How to be self-reliant in a stigmatising context? Challenges facing people who inject drugs in Vietnam

Abstract

Background :

Stigma works to reinforce dominant social values. The meaning of stigma is therefore not static but dependent on the regime in power. Taking into account the significant socioeconomic changes that took place in Vietnam over the last thirty years, this study explores the meaning of stigma directed at Vietnamese people who inject drugs in different social spheres.

Methods :

This qualitative study was conducted as part of an evaluation of a peer outreach program that distributes harm-reduction supplies and information, and provides treatment referral assistance to people who inject drugs in Haiphong, Vietnam. We conducted ethnographic field observations with peer outreach workers, home visits, and 54 in-depth interviews with participants in 2017 and 2018. Grounded theory led our theoretical sampling and analysis.

Results

Stigma towards people who inject drugs seems to centre on the ability to be self-reliant rather than on drug-using behaviours. Participants described how their families and neighbours expressed expectations that they should manage their substance use issues by themselves, without considering the barriers they face in the job market. Participants interpret stigma directed at them in terms of poverty rather than drug use. As a result, they sometimes engage in illegal income-generating activities to pursue financial autonomy and to regain their social status.

Conclusion :

People who inject drugs were struggling to conform to social expectations of self-reliance with limited support to realise it. Effective interventions must consider the many facets and challenges individuals encounter in their daily lives.

Introduction

Stigma towards people who use drugs is a complicated and alarming issue across contexts (Room et al., 2001; van Boekel et al., 2015). Stigma may lead to social alienation, and may incite the general public to exclude individuals who use drugs from communal activities (van Boekel et al., 2013, 2015). People who use drugs might be perceived as dangerous without tangible evidence that they pose any real threat (Callinan & Room, 2014). As a consequence, stigma may negatively impact their physical and mental health and prevent their ability to access healthcare services (Lloyd, 2013; Stone, 2015).

Some interventions targeting drug-related stigma have achieved promising results in reducing stigma, but their long-term effects have not been quite convincing (Livingston et al., 2012). Education targeting medical students might make it easier to discuss substance use issues with patients but does not necessarily improve medical students’ attitudes towards patients with substance use disorders (Bland et al., 2001; Ramirez-Cacho et al., 2007). Biomedical reframing of addiction as chronic disease was expected to reduce stigma by placing drug use outside of a moralising context (Volkow & Koob, 2015). However, this did not appear to be successful (Garriott & Raikhel, 2015; Meurk et al., 2014). Redefining addiction within a biomedical context can also reinforce stigma by shifting the process of stigmatisation from a moral to a medical ground: from that perspective, people who use drugs who do not succeed in adopting good practices to manage their addiction are not considered bad people, but irresponsible patients. (Jauffret-Roustide & Granier, 2017).

Stigma is conceptualised as an apparatus that maintains social order by reinforcing social norms (Link & Phelan, 2014). It is a site where the power relations present in a given society operate; therefore, the meaning of stigma depends on its relational context (Goffman, 2009; Parker & Aggleton, 2003). Stigma works in favour of dominant groups by legitimising their dominant status within existing social hierarchies (Link & Phelan, 2014; Parker & Aggleton, 2003). Fraser et al. (2017) argue that drug-related stigma is a political means to discipline human subjects into what is defined as legitimacy in contemporary societies. As legitimacy could not exist without illegitimacy, drug-related stigma must be considered as part of a complete social system (Fraser et al., 2017). Better understanding the social norms that underlie drug-related stigma can illuminate how society functions and help us rethink our interventions.

A number of studies have explored stigma towards people who use drugs in Vietnam. Studies reported methadone patients commonly experienced stigma and discrimination (Tran et al., 2016; Van Nguyen et al., 2017). Such negative treatment of methadone patients were related to participants’ anxiety/depression, level of education, HIV status and number of previous drug rehabilitation episodes (Tran et al., 2016; Van Nguyen et al., 2017). Drug-related stigma was associated with lower access to HIV and harm reduction services (Lan et al., 2018; Salter et al., 2010). From a structural perspective, Lim et al. (2013) suggested that income inequality and education inequality might also be associated with HIV stigma reported by people who use drugs and community members.

