-depth interviews with drugs workers and service users in one London borough, there was little agreement as to the nature of endemic drug use. These findings are illustrated in the light of health and drugs policy.

Contemporary British health and welfare policy has underlined that services should be provided in response to demonstrable needs. The rationale for this focus can be understood partly as the economisation of these services. The notion of ‘need’ as an economic measure assumes that not all demonstrable needs can be met (Ferguson and Ryder, 1991, p. 8). Given that not all needs can be met, health economists have argued that need should be interpreted as ‘what people can benefit from’ (Stevens and Gabbay, 1991). In considering needs for health services it is useful to distinguish between the needs of populations and the needs of individuals. Donovan et al. ( 1993 ) have argued that the latter should instead be thought of as ‘requirements’. In this article, the focus is on the perceived needs of local authority populations.

Transferring the notion of need as benefit to the provision of specialist health services for drug users begs some interesting questions about the definition of ‘benefit’. The treatment of current drug use is seen as one way of controlling the numbers using drugs. Furthermore, the discovery of HIV in injecting drug users asserted the role of these services in controlling the spread of the virus. Indeed, AIDS was seen as a greater threat ( in terms of the possible socioeconomic ‘costs’) than drug use itself (Advisory Council on the Misuse of Drugs - ACMD, 1988). Therefore, in incorporating notions of need into drugs service provision, it is necessary to disentangle the possible benefits for the potential service user from the benefits for the state via social control of drug users. The role of central government is fundamental to drugs service provision, and any discussions of that provision, even at the ‘local’ level, must incorporate the aims of central government in providing these services:

Local authorities’ interest in and response to problem drug users has often been in reaction to

the funding initiatives from central government - not to an awareness of the problem itself. Association of Metropolitan Authorities (1988, p.12)

Nationally, the increase in community services for drug users during the 1980s has been linked to two major moral panics. The first was precipitated by a sharp increase in the numbers of people known to be using heroin. The second followed the discovery that the sharing of injecting equipment among injecting drug users provided a very effective route for the transmission of HIV. MacGregor (1989, pp.11-13) has argued that the dominant themes articulated about drugs during the 1980s concerned perceived threats to the social order as a result of criminality. Researchers have explored the relationship between socioeconomic indicators and levels of problematic drug use. It is generally felt that drug problems are associated with indicators of socioeconomic deprivation (Pearson,1989; Giggs,1991).

METHODS AND INITIAL RESULTS

In 1992, 27 drugs workers were interviewed at drugs agencies in six London boroughs. These included local authority workers with a drugs service development brief, workers (counsellors and managers/ administrators) at specialist drugs agencies and workers at other agencies with a specialist interest in drugs. In one of the boroughs, 36 drug users attending specialist drugs services were also interviewed. Throughout this period, the author attended the meetings of a district Drugs Advisory Committee (DAC) as an observer. The aim of this work was to investigate the allocation and utilisation of specialist treatment services to drug users at the local (district) level. The methodological approach used is best described as an applied ethnography of drugs service provision. A driving focus of this work was an assessment of the accessibility of drugs services. However, within this approach a key area of interest was uncovering the needs for drugs services in the local context, and the relationship between these perceived needs and the services actually provided. In this article, I will present the results of this study concerning perceptions of need for drugs services.

For those drugs workers and DAC members interviewed, the primary need for drugs services articulated was the relative prevalence of illicit drug using activity: more services would be needed where there was more drug use. The measurement indicator for this concept of need was usually the activities or perceptions of drug users using specialist drugs agencies. Other notions of need derived from published research and ‘expert’ knowledge, e.g. from other drugs workers.

District DAC's were created in national policy (ACMD, 1982). They were charged, among other things, to monitor the effectiveness of services in meeting local needs. The DAC observed in this study had commissioned (and conducted) a range of small-scale original research projects concerned with the extent of illicit drug use in the borough. However, at the end of 1992 it was felt that there still remained a need to commission a population-based prevalence survey of drug use. In spite of the importance of the prevalence of illicit drug use as a need for drugs services, my own observations of the DAC led me to conclude that the provision of these services was determined primarily by the manner in which they were funded, i.e. centrally.

