THE PERSPECTIVES OF STRUCTURALLY VULNERABLE PEOPLE WHO USE DRUGS ON VOLUNTEER STIPENDS AND WORK EXPERIENCES PROVIDED THROUGH A DRUG USER ORGANIZATION: OPPORTUNITIES AND LIMITATIONS

Abstract

Background

While drug user organizations (DUO) have received public health attention as a means to potentially reduce the harms associated with drug use, there is a lack of research on the compensation and structural forces that promote or inhibit participation in DUO. Against the backdrop of structural vulnerability experienced by people who use drugs (PWUD), we examined the impact of monetary ‘volunteer stipends’ provided through a DUO and explore their role in providing low-threshold employment opportunities and shaping participation in DUO.

Methods

Participants were purposively sampled to reflect a range of perspectives and experiences volunteering at Vancouver Area Network of Drug Users (VANDU) and receiving stipends. Semi-structured qualitative interviews were conducted with 23 members of VANDU. Interview transcripts were coded in Atlas.ti 7 for key a priori themes and emergent categories from the data and analyzed thematically.

Results

Stipends provided participants with symbolic and material recognition of the time, effort, and expertise they contribute to the organization, and functioned to facilitate ongoing participation. Payments that rewarded, skills, labour and drug-related knowledge reduced participant’s perception of stigma against PWUD. Paid work in VANDU further provided participants with non-material benefits commonly attributed to regular employment, including social connections and a sense of purpose. Participants also identified the low level of pay as a limitation of VANDU’s paid participation program. The daily demands of survival (accessing shelter, food, and drugs) posed more complex structural vulnerabilities to participate in VANDU, as small stipends were not sufficient to address these needs.

Conclusion

Low threshold employment opportunities within DUO may provide significant individual and public health benefits. However, these benefits are constrained by the small size of stipends. Therefore, to ensure better inclusion of PWUD, our findings recommend the development and expansion of equitable, accessible, well-paying employment programs for PWUD.

INTRODUCTION

Over the past two decades, drug user organizations (DUO) have gained global attention for peer-driven initiatives resulting in improved health outcomes among people who use drugs (PWUD), including reductions in overdose mortality and the transmission of infectious diseases such as HIV/AIDS (Booth & Watters, 1994; Broadhead, Heckathorn, Grund, & Stern, 1995; Broadhead et al., 1998; Crofts & Herkt, 1995; Garfein et al., 2007; Grund et al., 1992; Hayashi, Wood, Wiebe, Qi, & Kerr, 2010; Kerr et al., 2006; Latkin, 1998; Weeks et al., 2009). Operating in over 40 countries (Frank, Anker, & Tammi, 2012), DUO mobilize “peer” members’ experiential knowledge (Casey & McGregor, 2012) and social networks to engage a wider range of PWUD than conventional health care and social service providers (Crofts & Herkt, 1995; Kerr et al., 2006). DUO originate from grassroots community organizing and activism, fighting against the war on drugs that has negatively impacted PWUD (DeBeck et al., 2017). Although most DUO face considerable organizational challenges stemming from their socio-political origins, including hostile political and legal environments, uncertain funding environments, and the criminalization and marginalization of their membership (Frank et al., 2012; Friedman et al., 1987; Kerr et al., 2006), they have in many instances catalyzed significant drug and health policy reforms and made essential contributions to the advancement of the human rights of PWUD (Frank et al., 2012; Kerr et al., 2006; Osborn & Small, 2006; Ti, Tzemis, & Buxton, 2012).

DUO represent an emancipatory response to interlocking systems of oppression that function to render drug-using populations structurally vulnerable. Notably, laws and policies (e.g., drug prohibition) are instruments that oppress PWUD, and often interact with other oppressions (e.g., racialized drug law enforcement practices, poverty and inequality, structural stigma) to limit their opportunities, adversely impact their social and economic well-being, and exacerbate their degree of vulnerability (Bourgois, Holmes, Sue, & Quesada, 2017). In this context, structural vulnerability can thus be understood as the vulnerability that groups, generally (e.g., PWUD), and certain members of these groups, specifically (e.g., women, Indigenous peoples) experience due to their marginal positions within social hierarchies and can stem from social categories (e.g., gender, race, class, sexuality) and attributed or assumed statuses (e.g., credibility, normality, and deservingness) (Bourgois et al., 2017; Lopez et al., 2013). For the purpose of this article, we conceptualize PWUD as a group that experiences significant vulnerability based on intersecting social and structural factors, including but not limited to: (1) structural inequities, such as drug policies and laws; (2) perceptions, stereotypes, and social norms that stigmatize particular behaviours (e.g., addiction, injection drug use) and groups (e.g., Indigenous peoples, women); and, (3) social inequities in terms of power, status, class, and income.