Vietnam presents a unique context in which drastic economic reforms led to major changes in the system of social norm (Marr & Rosen, 1998; H. Nguyen, 2015). In 1986, the country transformed its economy from a centrally planned to a free-market regime and opened its borders to foreign trade. This socioeconomic upheaval has brought in substantial material wealth (Q. H. Vuong, 2014). People gained access to money instead of consumable goods checks and enjoyed technological advances (Badiani et al., 2013). Free trade and access to money might have made drugs more accessible. Vietnam had the largest gross domestic product increase in the world at the time (7-8%) and continues to show this rate of economic growth today, although significant challenges remain (Q. H. Vuong, 2014; World Bank, 2019). Drastic economic reforms also led to an ideological transformation among Vietnamese youths who came of age in the 1990s: that generation went from upholding a restricted, communist personality to valuing a more extravagant, individualistic one (Marr & Rosen, 1998; H. Nguyen, 2015). Neoliberal ideals have become increasingly dominant in contemporary society (Kay Hoang, 2011; H. Nguyen, 2015).

Perceptions of drug use, whose social signification is subject to socio-political changes, has evolved over time in Vietnam: from a bad habit of the bourgeoisie in the feudal and imperial regimes (Ho Chi Minh, 1945; Ministry of Social Welfare, 1958), to a “social evil” influenced by Western cultural products in the post-reform years (H. V. Luong, 2006). With the decriminalisation of drug use in 2009 and the success of methadone maintenance treatment in minimising new HIV infections among methadone patients and ensuring public safety, people who use drugs came to be understood as patients (H. T. Luong et al., 2019; Pham et al., 2012; T. Vuong et al., 2012). However, there remained ambiguities about the nature of drug use and about how best to achieve demand reduction; ambiguities which created confusion and stress for professionals working directly with people who use drugs (H. T. Luong et al., 2019).

This article is based on a qualitative study exploring the daily hardships facing people who inject drugs in Haiphong, and the ways they cope with these challenges. Haiphong is one of the provinces with the greatest wealth disparities in Vietnam (Badiani et al., 2013). This harbour city is also a major site for drug use and HIV/AIDS incidence (National Institute of Hygiene and Epidemiology, 2014). Haiphong hosted the first methadone clinic in 2008 and as of 2018, its methadone program has served nearly 4,000 opioid users, likely 80% of the entire opioid-using population in the province (Des Jarlais et al., 2018). These characteristics made it an interesting location to study this research question.

The theme of stigma emerged as salient in participants’ accounts. In this article, we investigate the meaning of drug-related stigma from the perspectives of people who use drugs. We argue that drug-related stigma reinforces neoliberal expectations of self-reliance while also making it impossible for individuals to achieve that self-reliance. In the following sections, we will describe how stigma towards people who use drugs in different settings conveyed expectations of self-reliance and how participants attempted to conform to these expectations.

Methods

This qualitative study is part of a five-year longitudinal intervention (known as DRIVE) aiming to reduce HIV incidence among people who use drugs in Haiphong, Vietnam. DRIVE employs respondent-driven sampling to recruit drug-using individuals in the community and provides an intervention package of harm reduction, referral to treatment, and peer support (Des Jarlais et al., 2016). The Ethical Board of the Haiphong University of Medicine and Pharmacy approved DRIVE and its qualitative component. DRIVE participants provided written informed consent. On top of compensation for each study visit, participants received VND200,000 (~U.S.$10) for each in-depth interview.

Grounded theory led our data collection and analysis. Grounded theory is a sociological approach that is based firmly on data (Glaser & Strauss, 2009). The approach aims to generate theory through comparative analysis. Theoretical sampling is a process of data collection whereby the analyst ‘jointly collects, codes and analyses his data’ to develop the emergent theory (Glaser & Strauss, 2009).