RESULTS: THE VIEWS OF DRUGS WORKERS

Drugs worker: I know it's a very strange thing that has happened in [the borough] . . . I don’t know . . . exactly why so many agencies have started to come up at the same time, but they have and, you know, that’s just. But. But there is quite a serious drug problem, I mean that could be one of the reasons [laughs] . . .

The interviews that inform this article we semistructured in nature and undertaken in a conversational manner. Interviewees were forewarned of the topics of interest to the interviewer in a recruiting letter that was sent to all potential professional respondents. In interviewing drugs workers it rapidly became clear that perceptions of endemic drug use were a fundamental component of professional assessments of the need for drugs services. These perceptions were constructed from a range of sources. For example, the drugs worker interviewed below (who undertook mainly administrative and managerial functions) described the relative prevalence of drug use within one borough according to three criteria: lines of communication, the social geography of different parts of the borough and the inside knowledge of a former drug user turned drugs worker:

Drugs worker:. . . Demographically speaking, you were saying, ‘Is there trends ?’ Yes, there are trends. You tend to like in [a part] of the borough . . . you’ve got the largest part of the heroin use because it’s near the river and the railway lines, and that’s where the drugs come in . . . In like the more middle class area, it’s a lot of party drugs: a lot of ecstasy, a lot of amphetamine. In [that area] the highest amount of drugs that they deal there is amphetamine rather than heroin. You know, different demographic areas you’ve got particular preferred drugs. Amphetamine you can get anywhere and it’s by far the largest abused drug - more than heroin - but for some reason we’re in an area where heroin’s largely used. But yeah, you’re going [a region of] London, crack and cocaine is spreading. I was up at: Thames Television . . . and . . . I spoke to one of the West Indian workers in that area, and he used to be a cocaine user himself so he was in the scene and knew it. And he said, ‘Believe me . . .,’ he said, ‘I’m telling you in [a region of I London,’ he said, ‘Cocaine and crack is an increasing problem.’ It’s like a . . . crescent if you like, it was spreading round the [area]. He said, ‘It’s gonna get to be a big problem.’ So, you know, we’re waiting for the floodgates.

A further information source for the prevalence of drug use was provided by the clients of drugs agencies. For the worker below, who was employed in a joint managerial/counselling capacity, the perceptions of drug users themselves seemed the most important measurement indicator of illicit drug use. However, the interviewee realised the potential limitations of this approach himself:

Interviewer: . . . I was just wondering in sort of your experience of what (and from what you’ve heard) what . . . exactly the drug problems are; sort of around here at the moment? Or is it sort of a broad range of substances like? Drugs worker: Well, 1, again, you see we’re not really in contact with that many users, as such, to be able to sort of give an accurate assessment. But I think that generally . . . yeah opiates are the main, seem to be the main thing. I mean people smoke a lot of dope [cannabis] around here. I mean it’s . . . not uncommon for people to start at ten or eleven years old, you know or twelve years old you know. Have a . . . couple of puffs, go to school, meet after school, ‘ave a puff. Ehm, by the time they’re sixteen or seventeen they might be puffin’ every day and droppin’ out of school. I think that’s pretty sort of common.... But then again, I don’t think we’re any different from any other area within [the borough]. Ehm, I know there’s quite a lot of cocaine around.

[Later during the same interview]:

. . . We have got some local young people comin’ in with drug problems. We have opiate users, and they’re sayin’, you know, they’ve got problems. And they’re, they know, they are very important people in that they, you know they, they are feeding information about us back into that community and they’re. And there is quite a lot of, when I talk to them about these sort, are there many drug users in this [neighbourhood], and they’re sayin’, ‘There’s hundreds of ‘em’. I mean there’s quite a big problem here, you know, and ehm, but then how do you measure that, you know? I mean, is that drug, drug using exaggeration, you know?

Many respondent drugs workers explained where drug users were according to the perceived socioeconomic characteristics of discrete areas. Perceived high levels of drug-using activity were explained by indicators of social deprivation, such as high unemployment and large proportions of high rise council accommodation. We have already seen how one drugs worker explained a perceived predominance of amphetamines in one area by virtue of the social class of the residents (‘middle class’). The relative preva lence of drug use in a given area was also linked to the visibility of drug-dealing scenes. In this respect, King’s Cross was often mentioned as an area of high drug use. These visible scenes were also linked to particular substances, as in the case of a West End scene known for pharmaceutical opiates.

