The social-structural contexts of cannabis consumption and harm reduction among young Nigerian women.

BACKGROUND: Young women remain under-represented in the research literature on young people's cannabis use. This study explored cannabis use and harm reduction practices of young Nigerian women. METHODS: The study draws on 19 in-depth interviews conducted with young women aged 21-35 years who were recruited through time-location sampling in Uyo, Nigeria. Interview transcripts were subjected to thematic coding and analysis. RESULTS: Accounts highlighted a rapid progression from occasional consumption during hang-outs to regular and heavy consumption for most participants. Frequent and heavy cannabis use, shaped by trauma, stress and mental health problems linked to participants' marginal social locations, established a context of risk for health harms. The participants sought to reduce harms by attempting to reduce frequency and quantity of cannabis consumed, often with limited success. They also micro-dosed to monitor drug effects, avoided mixing cannabis with more potent drugs, sought out cannabis strains with lower THC as well as consuming privately to reduce social harms such as violence and police arrest associated with using in street milieus. On the other hand, cannabis consumption was seen as helping to reduce harms by providing a relatively safer and less addictive alternative to drugs such as heroin and pharmaceutical opioids, preventing high-risk sexual exchanges often associated with opioid withdrawal among women, and relieving pain. CONCLUSIONS: Cannabis was consumed recreationally at first, and harmful consumption patterns developed from using cannabis to treat the psychological symptoms of structural inequalities. The analysis supports the social-structural production of drug-related harms, foregrounding the importance of structural-level interventions for creating an enabling environment for safer consumption.

Addiction stigma and opioid use in chronic non-cancer pain management in Nigeria.

This study uses 26 in-depth interviews conducted with people who use drugs (PWUD) who had sought care for chronic non-cancer pain in public health facilities in Nigeria, to explore how drug consumption stigma constitutes patient legitimacy based on neoliberal ideals. It found drug consumption stigma to be salient and pervasive in PWUD health-care encounters, operating through interpersonal interactions and institutionalised policies and practices to shape access to care. Crucially, stigma emerged through disciplinary opioid prescribing and dispensing practices that defined, categorised and marginalised PWUD based on how their drug consumption disrupted normative values of rationality and responsibility. Accounts additionally revealed disengagement from biomedical care and reliance on alternative pain management approaches (e.g. herbal remedies and illegal drugs), which show how structural positions shape the exercise of choice and agency in socially marginalised populations. In conclusion, the study considers the need to improve the health-care experiences of PWUD as a strategy for enhancing health-care engagement and improving health outcomes. It called for interventions to address the structural factors and interactional dynamics that influence stigma in health-care settings as well as for a review of current guidelines and practices to improve access to opioids for chronic non-cancer pain management.

Medicinal use of cannabis: A qualitative study of the perspectives of doctors and pharmacists from six African countries.

We conducted a qualitative study to examine the enablers and barriers influencing the implementation of medical cannabis from the perspectives of practicing doctors and pharmacists within the African context. Interviews were conducted to investigate medical professionals' perceptions and concerns regarding medicinal cannabis. Three major themes were identified: beliefs about consequences, optimism, and environmental resources and context. Depending on the context of use, medical professionals described cannabis as potentially useful as an adjunct medicine and yet problematic owing to knowledge and social barriers, particularly religion. Implementation strategies tailored to address structural and social concerns to providing optimal care are needed to ensure that medical professionals are well versed in policy and clinical aspects.

The socio-economic context of entry and exit from retail drug dealing: Exploring the narratives of Nigerian dealers.