We conducted in-depth interviews and ethnographic field observation. The first round of interviews was done in the summers of 2016 and 2017. From the DRIVE database, we selected participants who represented a variety of characteristics including age, gender, substances used, MMT status, and HIV status. These interviews explored participants’ potential hardships and social support in relation to methadone and HIV treatment (T. T. Nguyen et al., 2019). During the first round of interviews, the interview was not directly focused on stigma but stigma emerged as a spontaneous and crucial topic in participants’ discourse. For this reason, adopting an inductive approach, we decided to investigate this topic more thoroughly with an additional sample in order to use participants’ perspective as a way to build our second interview guide.

The second round of interviews, which we conducted in 2017 and 2018, explored stigma and other hardships that people who inject drugs encountered. We selected participants who came to the research sites in June 2017 based on criteria similar to those of the first round. Due to transportation challenges, we did not select participants who lived farther than 20 kilometres from the city centre. We then communicated the list of potential participants to peer workers who invited them to participate in our in-depth interviews. Out of 32 people on our list, 15 could not be reached due to incorrect contact information; 17 agreed to be interviewed. No one declined the invitation.

The second round of interviews served as our main data source. After we began analysing our data, we realised we needed more data from women and people living in downtown Haiphong to assess our emerging hypothesis concerning the intersection between addiction, HIV status, gender, and residency. Thus, we conducted theoretical sampling to retrieve the transcripts of participants with these specific characteristics from the first-round interviews. In total, the analysis was based on the accounts of 54 people who inject drugs.

From June 2017 to January 2018, and from September throughout December 2018, the first author stayed at the research sites in Haiphong for about ten days a month. Since the research sites also served as offices for peer workers, she was able to join them in their daily activities (e.g. having tea and lunch together, discussing cases) and to meet some of their clients when they came to the sites. Thanks to the introduction of peer workers, she also visited some participants’ homes as a member of the DRIVE research team. Our field notes recorded observations outside the interviews and provided valuable context for the information we received from in-depth interviews. From our ethnographical work, we were able to directly observe interactions between participants and their families in concrete situations, and thus to complement participants’ accounts with their families' perspectives. For example, we were able to assess how the norm of self-reliance underlies both participants’ and families’ discourses.

We used an iterative approach between data collection and analysis (Charmaz, 2006). We coded our interview transcripts and field notes. We used open coding until no new themes emerged (after ten cases). The codes were then grouped into larger categories to create a coding frame on NVivo 12. The subheadings in the Results section were formulated from these categories. For example, under ‘family reaction to drug use’, we included ‘family obligations’, ‘family as a safety net’, ‘family as a source of depression’, ‘breadwinner’ and ‘kiến giả nhất phận’ (each sibling cares for herself). The codes across categories included ‘money is imperative’ and ‘poverty stigma’. Memo-writing and constant comparison were central in our analysis (Corbin & Strauss, 2014).

All interviews were conducted in Vietnamese, tape recorded and integrally transcribed verbatim. A summary of each interview and field notes (in English) were reviewed by LMG and LV. The first author coded and analysed data on NVivo 12 and discussed her insights with the other authors throughout the investigation, since many members of the research team do not speak Vietnamese.

Results

Table 1 presents the participants’ sociodemographic characteristics. Men made up two thirds of the sample. Most participants were between 30 and 50 years old and lived in downtown Haiphong. 40.8% reported being married or living with a partner. Half of the participants had intermittent jobs or were unemployed. Almost 60% were currently receiving methadone maintenance treatment.

