Optimizing Digital Tools for the Field of Substance Use and Substance Use Disorders: Backcasting Exercise.

BACKGROUND: Substance use trends are complex; they often rapidly evolve and necessitate an intersectional approach in research, service, and policy making. Current and emerging digital tools related to substance use are promising but also create a range of challenges and opportunities. OBJECTIVE: This paper reports on a backcasting exercise aimed at the development of a roadmap that identifies values, challenges, facilitators, and milestones to achieve optimal use of digital tools in the substance use field by 2030. METHODS: A backcasting exercise method was adopted, wherein the core elements are identifying key values, challenges, facilitators, milestones, cornerstones and a current, desired, and future scenario. A structured approach was used by means of (1) an Open Science Framework page as a web-based collaborative working space and (2) key stakeholders' collaborative engagement during the 2022 Lisbon Addiction Conference. RESULTS: The identified key values were digital rights, evidence-based tools, user-friendliness, accessibility and availability, and person-centeredness. The key challenges identified were ethical funding, regulations, commercialization, best practice models, digital literacy, and access or reach. The key facilitators identified were scientific research, interoperable infrastructure and a culture of innovation, expertise, ethical funding, user-friendly designs, and digital rights and regulations. A range of milestones were identified. The overarching identified cornerstones consisted of creating ethical frameworks, increasing access to digital tools, and continuous trend analysis. CONCLUSIONS: The use of digital tools in the field of substance use is linked to a range of risks and opportunities that need to be managed. The current trajectories of the use of such tools are heavily influenced by large multinational for-profit companies with relatively little involvement of key stakeholders such as people who use drugs, service providers, and researchers. The current funding models are problematic and lack the necessary flexibility associated with best practice business approaches such as lean and agile principles to design and execute customer discovery methods. Accessibility and availability, digital rights, user-friendly design, and person-focused approaches should be at the forefront in the further development of digital tools. Global legislative and technical infrastructures by means of a global action plan and strategy are necessary and should include ethical frameworks, accessibility of digital tools for substance use, and continuous trend analysis as cornerstones.

Negotiating an Illicit Economy in the Time of COVID-19: Selling and Buying Dilemmas in the Lives of People Who Use Drugs in Scotland.

The impact of COVID-19 itself and societal responses to it have affected people who use drugs and the illicit drug economy. This paper is part of a project investigating the health impacts of COVID-19 related control measures on people who use drugs in Scotland. It examines their roles and decisions as economically situated actors. It does this within a moral economy perspective that places economic decisions and calculations within a context of the network of social obligations and moral decisions. The paper uses a mixed methods approach, reporting on a drug trend survey and in-depth interviews with people who use drugs. It finds they were affected by restrictions in the drug consumption context and changes in the supply context, both in terms of what was supplied and changes in the relationship between sellers and buyers. Face to face selling became more fraught. Participants in more economically precarious circumstances were faced with dilemmas about whether to move into drug selling. The double impact of loss of income and reduced access to support networks were particularly difficult for them. Despite the perception that the pandemic had increased the power of sellers in relation to their customers, many full-time sellers were reported to be keeping their prices stable in order to maintain their relationships with customers, instead extending credit or adulterating their products. The effect of spatial controls on movement during the pandemic also meant that the digital divide became more apparent. People with good access to digital markets and easy drug delivery through apps were in a better position to manage disruption to drug sales contexts. We make recommendations in relation to how policy can respond to the interests of people who use drugs in a pandemic.

Potential Influences of the Darknet on Illicit Drug Diffusion.