While DUO work to address the marginalization of PWUD, structural vulnerabilities can also impact their participation in DUO. For example, poverty, criminalization, stigma, and homelessness among PWUD have been shown to pose barriers to participation in DUO (Allman et al., 2006). To increase participation of PWUD, many DUO provide payment for participation in the organization’s activities, ranging from small stipends or honoraria to salaried formal employment. Although paid participation or employment is common among DUO, there is a lack of research on the impact of stipends or wages on participant experiences and health outcomes or how such payments frame the engagement of PWUD with these organizations. Paid employment is commonly associated with significant physical and mental health benefits (Bartley, 1994) and employment predicts decreased mortality among HIV-positive PWUD living in our study setting (Richardson et al., 2013). Thus, research on the impact of paid participation in DUO may help to inform approaches that facilitate PWUD’s access to these same health benefits (Richardson, Sherman, & Kerr, 2012). This is particularly important in the context of limited labour opportunities for marginalized populations under neoliberalism (Braddock & McPartland, 1987; Ross, 2009), coupled with the discrimination and stigma already faced by PWUD (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000).

Vancouver, Canada’s Downtown Eastside (DTES) is an approximately 10-block neighbourhood that is home to an estimated 5000 people who inject drugs and was the site of overlapping overdose and HIV epidemics in the 1990s (Wood & Kerr, 2006). The Vancouver Area Network of Drug Users (VANDU) emerged at this time as a grassroots, PWUD-driven response to the failure of conventional health policies and services to address these epidemics (Kerr et al., 2006). Now a well-established organization, VANDU operates out of a storefront location in the DTES and its membership has grown to include more than 2,000 PWUD. The organization’s activities range from providing support to members through peer education, distributing harm reduction supplies and establishing unsanctioned supervised drug consumption sites, to engaging in targeted political activism on a wide range of issues including housing, poverty, and policing (Kerr et al., 2006; Osborn & Small, 2006; Small et al., 2012; Wood et al., 2003). VANDU provides stipendiary volunteer positions and informal employment to its members, including speaking at demonstrations or protests, participating in educational meetings, working at the reception area, serving as a member of the Board of Directors, and helping with peer support programs (e.g., outreach syringe distribution, injection support teams). At the time this research was conducted, paid participants between $3-$10 CAD per hour (Richardson, Sherman, & Kerr, 2012; Small et al., 2012).

For structurally vulnerable PWUD, stipendiary volunteer work is an accessible, licit form of income generating activity that some rely on to supplement stagnating income assistance rates (Klein & Reaño, 2017), earnings restrictions for income assistance recipients, and limited work opportunities. Previous research has documented the impacts of socio-economic marginalization of PWUD living in the DTES many of which face social-structural barriers to participating in the formal labour market, including health constraints, housing instability, and criminal record restrictions, and addictions treatment restrictions (Richardson et al., 2012; Richardson, Wood, & Kerr, 2013; Richardson, Wood, Li, & Kerr, 2010; Richardson, Wood, Montaner, & Kerr, 2012; Richardson et al., 2015; Richardson et al., 2013). In the absence of formal employment opportunities, PWUD often rely on high-risk income generating activities such as drug dealing, sex work, and other forms of street-based income generation such as recycling and street vending (DeBeck et al., 2011; Krebs et al., 2016; Richardson et al., 2015) that increase their exposure to violence, HIV infection risk, arrest, and incarceration (DeBeck et al., 2007; Richardson et al., 2015; Shannon, Goldenberg, Deering, & Strathdee, 2014; Small et al., 2012). Within this context, stipendiary volunteer work may play a role in the decreased exposure to the risks of street-based and criminalized income generation activities and improved health among PWUD.

