Patterns of Opioid Use among Substance-using FSU Immigrants
'What's your drug of choice? Heroin? Oh, you're Russian?'
It is the unanimous perception of participants, both opioid users and treatment providers alike, that the use of opioids, particularly heroin, is widespread among younger members of NYC's Russian-speaking immigrant community. Participants aver that among "Russians... dope is very popular.... more popular than any other drug." In Viktor's experience, Russians' predilection for heroin is so well-known among the City's substance users as to be commonplace knowledge: "almost like all the people that I've met in the treatment programs - 'Oh, what's your drug of choice? Heroin? Oh, you're Russian?'" (Following participants' own usage, the term "Russian" is used herein to refer broadly to individuals from countries of the former Soviet Union.)
Six respondents provided historical explanations for this propensity, noting that, while most illicit drugs were not readily available in the Soviet era, opium products, typically prepared at home from poppies, were in fairly widespread use: "Russians that come from the Soviet Union... [many] of them already are opiate-addicted. Because in my country, we didn't have cocaine... but we had a lot of poppies or poppy fields." (Pavel) Natalia explains that "a lot of" the immigrants who arrived in the U.S. with pre-established addictions to opium "were running from Russia to America to stop using... but once they heard that there's such a thing as heroin... they would switch to heroin." The substance use knowledge and practices of this early wave of immigrants then diffused to a younger generation; as Ivan puts it, older users who, in the Soviet Union, had used "morphine from hospitals, poppy in the kitchen," after immigrating to the U.S. "they shared the secrets. And the young people listened."
While opioid use is uniformly understood by participants to be a problem of the younger generation within the Russian community, heavy drinking is viewed as "old school", an affliction and emblem of one's parents and grandparents that is culturally accepted, especially for men. Although some participants had used alcohol in the past, they were consistent in expressing their strong preference for opioids over alcohol. Four reported paternal histories of alcoholism, with two proffering this as their primary motivation for intentionally avoiding alcohol. As Vladimir states, "My father, he drink all his life. I think he actually made me probably [an addict], and my grandfather died with vodka in his hand."
According to participants, opioid use patterns within the FSU immigrant community appear to be undergoing a shift, with the abuse of particular classes of opioids socially patterned by age cohort. Although there was relatively little abuse of opioids other than heroin within the present sample (only one participant - Viktor, the youngest at age 19 - reported significant abuse of prescription opioids), participants pointed out that illicit use of opioid analgesics is becoming increasingly widespread among teenage members of the FSU immigrant community. Vladimir attests that "I see... sixteen-, seventeen-year old kids... now they all have OxyContin, Percocet, everybody has in their pocket like change." This reported increase in the prevalence of prescription opioid abuse among FSU immigrants who are now adolescents is unsurprising as it mirrors the recent rise of prescription opioid abuse in the U.S. generally, particularly among youth [
41].
Although it has been reported [
17] that FSU immigrant opioid users in the U.S. tend to initiate their drug use careers with opioids, avoiding so-called "gateway" drugs, most participants in the present sample do not conform to this pattern. The majority (70%) initiated heroin use only after cycling through a succession of other drugs. Mikhail reflects that substance use was "like a ladder for me. First cigarettes, weed, and then I started doing cocaine" before ultimately progressing to heroin. This pattern is reversed with the two participants who began using drugs in the FSU prior to immigrating to the U.S., one of whom injected heroin before trying any other illicit drug while the other initiated heroin use very early in her drug use career. Yet providers report that, for most young Russian speakers, at least those whose substance use trajectories began in NYC, "heroin is the last stop on the train, not the first stop."
"Russians just seem to shoot, not sniff"
The uniform preference for injection heroin use in the present sample of opioid users corresponds to participants' perceptions regarding the wider NYC FSU immigrant community; they assert that injection is the predominant route of administration among Russian-speaking heroin users. According to treatment providers, a distinctly high prevalence of injection distinguishes FSU immigrants from other groups of heroin users in NYC.
Although two participants initiated heroin use via injection (one in Moscow and one in NYC), the majority of respondents began using the drug intranasally, progressing to injection after a period of time ranging from a couple days to three years. While treatment providers in the sample claim that "rapid" progression to injection is characteristic of young Russian-speaking heroin users, as has been reported by Isralowitz and colleagues [
17], present data reveal a fair amount of individual variation. Nevertheless, four respondents did attest to remarkably brief periods of intranasal (or, in one case, inhalation) administration of heroin prior to transitioning to injection: Natalia, like Pavel, "started shooting up very quickly... within... a couple of months"; Sergei began injecting "after a week or two" of intranasal use; and Alexandra (whose opioid use began in the FSU) smoked heroin on only two occasions before injecting the drug.