Table 1—

Characteristics of participants (N=54)

Age
<30	4 (7.4%)
30–39	21 (38.9%)
40–49	25 (46.3%)
>=50	4 (7.4%)
Sex
Male	35 (64.8%)
Female	19 (35.2%)
Education
Primary and middle school	20 (37%)
High school	7 (13%)
College	2 (3.7%)
No information	25 (46.3%)
Residency
Inner city	37 (68.5%)
Outer suburbs of Haiphong	17 (31.5%)
HIV status
Positive	33 (61.1%)
Negative	21 (38.9%)
Marital status
Married/Cohabited	22 (40.8%)
Single	20 (37%)
Divorced/Separated/Widowed	12 (22.2%)
Occupation
Unemployed	12 (22.2%)
Intermittent jobs	15 (27.8%)
Relatively stable jobs	27 (50%)
Currently under methadone treatment
Yes	32 (59.3%)
No	22 (40.7%)

Stigma in the family: no rejection but mistrust and disrespect

A close investigation of family reactions to addiction revealed that it was complex and heterogeneous and that family spaces were supportive but not exempt from stigmatisation. Most families expressed anger, disappointment, or sadness when they first learned about the individual’s drug use, often through rumours. Their first reactions included attempts to persuade their family member to stop using drugs and to support them with seeking out detoxification at home or in a facility. These attempts, however, often failed. After they witnessed repeated relapses and painful withdrawal from drug users, many families felt discouraged and gave up.

As in other Confucian societies, Vietnamese adult children, especially sons, often cohabit with their parents. Disclosing drug-using behaviour did not lead to rejection by the participants’ families; they allowed their family member to continue to live under the same roof and provided them with food and other amenities. For those who had children, families and relatives also offered childcare and provided for the children if needed. A female sex worker who had two children with her clients, described how her mother and her brother’s family assumed child-rearing responsibilities:

I only came home for delivery. I did not breastfeed them. I left them with my mum and headed back to the city. They don’t know who their mum is. They only know their grandma. (F, 37, sex worker, countryside)

While families did provide support for participants, this did not prevent them from devaluing their drug-using family member, whom they saw as morally compromised. Stigma deriving from the mistrusting and disdainful attitudes of family members towards participants was expressed in intimate, daily interactions within the family. Whenever a family member could not find something, they tended to exclaim: ‘The addict must have stolen it!’ even when they had misplaced something through their own absent-mindedness.

After they felt their trust had been broken, some families readily rejected participants’ requests for financial support, whether it was intended for a start-up project or for treatment-related activities. Family members suspected these were just new attempts to get money to purchase drugs. This attitude sometimes made participants feel helpless and frustrated:

[My parents] used to give me money but I spent all of it. Now they don’t trust me anymore. I asked them to buy me a motorbike to go to treatment but they replied: “So you can sell it.” Well… what else can I say? (M, 44, unemployed, downtown)

My health is not good. I often get sick. […] but when I complain, my father says I just fake it to use drugs. (M, 38, unemployed, downtown)

As evidenced, participants were sometimes met with discrediting reactions from their families when they requested support for something other than everyday necessities. This deprecating behaviour might give them little opportunity to move beyond what are considered their past failures.

Family assistance often came with moral lectures stressing the importance of self-reliance without considering the structural barriers participants might face. A woman discussed the reason why she did not go home after relapse:

My siblings said I needed to look after myself, to save myself, that no one could save me and that each person had her own life… Of course, I know this, but sometimes [I feel sad]… They have their family, and I have no one. (F, 49, sex worker, downtown)

Although this woman believed her siblings' lessons were morally right, she felt like they did not take into account her struggles as a middle-aged woman living alone, with little education, an unstable income, and a drug dependence issue. She felt she needed support beyond lectures and money. Her family's overemphasis on self-reliance might have prevented them from playing a more important role in her recovery.

During our field observations, families showed appreciation towards individuals who managed to afford their drug use without bothering their family for money. One participant we visited at home was a peer worker's partner. He was an active methamphetamine and heroin user, but he kept bringing money home, from gambling and drug dealing. His income covered expenses for the whole family, so his partner could save her salary to pay for her own daughter’s debt. She expressed her appreciation for him:

I feel better since I live with him. He is a talented person. He can earn a lot of money despite his addiction. The neighbours think I live with him because of his money but I’m very clear about that. I take care of my debt and my own expenses. (F, 42, peer worker, countryside)

She told him to quit using drugs, but her suggestions had little impact. Still, they got along well and her children loved him. By fulfilling the role of provider in the family, this participant and others similar to him were able to secure the respect and continued support of their loved ones.