This analysis examines how stipendiary volunteer positions provided by VANDU shape organizational participation, and its subsequent influence on health and social outcomes. By drawing on the accounts of DUO members, we explore how these positions function as a form of low-threshold employment for PWUD, as well as the limitations of the positions for PWUD within the context of reduced labour opportunities and overall structural vulnerabilities of PWUD. Finally, we consider the implications of our findings for the operations of DUO and the availability of these types of work opportunities to inform interventions promoting alternative forms of employment for PWUD.

METHODS

This study draws on semi-structured qualitative interviews conducted from May 2010 to April 2011 with PWUD (n=23) who were members and volunteers with VANDU. Members of our research team have collaborated with VANDU since 2001 (Kerr et al., 2006; McNeil, 2014; Small et al., 2012) and were invited by the organization to undertake research into factors that shape members’ engagement with the organization. While this data was collected several years ago, the underlying organizational, social, and structural conditions remain the same and thus the data is still relevant to current context of volunteer stipends.

Participants were purposively sampled in order to reflect a range of types of positions as well as lengths and levels of involvement with the organization (see Table 1 for sample characteristics). Members of the research team attended VANDU meetings and activities to recruit potential participants. Participants were recruited through word-of-mouth in collaboration with VANDU and through the investigators’ network of contacts, which were used to invite and recruit former members, including past presidents and long-term members who were no longer involved with the organization. This was done to ensure a diversity of perspectives regarding participation in VANDU. The VANDU board recommended a number of individuals who were in specific positions (e.g., president, secretary) to participate in interviews, as well as specific members at-large who had various levels of involvement. The investigators also independently recruited a number of individuals who volunteered with specific core VANDU programs (e.g., assisted with harm reduction programming). In these recruitment efforts, we sought to ensure adequate gender representation as well as both more recent or long-term members to obtain a diversity of perspectives on the organization. Recruitment concluded once twenty-three participants had completed interviews because we had reached saturation in data collection and had assembled a sufficiently diverse sample in relation to the characteristics noted above. No participants were excluded.

Table 1.

Sample Characteristics

Sample Characteristics (n=23)
Age
Average	45
Range	32 – 59
Gender
Women	13
Men	10
Ethnicity
White	10
Racialized/Indigenous	11
RNot Reported	2
Years Involved in VANDU
Average	5.5
Range	0.34 – 13

Interviews were conducted at a storefront research office in the DTES using an interview guide that was designed to facilitate discussion of (1) participation in VANDU; (2) the experiences and factors that shaped this participation; and (3) organization members’ perceptions of the impacts of their participation on a range of health and social outcomes. All participants provided written informed consent. Participants received a $20 CAD honorarium for their participation. Interviews were audio recorded and transcribed verbatim by a professional transcription service. Interview transcripts were imported into Atlas.ti 7, qualitative data analysis software program. Transcripts were coded in Atlas.ti 7 to develop a detailed coding framework comprised of key a priori themes identified in the relevant literature as well as emergent categories from interview data. Following the initial data analysis, additional axial coding was used to attribute data segments to emerging conceptual categories. Finally, preliminary findings were presented to the VANDU Board of Directors to solicit feedback and strengthen the interpretive validity of our findings. Research ethics approval was obtained from the University of British Columbia / Providence Health Care research ethics board.

RESULTS

Payment as initial motivator to participate in VANDU

Participants typically learned of VANDU and stipendiary volunteer opportunities through their social networks within the street-based drug scene, emergency shelters, prisons, or health and social services settings in the DTES. Participants described how structural vulnerabilities (e.g., housing instability, drug criminalization, extreme poverty) limited their opportunities for formal employment. Thus, in the context of limited employment opportunities, participants acknowledged that the potential of receiving a three to five-dollar stipend was their initial motivation for seeking low-threshold and stipendiary volunteer opportunities at VANDU. For example:

[Stipends are] a way to make people come, I guess, right? But that’s what made me go in the first place, you know? Honestly. But now, I would go and do stuff. Even if there wasn’t money I would go and do, but that’s what really made me go in the first place. (Participant #18, Indigenous Woman)

