We propose a 3-year, qualitative exploratory study of 'late initiates'{individuals who began injecting drugs at age 30 or later) and 'typical initiates'{those who initiate injection prior to 30) in order to better understand the circumstances, motivations, social environments and HIV, HCV, and HBV risk associated with injection initiation later in life. There are an estimated 3 million injection drug users {IDUs) in the US. Many of the detrimental health consequences of illicit drug use, including HIV, HCV, and HBV, as well as soft-tissue infections, and overdose, are related to the act of injection. Between 15% and 19% of IDUs initiated drug injection after turning 30 years old. Little is known about how late initiates differ from """"""""typical"""""""" initiates {initiating before age 30). We propose to examine how aspects of drugs, individual characteristics, and social environments affect transition to drug injection among adults 30 years of age and older. While there are more than a dozen published papers on initiation of drug injection, most studies have focused on young injectors and the specific circumstances of the first injection episode, and do not systematically consider how route of administration might intersect with drug use trajectories, life events, and accumulated health, social, and psychosocial vulnerabilities {e.g., HIV/AIDS and other conditions, multiple incarcerations, traumatic events, intergenerational poverty). This gap in knowledge is significant since late initiates are likely to need different approaches to HIV and substance abuse prevention and treatment than adolescents and young adults. The primary goals of the proposed qualitative study are to understand and compare late initiates to typical initiates and to provide a """"""""thick description"""""""" of the intersections amongst drug use, life events, HIV risk and infection, social and physical environments, and initiation of drug injection. Our proposal uses Zinberg's classic framework of Drug, Set, and Setting {DSS) and lifcourse theory {LCT) to guide the aims, research questions, and analyses of this exploratory study. We have established the following aims.
Aim 1 : To explore attributes of drugs and drug injection (DRUG) among late initiates using LCT constructs.
Aim 2 : To describe individual characteristics, including HIV status and perceptions of HIV/AIDS risks, drug use histories, and key life events (SET) of late initiates as compared to typical initiates using LCT constructs.
Aim 3 : To explore the interpersonal, social, and structural environments (including the prevalence of HIV/AIDS and other infectious diseases in the community- SETTING) of late initiates compared to typical initiates using LCT constructs. To accomplish these aims, we propose to conduct a qualitative, exploratory study comparing 80 late initiates and 80 typical initiates. Participants will be HIV negative and HIV positive, active IDUs recruited from community settings using targeted sampling methods. We will use the grounded theory method and life event approaches to explore in-depth the concepts related to DRUG, SET, and SETTING that influence late initiation to injection drug use. To capture a diversity of IDUs and settings, we will recruit IDUs in Los Angeles and San Francisco, two cities that have important differences in IOU demographics, drug use preferences, the incidence and prevalence of HIV/AIDS among IDUs, and other community and environmental influences. Exploring DSS among late initiates will help to identify influential factors for the prevention of injection drug use, injection-related risks for HIV/AIDS, and other health and social consequences.

Public Health Relevance

Individuals who initiate drug injection later in life (30 years of age or older) are at risk of acquiring and transmitting HIV/AIDS and other infectious diseases, such as HCV and HBV, as well as experiencing drug overdoses and abscesses. These late initiates to injection drug use constitute approximately 16% of active injection drug users, yet no research has been conducted exploring why and how they initiated drug injection. The goals of this study are to describe late initiation of drug injection and understand the unique risk factors and health outcomes- specifically HIV, but also HCV/HBV and other health, social, and psychosocial consequences- associated with this later-life development. The findings will also provide a foundation for the design of effective, age-appropriate interventions to prevent such adverse drug use trajectories.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
Project #
Application #
Study Section
Risk, Prevention and Intervention for Addictions Study Section (RPIA)
Program Officer
Lambert, Elizabeth
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of Southern California
Public Health & Prev Medicine
Schools of Medicine
Los Angeles
United States
Zip Code
Williams, Jeffery E; Dangerfield 2nd, Derek T; Kral, Alex H et al. (2018) Correlates of Sexual Coercion among People Who Inject Drugs (PWID) in Los Angeles and San Francisco, CA. J Urban Health :
Werb, Dan; Bluthenthal, R N; Kolla, G et al. (2018) Preventing Injection Drug use Initiation: State of the Evidence and Opportunities for the Future. J Urban Health 95:91-98
Bluthenthal, Ricky N; Chu, Daniel; Wenger, Lynn D et al. (2018) Differences in time to injection onset by drug in California: Implications for the emerging heroin epidemic. Drug Alcohol Depend 185:253-259
Bluthenthal, Ricky N; Wenger, Lynn; Chu, Daniel et al. (2017) Drug use generations and patterns of injection drug use: Birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California. Drug Alcohol Depend 175:210-218
Novak, Scott P; Bluthenthal, Ricky; Wenger, Lynn et al. (2016) Initiation of Heroin and Prescription Opioid Pain Relievers by Birth Cohort. Am J Public Health 106:298-300
Bluthenthal, Ricky N; Wenger, Lynn; Chu, Daniel et al. (2015) Factors associated with being asked to initiate someone into injection drug use. Drug Alcohol Depend 149:252-8
Kral, Alex H; Wenger, Lynn; Novak, Scott P et al. (2015) Is cannabis use associated with less opioid use among people who inject drugs? Drug Alcohol Depend 153:236-41
Davidson, Peter J; Martinez, Alexis; Lutnick, Alexandra et al. (2015) Drug-related deaths and the sales of needles through pharmacies. Drug Alcohol Depend 147:229-34
Dyal, Stephanie R; Kral, Alex H; Dominguez Gonzalez, Karina et al. (2015) Consistency of self-reported drug use events in a mixed methods study of people who inject drugs. Am J Drug Alcohol Abuse 41:332-8
Mars, Sarah G; Fessel, Jason N; Bourgois, Philippe et al. (2015) Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States. Soc Sci Med 140:44-53

Showing the most recent 10 out of 32 publications