1. Introduction
By 2050, there will be 2,000 million people aged over 60 years worldwide (World Health Organization, 2014). This increase will be accompanied by an increasing proportion of older adults using illicit drugs (Dufort & Samaan, Reference Dufort and Samaan2021). Although the total number of people using drugs in Hong Kong has declined to levels that are comparable to those in some Western contexts, the percentage of older drug users has been increasing over the last two decades (Department of Health (HKSAR), 2012). In Hong Kong, which is regarded as a “heroin society,” heroin is the most common type of drug abused by older drug users (Laidler, Reference Laidler2005). To address this issue, Hong Kong has adopted a prohibitionist drug policy with a dual focus on criminal justice involvement and clinical treatment (Cheung, Reference Cheung2009). To further facilitate drug rehabilitation, opioid agonist therapy (OAT) is provided in methadone clinics established by the Hong Kong government and administered by non-governmental organizations. In fieldwork from 2019 to 2022, I identified a specific group of older drug users, namely those who were enrolled in methadone treatment programmes but still used illicit drugs (hereafter, this behaviour is referred to as “mixed using,” and these individuals as “mixed users”). The official explanation for mixed use is that mixed users are controlled by their desire to use drugs, which is likely to be driven by their lack of self-control (On.cc, 12 January 2021). This explanation echoes some criminological literature that considers drug users as passive and powerless subjects controlled by drugs (Atkinson & Sumnall, Reference Atkinson and Sumnall2021; Kruis & Choi, Reference Kruis and Choi2020; Mars, Ondocsin & Ciccarone, Reference Mars, Ondocsin and Ciccarone2018).
Nevertheless, the findings indicate that mixed use is one of the various strategies employed by mixed users to improve their self-perceived quality of life (QOL) (Gowan, Whetstone & Andic, Reference Gowan, Whetstone and Andic2012). To facilitate analysis, this study utilized the selective optimization with compensation (SOC) framework to organize and explain their strategies. The author conducted in-depth interviews with 25 mixed users over 50 years of age in Hong Kong. The interview questions focused on the following two themes: (1) strategies adopted by older mixed users to improve their self-perceived QOL; and (2) ways in which these strategies were affected and constrained by Hong Kong’s drug policy. In contrast with popular beliefs, the results show that older mixed users are active human agents. To the knowledge of the author, this is the first study to focus on mixed use in the context of Hong Kong and Asia in general. This study contributes to a growing body of research on older drug users. It also provides evidence to show how some drug users may act as active agents to manage and coexist with their addiction, and how their agency seems to be constrained by the wider drug policy implemented in Hong Kong.
2. Literature review and research background
2.1 Drug use, human agency, and QOL
Studies on criminology and substance use can be divided into two camps based on their understanding of drug users’ human agency. Studies in this camp that utilized the general theory of crime as their framework (Gottfredson & Hirschi, Reference Gottfredson and Hirschi1990) have described drug users as passive agents who lack self-control and are highly vulnerable to the quick and easy gratification of drug use (Cheung, Reference Cheung2014; Costello, Anderson & Stein, Reference Costello, Anderson and Stein2021; Semlali et al., Reference Semlali, Tarik, Ahmed, Fatima-Zahrae, Khadija and Khaoula2018; Zhang, Reference Zhang2022). Others who have adopted the general strain theory or an intersectional approach (Agnew, Reference Agnew1999) have depicted drug users as powerless individuals negatively affected by a deficient social environment (Collins et al., Reference Collins, Boyd, Cooper and McNeil2019; Vilalta, López-Ramírez & Fondevila, Reference Vilalta-Perdomo, López-Ramírez and Fondevila2021). By adopting a statistical approach and predetermined scales to capture QOL, studies using this approach often measure whether and to what extent drug users’ QOL is influenced by their drug use and/or deficient individual/social environment (Yen et al., Reference Yen, Wang, Wang, Chen and Chang2011; Zhou et al., Reference Zhou, Li, Wei, Yin, Liang, Zhang and Kou2017). Although these positivist studies have contributed to our understanding of how personality traits and the social environment that could impact drug abuse and drug users’ deteriorating QOL, they have two limitations: (1) they ignore that drug users may have their own subjective interpretations of their QOL, which could differ from the items measured by predetermined scales; (2) they undermine drug users’ human agency in making choices and their ability to take action to improve their self-perceived living quality (Brookfield et al., Reference Brookfield, Selvey, Maher and Fitzgerald2021).