Stigma within the neighbourhood: avoidance, suspicion, or indifference

Most neighbourhoods in Vietnam, especially in the countryside and in small cities like Haiphong, consist of extended families and long-term neighbours. For many people, this is where most of their economic and social relationships occur. This makes the social space of the neighbourhood an important context of stigma.

Stigma was expressed in more diverse ways within the neighbourhood than within the family sphere. In general, it included social distancing based on fears of being bothered for money, suspicions that the drug user could not be self-reliant, and indifference when the participant was perceived to be self-reliant. Explicit aggression in the form on insults ("junkie" or “addict”) on the street was rare.

Social distance was the most common form of perceived stigma and many participants believed their acquaintances avoided them for fear of being asked for money. Participants felt their neighbours no longer welcomed them. Rural neighbourhoods typically engaged in bonding acts such as dropping by or watching each other’s houses. However, neighbours would find a reason to turn down participants’ offers to do so. Communication became minimal even when neighbours lived close to each other. A participant felt she was unfairly treated when her acquaintances avoided her for something she did not do:

I’d never asked anyone for a dime. I did everything by myself. But people still see me in a disdainful way. […] They heard about my drug use and they‘re afraid that I will come and beg them for money. (F, 41, sex worker, downtown)

Money-begging, or lack of self-reliance, therefore, has become part of the stereotype of drug users and a reason for which they are stigmatised.

On top of suffering from the begging stereotype, participants felt that people in the neighbourhood gave them suspicious or watchful looks:

We used to visit each other often, but after I was released from prison, I dropped by her house and she had to leave me alone for a while. I saw her looking vigilantly at her stuff, like some TV remote controls. (M, 35, plumber, countryside)

In the countryside, some local governments explicitly assumed that people who use drugs were potential thieves. Several participants described being summoned by the police whenever villagers reported a burglary. Individuals with a drug use history needed to provide proof of innocence before they were eventually dismissed from the list of suspects. Even when nothing happened, police officers or a chief villager still paid them regular visits to remind them not to disturb public peace.

Besides the above reports of discriminating attitudes, a majority of participants living in downtown Haiphong reported that their neighbours were indifferent to their drug use as long as participants did not bother them (or “touch” them, in the literal translation). An active user with a publicly known criminal record and compulsory rehabilitation history described how he maintained an apparently normal relationship with his neighbours by making sure he would not “touch” them.

Interviewer: How is your relationship with your neighbours?

Respondent: It’s alright.

Interviewer: Do they know you‘re using drugs?

Respondent: They do. But since I never steal in the neighbourhood, I don’t have a bad reputation.

(M, 23, unemployed, downtown)

This example shows that drug-using behaviour alone may not be the reason for perceived stigma towards people who use drugs within a neighbourhood, especially in the city.

When families and neighbourhoods stereotyped drug users as people lacking the values of hard work and self-reliance, they implicitly requested participants to manage their own financial problems and seek money somewhere else without thinking about how they might achieve that. This pushed participants to look outside their immediate networks for opportunities to support themselves. However, the larger social sphere did not respond favourably either.

Barriers to secure a socially approved job

Like in many countries, there are few job opportunities in Vietnam for people with a history of drug use. Although half of the participants had a relatively stable job, many held illegal occupations such as full-time sex work or pimping. Typically, employers are extremely reluctant to hire a person when they suspect that person to be a drug user:

I’ve knocked on so many doors asking for a job, but they firmly refused. […] Maybe because I’m too thin, and I’m labelled as an addict. They might hire me during the New Year period, but afterwards they kick me out (M, 43, unemployed, downtown)

Blue collar jobs like assistant mason or delivery worker were often the first choice for people who use drugs, as they require minimal skills. Participants were usually recruited for these positions through the recommendations of acquaintances, who for the majority were not drug users themselves. However, for many participants, years of struggle with addiction had damaged their network of non-using friends. In addition, many middle-aged participants with HIV infections could not endure the hardships of demanding physical labour.

