Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2015 Jan 1.
Published in final edited form as: Drug Alcohol Depend. 2013 Oct 27;134:10.1016/j.drugalcdep.2013.10.013. doi: 10.1016/j.drugalcdep.2013.10.013

Gender Differences in Circumstances Surrounding First Injection Experience of Rural Injection Drug Users in the United States

April M Young a,b,*, Nika Larian c, Jennifer R Havens b
PMCID: PMC3874445  NIHMSID: NIHMS535388  PMID: 24216393

Abstract

Background

Research has demonstrated that there can be substantial gender differences in circumstances surrounding initiation of injection drug use; however, little is known about the gendered dynamics of first injection in rural areas where syringe exchange is inaccessible or among those who predominantly inject prescription medications. The present study examines gender differences in first injection experience among rural residents who predominantly inject prescription opioids.

Methods

Interview-administered questionnaires collected data from a sample of injection drug users (n=394) recruited from Appalachian Kentucky using respondent-driven sampling.

Results

Women were more likely to have initiated injection due to social-pressure (p=0.001), received the drugs as a gift (p=0.011), initiated in their partner’s home (p=0.004) and in their partner’s presence (p<0.001), been injected by their partner (p<0.001), used an unclean syringe (p=0.026), and received the syringe from their partner (p<0.001). Women were also more likely to report having engaged in sexual intercourse before or after initiation (p<0.001). Men were more likely to have personally purchased the drugs (p=0.002), to have acquired the syringe from a pharmacy/clinic (p=0.004), and to have injected with a friend (p=0.001) or family member (p=0.020). Men were also more likely to have a friend administer the first injection (p=0.007).

Conclusions

In this population of rural drug users, notable gender differences in injection initiation were observed. Social pressure played a more substantial role in women’s first injection experience, and male partners had an integral role in women’s initiation.

Keywords: gender, injection drug use, nonmedical use of prescription drugs, risk behavior, rural

1. INTRODUCTION

Injection drug use is a well-established risk factor for blood-borne infections such as HIV and hepatitis C (HCV; Alter, 2002; Centers for Disease Control and Prevention, 2009), as well as drug dependence (Gossop et al., 1994; Strang et al., 1999) and overdose (Gossop and Griffiths, 1996). Numerous contextual factors influence drug users’ likelihood of initiating injection, and the circumstances surrounding the first injection experience are often laden with complex sociocultural norms, particularly those associated with gender. While both sexes commonly report curiosity as the motivation for initiating, women are more likely to cite social network influences (e.g., desire to emulate network members’ behavior, experience pressure from network members, be encouraged by sexual partner) as a reason to start injecting (Frajzyngier et al., 2007). At first injection, women are less likely than men to administer the injection (Draus and Carlson, 2006; Evans et al., 2003; Frajzyngier et al., 2007; Goldsamt et al., 2010), more likely to share equipment (Barnard, 1993; Evans et al., 2003; Frajzyngier et al., 2007; Macrae and Aalto, 2000; Neaigus et al., 2007; Tortu et al., 2003), and more likely to be injected by men, particularly their sexual partners (Crofts et al., 1996; Diaz et al., 2002; Frajzyngier et al., 2007). Male partners also often facilitate women’s initiation by purchasing or obtaining the drugs (Bryant and Treloar, 2007; Simmons et al., 2012). These phenomena can be driven by gender norms (Davies et al., 1996; Simmons et al., 2012) and feelings of trust and intimacy (Davies et al., 1996; Macrae and Aalto, 2000; Martin, 2010; Neaigus et al., 1995; Simmons et al., 2012). The drug-using and sexual networks of female injection drug users often have greater overlap than do men’s, thus potentially exacerbating women’s risk of blood-borne infection (Latkin et al., 1998).

While these studies have provided insight into gender differences in injection practices in urban settings and among users of heroin, cocaine, and crack (e.g., (Bryant and Treloar, 2007; Frajzyngier et al., 2007; Simmons et al., 2012), little is known about gender differences in injection among rural drug users or among users who primarily inject prescription medications. Some research suggests that injection of prescription medications is more prevalent among drug users in rural areas compared to those from urban settings (Young et al., 2010), and that use of prescription opioids, particularly oxycodone, may hasten the transition from non-injection to injection (Young and Havens, 2011). Furthermore, most of the studies conducted to date on initiation of injection have been based in urban areas where syringe exchange programs are available and/or where possession of drug paraphernalia is not criminalized (Bryant and Treloar, 2007; Frajzyngier et al., 2007; Novelli et al., 2005; Sherman et al., 2005; Simmons et al., 2012). This may present a significant gap in understanding given evidence suggesting that syringe availability and policing practices can have a major influence on drug users’ ability to practice risk reduction (Cooper et al., 2005).

