Ethnography of Drug Use and Barriers to Care in the Española Valley of New Mexico. Cathleen E. Willging1, Michael Trujillo2,W. Azul La Luz3. 1 Department of ...
NEW MEXICO EPIDEMIOLOGY REPORT Volume 2004, Number 5
May 21, 2004
Ethnography of Drug Use and Barriers to Care in the Española Valley of New Mexico Cathleen E. Willging1, Michael Trujillo2, W. Azul La Luz3 1 Department of Family and Community Medicine, University of New Mexico 2 Department of Anthropology, University of Texas at Austin 3 Department of Sociology, University of New Mexico Introduction This ethnographic study combines information from participant observation and in-depth interviews to understand substance use patterns and utilization of behavioral health services from the perspective of persons with drug use histories in the Española Valley of New Mexico, an area straddling the borders of Rio Arriba and Santa Fe Counties. The region is noted for extremely high overdose death rates. Ethnography is a qualitative data collection method in which researchers participate in activities with the people they study, observing what they do and talking with them about what they think and mean. This approach helps clarify how drug users conceptualize substance use problems, participate in harm reduction and treatment, and encounter barriers to care and recovery. Such information is intended to contribute to the enhancement, design, and implementation of behavioral health services and to target prevention efforts in a manner responsive to the needs of drug users and communities. Methods The project employed three ethnographic research techniques, each designed to check and complement the others: (1) participant observation, (2) unstructured interviews, and (3) semi-structured interviews. The work began in April 2002 and was completed in June 2003. Participant observation took place in harm reduction and treatment settings. These settings provided opportunities to ascertain the range of behavioral health services available to persons
with drug use problems and permitted access to key informants, such as administrators, providers, and clients for unstructured and semistructured interviews. The on-site observations focused on service delivery. Researchers participated in group treatment processes based on Twelve Step fellowship modalities, assisted staff engaged in needle exchange in community settings, and conducted observations in a methadone clinic. Researchers also participated in social gatherings involving drug users and/or their families outside treatment settings, and interacted with participants in settings where actual drug use practices could be observed. The researchers conducted 35 unstructured interviews with behavioral health providers, in addition to law enforcement and criminal justice officials, drug users, and community members. This element of the research was aimed at providing background information to inform the design of data collection instruments. The researchers produced and pilot-tested two sets of standardized questions for semistructured interviews with current and former drug users respectively. The instruments were designed to allow informants the freedom to add answers and address themes not anticipated in the sets of prepared questions. Eight pilot-tests were conducted prior to implementation. Upon completion of the pilot-tests, researchers conducted semi-structured interviews with 47 informants. Twenty-eight of the informants were male and 19 were female. The age of informants ranged between 20 and 59 years; the mean and median ages were both 36.5 years. Nineteen informants were classified as current
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New Mexico Epidemiology Report
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drug users, though many of these individuals simultaneously participated in drug treatment or methadone maintenance programs. At the time of the research, 28 informants were classified as former users. Twenty informants from the samples of current and former drug users were in methadone maintenance programs. Thirtyeight informants were Hispanic or Latino only, one was Native American, two were Hispanic or Latino and Native American, one was Asian and Native American, and five were White, nonLatino. Data were analyzed through a series of iterative readings, followed by a systematic line-by-line categorization of data into codes. Over 200 codes were identified during this process. The coding process contributed to the identification of several themes repeated often in the data or that represented unusual or particular ideas and concerns. Through multiple readings of the data and discussions among research team members, emerging themes were reviewed, alternative interpretations of the themes were considered, and interpretations were revised as warranted. Results As reported by informants, the most widely used substances in the Española Valley include alcohol, marijuana, heroin, cocaine, and prescription drugs. Poly-substance use is quite common. Drug use itself is characterized as an intergenerational and multigenerational phenomenon. Initial exposure to alcohol and drug use often is traced directly to an individual’s social support networks. Within these networks, substances classified as illicit or those taken under the direction of a medical authority are not necessarily perceived as posing the same harmful threats to users. Alcohol and marijuana use are normalized, routine aspects of daily living, as is the practice of self-medicating with prescription drugs. People describe themselves as “clean” despite consuming such substances regularly or occasionally. Overdoses are familiar occurrences for the drug using population. Many overdoses never come