The second camp treats drug users as active agents capable of measuring the costs and benefits involved in their actions and having unique interpretations of their QOL and wellbeing (Weinberg, Reference Weinberg2013; Guan & Lo, Reference Guan and Lo2021). For example, some criminology studies describe drug use as “edgework”—a kind of voluntary risk-taking behaviour in which drug users may calculate and balance risks and benefits before using drugs (Hickson, Reference Hickson2018; McGovern & McGovern, Reference McGovern and McGovern2011). Similarly, the theory of rational addiction portrays drug users as rational beings who can predict the future consequences of drug use and take drugs to maximize their utility (Becker & Murphy, Reference Becker and Murphy1988; Rogeberg, Reference Rogeberg2020). In line with this camp of studies, findings of this study demonstrates that (1) older drug users analyze the costs and benefits while making decisions related to drug use and treatment; and (2) mixed use is one of the four strategies that these users adopt to improve their perceived QOL. Moreover, older mixed users’ decisions are driven by concerns such as the potential adjustments required to achieve their goals and resource availability.
2.2 Conceptual framework: the SOC model
This study adopts the SOC model to understand how older mixed users actively make choices to improve their perceived living standards. Originating from developmental psychology, the SOC model explains strategies adopted by older adults to improve their perceived QOL by adjusting their life goals and mobilizing available resources to achieve these goals (Baltes & Baltes, Reference Baltes and Baltes1990). It assumes that as people proceed through different life stages they obtain (e.g. education qualifications at a young age) and lose (e.g. fitness at an old age) various resources (Zhang & Radhakrishnan, Reference Zhang and Radhakrishnan2018). These resources include physical strength, cognitive ability, and income-generation abilities. However, certain life events, such as chronic illness and ageing, may result in a loss of resources, which makes achieving life goals more difficult, thereby negatively impacting wellbeing. However, older people who can adopt “selection, optimization, and compensation strategies” can better cope with their losses and are more likely to age well (Cui et al., Reference Cui, Gujral, Galfalvy and Szanto2022; Regier & Parmelee, Reference Regier and Parmelee2021).
Selection refers to the process of prioritizing goals and activities by considering one’s available resources. It often involves deprioritizing a less feasible goal or giving it up in favour of a more achievable goal. For example, to spend more time on activities that they find meaningful (e.g. activities with their family members), some older people may reduce the time spent on products they do not perceive as particularly meaningful (e.g. information and communications technology (ICT) products) (Nimrod, Reference Nimrod2020). Similarly, some middle-aged job seekers prefer a lower-paid job to a higher-paid one because they are physically unfit (Watermann, Fasbender & Klehe, Reference Watermann, Fasbender and Klehe2021). Optimization involves finding ways to better utilize available resources to achieve desired goals. For instance, some older people may go to the gym every day to optimize their cognitive abilities (Carpentieri et al., Reference Carpentieri, Elliott, Brett and Deary2017). Compensation involves looking for alternative resources (e.g. through external assistance or new technology) to achieve selected goals. Overall, the SOC model argues that older people who can adjust their goals and mobilize available resources to achieve them are more likely to age well.
The SOC model has been widely adopted to explain strategies used by older adults and people with chronic illnesses to adapt to and overcome challenges brought by age and illnesses, respectively (e.g. chronic pain). For example, it helps explain how they tackle assisted living (Regier & Parmelee, Reference Regier and Parmelee2021), the job market (Watermann, Fasbender & Klehe, Reference Watermann, Fasbender and Klehe2021), and the new ICT environment (Nimrod, Reference Nimrod2020). Apart from explaining how older adults utilize various resources to achieve “successful ageing,” this model can also be suitable for understanding older mixed users strategies to improve their perceived QOL.