I was sort of hanging out, I was new to the city … I didn’t really have that great of finances, and I understood that there were these little meetings that we can partake that were, you know, directed for drug users, and that was me at the time. I heard there was a three-dollar stipend, so three dollars, to me that was, “Wow, I could use those three dollars.” So I went, and then I continued to go, and found out more information about it. (Participant #14, Asian Man)

Due to the considerable time and effort required to meet daily survival needs (e.g., shelter, food) and generate income to purchase drugs and manage withdrawal symptoms and drug cravings against the backdrop of illicit drug criminalization and the broader structural vulnerabilities (e.g., stagnating social assistance rates) participants appreciated the material reward provided by stipends. As one participant explained: “You get to go to a meeting and you get money and … three dollars isn’t that much but I mean you could buy a couple of butts [cigarettes] or pizza or you know something small anyways right?” (Participant #9, African-Canadian Man).

Valuing the time, skills, and labour of PWUD

Stipends also served as a symbolic recognition of the value of PWUD’s time and expertise. In contrast to popular stereotypes characterizing PWUD as ‘lazy’ or ‘chaotic’ that stem from and reinforce their structural vulnerability (Bourgois et al., 2017), participants expressed that stipends acknowledged the steep opportunity cost associated with attending meetings or work shifts at VANDU (e.g., forgoing other activities to meet basic needs). As one participant explained, “[Stipendiary volunteering] gives people a chance to get a sandwich – ‘cause everybody’s missing something when they’re at a meeting” (Participant #3, Woman). Moreover, stipendiary volunteer opportunities acknowledged and valued drug-related expertise and participants’ lived experience. These opportunities provided by DUO alleviated to some degree the immediate hardships imposed by structural vulnerabilities through modest improvements in financial circumstances and increased workforce and social inclusion. Further, our analysis of participant accounts demonstrated how these opportunities allowed them to reposition themselves as ‘dedicated’ or ‘employable’ in contrast to the characteristics associated with assumed or attributed statuses. Through their roles with VANDU, participants indicated that they could leverage their social status and influence gained through their experiences within the drug scene to recruit others to participate in the organization’s activities. The following excerpt illustrates how otherwise stigmatized experiences can have positive impacts on other PWUD:

“When the younger people see you [going to VANDU], that’s when they’re gonna [say], ‘Okay, she’s going in, we gotta try this out too’. They know me from years ago from dealing …. So it’s a positive step. If I can bring somebody into the group they’re gonna be happy and our group is getting bigger.” (Participant #15, Indigenous Woman)

Involvement with VANDU thus provided participants with an opportunity to reposition stigmatized and criminalized activities related to the drug scence as skills and experiences that are critically important to serving and helping others. For example:

Before I was with …VANDU if I put down [on a job application] that I was a drug user, then they’ll have me gone right? Now it’s like a prerequisite. The longer you’ve done drugs the more, the better it is…You have to know something about drugs if you’re gonna be in a organization like this. (Participant #2, White Man)

I always felt that my real value…my real expertise [at VANDU] would have to come in to, uh, in to my use of drugs. I lean on all the years that that I always thought were worthless and useless to me and now I’m turning it around and trying to use that to make things better for others. (Participant #23, White Man)

These excerpts illustrate the value that PWUD see in their lived experiences. Participants stressed that VANDU specifically allows PWUD to harness their expertise and lived experiences to influence policy, programmatic, and social change.

Drug use, harm reduction, and work

VANDU’s recognition of PWUD’s skills, experience and knowledge included a willingness to pay volunteers for shifts worked while using or under the influence of drugs. Given their structural vulnerability, obtaining and maintaining employment while also managing one’s daily drug use was perceived as challenging, if not impossible, in most workplace settings for participants. Workplace zero tolerance policies and the stigmatization of PWUD exacerbate their structural vulnerability, making formal employment a challenge. Unlike many formal jobs, participants were not required to abstain from using drugs during their shifts and, as a result, stipendiary volunteering was accessible to a wider range of people at various stages of their drug use. Consistent with other harm reduction best practice guidelines for employing PWUD (International HIV/AIDS Alliance, 2015), participation at VANDU was dependent on the capacity to perform the duties of the job rather than drug abstinence, an inclusion criteria that was characterized by participants as “meeting people where they are at” (Woolhouse, Brown, & Thind, 2011) through harm reduction support and the promotion of skill development and openness. For example:

“Most places where I had a job I had to hide my dope, … and you couldn’t go to work stoned. but you don’t have to hide being stoned this time, you know? if you’re a drug addict you can go [to VANDU] and they just don’t want your drug use to interfere with your job, right?” (Participant #14, Hispanic Man)

This excerpt illustrates a clear difference between past workplace experiences and those at VANDU, while also acknowledging the responsibilities that come with the positions. VANDU’s harm reduction workplace policy works against the stigmatization of PWUD. According to one participant: “drug users get a bad rap … There’s functioning addicts out there. [VANDU] helps to break the stigma that usually comes with [drug use]” (Participant #12, White Woman). The implementation of low threshold policies in the workplace at VANDU mitigate the institutional and structural barriers that occur in other workplaces, providing PWUD with an opportunity to work while also being cognizant of the realities of drug use among PWUD.

An alternative to prohibited and illegal income generation activities

Several participants framed their stipendiary volunteer work with VANDU as an alternative to illegal and informal income-generating activities associated with an increased risk of violence or arrest, such as sex work, theft, or drug dealing. For participants, these activities associated with documented increases in the structural vulnerability of PWUD through policing and incarceration are often the only opportunities available to them (Richardson et al., 2015). In contrast, the following excerpt illustrates the personal satisfaction participants derived from having the opportunity to engage in non-criminalized, non-stigmatized forms of labour at VANDU:

“[With] the stipends you don’t get paid a hell of a lot. It’s a good start, but it’s money in my pocket that I didn’t have at the start of the day, and when I do my job, I feel like I earned it, and I earned it in the right way. I’m not stealing, I’m not selling drugs. I’m not sucking dick or fucking ass. I’m not prostituting myself or doing anything illegal, so I’m earning it and it’s money that I earned so I feel good.” (Participant #14, Hispanic Man)

In addition to the personal satisfaction of earning some non-criminalized income, participating in VANDU also decreased the risk of arrest and detention for some participants, because participants had less time, energy, and willingness to engage in illegal activities when they became more involved at VANDU. As one participant explained, “This is the longest I’ve been out of jail…and it’s because of VANDU. Like, if I’m not at VANDU, I’m at home sleeping because I’m so tired from putting it all in there” (Participant #7, White Woman).

Non-material benefits of working at VANDU

Stipendiary volunteer work with VANDU had unexpected non-financial benefits, including social status, social contact, collective purpose and time structure, which accrued over time and emerged as strong motivators for ongoing participation. Many volunteer positions with VANDU involved outreach work or activism (e.g., speaking at demonstrations or protests), which increased participants’ sense of public acknowledgement and status in the DTES and across Vancouver. For example:

The Pedestrian safety [program] aids people. You know say they only get six dollars an hour but they were paid right after the shift. But it gave them [pause], like you wear your vest outside and … people start acknowledging you so that’s what. You get acknowledged. (Participant #8, Indigenous Woman)

This perspective illustrates how stipend volunteers receive social recognition in the community and an acknowledgement of meaningful labour for PWUD. Scheduled volunteer shifts also functioned to structure participants’ time with meaningful opportunities. For example:

[Interviewer: So how do you think being at VANDU has affected you?] It makes me feel like I’ve got a little bit of my life under control because now I’ve got these dates set … like a schedule. I write it down on the calendar and otherwise I’d be just outside like everybody else just doing their own thing and having a beer like I was over at the park today and you know I’ve got something to do today. It just makes you feel good. (Participant #15, Indigenous Woman)

“Before [I started working at VANDU] all I’d do is sit at home and do nothing and do my drugs. That’s all I did. That’s really all I did. … But now that I’m actually doing something it makes people think I’m happier, you know content.” (Participant #22, White Woman)

These excerpts reveal the increased satisfaction of community involvement through stipendiary volunteer work that also allows PWUD to have greater structure and control over other aspects of their lives.