BACKGROUND: There is a significant body of research that shows how economic decline, poor livelihood conditions and limited employment opportunities influence entry into retail drug distribution. Available research, however, neglects the lived experiences and accounts of these dynamics and how they inform exit from the trade, especially in African countries. This study explores the socio-economic context of entry and exit from retail drug distribution in Nigeria. METHODS: Data were gathered through in-depth interviews with 31 male retail drug dealers (aged 26-45 years) in Uyo, Nigeria. They were recruited via snowball sampling from diverse drug networks in the city. Recorded interviews were transcribed verbatim, and a framework approach was applied to code and analyse the data. RESULTS: Most participants took up retail drug trade as a means of income generation under difficult socio-economic conditions. Others entered the trade as part of a youthful search for social autonomy or to pursue entrepreneurial opportunities, although economic conditions formed the wider backdrop of their choices. Participants' social networks, including friends and relations, facilitated their entry into drug trade through linkages to suppliers. For many, the drug trade was seen as offering limited scope for social and economic mobility. This made them to aspire to quit the trade, with some seeing it as a pathway to legitimate livelihoods. Exit prospects were constrained by limited social support and entrenchment in the drug economy. CONCLUSIONS: Since socio-economic conditions are central to both entry and exit from drug trade, these should form the focus of policies addressing retail drug distribution. A development-based approach to policy that seeks to guarantee social and economic rights through the realization of key sustainable development goals offer potential to curb retail drug distribution in Nigeria.

Cannabis use for pain relief in the context of health service barriers: Accounts of street-involved Nigerian women suffering chronic pain.

INTRODUCTION: This study explored cannabis use for pain relief among socially marginalised Nigerian women in the context of barriers to pain management. METHODS: The study was designed as a qualitative exploratory study of pain experience and management. Sixteen in-depth, individual interviews were conducted with street-involved women who use drugs and had chronic pain. Transcripts were coded and analysed thematically. RESULTS: Pain was experienced as a pervasive feature of everyday life that disrupted daily routines, affected economic activities, strained social relationships and had adverse effects on health and wellbeing. Participants sought treatment in health facilities, but faced social and health system barriers to service utilisation including financial cost of services, dismissal of symptoms by providers, stigma due to physical appearance, substance use and lack of social support. These barriers encouraged disengagement from services and reliance on cannabis (along with heroin and diverted prescription opioids) for pain management. Cannabis use relieved pain and improved daily functioning, enabling participants to undertake economic activities. However, using cannabis to enhance the effects of opioids and heavy and long-term use owing to pain chronicity and disability generated concerns about harms. DISCUSSION AND CONCLUSIONS: Findings show the therapeutic benefits of cannabis in the face of barriers to pain management. This support calls to explore the potentials of cannabis for pain management for socially marginalised populations and to develop medical guidelines to reduce the risk of adverse health consequences. Therapeutic cannabis, provided based on medical guidance, could improve pain management for socially marginalised populations.

Consumption, not decriminalization: How Nigerian drug dealers/users account for cannabis harms.

BACKGROUND AND AIMS: Studies have shown that support for cannabis decriminalization and legalization is highest among users, but there is little research on constructions of cannabis decriminalization in the narratives of users who are also dealers. The aim of this study was to explore discursive constructions of cannabis consumption and decriminalization in dealers'/users' accounts of the drug's harms. METHODS: A qualitative study was undertaken in which in-depth interviews were conducted with 31 commercially oriented Nigerian men drug dealers who also use drugs. They were recruited through snowball sampling. Data analysis was based on a social constructionist approach to grounded theory, which emphasizes the role of language and discourse in the construction of reality. RESULTS: While harms from cannabis use were recognized, these were constructed as being relative to consumption practices and user's ability to manage drug effects. Accounts used different discourses and rhetorical strategies to deconstruct popular views of cannabis as a dangerous drug, including minimizing harms by juxtaposing them with harms from more potent drugs as well as with benefits from use. Harms were, however, amplified in relation to decriminalization to delegitimize the policy approach due to concerns about potential increase in consumption and harms to inexperienced consumers. CONCLUSIONS: Constructions of cannabis-related harms in the participants' accounts served discursively to delegitimize cannabis decriminalization, without stigmatizing its use and the users. There exists a need to raise awareness on cannabis decriminalization and legalization as part of measures to bolster support for policy reforms among stakeholder groups (e.g., consumers).