to the attention of the health care system or the legal authorities, as they are “handled at home” by family and friends. When persons present for an overdose fear that medical and legal intervention is eminent, they may leave the scene to protect themselves from being identified by health care providers and law enforcement officials as drug users. They fear the consequences of being identified, which can include exposure, imprisonment and, for parents, forced separation from children. Local explanations for overdoses include unfamiliarity with quantity and quality of drug, time lapse in obtaining assistance, “fixing” alone, and suicide. Co-morbid conditions influence decisions to use drugs and subsequent help-seeking behaviors. The unmet mental health needs of drug users and their social supports are substantial. Exposure to traumatic events (including death, physical abuse, and sexual abuse) abounds within the drug using population and may increase risks for depression, anxiety, and posttraumatic stress disorder. The pursuit of mental health care, however, is not typically part of the help-seeking processes of drug users in the Española Valley. Reluctance to access such care may relate to the social stigma of mental illness and the overall lack of services. Drug users also complain of chronic, debilitating physical health problems that underlie their decisions to use illicit drugs (above all heroin) and prescription medications, usually in combination. Persons with a history of drug use, their social support networks, and members of the community often consider prescription medications to be safe to consume because a medical authority has prescribed them. Misuse of such medications in attempts to curtail “pain” (psychological and physical) can facilitate entry into illicit drug and alcohol use, intensify use over time, and provide a transition to pain relieving drugs, such as heroin. Help-seeking for substance use problems is a complex process mediated by an individual’s social support networks, access to behavioral health resources, and broader social contexts.
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This process unfolds over several years and typically involves cycles of sobriety and relapse. Social support networks are critical to helpseeking, as they enable drug use or, conversely, motivate drug users to obtain services while imparting emotional and financial assistance. The structure of behavioral health care and attendant support services in the region is perceived as lacking capacity to meet the treatment needs of the drug using population. There are no detoxification facilities for drug users and the waiting lists for admission into facilities elsewhere in the state are lengthy. Waiting lists for residential treatment are long. Drug users emphasize intense struggles of avoiding drugs and alcohol when on these lists. Everyday problems that impact access to services include cost, insurance, transportation, and child care. Many people enter the behavioral health care system for reasons other than ending drug use (i.e., to “rest” from drug use or to moderate drug use). The criminal justice system is a major pathway into this system. Some people describe early recovery efforts as “faking it.” Treatment experiences are generally cast in terms of clients who want to succeed and clients who do not want to succeed. Awareness that clients are still using can adversely impact the treatment experiences of fellow clients. Persons in treatment for reasons other than ending drug use eventually profit from such experiences and learn to avoid the influence of clients who are “faking it.” Group camaraderie among clients is overwhelmingly seen as a facilitator to recovery, as is access to qualified counselors who are former users as well as non-judgmental listeners. The continuum of care in the Española Valley is fragmented. Persons re-entering community settings after periods of absence due to residential treatment or incarceration lack access to aftercare services to forestall drug use continuation and to prevent unintentional overdose. Such services include housing,
education, and employment assistance. While access to outpatient services is greater in comparison to residential treatment, the recipients of such services claim that they are more likely to engage in ongoing drug use activity because of the “free time” afforded to them. Twelve Step Fellowships offer alternatives to social support networks where drug and alcohol use occurs. However, persons seeking to discontinue drug use lament the lack of peer resources, including consistent access to fellowship meetings. Conclusion The study suggests that drug use and helpseeking processes are not solitary practices engaged in by individuals, but instead implicate a range of community, organizational, familial, and interpersonal factors. This range should be taken into consideration when planning and implementing drug use prevention and intervention efforts for the Española Valley. Recommendations 1. Focus prevention and intervention efforts on social supports. 2. Facilitate community outreach and case management to reduce drug overdose deaths. 3. Expand the continuum of care to ensure timely access to detoxification services, residential treatment, aftercare, and peer support resources. 4. Address mental health care needs in treatment settings. 5. Establish pain management programs in treatment settings. 6. Recruit qualified providers with drug use histories to provide behavioral health services. 7. Promote links among behavioral health programs, educational facilities, and vocational rehabilitation services, while fostering employment opportunities for recovering users.