The present study was conducted in rural Appalachian Kentucky, where drug paraphernalia laws prohibit the possession of syringes and syringe exchange is unavailable (Kentucky Legislative Research Commission, 2005, 2010). Illicit prescription drug use is prevalent in this population (Kentucky State Epidemiological Outcomes Workgroup, 2011; Young et al., 2012; Zhang et al., 2008) and, unlike many urban populations examined in previous research, the most common drug used at initiation of injection is oxycodone (Young and Havens, 2011). Furthermore, previous research has identified differences in use of illicit drugs such as heroin and marijuana in this population, speculatively attributed to complex gender norms, roles, and stereotypes (Shannon et al., 2011). No study to the authors’ knowledge has examined gender differences in injection initiation in this population; therefore, the purpose of the present study was to describe and compare the first injection experience of male and female nonmedical users of prescription drugs recruited from rural Appalachia.

2. METHODS

Data were collected from drug users (n=503) enrolled in the ongoing Social Networks among Appalachian People (SNAP) study (sample and methods described elsewhere (Young and Havens, 2011)). Eligibility criteria included being at least 18 years of age, residing in Appalachian Kentucky, and having used at least one of the following to get high in the past 30 days: prescription opioids, heroin, crack/cocaine or methamphetamine. Respondent-driven sampling (Heckathorn, 1997, 2002) was used for recruitment and interviewer-administered questionnaires were used to collect self-reported data between November 2008 and August 2010. For the present analysis, only data from injection drug users (n=394; 231 men [59%]; 163 women [41%]) were included. The Institutional Review Board at the University of Kentucky approved the protocol.

Questions about first injection experience assessed the following: major reason for first injection (coding described in Table 1), location, drugs used, source of drugs used, source of syringe, cleanliness of the syringe, individuals present, sexual behavior before/after injection, who administered the injection, intoxication of self and/or the person administering the injection, and awareness of HIV risk posed by injection. Data on age at first injection, age of person who administered first injection (if applicable), and amount of time elapsed between the first injection and becoming a ‘regular injector’ were also collected. Finally, respondents were asked if they had ever initiated someone else to injection, and if so, whom. Gender-stratified analyses of continuous dependent variables were conducted using Mann-Whitney U-tests performed with SPSS 20.0 (Chicago, IL). Rao Scott chi-square analyses were conducted in SAS version 9.3 (Cary, NC) and weighted for RDS recruitment using individualized weights produced by RDS Analytical Tool (RDSAT) version 7.1 (Volz et al., 2012).

Table 1.

Characteristics of first injection experience by gender (n=394)