Participants' individual reasons for favoring injection reflect those documented for other groups of heroin injectors [
42‐
44], and include the perceived cost-effectiveness of injection as one's drug tolerance increases and the incomparable rush obtained from injecting heroin. Yet respondents also reported that injecting behavior has particular antecedents in Soviet and post-Soviet culture that may help explain FSU immigrants' distinctively strong preference for this route of administration. Several participants located the genesis of this preference in the Soviet era, when the primary psychoactive substances available, apart from alcohol, were homemade poppy-based formulas which were typically prepared in liquid form and thus had to be injected. As Igor, a Russian-born treatment provider, explained:
"Because it's homemade opiates, they started to inject it. Because [they] cannot sniff homemade liquids. They cannot drink it... there's only one way... they started injecting in Russia, and they come here with now the habit of injecting... now they're ready to continue injecting heroin. That's why a lot of Russians just seem to shoot, not sniff."
Thus, out of necessity, specific behavioral standards normalizing injection may have been forged among Russian that were then carried over into FSU immigrant communities.
Three interviewees advanced the possibility that the commonality of injection in routine Russian medical practice may function to legitimize injection among users of illicit opioids both in Russia and in the Russian immigrant community. Igor explains that, in Russian culture, not only is injection viewed as the safest and most effective mode of ingesting medications, "if you're afraid to [get an] injection, you're a coward. You have to be strong." Ivan further speculates that because blood donation was ennobled as "a part of [one's] social duties" in the Soviet era, some addicts developed "a very good relationship with [the] syringe." As a result of these sociocultural factors, in "the Russian drug addict community", there is "not such a big stigma of shooting... shooting is more acceptable." (Igor)
Social Contexts Structuring Opioid Use within the FSU Immigrant Community
Cultural norms and values: Stigmatization of substance use within FSU immigrant culture
The reported cultural acceptance of injection does not extend to substance use or substance users, however; participants emphasized that an extreme stigmatization of drug users exists within Russian and FSU immigrant culture which stands in marked contrast to the acceptance of heavy drinking. According to these dominant cultural mores, drug use, especially heroin use, invokes multiple shames, as morally reprobate and déclassé: "my family was always telling me drugs is like it's the bottom... you can't have it worse than that" (Pavel). As Natalia elaborates, within this normative value system, drug addicts are viewed as both socially irredeemable: "Basically, once you have a habit... you're a lost cause to society... don't waste your time on them" and contaminated: "old-school Russians, they'll look at drug addicts as garbage... like people with leprosy, you don't want to go near them." Natalia traces the roots of this stigmatization to the treatment of addicts in Soviet and post-Soviet society: "As I was leaving Russia [in 1995]... there were no treatment centers at all. Drug addicts were not treated by anyone and no one wanted to deal with them, so it was like they usually get locked up with crazy people."
Yet, despite - or because of - the heavy stigmatization of drug use within mainstream Russian/FSU immigrant culture, among some FSU immigrants injection heroin use in particular has reportedly begun to accrue a counter-normative, 'outlaw' appeal. Ivan animates this attitude thusly: "They [are] proud to be addicts[s]. It's cool. 'I'm on the needle... I'm cool. Not like you, your life is so boring. My life is cool.'" Likewise, a Russian-born clinical staff member asserts that "when they use heroin, they are very proud... 'I don't drink, I don't do coke. I do heroin. That's a strong drug and I can handle that.'"
One potential ramification of this stigmatization of substance use may be reluctance within the immigrant community to openly discuss and educate youth about illicit drugs and addiction. Participants consistently disavow having had any substantive knowledge of opioids or the addiction process prior to becoming dependent. Marina's assertion that "I didn't know anything ... No information at all" is typical. Natalia implicitly links her ignorance about drugs to a moralization of substance use in which "good," middle-class people stand in contrast to drug users: "My parents were very well-educated... my whole family is like a good family. So no one ever taught me about drugs."