Prsrt Std US Postage PAID Santa Fe, NM #390
Volume 2004, Number 5 • Ethnography of Drug Use and Barriers to Care in the Espanola Valley of New Mexico
THE NEW MEXICO EPIDEMIOLOGY REPORT C. Mack Sewell, Dr.P.H., M.S., State Epidemiologist Ronald E. Voorhees, M.D., M.P.H., Deputy State Epidemiologist Michael G. Landen, M.D., M.P.H., Editor The New Mexico Epidemiology Report (ISSN No. 87504642) is published monthly, free of charge, by the Office of Epidemiology, Public Health Division, New Mexico Department of Health, 1190 St Francis Drive, PO Box 26110, Santa Fe, NM 87502 Toll-Free Reporting Number: 1-800-432-4404 24 Hour Emergency Number: (505) 827-0006 or (505) 984-7044
Selected Infectious Disease Rates, New Mexico 2003 and 2003 2002
2003
State Total
State Total Bernalillo Cnty District 1*
Cases Rate ** Cases Rate Cases Rate Chlamydia
7417 399.8 7454 401.8
Gonorrhea
1463
78.9 1149 61.9
District 2
District 3
District 4
Cases Rate Cases Rate Cases Rate Cases Rate
3381 589.4 1568 391.1 616 107.4
165 41.2
489 175.6 75 26.9
945 281.6 1049 393.7 135 40.2
155 58.2
Syphilis
39
2.1
67
3.6
33
5.8
25
6.2
4
1.4
3
0.9
2
0.8
Hepatitis A
32
1.7
25
1.3
8
1.4
2
0.5
6
2.2
8
2.4
1
0.4
Hepatitis B
146
7.9
35
1.9
13
2.3
9
2.2
4
1.4
7
2.1
2
0.8
Hepatitis C
3
0.2
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
347
18.7
305 16.4
70
12.2
Campylobacter
14
0.8
0.7
8
1.4
18.2
305 16.4
117
20.4
63 15.7
48 17.2
37 11.0
40 15.0
Shigella
250
13.5
282 15.2
67
11.7
94 23.4
21
7.5
75 22.3
25
9.4
20
1.1
17
0.9
3
0.5
1
0.2
1
0.4
5
1.5
7
2.6
153
8.2
55
3.0
19
3.3
16
4.0
4
1.4
14
4.2
2
0.8
0
0.0
2
0.1
0
0.0
2
0.5
0
0.0
0
0.0
0
0.0
Pertussis
262
14.1
86
4.6
24
4.2
25
6.2
22
7.9
5
1.5
10
3.8
HIV/AIDS
130
7.0
130
7.0
56
9.8
20
5.0
23
8.3
22
6.6
9
3.4
4
0.2
12
0.6
2
0.3
3
0.7
2
0.7
3
0.9
2
0.8
Group A Streptococcal Disease (invasive)
114
6.1
125
6.7
76
13.2
21
5.2
9
3.2
15
4.5
4
1.5
Pneumococcal Disease (invasive)
333
18.0
180
9.7
73
12.7
44 11.0
16
5.7
40 11.9
7
2.6
57
3.1
49
2.6
11
1.9
11
2.7
3
1.1
18
5.4
6
2.3
2
0.1
1
0.1
0
0.0
1
0.2
0
0.0
0
0.0
0
0.0
10
0.5
5
0.3
1
0.2
0
0.0
0
0.0
3
0.9
1
0.4
Meningococcal Disease (invasive)
Tuberculosis Plague Rabies (animal) * excludes Bernalillo County ** Rate per 100,000 population
Population data from the US Dept. of Commerce, Bureau of the Census, Data released 4/17/2003
1
0.4
0
0.0
36 13.5
338
H influenzae B (invasive)
0.5
54 16.1
Salmonella
Giardia
2
35 12.6
E coli O157
Cryptosporidium
13
110 27.4
2
0.8