Total – n(%) Male – n(%) Female – n(%) p-value
Age at first injection – median (IQR) 24.0 (20.0 – 30.0) 24.0 (20.0 – 28.0) 24.0 (20.0 – 30.0) 0.237
Reason for first injection
 Curiosity a 243 (65.5) 155 (71.1) 88 (57.5) 0.053
 Social pressure b 59 (15.0) 23 (10.0) 36 (22.1) 0.011*
 Emotional distress c 17 (4.3) 7 (3.0) 10 (6.1) 0.201
 Transitioned from oral/nasal 30 (7.6) 23 (10.0) 7 (4.3) 0.130
 Injection was normative d 18 (4.6) 7 (3.0) 11 (6.7) 0.196
 Other 16 (4.1) 8 (3.5) 8 (3.5) 0.176
Condition at first injection
 Sober 194 (49.2) 114 (49.4) 80 (49.1) 0.813
 Intoxicated (drugs or alcohol) 174 (44.2) 106 (45.9) 68 (41.7) 0.541
 Ill from withdrawal 26 (6.6) 11 (4.8) 15 (9.2) 0.055
Source of drugs for first injection
 Received as a gift 134 (34.0) 61 (26.4) 73 (44.8) 0.005**
 Purchased 253 (64.2) 168 (72.7) 85 (52.1) 0.002**
 Other 7 (1.8) 2 (0.9) 5 (3.1) --
Location of first injection
 Personal residence 294 (74.6) 173 (74.9) 121 (74.2) 0.936
 Partner’s home 21 (5.3) 3 (1.3) 18 (11.0) 0.004**
 Dealer’s home 5 (1.3) 4 (1.7) 1 (0.6) --
 Car 24 (6.1) 14 (6.1) 10 (6.1) 0.984
 Party 15 (3.8) 12 (5.2) 3 (1.8) 0.023*
 Public space 15 (3.8) 12 (5.2) 3 (1.8) 0.224
 Hotel 5 (1.0) 2 (0.7) 3 (1.4) --
 Other 6 (1.5) 3 (1.3) 3 (1.3) 0.815
Who was present at first injection
 Alone 62 (15.7) 44 (19.0) 18 (11.0) 0.518
 Friend 223 (67.2) 141 (75.4) 82 (56.6) 0.001**
 Partner 66 (19.9) 13 (7.0) 53 (36.6) <0.001**
 Immediate family 20 (6.0) 16 (8.6) 4 (2.8) 0.020*
 Extended family and/or in-laws 28 (8.4) 17 (9.1) 11 (7.6) 0.590
 Other 8 (2.4) 6 (3.2) 2 (1.4) --
Sexual behavior at first injection
 Before injecting 20 (5.1) 6 (2.6) 14 (8.6) 0.045*
 After injecting 57 (14.5) 19 (8.2) 38 (23.3) <0.001**
Aware of HIV risk posed by IDU 283 (71.8) 174 (75.3) 109 (66.9) 0.411
Time passed between becoming a regular injector
 Never became a regular injector 142 (36.0) 82 (35.5) 60 (36.8) 0.462
 Less than one week 114 (28.9) 61 (26.4) 53 (32.5) 0.475
 Less than six months 85 (21.6) 52 (22.5) 33 (20.2) 0.534
 Less than one year 17 (4.3) 13 (5.6) 4 (2.5) 0.188
 Less than 5 years 29 (7.4) 18 (7.8) 11 (6.7) 0.652
 More than 5 years 7 (1.8) 5 (2.2) 2 (1.2) 0.470
Open in a new tab

IQR: Interquartile range; IDU: injection drug use

*

p<0.05,

**

p<0.01

a

Includes: “curious to know”, “didn’t know what to expect”, “felt adventuresome”

b

Includes: “felt pressured into it”, “wanted to be cool”, “Sister talked [me] into it”

c

Includes: “depressed/having problems”, “marital problems”

d

Includes: “best friend/partner was [injecting] and [I] … gave it a try”, “everyone was doing it”

3. RESULTS

Contextual factors surrounding first injection are described in Tables 1 and 2. The median age for initiation of injection was 24 years. Approximately 36% reported that they never became a regular injector. The majority of men and women reported curiosity as the primary reason for first injection (71% and 58%, respectively), that their personal residence was the location for first injection (75% and 74%, respectively), that a friend was present (75% and 57%, respectively), and that they personally purchased the injected drugs (73% and 52%, respectively). The first injection was most commonly administered by a friend for both men (56%) and women (44%), though 30% of women reported that a partner had administered the injection and 26% of men reported they had administered their own. Among those who did not administer their own injection (n=311), 80% reported that the person injecting them was intoxicated at the time. For men and women, the most common source of the syringe used at first injection was a friend/acquaintance (42% and 37%, respectively), followed by a diabetic (22% and 18%, respectively). Overall, 10% reported that the syringe had previously been used.

Table 2.