For almost all participants, their ignorance regarding illicit drugs encompassed the potential for developing physical and psychological dependence with continued use of opioids, as well as the physiological symptoms of dependence. Because they lacked an understanding of the highly addictive nature of opioids relative to other substances, three interviewees recounted being unable to recognize what was happening when they first experienced withdrawal symptoms. As Marina vividly describes:
"It was my first withdrawals, and I really don't know what is going on. I thought I just got sick. So when... I felt really terrible, I called my boyfriend [who had become her primary using partner] and I explained to him what is going on, and he just said, 'Listen, welcome to the club.' And I didn't understand. 'What do you mean, welcome to the club?' He said, 'It seems, baby, you hooked up and... from now on you're going to need it just to keep going.'"
The stigmatization of drug use within FSU immigrant culture may also complicate immigrants' harm reduction efforts, as the desire to protect oneself from disease was described as existing in tension with fear of community exposure as a drug addict. A Russian-born treatment provider explains how, for FSU immigrants, particularly youth, presenting oneself to a pharmacy in one's own neighborhood in order to purchase syringes can be fraught with the risk of social shame:
"It's too tight community. If I go to pharmacy to [buy syringes], everybody gonna know it. My relatives could come to the same pharmacy and pharmacist not going to keep my confidentiality. Not in Russian culture [laughs]. He or she definitely going to tell my mother that I do it."
As a result, other, more covert, channels for accessing syringes may be preferred; in addition to secondary exchange from network members, several interviewees reported drug dealers as their primary source of syringes and other injection paraphernalia. Although putatively sterile, the provenance of this dealer-sourced injection equipment is unverifiable.
The "trauma" of the immigration experience: "This is the best medicine"
Another key reason for the appeal of opioids underscored throughout respondents' narratives is the drugs' unparalleled ability to alleviate stress - in particular, the stress of the immigration experience.
Participants uniformly described opioids as psychic armor, a powerful means for coping with the upheaval and dislocation of immigration which most characterized as stressful, or even "traumatic" and "scary". Marina, who emigrated from Moscow at age 30 (at a significantly older age than most participants), describes her feelings upon her arrival in a well-known Russian neighborhood in Brooklyn:
"Actually it was shock for me because in my mind, America was something special. It was like a dream, dream country, and especially New York City... So when I got here, the first place I saw in Brooklyn was Brighton Beach, and I was shocked. It was dirty, a lot of garbage, the bad smell... And this is the first time in my life when I got really scared... .it was hard for me because I didn't know the English... I was depressed, I wasn't sure about my future, I wasn't sure if I made mistake to come in this country."
For these interviewees, opioids initially seemed to provide a benign "emotional crutch", in Anna's words - an anodyne to relieve the pressure of trying to assimilate into a new culture and the fear and loneliness that frequently accompanies these struggles. In Vladimir's view: "I think [heroin] is so popular [in the Russian community] because everybody... came to the new country, they have so much anxiety and this is the best medicine, a lot of people find." Vladimir who, by age 21 was working a high-pressure job on Wall Street with a wife and two children to support, describes his initial experience with heroin as a welcome respite from the pressure to succeed: "It was unbelievable... Nothing I ever felt in my life, that's how I felt... Depression gone, no feelings, I was numb, no work, no wife, no job, no money, nothing existed for seven hours."
For the majority of participants who immigrated to the U.S. during their adolescence, the stresses of immigration were compounded by the developmental pressures that are often emblematic of the teenage years. For these youth, opioids were commonly used to fit in with teenage peers and to camouflage their identity as outsiders in America. "Me moving to the United States being sixteen and like having to dive in into a different culture, different language, different values, different beliefs, different mentality, different everything... I know most of the peers I was with... We [used heroin] to kind of like cope and deal and blend in and like kind of like survive the teenage years in one piece." (Natalia); "I just wanted to... not feel like a white bird in between black birds. I just wanted to be accepted... " (Pavel) An additional strain felt by many of these young immigrants was the burden of parental expectation, a pressure to succeed in America that several participants reported was exerted on them by their families. Pavel reflects that his now-deceased mother made her hopes for him explicit - "I remember my mother [on] the plane... she told me, 'This is your new beginning, new country, new people. Make the best of it.'" - and he rues the fact that, in his mind, he disappointed her expectations through his years of opioid addiction and failed treatment attempts.