Rationalities of Space and Drug-Related Harms: Accounts of People Who Inject Drugs in Nigeria.

BACKGROUND: Studies have examined how people who inject drugs (PWID) navigate public spaces for drug consumption, but little is known about consumption of drugs in private apartments. This study explores social, structural and physical environment factors influencing injecting practices and the rationalities shaping how PWID make decisions about where to consume drugs. METHODS: The study is based on qualitative data from 41 in-depth interviews conducted with both homeless and housed PWID recruited through snowball sampling in Uyo, Nigeria. Thematic analysis, framed by the theoretical constructs of structural and everyday violence, and situated rationality theories, was undertaken on transcripts. RESULTS: Analysis revealed different socio-spatial rationalities underlying decisions about where to use drugs: avoidance of police arrest, convenience and relaxation, avoidance of drug sharing, avoidance of drug-scene violence, and stigma and shame. These factors show the impacts of social, structural and physical environment factors on the lived experiences of PWID. Injecting in private apartments potentially offset the risk of stigma, police arrest and violence linked to public injecting, but increase the risk of overdose and sharing of drugs and needle-syringes based on social relations of trust. CONCLUSIONS: Findings show that PWID chose between competing risks when deciding on where to inject drugs. Interventions should consider the situated contexts of risk, and adapt harm reduction measures to the risk profile of different populations of PWID.

Structural violence and barriers to pain management during an opioid crisis: accounts of women who use drugs in Nigeria.

Chronic pain management among marginalised populations have been extensively researched in North America, particularly amidst the opioid crisis. But little published research exists on this subject from Africa. This study explored experiences and management of chronic pain among marginalised women in the context of regulation of opioid prescribing using data from 16 qualitative interviews with women who use drugs (WWUD) in Uyo, Nigeria. Chronic pain was exacerbated by structural and everyday violence that acted to marginalise women and create a context of risk for inadequately managed pain. Participants experienced difficulty accessing biomedical pain management due to structural and systemic barriers, including cost, restrictions on opioid prescribing, stigma and other discriminatory practices, communication barriers and lack of social support. Restrictions on opioid prescribing and systemic discriminations against marginalised WWUD encouraged reliance on informal sources for falsified and substandard medications for pain treatment, which increased the risk of harm. Findings highlight a need for multi-component responses that address structural and systemic barriers to pain management, including improving access to opioid medications.

Redefining recovery: Accounts of treatment experiences of dependent cannabis users in Nigeria.

BACKGROUND: Research on addiction recovery describes recovery as a process leading to cessation of drug use. Few researchers have explored alternative views of recovery, and the interplay of individuals' agency and social context in the recovery process. This study explored situated understandings of recovery among cannabis users that emphasized process and contingency. METHODS: We conducted the study in Uyo, Akwa Ibom State in Nigeria. Participants were current (street-involved) cannabis users aged 21 to 34 (n = 97), recruited through time-location sampling. The study collected data through in-depth, individual interviews, which study staff transcribed, coded, and analyzed thematically. RESULTS: Participants' accounts indicated a quest for treatment as a means of recovery and redemption (i.e., repairing an identity damaged by dependent cannabis use). Relapse affected recovery when participants defined the latter as abstinence. Framing recovery this way showed the effects of social and structural factors on individual agency and treatment experiences. Yet some participants' accounts highlighted a redefinition of recovery as a process ("recovering"), measured by such outcomes as reduced drug use and improved overall well-being. CONCLUSIONS: Reframing recovery, as some participants' accounts in our study capture, speaks to the need for treatment programs that are informed by the principles of harm reduction and health promotion. Instead of foisting a singular treatment goal defined as total abstinence onto drug users seeking treatment, treatment should be attuned to the experiences and life circumstances of users and support them in achieving their recovery goals.

Intersectional analysis of cannabis use, stigma and health among marginalized Nigerian women.