When drugs workers lived in the boroughs in which they worked, they gave their own observations on drug-using activity in these places. However, the only workers who offered assessments of this kind were youth workers. This is probably a reflection of the fact that the youth workers interviewed for this study were more usually involved in street-based work. Indeed, youth workers often criticised agency based drugs workers as having little awareness of drug use among young people, who would be less likely to be in touch with drugs services. Drugs workers with a special interest in younger people have previously identified the particular view of drugs workers in relation to the service needs of younger drug users (Cripps et al., 1990). They suggest that one reason for this is that drugs agencies were set up to serve injecting and dependent drug users. Younger users would be less likely to fit these categories. In a similar manner, other workers felt that specialist drugs agencies had missed the service needs of non-white ethnic groups.

For the workers in one inner London borough, with a perceived absence of notorious street-dealing scenes, drug use was viewed as new to the area. One drugs worker explained this by virtue of the large numbers of working class people in the borough. The use of drugs, especially heroin, among working class people was viewed as a relatively recent phenomenon by this informant. We are beginning to see how an individual drugs worker’s views of endemic drug use were primarily linked to contact with drug users attending the agency at which they worked. Further support for this thesis is provided in the following extract of an interview with a drugs worker, who said that the type of client a worker sees is dependent upon the type of agency in which they work:

Interviewer: . . . What’s, what are the main problems in the borough . . . as far as drugs are concerned?

Drugs worker: Well, I mean we see everyone on, who uses, different kinds of drugs. I mean every kind of drug user comes in here, ehm. And we also see people who’re using prescribed ones like, you know, Valium and tranquillisers. But that’s mainly an older client group you know, and mainly women who’ve been prescribed them for twenty years you know. It’s like doctors saw them as a great life saver in the 60s or 70s, for depression or. Anything a woman came in about, you know, they said, ‘Oh have these things,’ an’ that. Ehm, but you know we see, I mean cannabis is quite a high one in this area in that it’s, it is. You know, from working in other boroughs it is kind of quite unique about [this one]. If you work in other, ehm, areas they mostly would be getting in opiate users, or what’s coming up a bit more is the . . . cocaine and crack. Ehm, but you know [we] see every kind of drug; ecstasy, acid, the y’know. Whatever out there that people are taking, you know they come in. I think it’s really good. It’s a great experience, you know, see that. I mean ‘cos I know the [needle exchange] is just opiate-based, so you tend to see the same type of client, with, you know, the same sort of ‘er stories or whatever. But, you know, you can always put clients into a type I’m afraid. Probably kind of, you know be really frowned upon, but you can.

RESULTS: THE VIEWS OF AGENCY USERS

Eddy:. . . Like I said . . . it’s not just the drug user that’s gettin’ hurt by it [i.e. heroin use]. It’s the victims of crime. . . Like you’re takin’ the drug, to be able to get that drug you’ve gotta have money. Commit a crime an’ you’re hurtin’ the people you’re robbin’ from or you’re stealin’ from. You’re hurtin’ your family, you break up your family, it can cause murders in your family. Like I say it’s a whole circle of people you’re hurtin’, you know I mean not just yourself. You’re bringing a load of people down with ya. Aaagh it’s a shame really ‘cos it’s like. That’s why it’s like, these areas are changing. That’s why like all the old people and whatnot are gettin’ scared and all that. It’s, it’s a lot of bad shit is happening and like all these people are takin’ this drug. Not only this drug, crack’s the same, coke an’ that. It’s all bad.

Having interviewed drugs workers, it seemed that the perceptions and habits of those attending the drugs agencies at which they worked were an important component of their assessments of needs for drugs services. We have seen how the views of drugs workers varied according to the type of client that their particular agency had traditionally dealt with. Therefore, when speaking with drug users the interviewer was keen to explore their perceptions of endemic drug use. It should be stressed that these drug users were drawn exclusively from three agency venues where drugs workers had also been interviewed. At one drugs project a qualitative consumer evaluation of drugs agencies was undertaken. During the course of these highly structured interviews (a topic guide was used) respondents were also prompted to talk about levels of drug use in the local area. At the second interview site the researcher acted as an observer in the agency drop-in for a period of one month. An open-ended pilot agency satisfaction questionnaire was also undertaken here and was self completed by nine people. This questionnaire included questions about perceptions of local drug use. Finally, at a third agency tape-recorded depth interviews were conducted with 14 service users.