Characteristics of administration of first injection by gender (n=394)

Total – n(%) Male – n(%) Female – n(%) p-value
Person administering injection
 Self 83 (21.1) 59 (25.5) 24 (14.7) 0.291
 Partner 57 (14.5) 8 (3.5) 49 (30.1) <0.001**
 Siblings 15 (3.8) 11 (4.8) 4 (2.5) 0.104
 Extended family 25 (6.3) 15 (6.5) 10 (6.1) 0.591
 Friend 201 (51.0) 129 (55.8) 72 (44.2) 0.007**
 Other 13 (3.3) 9 (3.9) 4 (2.5) 0.942
Age of person administering injection (n=311) – median (IQR) 26.0 (22.0 – 32.0) 25.0 (22.0 – 30.0) 28.0 (24.0 – 35.0) 0.007**
Condition of person administering injection (n=311)
 Sober 56 (18.0) 37 (21.5) 19 (13.7) 0.295
 Intoxicated (drugs or alcohol) 250 (80.4) 132 (76.7) 118 (84.9) 0.251
 Ill from withdrawal 5 (1.6) 3 (1.7) 2 (1.4) --
Source of syringe for first injection
 Partner 32 (8.1) 4 (1.7) 28 (17.2) <0.001**
 Family 50 (12.7) 30 (13.0) 20 (12.3) 0.107
 Friend/acquaintance 158 (40.1) 97 (42.0) 61 (37.4) 0.480
 Pharmacy/clinic 24 (6.1) 21 (9.1) 3 (1.8) 0.004**
 Diabetic 81 (20.6) 51 (22.1) 30 (18.4) 0.288
 Drug/syringe dealer 33 (8.4) 18 (7.8) 15 (9.2) 0.085
 Other 16 (4.1) 10 (4.3) 6 (3.7) 0.993
Syringe had previously been used 38 (9.6) 16 (6.9) 22 (13.5) 0.026*
Open in a new tab

IQR: Interquartile range

*

p<0.05,

**

p<0.01

As displayed in Table 1, women were significantly more likely to have initiated injection due to social-pressure (e.g., “felt pressured into it” or “wanted to be cool”; p=0.011). Women were more likely to report having received the drugs for first injection as a gift (p=0.005), and men were more likely to have purchased the drugs (p=0.002). Women were also more likely to have initiated injection in their partner(s)’ home (p=0.004) and in their partner(s)’ presence (p<0.001), and were more likely to have engaged in sexual intercourse before or after first injection (p=0.045 and p<0.001, respectively). In contrast, men were more likely to have initiated injection with a friend (p=0.001), or with an immediate family member (p=0.020).

Gender differences in administration of the first injection are described in Table 2. Women were more likely to report that their partner administered the first injection (p<0.001), while men were more likely to report that it was administered by a friend (p= 0.007). The median age of the person administering the first injection was significantly older among women (p=0.007). Women were more likely to report that the syringe had been previously used (p=0.026). Women were more likely to report that the syringe was provided by a partner (p<0.001), while men were more likely to have acquired theirs from a pharmacy/clinic (p=0.004).

There were no gender differences in age at initiation, condition at injection, drugs used, or time elapsed from initiating to becoming a regular injector. Of note, 25% of participants reported having initiated someone else to injection, a behavior that was more common among men (31%) than women (18%, p=0.009). Among those who had initiated someone to injection (n=100), significantly more men (20%) reported having initiated a partner than did women (6%, p=0.015). However, significantly more women (88%) than men (66%) reported having initiated a friend (p=0.019).

4. DISCUSSION

Few studies to date have examined the circumstances surrounding men and women’s injection initiation in settings where syringe exchange is unavailable, possession of drug paraphernalia is criminalized, and the predominant drugs of abuse are prescription opioids. In this rural sample of nonmedical users of prescription drugs, social factors played a larger role in women’s first injection experience than in men’s. Women were more likely to report social pressure as the primary reason for their first injection, were more likely to report that they received the drugs and syringes from someone else, and were less likely to have used a clean syringe. These findings are consistent with previous studies (e.g., Crofts et al., 1996; Diaz et al., 2002; Draus and Carlson, 2006; Evans et al., 2003; Frajzyngier et al., 2007; Goldsamt et al., 2010). Similarly consistent with previous research (Bryant and Treloar, 2006; Robertson et al., 2010; Simmons et al., 2012), the present study found that partners played an important role in women’s first injection experience. Women were more likely to report being with their partner and in their partner’s home during their first injection, that their partner administered the injection and provided the syringe, and that they had sexual intercourse before or after injecting.