Cannabis use by women has been under-researched, particularly use by marginalized women in developing societies. This article draws on qualitative research in Uyo, Nigeria, to explore how intersecting stigmas around social identity categories (e.g. gender, sex work) shapes cannabis use and contributes to health harms for marginalized women. Qualitative data were collected via in-depth interviews with street-involved female cannabis users, and transcribed, coded and analysed thematically. Initiation of cannabis use was influenced by social networks and sexual relationships. Heavy cannabis use enabled some women to perform alternative femininity thereby challenging the boundaries of appropriate gendered behaviour, while others were pressured by normative expectations to enact moderation according to traditional femininity. Recreational cannabis use overlapped with marginalized forms of use, including using heavily to cope with the mental health sequalae of gender-based discriminations and structural inequities. Cannabis use attracted heightened stigma, operating as part of intersecting stigmatizing identities that adversely impacted mental health and wellbeing. Cannabis stigma does not exist in isolation from other social identity categories that shape women's lives. There exists a need to combat stigma through interventions that seek to mediate changes in gender relations, improve living conditions and access to health-care services for marginalized women.

Structural inequities, HIV vulnerability and women's agency: Street-based sex workers in Nigeria.

Drawing from thematic analysis of qualitative data from 27 in-depth interviews with cisgender women street-based sex workers recruited through snowball sampling in Uyo, Nigeria, this article explores structural inequities, HIV vulnerability and women's agency. Structural and gendered inequities influenced women's decision to enter street-based sex work and created conditions that facilitated substance use and increased vulnerability to violence, unprotected sex and HIV transmission. Although women's agency and creative negotiation of structural forces offered possibilities for increased choices, their routine coping strategies ultimately posed as sources of risks. Women's socio-legal position constrained their choices, and this highlights how structural vulnerability is embodied as everyday survival strategies that shape exposure to harm and poor health. Findings indicate a need for policy shift towards decriminalisation of sex work and structural HIV interventions, economic empowerment measures to alleviate poverty and substance use treatment and trauma management services to improve the health and well-being of women involved in street-based sex work.

The lived experience of violence and health-related risks among street sex workers in Uyo, Nigeria.

This study examined the lived experience of violence and health-related risks among street sex workers in Uyo, Nigeria. Data were collected through in-depth, individual interviews with 27 female sex workers recruited through venue-based snowball sampling. Thematic coding and analysis were undertaken on interview transcripts. Findings show that sex workers experienced physical, emotional, sexual and economic violence linked to the criminalisation and stigmatisation of sex work. Violence, perpetrated by clients, police, sexual partners and co-sex workers, was used to coerce unprotected sex and free and unacceptable sexual services; to extort money; to prevent client-snatching; and as moral punishment. Violence harms sex workers' health, undermines condom negotiation and increases STI/HIV risk. Sex workers displayed agency by adopting safety strategies, including screening clients, collaboration, bribing the police for protection and self-defence. Agency was constrained by criminalisation and lack of legal protection. Within this context, the decriminalisation of sex work, the regulation of sex work premises, community mobilisation, economic empowerment and health services are relevant measures for addressing violence and improving sex workers' health.

The Risk Environment for Adopting and Continuing Injecting Drug Use: A Qualitative Study in Uyo, Nigeria.

Background: The bulk of research on adoption of injecting is from Europe and America, despite the existence of syndemics of drug injecting, HIV, and viral hepatitis globally. Objectives: This study explores adoption and continuation of injecting drug use. Methods: The study draws on in-depth interviews with 41 (n = 41) current male and female people who inject drugs recruited via snow-ball sampling in Uyo, Nigeria. A thematic and descriptive analysis was undertaken informed by the risk environment framework and focused on accounts of the factors influencing the process. Results: Accounts emphasized injecting adoption and continuation as a process influenced by individual, social, and structural factors within the risk environment, including concerns for pleasure/efficiency, prestige, exposure to/support for injecting within peer and sexual relationships, availability and purity of drugs, and dependence and increased cost of drug use. Conclusions/implications: Findings highlight the need to prevent adoption of injecting, reduce prevalence of injecting, and promote safe injecting through multi-level interventions, including peer-driven education, drug treatment services, needle and syringe distribution, oral drug substitution, and law enforcement targeting drug suppliers. The need for equivalent pleasure with minimal risk points to the strategic importance of peer interactions for inculcating new understandings of drug use and pleasure.