2.3 Research context: the prohibitionist drug policy in Hong Kong
This section provides an overview of the drug policies in Hong Kong. Over the last three to four decades, the total number of registered drug users in Hong Kong dropped rapidly by 66% from 17,598 in 1986 to 6,019 in 2021.Footnote 1 However, consistently with the global trend, during the last two decades, the percentage of older drug users (defined as 51 years old or above in Hong Kong) increased from 9.7% in 1995 to 22% in 2021. Most older mixed users in Hong Kong were born between the 1950s and 1960s (Cheung, Reference Cheung2009; Laidler, Reference Laidler2005).Footnote 2 During this period, the use and trade of substances such as opium, morphine, heroin, and cocaine were, at least officially, prohibited by the Hong Kong government. However, according to the childhood memories of some of the informants in the 1970s, with the support of some corrupt police officers, heroin was commonly available in the 1960s. The drug trade went underground only after the establishment of the Independent Commission Against Corruption in 1974. Since then, the government has de facto enforced a prohibitionist policy to control drug use. In accordance with the Dangerous Drug Ordinance, the use, possession, and trade of substances such as heroin, methamphetamine, and marijuana was deemed illegal. Presently, any person who possesses or uses illicit drugs could be fined up to 1,000,000 Hong Kong dollars and imprisoned for up to seven years.
Since the 1970s, law enforcement has been accompanied by the widespread availability of abstinence-based and control-oriented drug treatments (Kong & Laidler, Reference Kong and Laidler2020). It was also in around the 1960s and 1970s that some of the informants started to use drugs and were repeatedly arrested after the 1970s because of it. Once arrested, people who use drugs are subjected to compulsory drug treatment at various facilities. Most informants had received compulsory drug treatment in prison-like facilities operated by the Correctional Services Department (known as the Prison Department before 1982). There are four facilities of this kind (two for males and two for females). Inmates staying in these facilities are those who meet all the following conditions: (1) use drugs; (2) are convicted of minor offences; and (3) are considered suitable for treatment by the courts. Compulsory drug treatment facilities in Hong Kong are similar to those in Mainland China and other Asian countries (Cheng & Lapto, Reference Cheng and Lapto2021). The inmates are not allowed to leave the facilities until they have completed their treatment programmes. They must follow a set of rules that guide their appearance, behaviour, and daily routine in these facilities. This might explain why although these facilities are officially termed as “treatment centres” and “correctional institutions,” the informants considered them as “prisons” and described their experience in such places as “serving time.” In addition to compulsory treatment programmes, informants were also engaged in various abstinence-based voluntary drug treatment services and a methadone treatment programme. The methadone treatment programme was first introduced in Hong Kong in 1972 and formally launched by the government in 1976 (Legislative Council Secretariat, 1996). Methadone is currently offered in 18 methadone clinics to provide OAT to people using drugs. This dual focus on law enforcement and treatment has led some scholars to term Hong Kong’s drug policy as “enlightened prohibition” (Cheung, Reference Cheung2009). Notably, as indicated by other scholars, “control” lies at the core of this prohibitionist drug policy because of the widespread use of compulsory drug treatments (Kong & Laidler, Reference Kong and Laidler2020).
In accordance with a prohibitionist drug policy, all compulsory and voluntary drug treatment programmes in Hong Kong are abstinence-based. Informants of this study were told to stop using drugs if they wanted to improve their QOL when they participated in these programmes, which was in line with the message communicated by all the drug prevention advertisements at the time. The ethos of such programmes can be summarized by one of the most frequently used slogans in Hong Kong’s anti-drug campaigns: “Not now. Not ever. Say no to drugs.” In other words, abstaining from drugs should be their primary goal. However, while all the 25 informants participated in methadone treatment programmes, none of them completely stopped using drugs. Instead, to improve their perceived QOL, they employed various strategies that allowed them to continue using drugs. Using the SOC model, this study attempts to answer two research questions:
-
(1) What strategies have Hong Kong’s older mixed users adopted to improve their self-perceived QOL?
-
(2) How have these strategies been affected and constrained by Hong Kong’s drug policy?