The majority of men and women injected in their personal residences and acquired their needles from sources aside from pharmacies. These findings should be interpreted in light of contextual circumstances, as criminalization of syringe possession and strict regulation of needle provision (Kentucky Legislative Research Commission, 2005, 2010) may have prompted individuals to inject in more “private” spaces and to seek non-medical sources of syringes. The ubiquity of the syringe possession policy may underlie the absence of a gender-difference in injection location in this population. However, the finding that men were more likely to acquire the needle for their first injection from a pharmacy is notable, and suggests that current policies may not have a uniform impact. Future qualitative research would be especially helpful in determining if there are gender differences in how drug users in this region are impacted by current drug policies and enforcement.

No gender differences in the types of drugs used at first injection, intoxication at first injection, length of time between first injection and “becoming a regular injector”, or age at first injection were observed. The latter finding is consistent with that of similar studies (Bryant and Treloar, 2007; Frajzyngier et al., 2007). Previous research in this population suggests that there was a spike in injection initiation around the year 1995. While causality cannot be determined, it is notable that this is when oxycodone entered the market and oxycodone has been associated with rapid transition from first use to injection in this population (Young and Havens, 2011). Thus, the absence of a gender-difference in age at first injection in this population may be a product of the pervasiveness of nonmedical use of oxycodone at the time of the interviews (2008–2010).

The findings from this study should be interpreted in the context of the study’s cross-sectional design and reliance on self-reported behavior. Despite limitations, however, the study is one of the first to provide insight into the gender dynamics of injection drug use in a rural setting. The data provide strong evidence that interventions aimed at preventing the initiation of injection in this setting should take into account social dynamics and gender norms. Interpersonal relationships, particularly women’s agency within relationships, are shaped by complex economic realities and sociopolitical forces; additional qualitative research would be especially valuable to exploring these dynamics and providing insight into the role that empowerment and structural-level intervention could play in curbing injection in this population. Findings from this study clearly suggest that programs targeting male partners should be considered and designed with the aim of reducing their personal risk for initiating injection, as well as their likelihood of facilitating the initiation of female partners. An ideal intervention in this setting would involve the establishment of a syringe exchange program; however, current policies prohibit this approach. In the short-term, interventions that align with or circumvent current policy, such as the promotion and distribution of bleach for needle cleaning and improved access to mental health and substance abuse treatment, will be necessary. To appropriately design such programs, more research is needed to fully capture the lived experience of these rural injection drug users and the circumstances surrounding their first injection.

Acknowledgments

Role of Funding Sources

Funding for this study was provided by the National Institute of Drug Abuse (R01-DA02498 to JRH). NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Contributors

Jennifer Havens designed the study and wrote the protocol. Nika Larian conducted literature searches, provided summaries of previous research studies, and assisted with drafting the Introduction. April Young conducted the statistical analysis and drafted the complete manuscript. All authors contributed to and have approved the final manuscript.

Conflict of Interest

All authors have no conflict of interest in relation to this research.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributor Information

April M. Young, Email: amyoun2@emory.edu.

Nika Larian, Email: nika.larian@gmail.com.

Jennifer R. Havens, Email: Jennifer.havens@uky.edu.