Multiple Barriers to Utilization of Drug Abuse Treatment by Female Street Sex Workers in Nigeria.

This study investigates barriers to utilization of drug abuse treatment by female street sex workers in Nigeria. Twenty-seven (n = 27) street sex workers were recruited through venue-based snow-ball sampling. In-depth, individual interviews were conducted, and transcripts were subjected to thematic, inductive and data-driven analysis. Sex workers use psychoactive drugs to manage the hazards of street sex work, including guilt, stigma, and violence. While a few denied drug-related harms, doubted treatment efficacy and evinced self-efficacy in managing drug problems, the majority of sex workers recognized drug-related harms and the need for treatment. Inadequate information on services, financial and time cost of treatment, fear of police arrest, stigma and lack of male partner support posed as barriers to drug abuse treatment. Social and structural barriers to treatment utilization violate sex workers' rights to health and exacerbate drug-related harms. Findings highlight the need for changes in policy and societal perceptions of sex work, and multi-level, rights-based interventions to remove barriers to drug abuse treatment for female street sex workers.

Ethnomedical Beliefs and Utilization of Alcohol Herbal Remedy for Malaria in South-Coastal Nigeria.

We studied ethnomedical beliefs and utilization of alcohol herbal remedy for malaria in Uyo, south-coastal Nigeria. In-depth interviews were conducted with 213 respondents aged between 25 to 65 years, who were recruited through venue-based sampling. Malaria is recognized by its symptomatic presentations, which is reflected in different local names for the disease. Local etiological beliefs attribute malaria to mosquito bites, exposure to sunlight, fatigue, witchcraft, and excessive consumption of palm oil. There is a disease-specific preference for alcohol herbal remedies because they are accessible, affordable, and responsive to sociocultural realities. The therapy veils excessive consumption of alcohol with associated risks. Lack of quality control in production and dosage for the administration of these herbal remedies also put users at risk. Local beliefs should be integrated into malaria control programs to enhance community acceptance and participation. Herbal remedies should be subjected to regulation to ensure quality and minimize harms. Community health education should be mounted to improve knowledge of malarial transmission and promote utilization of appropriate health-care services.

Police crackdowns, structural violence and impact on the well-being of street cannabis users in a Nigerian city.

BACKGROUND: There is abundant literature on the impact of law enforcement on cannabis markets, but scant literature on the effects of law enforcement on cannabis users. This study undertook a qualitative exploration of police crackdowns as a form of structural violence and examined their impact on the well-being of street cannabis users in a Nigerian city. METHODS: The study was qualitative and descriptive. It was carried out in Uyo, southern Nigeria. Ninety-seven (97) frequent cannabis users (78 males and 19 females) took part. They were aged between 21 and 34 years and recruited from 11 cannabis hot-points in the city. Data were collected through in-depth, individual interviews, conducted over six-months. Data analysis was thematic and data-driven, involving identifying themes, assigning codes, revising codes and verification by independent qualitative methodology experts. RESULTS: Police crackdowns are commonly experienced by street cannabis users. These do not reduce cannabis use, but displace cannabis markets. Crackdowns are associated with police brutality, confiscation of funds, drugs and belongings, stigma and discrimination, arrest and incarceration, which impacts negatively on the health, livelihoods and well-being of cannabis users. Cannabis users try to escape arrest by running from police, disposing of cannabis, disguising themselves and, when caught, bribing officers to secure release. CONCLUSION: Crackdowns constitute a form of structural violence in the everyday life of cannabis users, and have negative effects on their health and social and economic well-being. Cannabis use should be decriminalized de facto and arrested users directed to treatment and skills training programmes. Treatment and social services for users should be expanded and legal aid interventions should be mounted to support users in addressing discriminatory practices and human rights violations.