3. Method
Drug users are a highly stigmatized group (Kruis & Choi, Reference Kruis and Choi2020; McGinty, Kennedy-Hendricks & Barry, Reference McGinty, Kennedy-Hendricks and Barry2019). The fieldwork was conducted by the author between 2019 and 2022 in Hong Kong. To establish trust between the author and informants, the researcher conducted extensive fieldwork in specific locations and gathering points (including several tunnels and parks) outside three methadone treatment centres, based on the informants’ preference (Wei et al., Reference Wei, Jiang, Hu, Liang and Xu2023). During these three years, 25 people over 50 years of age who used illicit drugs while joining methadone treatment programmes were recruited for in-depth individual interviews. All interviews were audio-recorded and each lasted 45 to 90 minutes.
Among the interviewees, 23 were male and two were female. The gender ratio of the sample (i.e. 11:1) was roughly aligned with the gender ratio of all older drug users recorded in Hong Kong (i.e. 10:1). The mean age was 64, with five informants in their 50s, 17 in their 60s, and three in their 70s. All informants reported using substances, including heroin, methamphetamine, cough medicine,Footnote 3 and midazolam, and were enrolled in a methadone treatment programme for at least three years while using illicit drugs at least three times a month. Twenty of them did not engage in any income-generating activities and five had low-income part-time jobs. Twenty-two were welfare recipients.
Semi-structured interviews were conducted to allow the informants to take the lead in the data collection process. The interviews focused on the following aspects: (1) the interviewees’ perception of their desired life; (2) strategies adopted by them to achieve their desired life; and (3) ways in which these strategies were related to Hong Kong’s drug policy. All transcripts were thematically coded with the help of ATLAS.ti (2019) using the following procedure. First, all 25 transcripts were read thoroughly. An initial coding was conducted to identify the themes in the data. More detailed coding was then conducted to identify the themes that were specifically related to the two research questions. Finally, passages and quotations related to the identified themes were selected from the transcripts.
Ethical approval for this study was obtained from the University Research Centre of Hong Kong Metropolitan University. All participants were given an information sheet to fill in and were told that they could refuse to answer any questions and withdraw from the study at any time. Written informed consent was obtained before the interviews were conducted. Pseudonyms were used throughout this study to protect participants’ identities and the transcribers were also required to sign non-disclosure agreements.
4. Results
4.1 Selection: coexisting with addiction
Under the SOC model, selection strategies involve abandoning goals that are no longer considered feasible and setting goals that are achievable. In this study, all participants chose to give up drug abstinence as a life goal because of the frustration caused by the frequency of compulsory treatments and relapse they underwent in their lives. Ngon, a 59-year-old man who had used heroin since the age of 15, explained why he did not stop using drugs despite having joined the methadone treatment programme:
Stop Footnote 4 ? I have gaai for so many times … I stopped each time I was put in prison …. You know, right after I got released from the Island [a compulsory treatment facility managed by the Correctional Service Department], I went straight to buy drugs … because at that time I did not want to quit. I was forced to stop using drugs … I certainly went to buy drugs immediately after I was released.
The informants did not aim to cease using drugs before they were sent to prisons or compulsory drug rehabilitation programmes; hence, from their perspective, relapse was an inevitable consequence. One adverse outcome of the frequent experiences of relapse was that their determination and confidence in achieving abstinence when they were triggered to quit drugs at a later stage of their life course gradually diminished (Kelly & Vuolo, Reference Kelly and Vuolo2021; Sohrabi, Shamsalinia & Ghaffari, Reference Sohrabi, Shamsalinia and Ghaffari2018).Footnote 5 As Coeng described:
When we are younger, we still have hope sometimes. Maybe I failed this time, but maybe I will be successful next time. However, every time we relapse, we feel hurt and exhausted. Every single time. The more we relapse, the more we “wear out.”Footnote 6 When one really feels the need to quit, like I feel now, I find myself no longer having the will [power] to quit.
All informants had attempted to seek drug rehabilitation at some point in their lives when they were younger. However, according to the informants, as the number of relapses increased after repeated compulsory rehabilitation, their motivation for abstinence was exhausted. Therefore, not only did they decide to drop the life goal of drug abstinence, but they also sought ways to coexist with drug addiction to improve their perceived QOL. These strategies aim to increase their incoming-generation ability and reduce the financial cost of using drugs.