The few people who were able to secure a legal job also encountered mistrust and social distance at their workplace. One participant, a well-spoken college graduate and methadone patient, had been working for a company delivering official correspondence. However, whenever cash was involved, the company called on a non-using driver to perform the task.

I protested to the manager, “why can’t I carry this package?” He said, “This involves money. If you deliver it to a wrong address, it’ll be complicated.” But I immediately understood that he was afraid I’d take that money. (M, 53, motorbike taxi driver, downtown)

Although that person had secured enough trust from his manager to deliver correspondence, the drug user stereotype continued to bar him from performing certain tasks that involved cash delivery.

Workplace stigma did not exempt ex-drug users who worked with non-using individuals, even in rather tolerant environments. The following observations made on our research sites showed that, rightly or wrongly, peer workers believed their non-using colleagues engaged in stigmatising behaviours with them. While there was no obvious act of discrimination, participants did feel significant social distance.

X. kept saying that he liked us because we were “sociable, not like the girls here (the interviewers and lab technicians working at the study site) who distinguished [them from us].” (Field notes).

What were people who inject drugs stigmatised for?

Several participants witnessed negative social treatment not as a consequence of their drug-related behaviour, but as an outcome of their poverty. A participant rejected our hypothesis that his drug use caused the disdainful attitude of his relatives towards him. He argued that despite his addiction, he had never “touched” them. He said: “Being poor is being guilty” and explained animatedly:

You ask why being poor is being guilty? Society is helping the poor, right? The poor gets 100% free medical care. Where does this money come from? People ask, “why are you poor?”! No one wanna be poor. You work but don’t have enough to eat. Don’t you feel humiliated? (M, 40, mason, downtown)

The poor were guilty because others had to help them. The question “why are you poor,” implied blame on the individuals who were seemingly not self-reliant enough to overcome their situation.

Sharing the above opinion, other participants pointed to the intimate link between stigma stemming from poverty and addiction, and framed their situation in terms of poverty rather than addiction.

Addiction leads to poverty, then it destroys affection. People who have money have a say. Without money, no one will listen to you.” (M, 38, unemployed, downtown)

From this perspective, poverty, rather than addiction, is the direct cause of the individuals' loss of status. Thus, individuals’ social status seems to be dictated by their economic situation rather than by their behaviour.

Discussion

The role of stigma in reinforcing dominant social values has been extensively theorised (Fraser et al., 2017; Link & Phelan, 2001; Parker & Aggleton, 2003). The meaning of stigma is not static, but dependent on the regime in power. Taking into consideration the significant socioeconomic changes of the last thirty years in Vietnam, this study explored the meaning of stigma towards people who use drugs in various social spheres of contemporary Vietnamese society. Self-reliance, together with self-regulation and self-determination, is a hegemonic value in the global free market (Alexander, 2008; Moore & Fraser, 2006). It implies that one should rely on one’s own ability and resources to take care of oneself (Moore & Fraser, 2006).

Our findings regarding simultaneously supportive and tense familial attitudes towards people who use drugs parallel previous works, but with a different emphasis (A. J. Gunn et al., 2018; Higgs et al., 2009; Rudolph et al., 2012; Tomori et al., 2014). Like Tomori et al. (2014), we found that the family was a major resource for participants, especially for basic needs like food, housing, and healthcare costs. However, while other studies reported that familial tension was expressed through verbal (shouting) or physical (home confinement) aggression (Higgs et al., 2009; Rudolph et al., 2012; Tomori et al., 2014), our participants reported that family members disregarded their opinions and requests through more subtly derogatory attitudes. Such reactions could have long-term implications for their mental health. (Charles et al., 2013)

