Down in the valley: Trajectories of injection initiation among young injectors in California's Central Valley

Background: Injection drug use initiation represents a critical point of public health intervention, as injection increases risk for blood borne infections including Hepatitis C and HIV. In this paper, we explore pathways to injection initiation among youth (<= 30) in the rural context of California's Central Valley, where rates of injection drug use are among the highest in the nation. Methods: We draw on semi-structured qualitative interviews with 20 young injectors to examine drug use histories, including the factors that participants associated with their transition to injection drug use. Results: The average age was 24.7 years (range: 20-30), 45% were female (n = 9), and 30% were Latino (n = 6). Participants described a variety of pathways to injection, culminating in a first injection that involved either opioids (n = 12) or methamphetamine (n = 8). Among the opioid group, the majority used prescription opioids before transitioning to injection, while a smaller number transitioned to opioid injection from non-opioid recreational drug use. Injectors who first used prescription opioids often described growing up in affluent suburban areas and transitioned to injection with peers, owing to a combination of factors related to individual tolerance, cost, and shifting drug markets. In contrast, methamphetamine initiates grew up in less affluent families with histories of substance use that exposed them to drugs at an early age. Methamphetamine users transitioned from smoking and snorting to injection, often with family members or intimate partners, within broader contexts of social disadvantage and stress. Conclusion: While much of the focus on young injectors has centred on the current opioid epidemic, our data suggest a need to consider multiple pathways towards injection initiation of different drugs. Targeted interventions addressing the unique injection transition contexts of both opioids and methamphetamine are urgently needed in the Central Valley of California. (C) 2017 Elsevier B.V. All rights reserved.