4.2 Optimization: using a suitable quantity of drugs as an energy booster
To survive and make drug use more financially manageable, some older mixed users use drugs as energy boosters to seek extra income. To implement this strategy, they relied on their knowledge and experience related to the impact of drug use on their bodies. Most informants took a relatively short period of time (from a few days to weeks) to master the techniques of using and “enjoying” drugs. After prolonged use, they had gradually understood the effects of drugs on their physical and mental conditions. This knowledge was utilized to deal with financial shortages more effectively in their older age. For example, Wah, a 65-year-old male, shared his experience of carefully adjusting the quantity of drugs so that he could work more efficiently and earn more money:
I can work [up to] ten hours a day, and I can use this thing (heroin) to sustain [myself] … I would not have a clear head if I used too much [heroin]. If I use a suitable amount, I can suppress the drug craving. It does not cause any problems [for work] … I feel even more energetic [after using heroin].
Likewise, some used cough medicine to enhance their work performance and earn more money. Below, the informant Man (60-year-old male) describes how he used drugs to improve his work efficiency:
Working with and without [using drugs] are completely different [experiences]. For example, my work [is] very boring and dull: stacking boxes in the warehouse …. Emotionally, after using, I can be very hyper, very enthusiastic. I become very motivated and efficient. I can stack those boxes quickly and well. They [other colleagues] are surprised by how efficient I could be.
Our findings demonstrate that some informants used drugs such as heroin and cough medicine to increase their ability to generate income. However, as many of the informants did not have a job, such optimization strategies were only adopted by a few of them. Rather, most informants used compensation strategies to reduce the financial costs of their drug use. That is, while these informants were unwilling to stop using drugs completely, most were willing to temporarily stop consuming drugs or lower their drug-use level. There are two reasons for this finding. First, maintaining their original levels of drug use from when they were younger was no longer financially affordable. Second, reducing their level of drug use could help them better manage their addiction so that they could get high with a smaller quantity of drugs, thereby reducing the amount of money they need to get high in the long term.
4.3 Compensation: using methadone, injection, and midazolam to reduce drug-use costs
The first compensatory strategy adopted by older mixed users to alleviate their financial burden was to seek alternative methods that enabled them to use drugs in smaller quantities. One method was to enrol themselves in methadone treatment programmes when they did not have enough money to buy drugs so that drug cravings could be suppressed. Some older mixed users such as 70-year-old Kei opted for methadone when they had used up their money for purchasing heroin:
You will not see many people around the methadone treatment centre during this period of time, because they just received money from the government [via the Comprehensive Social Security Assistance Scheme], and they can now buy drugs. You will soon see them a few days after they use up their money. That’s our life. A few doses of drugs after getting the money … then use methadone for the rest of the month to suppress the craving.
Another method was to switch the method of using drugs from inhaling or smoking to injection. Older mixed users generally regard drug injection as a more dangerous and harmful way to use drugs. However, some still chose to do so because they could become high much faster in this way compared with other ways. In other words, they could reduce the cost of using drugs by experiencing similar sensations with a smaller quantity of drugs. Hui, a 65-year-old informant, stated:
I don’t get the money for “chasing dragon” [which means smoking heroin on an aluminium foil]. I do not like injections, but it is not like I have a choice. Although it is very dangerous, it is fast and strong.
The third method adopted by older mixed users, especially those who were receiving drug injections, was to supplement drugs with midazolam (also known as “blue fairy” on the street) to boost their feeling of becoming high. As mentioned above, older mixed users have experienced a rapid decline in the quality of drugs (especially heroin) available in the underground market over the past two decades. To keep their long-term use of drugs financially manageable, some informants chose to have heroin and midazolam injected simultaneously. Midazolam is a prescription-only medicine used in Hong Kong for the short-term alleviation of insomnia (Department of Health (HKSAR), 2012). However, some patients sold the midazolam they had acquired from physicians to older mixed users at a relatively low price. Older mixed users bought it and used it together with heroin to compensate for low-quality heroin. For example, Mang explained how he used midazolam with heroin during the interview:
First, you mix the white powder [heroin] with water, then crush the blue pill. The finer the powder, the better. You mix the blue powder into the water, then tear the sponge in the cigarette butt and place it in the water, and then use a syringe to suck up the water … it gives you a feeling of dizziness, very similar to that given by the white powder. If you see blue in the syringe, it means it is mixed with blue fairy.