References

  1. Alter MJ. Prevention of spread of hepatitis C. Hepatology. 2002;36:S93–S98. doi: 10.1053/jhep.2002.36389. [DOI] [PubMed] [Google Scholar]
  2. Barnard MA. Needle sharing in context: patterns of sharing among men and women injectors and HIV risks. Addiction. 1993;88:805–812. doi: 10.1111/j.1360-0443.1993.tb02094.x. [DOI] [PubMed] [Google Scholar]
  3. Bryant J, Treloar C. Risk practices and other characteristics of injecting drug users who obtain injecting equipment from pharmacies and personal networks. Int J Drug Policy. 2006;17:418–424. [Google Scholar]
  4. Bryant J, Treloar C. The gendered context of initiation to injecting drug use: evidence for women as active initiates. Drug Alcohol Rev. 2007;26:287–293. doi: 10.1080/09595230701247731. [DOI] [PubMed] [Google Scholar]
  5. Centers for Disease Control and Prevention. Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007: HIV/AIDS Surveillance Report, 2007. Vol. 19. Department of Health and Human Services; Atlanta, GA: 2009. [Google Scholar]
  6. Cooper H, Moore L, Gruskin S, Krieger N. The impact of a police drug crackdown on drug injectors’ ability to practice harm reduction: a qualitative study. Soc Sci Med. 2005;61:673–684. doi: 10.1016/j.socscimed.2004.12.030. [DOI] [PubMed] [Google Scholar]
  7. Crofts N, Louie R, Rosenthal D, Jolley D. The first hit: circumstances surrounding initiation into injecting. Addiction. 1996;91:1187–1196. doi: 10.1046/j.1360-0443.1996.918118710.x. [DOI] [PubMed] [Google Scholar]
  8. Davies AG, Dominy NJ, Peters AD, Richardson AM. Gender differences in HIV risk behaviour of injecting drug users in Edinburgh. AIDS Care. 1996;8:517–527. doi: 10.1080/09540129650125489. [DOI] [PubMed] [Google Scholar]
  9. Des Jarlais DC, Friedman SR, Perlis T, Chapman TF, Sotheran JL, Paone D, Monterroso E, Neaigus A. Risk behavior and HIV infection among new drug injectors in the era of AIDS in New York City. J Acquir Immune Defic Syndr Hum Retrovirol. 1999;20:67–72. doi: 10.1097/00042560-199901010-00010. [DOI] [PubMed] [Google Scholar]
  10. Diaz T, Vlahov D, Edwards V, Conover S, Monterroso E. Sex-specific differences in circumstances of initiation into injecting-drug use among young adult Latinos in Harlem, New York City. AIDS Behav. 2002;6:117–122. [Google Scholar]
  11. Draus PJ, Carlson RG. Needles in the haystacks: the social context of initiation to heroin injection in rural Ohio. Subst Use Misuse. 2006;41:1111–1124. doi: 10.1080/10826080500411577. [DOI] [PubMed] [Google Scholar]
  12. Evans JL, Hahn JA, Page-Shafer K, Lum PJ, Stein ES, Davidson PJ, Moss AR. Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco (the UFO Study) J Urban Health. 2003;80:137–146. doi: 10.1093/jurban/jtg137. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Frajzyngier V, Neaigus A, Gyarmathy VA, Miller M, Friedman SR. Gender differences in injection risk behaviors at the first injection episode. Drug Alcohol Depend. 2007;89:145–152. doi: 10.1016/j.drugalcdep.2006.12.021. [DOI] [PubMed] [Google Scholar]
  14. Goldsamt LA, Harocopos A, Kobrak P, Jost JJ, Clatts MC. Circumstances, pedagogy and rationales for injection initiation among new drug injectors. J Community Health. 2010;35:258–267. doi: 10.1007/s10900-010-9231-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Gossop M, Griffiths P. Frequency of non-fatal heroin overdose: survey of heroin users recruited in non-clinical settings. Br Med J. 1996;313:402–402. doi: 10.1136/bmj.313.7054.402. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Gossop M, Griffiths P, Powis B, Strang J. Cocaine: patterns of use, route of administration, and severity of dependence. Br J Psychiatry. 1994;164:660–664. doi: 10.1192/bjp.164.5.660. [DOI] [PubMed] [Google Scholar]
  17. Heckathorn D. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl. 1997;44:174–199. [Google Scholar]
  18. Heckathorn D. Respondent-driven sampling II: deriving valid population estimates from chain-referral samples of hidden populations. Soc Probl. 2002;49:11–34. [Google Scholar]
  19. Kentucky Legislative Research Commission. [accessed on May 10 2013];Sale and disposal of hypodermic syringes or needles, KRS 217.177. 2005 http://www.lrc.ky.gov/krs/217-00/177.pdf.
  20. Kentucky Legislative Research Commission. [accessed on May 10 2013];Definitions for KRS 218A.500 and 218A.510 - Unlawful practices - Penalties. 2010 http://www.lrc.ky.gov/krs/218a00/500.PDF.