One salient conclusion arising from drug users’ accounts of the geography of illicit drug use is that theiraccounts differedmarkedly. As an illustration, consider the results of the pilot self-completed questionnaire survey (Table 1). It should be stressed that these questions were open-ended in the sense that the researcher was also interested in, for example, respondents’ own definitions of the ‘drug problem’.

TABLE 1: Results of a pilot survey: drug users' views of the relative prevalence of drug use (self completed)

What do you think of the 'drug problem' in this part of London

How does the use of drugs around here compare with other parts of London?

Bad all drugs very available

To be honest there is enough!! I mean that, most of my waking time is spent chasing them (physically) leaving no time (as a creative person) for much else

No idea

Don't know

No. It's a part of life

Fairly quiet

Don't know

Similar concentration people, similar problems


 

In contrast to the open-ended questionnaire featured above, interviews were focused in-depth to explore drug users’ assessments and perceptions of drug-using activity. However, as with the questionnaire above, there was little consensus among those interviewed as to the relative extent of drug use in various areas of London. For some respondents, a perceived raised incidence in the numbers using drugs locally was linked to the perception that the area was economically deprived. For example, one respondent said, ‘If you put loads of people in council flats, what do you expect?’. Andy, a cannabis user, linked high levels of drug use locally with poverty, and the ‘boredom’ and ‘frustration’ engendered by unemployment. He linked an individual’s use of drugs with exposure to them. Although Andy believed that the prevalence of drug use had risen during the 5 years that he had been smoking cannabis, it would seem as though this perceived increase may have resulted from his increasing involvement with other drug users over this period:

 

Andy: Er well my personal experience, I started using cannabis about . . . five years ago . . . Ehm, at that time I couldn’t actually get hold of any, like myself. I had to get it through friends and people I knew and stuff. But ehm, since the, like there’s been a lot of sort things like speed and ecstasy. I mean like ecstasy’s gone right up, the scale of people using it. And there’s LSD. I’ve never really come into contact with any coke or heroin yet, and I hope that it won’t ever happen. But I mean I’ve heard sort of like, a lot of people that have been using crack, which is like could get pretty worrying. . .

[Later, during the same interview]:

. . . I mean, when I first started smoking hash about five years ago, there were not a lot of people that I knew that did it. Only a small group of friends that I had did it, an’ a couple of other people. But I mean since then, that levels gone sky high. I mean every, virtually everybody I know who’s about the same age as me ehm does it all the time an’, or has done it. or would do it.... not very many people that I know don’t do it. It’s easier to count the people that don’t do it than the people that do it. Because the people who don’t do it are sort of unusual. Everyone else does it, it’s that sort of what the problem is, we[’ve] got sort of er 80% of people within the say 16 to 25 year old age group, and lower as well. Let’s just say 13 to 25 that . . . ‘re smoking, are using some kind of drug at some time or other. Some use it on a more regular basis than others. Myself . . . I was a short while ago just usin’ like, smoking hash every day. Drinking every single day. Ehm, havin’ a- not really a large amount - but just er something all the time. I was constantly in a sort of haze.

For the regular heroin user, perceptions of the prevalence of drug use in a given area are coloured by their involvement in secretive and ‘underground’ networks of other drug users. The following extract of an interview with Gary is exemplary. Notice how although conceding that there may be more drug use in some areas than others - he has encountered drug use in different areas (Chelsea and Hackney):

lnterviewer: Well, er something else that I’m quite sort of interested in . . . some of the people I’ve spoken to have said that . . . drugs are especially more prevalent in some areas of London than others.

Gary: Mmm.

Interviewer: Do you think there’s any truth in that?

Gary: It’s hard to say. I mean inevitably they’re gonna be more prevalent in some places than others, but then again you’d be surprised you know. I mean you don’t know what goes on behind closed doors. I mean I go . . . to Chelsea sometimes . . . but, well obviously there’s more on like Hackney council estates I should imagine than there are in kind of suburban, you know semi-detached. But.