The feelings of shock and disappointment that the participants’ families expressed are consistent with what has been described in other Vietnamese communities and other collectivist contexts (Fereidouni et al., 2015; A. Gunn & Guarino, 2016; Higgs et al., 2009; Li et al., 2012; Rudolph et al., 2012). The individual’s drug use is not an individual affair; it affects the whole family. Such feelings reflect the importance of family cohesion, and possibly a fear of “losing face”, both of which are salient in many family-centred cultures (Fotopoulou et al., 2015; Yang & Kleinman, 2008). For that reason, families feel responsible for rescuing individual members, as well as themselves, from drugs. As methadone maintenance treatment and the perception of addiction as a chronic disease have only recently been introduced in Vietnam, most families still believe addiction is an acute condition that can be solved with detoxification and determination (Higgs et al., 2009; Tomori et al., 2014).

The practice of stereotyping people who use drugs as untrustworthy individuals has been reported in other studies (Earnshaw et al., 2013; Rudolph et al., 2012). As in previous findings, the families in our study readily viewed participants as liars and potential thieves who could deceive their families for money. Although the stereotype might have been construed from lived experience, maintaining such negative definitions of drug users makes it impossible for families to appreciate the good intentions of participants and to provide them with needed support during their recovery.

Familial appreciation of participants who were able to manage their drug use by themselves illuminates the social expectation of self-reliance in the Vietnamese context. People who use drugs might still be able to secure respect from others if they can prove their financial independence and fulfil their expected duties, including those of provider, although what respect they secure as providers might still be compromised by drug user stereotypes. This finding explains the aspirations to financial self-reliance we found among drug-using individuals who self-discharged from or refused methadone treatment so that they may be able to work (T. T. Nguyen et al., 2019).

While social alienation and mistrust of people who use drugs have been commonly reported in previous studies (Maher et al., 2007; Nieweglowski et al., 2018; Rudolph et al., 2012; Tomori et al., 2014), the indifferent attitude of neighbours towards participants who did not bother them is quite novel. This perceived indifference might come from both sides. The neighbours might be more indifferent to how their drug-using neighbours are doing; and participants might also be paying less attention to how their neighbours see them. Alexander (2008) suggests this indifference results from a weaker engagement in communal life in an encompassing market economy. This attitude might signal its members' lack of community interest, but also that the end goal in a neoliberal society —being self-reliant—is more important than creating the necessary means to achieve it.

The challenges people who use drugs encounter in securing a socially approved job have been well known (Lloyd, 2013; Nieweglowski et al., 2018). Participants’ limited professional training may restrict their job opportunities to low-wage and less skilled occupations. A known drug-use history may discourage potential employers and attract negative rumours and prejudice among co-workers (Nieweglowski et al., 2018; Tomori et al., 2014). Moreover, the inflexible operation of methadone treatment programmes may also hinder participants’ opportunities to secure a job (T. T. Nguyen et al., 2019). In addition, the stigmatising attitudes of co-workers can discourage people with a drug use history from engaging in their jobs (Earnshaw et al., 2013).

While we observed that families and communities seemed to judge participants based on their ability to self-sustain, we cannot say that activities generating illegal income were socially approved. Families and neighbours might assume that participants were good enough to secure a legal job to support themselves and their family while being oblivious of the structural barriers they face. This might push drug-using individuals into the Mertonian deviant conformism whereby they engage in illegal activities, trading their health and safety for social status within their immediate networks (Ogien, 2012). Bourgois (2003) found similar findings in his seminal ethnographical work in a drug-laden neighbourhood of New York where its Puerto Rican inhabitants internalised the American virtues of self-reliance and material wealth and sought to achieve it in the clandestine economy after multiple failed attempts to get a socially approved job. Those who could not conform to social expectations were prone to depression due to a feeling that they had failed to achieve important goals (Ahern et al., 2007).