For many, working at VANDU helped to generate a unique sense of collective purpose within a shared political struggle. The awareness of collective purpose was often generated during highly public or expressive political activities, such as disrupting meetings at city hall or political marches or demonstrations. For example:

[VANDU’s political work] is a good thing ‘cause it gets everybody together. … We have a common ground when we meet up there [for a protest] and we’re all like really stoked and it’s all in a peaceful way too. It’s kind of neat to see everybody getting involved and excited about something and making a difference … All of us put together we’re a loud voice [laughter]. (Participant #12, White Woman)

Community acknowledgement, meaningful labour, structured shifts, and collective purpose, provided participants with opportunities to establish and strengthen social ties and work towards broader change.

Impact of VANDU participation on drug use patterns

Participants commonly articulated that the noted non-material functions of working at VANDU (e.g., social connection, time structure) created circumstances that supported decreased drug use. Among some participants, the increased sense of responsibility associated with volunteer positions at VANDU and regular contact with others offered a meaningful motivation to reduce their drug use. These participants emphasized how they preferred not to be intoxicated prior to or during scheduled shifts or when interacting with peers at VANDU. For example:

“[I use] less, because it’s a responsibility I have...responsibility [to show up for my shift], ok I’m gonna be there. I’m not gonna be hungover or nothing.” (Participant #19, Indigenous Woman)

These reductions in drug use also enabled participants to limit their involvement in high-risk income-generating activities that had supported their drug use. For example, one woman described how she had reduced her involvement in sex work because she no longer needed to generate income to accommodate her high-intensity crack smoking:

“Well for me, it feels good [to be working at VANDU and smoking less crack rock] because right now I’d probably be phoning one of my regulars [clients] and telling them could you please come down … I need some money right now.” (Participant #13, Indigenous Woman)

On account of reductions of high-risk income generating activities and high-intensity drug use, DUO stipend volunteers are abating their structural vulnerability through non-judgemental and low-threshold workplaces.

Low wages as barriers to participation

Although participants valued the symbolic, material and social rewards of working at VANDU, the low level of pay acquired through stipendiary volunteering was also seen as a limitation of participating in VANDU activities. For the most marginalized participants, the relatively small stipends were insufficient in addressing their needs or compensating them at the same level of the illegal and prohibited income generating opportunities available to them, such as drug dealing or sex work. Low-pay stipends consequently reinforced the poverty and marginalization of participants. Involvement in VANDU activities was, for example, not a feasible option for some participants that were experiencing homelessness and drug withdrawal symptoms, as demonstrated in the following account:

The street addict is not going to go [to VANDU]. He gotta hustle for his dope. He gotta hustle for a place to stay. He can’t be sitting down in meetings and not knowing if this hour that he’s sat down is going to do anything for him…When you’re dope sick, and … your woman’s home sick, can’t go to work. You know, when you’re sleeping behind the fucking bin or something. You don’t have a home. So they can’t go out and fight for change. (Participant #6, African-Canadian Man)

This participant’s experience highlights the multiple structural vulnerabilities simultaneously at play and how these negatively impacted his ability to participate in VANDU. Some participants expressed that they felt ‘stuck’ in low-paying positions, indicating that stipendiary volunteer work was “kind of holding you down at the same spot” (Participant #21, White Man).

There was also an absence of opportunities for advancement into better paying positions at the DUO that still accommodated ongoing drug use, as all the salaried positions at VANDU were occupied by non-using staff members. Given this barrier, some participants viewed stipendiary volunteering as taking advantage of their financial vulnerability because, in the words of one participant, “we’re not even getting minimum wage” (Participant #22, White Woman). Participants further criticized the vast disparity between volunteer stipends and the higher salaries received by other employees within the organization. For example, according to one participant, “The board gets five bucks and the staff is in the same room getting twenty-five bucks an hour. I mean there is an imbalance, definitely. [It’s] never going to be perfect until everybody in the room is getting twenty-five bucks an hour” (Participant #23, White Man). While wages for stipendiary volunteer work were low, some participants nonetheless viewed volunteering in VANDU as an opportunity to develop skills, gain experience, and make connections that would enable them to transition to higher paying, formal employment.