Using methadone, switching to injections, and injecting other drugs like heroin with midazolam were three methods that many mixed users used to make their drug use more financially manageable. While injecting a mixture of heroin and midazolam was seen as the most cost-effective method by older mixed users, it was also recognized as the most dangerous method because it could lead to serious health problems, such as collapsed veins and bacterial infections in the blood vessels. To simultaneously prevent such health problems and relieve their financial burden, some older mixed users chose to enrol themselves in residential treatment programmes.
4.4 Compensation: joining residential treatment programmes to reduce drug tolerance
Another strategy adopted by older mixed users to compensate for the financial burden of drug use was to enrol themselves in short-term residential treatment programmes that last for two to three months. The aim was to seek temporary drug cessation so that they can “reboot” their drug tolerance, thereby making their post-programme drug use more financially manageable. Prolonged drug use can easily result in drug tolerance; therefore, drug users often search for ways to re-experience the feeling of being high (Mars, Ondocsin & Ciccarone, Reference Mars, Ondocsin and Ciccarone2018). Increasing the quantity of drugs is likely to help them achieve this effect; however, as mentioned above, older mixed users may not be financially equipped to use more drugs. Hence, some informants chose to abstain from drugs temporarily by voluntarily enrolling in short-term residential treatment programmes. Sixty-year-old Yau described this process as “cooling down”:
Many of us who go there [to a residential treatment facility] do not really want to quit drugs (gaai). We go there because we want to “cool down.” Before we go there, both “white powder” and “blue fairy” need to be injected to get high. After cooling down, we can get high by smoking. The longer we stop using drugs, the better we will feel next time, and the smaller the amount we will need next time … [In the residential facility,] we have a clean place to stay, and we do not need to worry about food. Thus, after we live there for a few months, our bodies recover. Then [after leaving the facility], we can get high with a much smaller amount.
Older mixed users asserted that temporary drug cessation of this kind could only occur in residential treatment facilities where they cannot obtain any drugs. Outside the facilities, they would be unable to stop themselves from purchasing drugs, especially after receiving the Comprehensive Social Security Assistance from the government. Hoi, a 51-year-old male, shared his experience:
When we get money, … we will think about buying drugs. However, if we are on the “Island” [a treatment facility], there is no place where we can buy drugs. Then, we can clear our minds, as there is no temptation [in the treatment facility].
In addition, 70-year-old Kei discussed the risks of using drugs after leaving a treatment programme and how they managed them:
The quantity [of drugs] we can use after leaving a treatment programme is very different from that we can use beforehand. We cannot simply use the same quantity because your body can no longer tolerate that much quantity of drugs [after leaving the treatment]. Those novices [people who do not have the experience of using drugs after leaving a treatment programme] do not know that. Sometimes, they overdose and die because of that. So, one needs to be very careful.
Older mixed users such as Kei are clearly aware of the risks and benefits of different strategies, including participating in residential drug treatments and switching from drug inhalations to injections. Instead of portraying them as passive agents incapable of self-control or logical reasoning, the interview responses appear to show otherwise. Participating in a short-term residential treatment programme to make subsequent use of drugs more financially manageable and enjoyable is a conscious decision involving cost-benefit analysis and a prioritizing delayed gratification. The informants seemed to engage in an active risk-and-pleasure management to enhance their perceived QOL while coexisting with their drug addiction.
5. Discussion and conclusion
This study explored how older mixed users adopt various strategies to manage their drug addiction and improve their perceived QOL. Using data collected from 25 older mixed users, I found that, in accordance with the SOC model, these users use their agency to adjust their life goals and adopt various strategies to achieve what they desire and to compensate for what they lost (Cui et al., Reference Cui, Gujral, Galfalvy and Szanto2022; Regier & Parmelee, Reference Regier and Parmelee2021). In contrast to mainstream criminological literature, the findings of this study illustrate that older mixed users have their own understanding of what entails a desirable QOL, which is, from their point of view, to coexist with their drug addiction while striving to make it financially feasible (Barnes, Reference Barnes2015). This finding reflects the disparity between objective conditions and subjective experiences of living quality highlighted in previous studies (Haas, Reference Haas1999; Moons, Budts & De Geest, Reference Moons, Budts and Geest2006; Cheung, Chui, & Chow, Reference Cheung, Chui and Chow2022). While drug use is typically regarded as both a cause and a consequence of a low level of QOL in mainstream academic and non-academic public health discourse, the informants considered it a part of the life they chose, which prompted them to adopt various strategies to maintain this kind of life.