Interactional contexts of opioid use: The role of peer networks and romantic partnerships
One of the most robust findings in the present data concerns the specific interactional context in which participants' opioid use initiation and early-stage use occurred; nine respondents began using opioids in the context of peer groups comprised of fellow FSU immigrant youth - small circles of close friends, sometimes including relatives such as cousins and romantic partners as well. For some of these interviewees, witnessing members of their peer group using opioids sparked their curiosity, as they wanted to experience the high their friends were enjoying. Others, like Olga, began using heroin to avoid standing out as different from her circle of teenage friends: "I see everybody's using so... I started using like everybody." In other cases, peers exerted persuasion, even manipulation, to get their friends to try the drug. Mikhail's cousin, who was also his "best friend" and who had already become dependent on heroin, dared him to use the drug for a week and not become dependent. "Ever since then," Mikhail says, "I just, I couldn't stop"; for years thereafter this cousin, along with another close Russian friend, became Mikhail's primary using partners. Within this peer-based interactional context, the use of opioids thus becomes a shared ritual that seemingly functions to enhance interpersonal identification and facilitate bonding with one's Russian-speaking peer group.
The peer group is also a key source of norms regulating youths' substance-use behavior. Reflecting on his teenage years, Pavel explains that: "All my friends... normal guys that I used to just chill with, I see they do it and it's like, well, nothing happened to them... I see the guy's normal... he's got a car, he's living the good life. If he can try it, then... why not me?" Seeing his friends using heroin yet seeming to thrive normalized the behavior for him and reinforced the drug's seductive aura. Viktor captures the way in which opioid use can radiate through a peer network via behavioral modeling: "The certain people that I hung out with, that's when like a wave came. Like as soon as like one of them would try it, like everybody would do it." Thus, peer network connections appear to play a central role in producing and reproducing young FSU immigrants' vulnerability to opioid abuse. It should be noted that, while the social setting of the FSU immigrant peer group dominated interviewees' accounts of the early stages of their opioid use, as these individuals' drug use careers became more established and their dependence increased, there was a concomitant tendency for opioid use to become an increasingly solitary ritual and isolating experience.
Four of the five women in the sample also identified relationships with opioid-using, FSU-born boyfriends or husbands as a salient micro-contextual factor propelling the escalation of their heroin use. In Natalia's case, her boyfriend was a member of the FSU peer network in which she was introduced to heroin. Although three other women began using heroin with a group of platonic Russian-speaking friends, their use intensified to dependence in the context of an emotionally intense - and ultimately, socially isolating - romantic partnership.
For the vast majority of participants, their initiation to IDU occurred within a similar social context as did their initiation to opioid use, with the influence of the FSU immigrant peer network playing a critical role in their transition to injection. Pavel reflects that although he "would never [have] pick[ed] up a needle by myself," being embedded in a circle of opioid-using peers, most of whom were a few years older and had already progressed to injecting heroin, served to normalize this route of administration for him.
Respondents acknowledged that sharing of injection equipment is not uncommon among their FSU immigrant peers, particularly in exigent circumstances. In Pavel's experience, "[sharing] happened a lot... because there was a lot of circumstances... where we had the drugs, but there was no needles." As has been documented with other groups of IDUs [
45], many interviewees explained that while they generally tried to avoid sharing, they were sometimes compelled to do so by extreme levels of physical discomfort and by environmental constraints: "When you're on cravings, you don't really [care] so much. You just need to feel better and... if it's late or something and the pharmacy's closed, I mean everybody... shares needles." (Sergei)
Several interviewees who initially disavowed sharing syringes clarified that they only share with certain people - namely, those with whom they regularly interact and have strong emotional bonds, such as close friends and romantic partners. Highlighting the logistical complications that can promote sharing within a peer group of injectors, Alexandra states, "It was like we were like a group of friends and we always used together, and then we did [share]... sometimes 'cause [our syringes got] mixed and we didn't know which one is whose." According to Mikhail, he and his small network of good friends felt safe sharing with each other: "we would share... but we knew that none of us had anything... " Marina and Olga each noted that they only shared syringes with their current or former boyfriends. These accounts suggest that among FSU injectors different social norms may regulate the sharing of injection equipment with strangers or casual acquaintances, on the one hand, and with intimates, on the other hand, such that the general prohibition against sharing is relaxed within the context of close peer-based groups and romantic relationships. The emotional closeness and trust that characterize these relationships may provide injectors with a false sense of security regarding their risk of HIV/HCV transmission. As if to underscore this point, Marina and Olga volunteered that they strongly suspect they contracted HCV from the boyfriends with whom they had shared injection equipment.