Purpose of Review: Darknet-hosted drug markets ('cryptomarkets') are an established model of illicit drug distribution which makes use of specialised online hosting and payment systems to link buyers and sellers remotely. Cryptomarkets appear to professionalise, gentrify and integrate drug markets. Therefore, they can be hypothesised to have effects on drug availability by allowing purchases by people who use drugs (PWUD) outside of face-to-face networks that have typified drug distribution. They may attract new buyers and may change use patterns by offering a greater range of higher-potency drugs. This paper examines the research on cryptomarkets' potential impacts on drug availability. Recent Findings: 1. Cryptomarkets tend to address established PWUD who mainly already have access to existing distribution systems. Their greatest impact may be on what is available and the quantities available, and not the overall ease of access.2. Cryptomarkets may provide new data sources which can inform our understanding of drug markets.3. Cryptomarkets may define PWUD as consumers and contribute to reshaping their identities around principles of self-directed, informed consumption.4. In terms of size, cryptomarkets are currently smaller than other modes of digital drug distribution such as through social media and messaging apps and should be seen as a specialist subset of that genre.5. Users of cryptomarkets often integrate drug-purchase and consumption repertoires across multiple sites, online and offline, and cryptomarkets can be one element. Summary: The cryptomarkets are of interest partly because they alter the practical calculus around drug diffusion and partly because they contribute to the formation of digitally enabled drug use which emphasises a consumer relationship between buyer and seller.

Stakeholder views of current laws surrounding alcohol at UK football matches: Is it a case of using a "sledgehammer to crack a nut"?

BACKGROUND: In 2021, a fan-led review of football governance in England recommended that legislation surrounding alcohol and football be reviewed to determine whether it is still fit for purpose, the first such review since the mid-1980s. Restricting football fans' alcohol consumption has been debated in the UK for over 40 years. However, more research is needed into the current attitudes of fans and influential stakeholders on this matter. METHODS: Focus groups with football supporters (n=79) and semi-structured interviews (n=15) with key organisational stakeholders were conducted between November 2019 and February 2021. Focus groups included fans who regularly attended matches and supported various teams from professional leagues in Scotland and England, casual fans who usually watched games at home or in bars, and fans who followed the Scotland and England national teams. Stakeholders were selected to represent organisations likely to be instrumental in any regulatory change, such as the UK and Scottish Governments, Police, football supporters' groups and safety organisations. RESULTS: The current law does not allow for alcohol to be consumed within view of the pitch. Participants from England suggested this could be changed. While in Scotland, where the legislation only allows alcohol to be sold in hospitality, most participants were in favour of allowing the general sale of alcohol at football stadia via a pilot scheme. The reasons for these changes included: reducing unhealthy drinking behaviours; minimising the health and safety risk of fans arriving at the stadium just before kick-off; and a potential increase in much needed revenue for clubs. CONCLUSION: Our data suggests an evidence-based review of current laws regarding alcohol and football may be appropriate. However, any discussion regarding changes to the law regarding alcohol at football stadia, including potential pilot schemes, should be evaluated and monitored in terms of both financial impact and the impact on public health and safety.

The impact of COVID-19 on access to harm reduction, substance use treatment and recovery services in Scotland: a qualitative study.

INTRODUCTION: People who use drugs (PWUD) are considered vulnerable to COVID-19 exposure and the sequelae of infection due to their social circumstances, health conditions, drug purchasing, and substance use. They can depend on access to services that provide harm reduction, substance use treatment, recovery and support, and general healthcare. Social distancing measures and service restrictions posed significant challenges to the health and wellbeing of PWUD. METHODS: Ethical approvals were secured. PWUD were recruited from voluntary sector homeless and housing, harm reduction, and recovery organisations across central Scotland. Data was collected via semi-structured interviews and analysed using the Framework Method. RESULTS: Twenty nine PWUD participated and reported mixed experiences of the impacts of COVID-19 lockdown. Several benefitted from policy and practice developments designed to sustain or increase access to harm reduction services. Some PWUD reported improved access to substitute prescribing and/or appreciated being trusted to manage multiple take-home doses. Others noted the loss of regular in-person contact with treatment providers and dispensers. Access to recovery support was challenging for many, especially those unable to access or uncomfortable with online provision who experienced greater isolation. Lack of access to general healthcare services was common, and especially problematic for PWUD with chronic physical and mental health conditions. CONCLUSIONS: This qualitative research describes the impacts of COVID-19 social and service restrictions on PWUD in Scotland. These impacts were anticipated by policy makers and service providers. Effective and acceptable developments were shown to maintain and even increase service provision for PWUD. Developments were geographically dependent and significant challenges remained for many people. The learning generated can inform responses to increase service access and uptake in post-pandemic times.