To sustain their drug use and improve their QOL, some older mixed users in this study employed their prior knowledge and experience of drug use and drug treatment to promote their income-generating ability and reduce the financial burden of their drug use. The strategies they adopted allowed them to resist the life goals (of abstaining from drugs) that had been imposed on them by the government and wider society and to live the life they preferred. Some strategies that the informants used were similar to those used by drug users in other contexts, whereas others were not. For example, polydrug use (using more than one type of drug) has been observed in the American and European contexts to increase and prolong the state of being high (Boileau-Falardeau et al., Reference Boileau-Falardeau, Contreras, Garipy and Laprise2022; Valente et al., Reference Valente, Bazzi, Childs, Salhaney, Earlywine, Olson, Biancarelli, Marshall and Biello2020). Some drug users in America and Vietnam have made similar transitions from smoking to injecting heroin to increase the cost-effectiveness of drug use (Des Jarlais et al., Reference Des Jarlais, Arasteh, Perlis, Hagan, Heckathorn, Mcknight, Bramson and Friedma2007). The use of illicit drugs for performance enhancement has also been recorded in other parts of the world (Dyba et al., Reference Dyba, Moesgen, Klein and Leyendecke2019). In contrast, to the best of my knowledge, strategies such as enrolling in residential treatment programmes to reduce drug tolerance and the concurrent use of methadone and other drugs to reduce the financial burden seem to be unique to older mixed users in Hong Kong. In the American and European contexts, studies show that while drug users may be motivated by various factors to join a residential treatment programme, their ultimate goal is to stop using drugs (Caputo, Reference Caputo2019). However, in this study, one of older mixed users’ motivation to join short-term residential treatment programmes originated from their desire to make drug use more financially manageable. In the Western context, drug users who continue to use drugs or relapse after joining a methadone treatment programme tend to drop out of the treatment programme very quickly (Davstad et al., Reference Davstad, Stenbacka, Leifman, Beck, Korkmaz and Romelsjo2007; White et al., Reference White, Campbell, Spencer, Hoffman, Crissman and DuPont2014). However, for the participants of this study, concurrent use of methadone and other drugs was a long-term strategy to maintain their drug use and perceived QOL.
Based on the findings, we scrutinized the narratives that attributed relapse to a lack of self-control. In substance use and criminological studies, drug relapse is defined as a return to drug use following a period of abstinence (Milhorn, Reference Milhorn2018); in contrast, data of this study show that there could be two types of relapse: “unintended relapse” and “intended relapse.” The first type, which can presumably be explained by a lack of self-control (Cheung, Reference Cheung2014; Costello, Anderson & Stein, Reference Costello, Anderson and Stein2021; Semlali et al., Reference Semlali, Tarik, Ahmed, Fatima-Zahrae, Khadija and Khaoula2018), is experienced by people who desire to stop using drugs and have successfully maintained a period of abstinence, but unfortunately resume using drugs. Such a relapse has been frequently documented in academic and non-academic narratives. The second type, as reflected in the findings, cannot be explained by a lack of self-control, for the “relapse” is intentional and is aimed to help the participants enrol in drug treatment programmes by sacrificing short-term gratification (i.e. exercising self-control abilities to temporarily stop using drugs and receiving residential treatments for a short period) for long-term self-perceived benefits (i.e. reducing one’s drug tolerance, lower financial costs, and increased gratification during future drug use). Such an ability has been conceptualized as an essential part of self-control in criminology literature (Burt, Reference Burt2020; Gottfredson & Hirschi, Reference Gottfredson and Hirschi1990). Additionally, findings of this study clearly demonstrate that long-term drug abstinence is not the purpose of some drug users participating in drug treatment programmes. Further research could expand the focus on older mixed users in Hong Kong and other contexts, and investigate the proportion of drug users who have similar goals to those of the sample in this study. Future research could also examine the applicability of existing drug treatment models on a similar sample of drug users.