The reframing of drug-related stigma as poverty stigma is unique, although some entanglement between drug use and poverty stigma has been reported in other studies (Conner & Rosen, 2008; Lim et al., 2013; Rudolph et al., 2012). Conner & Rosen (2008) argued that people who use drugs were subjected to poverty stigma besides negative treatment for their drug-use behaviour. Previous studies conducted in Vietnam showed that economic power differences were positively associated with levels of drug-related stigma (Lim et al., 2013), and that financial dependence was the cause of drug users’ loss of status in their family (Rudolph et al., 2012). This finding suggests that the interpretation of drug using behaviour has evolved from an anti-communist, evil act to the opposite of self-reliance. From this perspective, modern Vietnamese society may be undergoing social changes whereby material wealth becomes the utmost criteria of judgement.

The relationship between addiction and free market mechanisms has been discussed by Alexander (2008), although he theorises the causal relationship between the psychological dislocation brought about by the global free-market economy and addiction. This can be indeed a vicious circle whereby relative poverty causes addiction and addiction reinforces poverty through stigma mechanisms or vice versa.

Recommendations

This study’s findings show that it is necessary to place drug-related stigma within a larger social context. Link & Phelan (2001) suggest intervention must be multifaceted and multileveled to address both individual and structural discrimination. We recommend concerted interventions that take into account the many facets of participants’ challenges instead of narrowly focusing on drug-using behaviour.

At the policy level, further aid on income generation would help people who use drugs regain a sense of self-reliance. First, it is necessary to put in place mechanisms to improve the implementation of current financial assistance policies for this population such as low-interest loans (Government of Vietnam, 2014). Given their low education, assistance to develop a sound project and to navigate the administrative procedures would increase the uptake of such aid. Second, the government could recruit people who use drugs for jobs that best suit their expertise, e.g. peer outreach workers or peer educators in community-based organisations or in treatment programmes. An insider’s knowledge would help them work effectively with other users to deliver harm reduction information, refer clients to treatment and assist patients during the treatment process. Thus, this would foster their financial independence, increase their social status, and most importantly help them gain a sense of meaning.

At the programme level, medication-assisted treatment programmes should be more patient-friendly. A flexible dosing schedule and medications with longer-term effects (e.g. extended-release naltrexone (Jarvis et al., 2018), prolonged-release buprenorphine (Vorspan et al., 2019)) should be made available to accommodate those who work or seek a job. Most importantly, addiction professionals should be trained to view the big picture where drug problems interrelate with other personal and structural issues, so that they can develop a comprehensive treatment plan with referral to social services. To foster more meaningful family support, treatment programs might start by developing a three-party treatment plan that involves families, patients, and addiction professionals. One goal of the treatment plan would be for patients to regain their self-reliance. The plan would specify how different parties would contribute to achieving this goal. Regular reviews of the treatment plan would help families better understand the broader situation of patients, and would enable them to provide assistance to their family member.

Limitations

The findings of this study should be examined within its limitations. Most of our participants belong to the lowest social classes and therefore face poverty and low levels of education. In attempting to assert their self-reliance, they might encounter distinct barriers from people who use drugs with greater resources. Haiphong might also be unique in its transition from a rural, collectivistic lifestyle to a more urban, individualistic one. Thus, the challenges our participants experienced might be different from people who use drugs in larger cities or in more rural areas. The methods we used for this study would have been more rigorous if we had been able to conduct more interviews to strengthen our findings instead of using previously conducted interviews, although the two samples had similar characteristics and came from the same population.

Conclusion

This article describes the meaning of stigma towards people who inject drugs in Vietnam. It sheds light on the evolving values of contemporary Vietnamese by evincing what is considered legitimate. Stigma towards drug-using individuals was expressed in daily, intimate interactions within families and in neighbourhood contexts. Stigma was perceived as being not centred on drug-using behaviour but on the ability of individuals to be self-reliant. However, participants do not receive the support they needed to overcome the obstacles necessary to secure a socially approved job. Consequently, in order to conform to social expectations of self-reliance, many have taken part in the illegal economy. Thus, instead of focusing exclusively on drug-using behaviour, effective interventions must take into account the multileveled, multifaceted issues of people who use drugs.