Digital localisation in an illicit market space: interactional creation of a psychedelic assemblage in a darknet community of exchange.

Sociology of drugs and digital sociology-albeit for different reasons-need the analysis of interactions, an approach underdeveloped in current scholarship. We address this gap by providing a specific analytical framework for the analysis of digital interactions which enables an ethnomethodological account of micro-interactional dynamics within a cryptomarket: an anonymous darknet market of  illicit drugs. As a case study we chose the 'PsychForumMarket' which is unusual in that it operates as a forum based market space and explicitly rejects centralised technical market solutions such as escrow and encryption systems. Instead, it emphasises personal relationships between buyers and vendors as the basis of trust. Hence it forms a community of exchange, both material and cultural. The data were collected through a process of manual scraping from the forum from 2017 to 2020. The data was purposefully sampled to construct a 'thick data' set, and analysed thematically to examine the micro interactional turn taking, sanctioning and norming processes by which the market culture is normalized and embedded. This market is a laboratory  to investigate the constitutive nature of digital group interactions. Due to the very nature of this market the disciplining process cannot lie with external authorities. Interactions between community members are permeated with mutual monitoring and policing. We find that in and through digital communication a particular culture emerges to which individuals who wish to join this community have to ascribe. We refer to this particular culture as a 'psychedelic assemblage,' i.e., a local constellation of cultural constructs which frames the experience of drug using and trading. Our investigation reveals the constitutive methods which enable the norming of members' practices and underpin the emergence of a shared lifeworld which in turn ensures the operability of this cryptomarket.

Theorising survivorship after intensive care: A systematic review of patient and family experiences.

AIMS AND OBJECTIVE: This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined. BACKGROUND: Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research. DESIGN: Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed. RESULTS: The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship. CONCLUSION: We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.

Research in fractured digital spaces.

The internet is a medium for research, a place for the exchange of drugs and knowledge, and a method for governing and surveilling drug users. Opportunities for drug research with and in digital spaces are expanding, using internet mediated methods such as online surveys, web scraping, and research with web communities and users of cryptomarkets and apps. As the sphere of social data grows, so does the degree to which data itself is a product of fractured, governed, privatised set of spaces. Research often has to work with these structural aspects and researchers have to be aware of the structural mediation of their data. The opportunities for research also demand that researchers consider the validity of traditional scientific hierarchies such as the assumed superiority of probability sampling, and parse the naturally occurring taxonomies that are produced by the systems they research. A positive development has been the growth of internet focused researchers who operate in and outwith the academy and who are creating an independent research infrastructure with potential for a democratic research politics.

'Nice people doing shady things': Drugs and the morality of exchange in the darknet cryptomarkets.

BACKGROUND: An ethnographic analysis of drug-centred cryptomarket community and exchange, this article explores the embedded values around drug distribution and consumption within this setting. Drawing on our interviews with cryptomarket users, we analyze the ways in which users claim the cryptomarket as a space of morality, empathy, trust, reciprocity, knowledge transfer, harm reduction and self-limitation. The anthropological concept of the morality of exchange is central to our theoretical approach. METHODS: Between December 2014 and July 2017, nine interviews were undertaken with users of drug cryptomarkets. These were conducted in person, using Skype video calling, and using the encrypted 'self-erasing' chat app Wickr. The researchers also used overt non-participant observation (NPO) within the cryptomarket forum. This two-pronged approach - interviews and spending time within the community via NPO - enabled a thick description style of ethnographic analysis. RESULTS: Our research reveals online drug markets less as perfect markets (working to rules of supply and demand) and more as constructive communities of interest that perform and negotiate drug use and supply. We found that participation within these interest communities had practical impact such as changing the type of drug that users consume and the ways in which they participate in street drug supply. Significantly, these values and actions mediate the interface between online action and 'meatspace' (the offline world) and reinforce that the motivations and processes of internet activity are just as 'real' as offline action. CONCLUSION: We redefine the illicit drug focused cryptomarket as a place of exchange, mediation and reciprocity. Real-time knowledge transfer with the aim of harm reduction is one example of the impact of cryptomarket interaction. We caution that this is not a space of kinship and affinity: it is not without its scams, hackers and threats. It is, however, much more than a 'drug marketplace' and to understand how users themselves conceptualise this space is fruitful for any understanding of cryptomarkets. Cryptomarket exchange is a form of social action that is not restricted to its economic value for participants.