Interviewer: Why?

Gary: Why? Probably because these people have a great deal less to do and they come into contact with . . . [inaudible] . . . That’s the thing you see. Once people find out that you’re using drugs, a certain type of drugs you use, you suddenly find yourself. It’s odd ‘cos like the heroin, the heroin networks they run very underground - because everyone’s so secretive - so that when you kind of like find yourself in the network to any extent, then everyone else who’s in it kind of comes . . . [inaudible] . . . and you find complete strangers knocking on your door and stuff. Because er, I don’t know, just word seems to get around, it’s strange.

Later during the same interview the interviewer brought the subject back to these ‘networks’ to learn whether or not Gary felt that they were local in character. From his reply, it is evident that they may operate at a variety of scales (both local and trans-London in nature) reflecting the paths trodden by those looking to buy heroin:

Interviewer: Is it, is there really this like dark, secret underworld?

 

Gary: Yeah.

 

Interviewer: Underground network?

 

Gary: I think so, just simply because, like I say, people erm, because people are just very secretive about the whole business. It’s like I had a friend who started getting into it when I was living in Hackney, and like, a couple of days later he came back with a couple of friends who, had kind of like sorted his supplier out for him. And then the next day I came home from work and there were like 4 or 5 people who were sittin’ around kinda chasing heroin. And then the next day I came home from work and there were literally like 15 people in his lounge yeah, like complete and utter strangers. I mean, it’s just someone finds out that there’s a safe house to go for. So-and-so you know, might have a bit of money that’d er, and er, I don’t know it’s just like flies round shit.

Interviewer: [Laughs] Do you think, are these, are these networks, would they be localised?

 

Gary: Yeah.

 

Interviewer: Or would they be sort of across, all across town?

 

Gary: I think that they’re kind of localised yeah, but then again you find, you know, there’s kind of strange coincidences. You find yourself running into people from the other side of London who just know the same people you know, by a, by a kind of precarious link they know someone who knows someone who you find out through meeting on the other side of London.

The interviewees considered so far in this section have, for the most part, explained perceived high levels of drug use by indicators of so-called deprivation. The borough in which drug users were interviewed was viewed as ‘deprived’ and this was used to explain high levels of drug use. Some interviewees said that the levels of drug use in the borough were so high that they approached the notoriety of areas such as King’s Cross. However, other drug users said that the prevalence of drug use in this borough was not as great as in other areas of London. Some respondents linked the relative prevalence of drug use with the perceived openness of drug-dealing scenes. For these respondents, the borough in which they were interviewed was not judged to have visible street-dealing scenes. Accordingly, the use of drugs here was felt to be less than in areas with more visible street-dealing scenes. Other respondents linked perceptions of the relative prevalence of drug use not to the openness of the scene, but to the extent to which different areas were popularly known for drugs.

INVISIBLE DRUG USERS

We have seen how the prevalence of illicit drug use was widely articulated by drugs workers as a need for drugs services. However, we cannot know the extent to which these perceived needs influence decisions about service provision. Access was not secured to the venues in which decisions about the funding of services were made. However, it is likely that those working in the drugs field will have some influence over decisions about funding, given their ‘expert’ status. The relationship between perceived needs and the provision of drugs services (at all levels) is worthy of further study.

Paradoxically, it appears as though drugs workers’ perceptions of the relative prevalence of illicit drug use are constructed in the light of the services that are provided, i.e. their perceptions of service needs derive from the type of clients in touch with the drugs services in which they work. We have seen some of the ways in which groups of drug users not in touch with services might be invisible to drugs workers in specialist agencies. A further example is provided in the case of female drug users. One drugs worker spoke about a drug-dealing scene near to the agency at which he worked as being ‘very male’. Accordingly, women were seen as being less visible to this agency:

Drugs worker: . . . We don’t provide any specific services to women. Interviewer: Is that, is that er something that, that you think needs addressing? I mean you, you’ve brought that up, so.

 

Drugs worker: It’s been bandied around that it is an issue. We see, I don’t know, well what do the figures tell us?

lnterviewer: Well it’s what, I mean it’s obviously predominantly men.