DISCUSSION

Stipends were an important incentive in promoting engagement within DUO and a significant symbolic recognition of the value of the time, skills, experiential knowledge, and labour of PWUD. Paid stipendiary volunteer work in VANDU provided a unique alternative opportunity for PWUD to earn ‘legitimate’ non-criminalized income in a workplace that does not stigmatize drug use and for members of a structurally vulnerable population. Alongside financial compensation for their labour, participants valued the non-material benefits of participating in VANDU, including social contact, prestige, scheduling, and a sense of collective purpose. These benefits also challenged attributed social statuses applied to PWUD such as ‘lazy’ or ‘chaotic.’ Nonetheless, low levels of pay were a notable limitation of stipendiary volunteering, alongside an absence of opportunities to transition to higher paying employment.

While the contributions of DUO and the benefits of peer involvement in health programming are well documented (Booth & Watters, 1994; Broadhead et al., 1995; Broadhead et al., 1998; Crofts & Herkt, 1995; Garfein et al., 2007; Grund et al., 1992; Hayashi et al., 2010; Kerr et al., 2006; Latkin, 1998; Weeks et al., 2009), this is the first study to explore how stipend or paid opportunities foster engagement within DUO. Our findings indicate that VANDU’s stipendiary volunteer program functions as a form of low-threshold employment, insofar as PWUD are able to access flexible paid work arrangements that accommodate the realities of on-going drug use and episodic absences (Richardson et al., 2015), and provide immediate financial rewards. Our findings underscore how even low-paying positions can function to help produce some positive social outcomes among PWUD through both material and non-material benefits stemming from engagement in this kind of work. Notably, participants repeatedly referred to how stipendiary volunteer work provided an alternative to high-risk income generating activities more conventionally undertaken within the drug scene (e.g., drug dealing, sex work). Given the risks of arrest, incarceration, violence, and HIV transmission associated with involvement in high risk informal and illegal income generation (DeBeck et al., 2007; Kerr et al., 2008; Shannon et al., 2009), providing PWUD with opportunities to engage in flexible paid work through DUO may produce significant improvements in health and social outcomes. While additional research is needed to further explore this issue, our findings nevertheless suggest that low-threshold employment interventions are a promising approach that should be incorporated into harm reduction strategies and social programming.

Although stipends were critical to motivating PWUD to initially engage with VANDU, our results also point to the critical importance of the latent features of low threshold employment (e.g. social contact, prestige, scheduled activity, collective purpose) in producing wider improvements and sustaining involvement over time. Importantly, not only did participants identify the latent functions of stipendiary volunteering as intrinsically valuable, but these functions were also seen to foster reduced drug use for some participants. While existing research has linked latent functions of employment to physical and mental health within the general population (Bartley, 1994; Grzywacz & Dooley, 2003; Jahoda, 1981), our study extends this research by illustrating how low-threshold positions may lead to decreased drug use and increased well-being among PWUD. This finding suggests that low-threshold employment programs have the potential to serve as a component of innovative public health interventions seeking to decrease drug use while improving PWUD’s ability to meet their materials needs and decrease socio-economic vulnerability. In turn, the expansion of low-threshold employment interventions may prove to be more effective than traditional ‘law and order’ approaches that can exacerbate the structural vulnerability of PWUD and limit positive health outcomes.

The significance of the latent functions and other characteristics of stipendiary volunteer work also highlight how the quality of a work experience shapes motivation to participate in DUO and, potentially, other forms of work. Qualitative factors such as the social acceptance of drug use within the workplace, social contact and prestige within the broader community, structured time, and meaningful positions that reward rather than stigmatize the skills of PWUD were are all key elements that motivated participants to remain involved in VANDU activities. It has been well-documented that the quality of employment significantly impacts job satisfaction, retention outcomes, and the perceived and real benefits of work in the general population (Kalleberg, 2011). The findings of the current analysis support the relevance of prior findings about the importance of work quality to vulnerable populations and unconventional employment models. These factors can start to alleviate some of the structural vulnerabilities experienced by PWUD. Future interventions to promote participation in DUO or other low-threshold employment programs should consider these qualitative features, alongside stipends or other payments, as critical when designing interventions and programming. Increased and sustained participation of PWUD in DUO will further support the development of innovative DUO programming and advocacy, which is well documented to have significant positive public health outcomes (Hayashi et al., 2010; Kerr et al., 2006; McNeil et al., 2014; Small et al., 2012). Furthermore, low threshold opportunities available through DUO could promote the transition into broader social participated as well as community and workplace integration.