Concepts of illicit drug quality among darknet market users: Purity, embodied experience, craft and chemical knowledge.

BACKGROUND: Users of darknet markets refer to product quality as one of the motivations for buying drugs there, and vendors present quality as a selling point. However, what users understand by quality and how they evaluate it is not clear. This article investigates how users established and compared drug quality. METHODS: We used a two-stage method for investigating users' assessments. The user forum of a darknet market that we called 'Merkat' was analysed to develop emergent themes. Qualitative interviews with darknet users were conducted, then forum data was analysed again. To enhance the applicability of the findings, the forum was sampled for users who presented as dependent as well as recreational. RESULTS: Quality could mean reliability, purity, potency, and predictability of effect. We focused on the different kinds of knowledge users drew on to assess quality. These were: embodied; craft; and chemical. CONCLUSION: Users' evaluations of quality depended on their experience, the purpose of use, and its context. Market forums are a case of indigenous harm reduction where users share advise and experiences and can be usefully engaged with on these terms.

'I came back here and started smoking again': perceptions and experiences of quitting among disadvantaged smokers.

This paper draws upon qualitative research with 100 smokers (50 male and 50 female) in two Scottish areas of disadvantage to investigate their perceptions and experiences of quitting. The fieldwork took place between 1999 and 2000, with data collected through in-depth individual interviews and the completion of a smoking day grid. While many interviewees wanted to quit, they drew on their understandings of habit and addiction to illustrate the difficulties which quitting posed. Addiction was referenced through accounts of actual and anticipated unpleasant withdrawal symptoms, while accounts of the difficulties associated with quitting drew primarily upon habitual usage and routine aspects of their lives. Interviewees reported interacting frequently with other smokers. They also highlighted how stressful aspects of their lives perpetuated habitual smoking and prompted relapse following periods of cessation. Although the contexts inhabited by the interviewees were crucial in inhibiting successful quitting attempts, these factors acted in conjunction with and exacerbated feelings of physiological dependence on tobacco. Interviewees were sceptical about the effectiveness of nicotine replacement therapy (NRT) other than in the immediate or short term. For the most part, interviewees felt that NRT could not address aspects of their lives that appeared to support and sustain smoking in the long term. The paper concludes that in order to facilitate and sustain smoking cessation, tobacco control interventions need to tackle both nicotine addiction and the material circumstances experienced by disadvantaged smokers.

"It's like an addiction first thing...afterwards it's like a habit": daily smoking behaviour among people living in areas of deprivation.

The paper draws on qualitative interviews with a sample of male and female smokers who live in areas of disadvantage in Edinburgh, Scotland, to examine their perceptions of habit and addiction and the implications for smoking behaviour. The paper shows how smokers have a sophisticated understanding of these concepts and the way in which they affected their smoking behaviour across the course of a 'typical' day. The paper argues that daily contexts which smokers inhabit either constrain or facilitate smoking and as such play a central role in the way in which they smoke. In contexts where smoking was constrained (by externally or self-imposed restrictions) smokers described how they employed various strategies to achieve and maintain what they perceived to be a desirable level of nicotine intake, such as by anticipatory smoking. Where restrictions on smoking were absent, men's and women's smoking appeared remarkably similar. However, for the most part, the contexts which men and women inhabited over the course of the day differed, with women assuming the largest share of domestic and child care responsibilities. Apparent gender differences in smoking behaviour appeared to be related to the different daily contexts which men and women inhabited. Crucially, the influences on smoking described by respondents in this study were closely related to circumstances of socio-economic deprivation.