Drugs worker: . . . I have opinions about that, but . . . I think it’s a big issue. I think because of society’s view of drug use and drug users . . . and women’s particularly low status in society, that a lot of female drug use is hidden. I mean if you go into a pub, you know, you know that 90% of them’ll be men. Now I don’t know whether, you know, equal amounts of women are drinking. If they are they’re doing it . . . in the private and personal sphere which . . . is . . . a reflection of the way . . . women’s lives are in the rest of society. . .

The primary determinants of service provision, the local level were not seen to be perceptions i local needs. Rather, the essential determinant 4 drugs service provision was the funding activities central government. That central government see to control drug users by providing them with treatment may colour their attitudes towards service provision. The treatment of drug users is put forward a means of preventing drug use:

Helping them to stop taking drugs is beneficial for society as well as for the individual concerned, and is a direct means of reducing the demand for drugs. It also has important implications for prevention, because the most common form of introduction to drug taking is an offer from a friend or acquaintance who is already misusing (sic.) drugs. Central Office of Information ( 1985. p 21).

More recently, the spectre of HIV has seemingly changed the practice of drugs service provision. Whether or not it has changed the rhetoric is outside the scope of this article.

The ACMD (1988) described a harm-minimisation approach to the delivery of drugs services that needed to bring drug users in to services to educate them about HIV infection. Their report recognised that only a minority of drug users were in contact with services and outlined ways of attracting ‘hidden’ populations to drugs services. Thus, the aim of services became not to control drug users’ drug use in the sense of stopping that use, but in the sense of making that drug use safer in terms of HIV. Within a harm-minimisation approach to the delivery of drugs services, some of the possible benefits of seeking treatment for the individual (e.g. a prescription for opioids or welfare benefits advice) have been posited as ‘carrots’ to attract people into services where the state’s need to limit the spread of HIV might be effected. Harm minimisation asserted the importance of ease of access to drugs services. In doing so, it leaned heavily on models of accessibility and general welfare provision. This focus on access has reinforced the institutional and professional view that services are necessarily a good idea, relevant to the needs of drug users and that they should be utilised (see also Berridge, 1991). These have been the notions of need for services articulated at the national policy making level.

At the local (DAC) level, an important influence on service provision was the recommendations of the ACMD. In particular, the provision of the Community Drug Team (CDT) in the borough of special interest in this study was seen to be associated with ACMD recommendations in the 1982 report Treatment and Rehabilitation(ACMD, 1982). However, the District Drug Problem Teams (DDPTs) described in that report are somewhat different from CDTs as we commonly see them today. They were originally conceived of as multidisciplinary resource teams that need not have a fixed base. However, the ‘might’ seems to have become the reality, perhaps fuelled by the shifting of resources more generally from psychiatric hospital venues to ‘community’ sites:

. . . the development of specialist secondary services other than the team members acting in their own agencies could of course take place through drug advisory committee recommendations, and might lead to the development of a small community psychiatric service or the establishment of a non-statutory day centre for drug problems. Development of services would be left to those at the local level, but a prerequisite of service development would be the early establishment of a DDPT.

ACMD (1982, p. 136, para. 6, emphasis added)

 

 

One aim of DDPTs was to draw ‘generalists’, such as GPs, into the management of drug users. Others have already demonstrated how CDTs have rather ‘recreated the specialist at local level’ (Strang et al., l991,p.6).

The drugs workers interviewed in this study articulated a model of a hierarchy of increasing needs where those considered the most needy were those understood to be most at risk of HIV infection. This demonstrates the effect on drugs workers of expert recommendations concerning harm minimisation. However ( and paradoxically ), these people were also those who have traditionally been seen at drugs agencies: injecting drug users ( of predominantly opiate drugs). Thus, although harm minimisation stressed that ‘hidden’ drug users should be brought into drugs services, this was not necessarily translated into new groups of drug users. As far as the substances used were concerned in terms of needs for services, heroin was seen as the most serious, addictive or ‘hard’ drug, the prolonged use of which would be most likely to lead to problematic drug use. However, cocaine (especially crack) was also viewed as serious in terms of the likelihood of the use of that drug leading to a ‘problem’.