Institutional contexts of opioid use: The role of community establishments
In relating the stories of their initiation into opioid use and injection, four interviewees highlighted the pivotal role played by local businesses in FSU immigrant neighborhoods. These community-based establishments cater to a Russian-speaking immigrant clientele and routinely hire fellow community members for low-skill, low-wage positions - particularly youth with limited work experience and recent immigrants who, if they lack facility in English, may be unable to obtain employment outside the community. These institutional settings provide opportunities for recent immigrants and youth to form social connections with fellow FSU immigrants and, in so doing, may simultaneously function as sites in which immigrants are initiated into opioid use. According to Natalia:
"Every unqualified job that you can possibly have in terms of moving companies, Russian waiters or busboys, dancers, escort service, any type of construction... they all like are shot through with drugs... My ex-husband had a moving company, ninety-five percent of people that worked for him were Russians and ninety-five percent of those people were heroin addicts."
Viktor directly attributes his introduction to heroin and the rapid escalation of his use to the succession of Russian restaurants in Brooklyn in which he worked starting at age 15. He describes these restaurants as locations in which not only is heroin (as well as prescription opioid and cocaine) use widespread among staff, but: "There's [drug dealers] that come to the restaurants [and] the owners wouldn't dare say anything, like they know what goes on and they know how fat their pockets are. Like business goes well for them when they come."
Viktor narrates a life story in which his substance use trajectory paralleled his employment history; as he progressed from busboy to runner to waiter at a series of ever-swankier restaurants and supper clubs in Brooklyn, so too did his heroin use progress from occasional sniffing with a few close friends and co-workers to daily use and ultimately to solitary injecting in the stairwell of his mother's apartment building. Underscoring the key role the Russian restaurant environment played in sustaining his opioid use, Viktor states, "as soon as I got out [of treatment] and got involved in the same circle, that's it. As soon as I would... go back to the same job, the same environment, I'd start using again in a matter of days."
Although Vladimir had already been sniffing heroin for three years by the time he lost his Wall Street job, his new-found work as a driver for an escort service which employed a number of Russian women as escorts served as a convenient source of heroin and provided his entrée into injection. When asked how he began injecting, he explains:
"I found one girl who was from Russia. I was driving escort - instead of Wall Street, of course I lost everything, so I was driving, escort service driver - and she just came from Russia. She knew me so she was shooting dope [in the car]. And she said, 'Why waste eight bags when you can do one?''"
Highlighting the catalytic role that involvement in sex work can play in abetting drug use for some young FSU women, two female interviewees described their work as strippers - work which, they reported, sometimes leads to informal paid sex with male customers - as pivotal to the initiation and escalation of both their substance use in general and their opioid use in particular. As Natalia explains: "We came to the United States and everyone was broke, and what happened to me as... a female teenager, as it happens with many women here, it's either prostitution or dancing, so I was a stripper for seven years... that's how I fell into drugs." According to Natalia and Marina, in the many large strip clubs in the greater NYC area employing stables of FSU immigrant women as dancers, drug use and drug selling are rampant. Marina explains that it was difficult to avoid drugs in this environment: "a lot of customers... used to bring the stuff in the club and share it with the girls... [and] in every club, there was a man who sell this stuff, whatever you want." In addition, Marina felt she needed to use some psychoactive substance in order to cope with the emotional depredations of "danc[ing] almost naked." She started with alcohol, progressed quickly to cocaine, but soon found her drug of choice in heroin; after trying heroin for the first time, she "thought this is my best friend now."
"This is something you can really do things on"
The importance of certain workplace contexts in fueling participants' opioid use helps elucidate a pervasive theme in these interviews - namely, that a central part of heroin's appeal lies in the sense of being "in control" a user may maintain while under the drug's influence. Relative to alcohol and other drugs, participants reported, opioids allow one to remain able to function and work without being obviously impaired. As Pavel puts it, "[Heroin] is something that you could really do things on it, not be like running away from your shadow." For many, heroin initially seemed to "kill the pain," helping them to endure exhausting or degrading work. In Viktor's portrayal, heroin is widely viewed by Russian restaurant staff as a work aide; he recalls the co-worker who introduced him to heroin stating: "Oh, this is the only way that I'm able to work." Moreover, Natalia points out that, in contrast to alcohol, it is easier to conceal one's use of heroin from others - perhaps a critical factor within a culture that heavily stigmatizes substance use: "With heroin, it's one of the drugs that is not very visible when you use it... you can hide and you can camouflage, and it kind of gives you that protection... " Yet, for almost all interviewees, this sense of "control" proved to be illusory, as their dependence ultimately grew beyond their ability to manage.