  21. Kentucky State Epidemiological Outcomes Workgroup. Prescription Drug Trends in Kentucky Short Report. REACH of Louisville, Inc; Louisville: 2011. [Google Scholar]
  22. Latkin CA, Mandell W, Knowlton AR, Doherty MC, Vlahov D, Suh T, Celentano DD. Gender differences in injection-related behaviors among injection drug users in Baltimore, Maryland. AIDS Educ Prev. 1998;10:257–263. [PubMed] [Google Scholar]
  23. Macrae R, Aalto E. Gendered power dynamics and HIV risk in drug-using sexual relationships. AIDS Care. 2000;12:505–516. doi: 10.1080/09540120050123909. [DOI] [PubMed] [Google Scholar]
  24. Martin FS. Becoming vulnerable: young women’s accounts of initiation to injecting drug use. Addict Res Theory. 2010;18:511–527. [Google Scholar]
  25. Neaigus A, Friedman SR, Goldstein M, Ildefonso G, Curtis R, Jose B. Using dyadic data for a network analysis of HIV infection and risk behaviors among injecting drug users. NIDA Res Monogr. 1995;151:20–37. 20–37. [PubMed] [Google Scholar]
  26. Neaigus A, Gyarmathy VA, Miller M, Frajzyngier V, Zhao M, Friedman SR, Des Jarlais DC. Injecting and sexual risk correlates of HBV and HCV seroprevalence among new drug injectors. Drug Alcohol Depend. 2007;89:234–243. doi: 10.1016/j.drugalcdep.2007.01.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Novelli LA, Sherman SG, Havens JR, Strathdee SA, Sapun M. Circumstances surrounding the first injection experience and their association with future syringe sharing behaviors in young urban injection drug users. Drug Alcohol Depend. 2005;77:303–309. doi: 10.1016/j.drugalcdep.2004.08.021. [DOI] [PubMed] [Google Scholar]
  28. Robertson AM, Vera AY, Gallardo M, Pollini RA, Patterson TL, Case P, Nguyen L, Strathdee SA. Correlates of seeking injection assistance among injection drug users in Tijuana, Mexico. Am J Addict. 2010;19:357–363. doi: 10.1111/j.1521-0391.2010.00053.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Shannon LM, Havens JR, Oser C, Crosby R, Leukefeld C. Examining gender differences in substance use and age of first use among rural Appalachian drug users in Kentucky. Am J Drug Alcohol Abuse. 2011;37:98–104. doi: 10.3109/00952990.2010.540282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Sherman SG, Fuller CM, Shah N, Ompad DV, Vlahov D, Strathdee SA. Correlates of initiation of injection drug use among young drug users in Baltimore, Maryland: the need for early intervention. J Psychoactive Drugs. 2005;37:437–443. doi: 10.1080/02791072.2005.10399817. [DOI] [PubMed] [Google Scholar]
  31. Simmons J, Rajan S, McMahon JM. Retrospective accounts of injection initiation in intimate partnerships. Int J Drug Policy. 2012;23:303–311. doi: 10.1016/j.drugpo.2012.01.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Strang J, Griffiths P, Powis B, Gossop M. Heroin chasers and heroin injectors: differences observed in a community sample in London, UK. Am J Addict. 1999;8:148–160. doi: 10.1080/105504999305956. [DOI] [PubMed] [Google Scholar]
  33. Tortu S, McMahon JM, Hamid R, Neaigus A. Women’s drug injection practices in East Harlem: an event analysis in a high-risk community. AIDS Behav. 2003;7:317–328. doi: 10.1023/a:1025452021307. [DOI] [PubMed] [Google Scholar]
  34. Volz E, Wejnert C, Cameron C, Spiller M, Barash V, Degani I, Heckathorn D. Respondent-driven Sampling Analysis Tool (RDSAT) Version 7.1. Cornell University; Ithaca, NY: 2012. [Google Scholar]
  35. Young AM, Havens JR. Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis. Addiction. 2011;107:587–596. doi: 10.1111/j.1360-0443.2011.03635.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Young AM, Havens JR, Leukefeld C. A comparison of rural and urban drug users’ lifetime and recent drug use. Am J Drug Alcohol Abuse. 2012;38:220–227. doi: 10.3109/00952990.2011.643971. [DOI] [PubMed] [Google Scholar]
  37. Young AM, Havens JR, Leukefeld CG. Route of administration for illicit prescription opioids: A comparison of rural and urban drug users. Harm Reduct J. 2010;7 doi: 10.1186/1477-7517-7-24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Zhang Z, Infante A, Meit M, English N, Dunn M, Bowers K. [accessed on May 26 2011];An Analysis of Mental Health and Substance Abuse Disparities and Access to Treatment Services in the Appalachian Region. 2008 http://www.arc.gov/assets/research_reports/AnalysisofMentalHealthandSubstanceAbuseDisparities.pdf.

RESOURCES