Despite the positive impacts of paid participation in DUO, our findings also suggest that while these positions were more accessible than other licit forms of employment to an otherwise vulnerable population, some PWUD with significant structural vulnerability (e.g., homelessness, drug addiction, Indigenous ancestry, involvement in sex work) are also constrained in benefitting from these positions because of the low level of the stipends preclude their disengagement from other sources of income generation, given the complexities of the barriers that the more marginalized PWUD face. Therefore, while we identified low stipends compared to the income generated from other activities as a barrier to DUO participation, additional research is needed to examine the structural factors that limit one’s ability to participate in DUO and the ways in which DUO and other low-threshold employment programs can better include and support the more marginalized PWUD.

Participants who benefitted from stipend volunteer work additionally experienced barriers in transitioning into formal employment despite their desire to do so due to the lack of opportunities afforded to PWUD, sufficient supported training opportunities, and the stigma that PWUD face in the workplace. Additional research is therefore also needed to examine the structural factors that curtail the employment opportunities and trajectories of PWUD who want to transition from low-threshold positions into higher paying employment opportunities. Despite the many benefits of stipendiary volunteer work, there is a risk that quasi-wage employment may “function mainly as a way of socializing people into low wage labour” (Gough, 2002, p. 70), rather than serving as a catalyst for improving the socio-economic status of PWUD. Within the context of structural vulnerability for PWUD, then, greater attention to how low threshold employment interventions function in relation to formal employment is needed, as well as more formal supports (e.g., apprenticeship programs, training, support) to facilitate transitions into more long-term formal employment opportunities paying living wages.

Understanding these as volunteer roles can potentially lead to unintended consequences outside of DUO. While this study has identified numerous benefits to these positions at VANDU, developing these roles in other employment contexts (e.g., health or social services) may prove to be detrimental. For instance, if low-threshold employment is persistently synonymous with low-paid employment, funding agencies that rely on ‘peer workers’ to deliver program and services, however well-intended, run the risk of exploiting and appropriating the labour of structurally vulnerable PWUD. Labour protections such as the provincially-mandated minimum hourly wage, are not necessarily upheld for these positions when participation is framed as stipendiary ‘volunteering.’ In studying how economically marginalized populations frame their participation in research as ‘work’, Davidson and Page (2012) similarly note that Research Ethics Boards’ framing of participants as ‘volunteers’ as opposed to ‘expert consultants’ has important ethical ramifications, including diminished labour protections for participants (Davidson & Page, 2012). We stress the need for adequate funding for future paid ‘volunteer’ or low-threshold employment programs aimed at PWUD – especially for DUO with inconsistent or minimal funding – in order to ensure better involvement of all PWUD and that wages and working conditions do not violate the fundamental labour rights of those intended to benefit from such programming. These undoubtedly have the potential to foster stronger and more equitable organizational, social, and economic inclusion for PWUD.

This study has limitations. First, the views represented in our sample participants (n=23) are not generalizable to the experiences of all VANDU members (n>2000). Moreover, this study recruited VANDU members who were currently involved in the organization and, therefore, the views of PWUD who have participated but subsequently ceased their involvement in VANDU or PWUD with barriers to participation in DUO are not represented. Consequently, our findings may understate the barriers to on-going participation in DUO. Further, given that we only interviewed participants from VANDU, our findings may not be entirely generalizable to other DUO.

In conclusion, we found that paid participation in a drug user organization provided important material and non-material benefits to participants, including increased social contact, structured time, prestige and recognition of the value of commonly stigmatized skills. Stipend volunteer programs also facilitated lower levels of drug use and decreased participation in high-risk criminalized income generation for some participants. These benefits were curtailed by low payment, which posed a barrier to participation for the most structurally vulnerable PWUD. Our findings support the expansion of interventions that acknowledge the varying levels of structural vulnerability faced by PWUD as well as the labour rights, skills, and experiential knowledge of PWUD through paid participation in DUO or in partnership with other low-threshold employment programs and social enterprises to expand opportunities for PWUD.