There are many reasons why drug users might be hidden to drugs services. Drug users are often engaged in illegal activities and many would not want to be identified as drug users (either by individuals or authorities) for fear of subsequent arrest, harassment, prejudice or stigmatisation. Other factors will contribute to the marginalisation of drug users, for example, the stereotypical view that ‘addicted’ drug users commit property crimes in order to ‘feed’ their habits. Following the discovery of HIV, drug users may also be viewed as a threat by virtue of their perceived HIV status. For these and other reasons, drug users may wish to hide their drug-using activities from all but fellow drug users.

We have seen that an important source of professional assessments of local needs for drugs services was the activities of those using drugs services. Most of these people were opiate users. An examination of the views of drug users attending drugs agencies regarding the relative prevalence of drug use in different London boroughs revealed marked differences of opinion. These differences seemed to reflect the degree to which an individual respondent was involved in drug-using/dealing scenes. Those most heavily involved in covert drug scenes will spend most of their time around drug users (wherever they travel for drugs), perhaps reinforcing the perception that drug use is ‘everywhere’. Thus, although these perceptions may indicate the extent to which an individual is involved with other drug users, they cannot give an accurate picture of levels of drug use in a given area. Evidence would suggest that these scenes are not ordered spatially. In particular, these scenes were not necessarily linked to particular parts of London but were trans-London in nature. Taken together, these findings indicate both the plurality and the covert nature of drug-using scenes in the capital. Given that drug users will wish to hide their activities from others, it is likely that the members of some scenes in a given area will not be aware of other scenes that may even be nearby. Drug users may only be visible to each other at certain times, e.g. when they are buying drugs or using drugs services. The nature of drug-using scenes is an important area for research. It is likely that research in these venues may be best undertaken within an action research framework which takes services to those drug users who are not currently in receipt of them. In addition, it would be interesting to apply social network analysis to groups of drug users. This would further aid our understanding of how information about health behaviour or health services travels along these networks. Indeed, within an action research framework it would transmit these messages as part of the project. This study did not consider the views of drug users not in touch with treatment agencies, and such an approach would allow for a consideration of their views.

When respondents saw the use of drugs in one London borough as being different from that in other areas of London, this did not necessarily refer to observable levels of drug use. Rather, it seemed to relate to the perception that the borough was more ‘deprived’ than others. In addition, perceptions of the relative extent of drug use seemed to refer more to the extent of the openness or visibility of drug-dealing scenes than they did to the actual prevalence of drug use or drug users in given areas. The results of this article seemingly complement those from a study of 210 young drug users in Glasgow by Forsyth et al. ( 1992 ) .

They found that ‘more people were apparently travelling into deprived areas than out of them to buy drugs’. They concluded:

Drugs are often linked with deprivation and crime, but this association may in part derive from where drugs are sold, rather than who takes them. . . The drug users of today are most visible in the deprived areas where they go to score [buy drugs]. Counting drug users present in deprived areas is liable to exaggerate their prevalence, because many live elsewhere. . .

The primary determinants of service provision at the time of this study were the funding activities and recommendations of central government, not the specifics of demonstrable local needs. However, this article has been mainly concerned with the provision of drugs agencies, rather than the specific services provided at those agencies. These may be more adapted to perceived local needs. This is worthy of further investigation.

It is concluded that views of the prevalence of illicit drug use are constructed primarily from dominant theories about what sort of areas are commonly associated with drug use. ‘Drug use is more likely in areas of socioeconomic deprivation’, has become ‘It’s a deprived area so there must be high levels of illicit drug use there’. The effect of media representations of drug use on these constructions is not considered in this article, but would provide a useful avenue for future research. The results of this study would support the view that ‘problematic’ drug use is most likely where drug use and socioeconomic deprivation conjoin. Finally, this study has demonstrated how perceptions of the local prevalence of drug use are affected by theories derived from social research Social scientists will have to pay more attention to the effects of their own activities on the phenomena that they seek to explain.

ACKNOWLEDGEMENTS

The research described in this article was funded by an ESRC research studentship (Award No: R00429024730) held at the Department of Geography and Earth Sciences, Queen Mary and Westfield College, and was supervised by Dr Sarah Curtis.

Dr Gavin Daker-White, Researcher, Lydia Department of Genitourinary Medicine, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, I 1K.

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