Furthermore, this paper argues that some older mixed users are active agents capable of making decisions to improve their desired QOL (Hickson, Reference Hickson2018). According to the findings, older mixed users desire a life that is, to a certain extent, different from that commonly described in dominant discourse (Gowan, Whetstone & Andic, Reference Gowan, Whetstone and Andic2012). By accepting drug addiction and ageing as part of their lives, older mixed users in this study actively employed strategies such as making the best use of existing resources (e.g. by adjusting the quantity of drugs they used to enhance their work performance) and seeking alternative resources (e.g. seeking alternative ways of using drugs and attending treatment programmes strategically) to improve their QOL. Throughout the process, they considered the benefits (e.g. having an increased income, a reduced financial cost, and better post-drug-use feelings) and potential harms (e.g. negative impact of drugs on their income-generating ability and risks of overdose), and took action to alleviate potential harm (e.g. by fine-tuning the quantity of drugs they used under different situations). In this regard, findings of this study are corroborated by scholars who argue that drug use is a kind of voluntary risk-taking behaviour involving a calculation of costs and benefits (Weinberg, Reference Weinberg2013; Hickson, Reference Hickson2018; Becker & Murphy, Reference Becker and Murphy1988; Rogeberg, Reference Rogeberg2020).
This study also contends that the informants’ strategies were affected and constrained by Hong Kong’s prohibitionist drug policy. Prohibitionist drug policies and the criminalization of drugs pushed drug trade in the hands of organized syndicates underground (Von Lampe, Reference Von Lampe2015). Unlike agencies in the legal community, organized syndicates usually fail to provide reliable quality control, often leading to the circulation of low-quality drugs on the street (Bourmaud et al., Reference Bourmaud, Dahm, Meys, Gengler, Origer and Schneider2021; Stam et al., Reference Stam, Gerostamoulos, Gerstner-Stevens, Scott, Smith, Drummer and Pilgrim2018; Mars, Ondocsin & Ciccarone, Reference Mars, Ondocsin and Ciccarone2018). Older mixed users in this study also cited the worsening drug quality as a reason for increasing their dosage (to maintain the same level of feeling) and the corresponding increase in their financial burden. However, Hong Kong’s prohibitionist drug policies also prevent these users from seeking less harmful reduction initiatives that do not require drug abstinence, such as supervised injection facilities (Levengood et al., Reference Levengood, Yoon, Davoust, Ogden, Marshall, Cahill and Bazz2021). Without a proper channel to acquire better-quality drugs, older mixed users who are incapable of quitting drugs resort to alternative strategies available to them in the underground market. As reported in this study, these strategies include the use of more dangerous but more cost-effective methods of drug use (e.g. switching from inhaling to injecting drugs) and injecting a mixture of heroin and midazolam.
Finally, findings of this study reflect the characteristics and potential shortcomings of the prohibitionist drug policy implemented in Asia and, more specifically, in Hong Kong. Although Hong Kong’s drug policy has served the needs of many people who were determined to stop using drugs through the widespread provision drug treatment facilities, the existing policy does not cater to the needs of drug users who are not ready to quit drugs, other than providing them with methadone. Hong Kong’s drug policy, which is characterized by a dual emphasis on law enforcement and control-based drug treatment, is similar to that of many Asian countries that have adopted compulsory drug treatment (e.g. Mainland China, Laos, Malaysia, and Thailand). This policy has exposed many older mixed users to repeated experiences of involuntary drug treatment and drug detention (Cheng, Reference Cheng2019; Cheng & Lapto, Reference Cheng and Lapto2021; Loera, Reference Loera2017; Yuan & Liu, Reference Yuan and Liu2023). Findings of this study are consistent with the findings of studies in American and European contexts that do not find compulsory drug treatment more effective than other treatment methods (Werb et al., Reference Werb, Kamarulzaman, Meacham, Rafful, Fischer, Strathdee and Wood2016) and suggest that compulsory drug treatment generates increased frustration that may adversely influence their determination and confidence in achieving abstinence when they become more ready to do so.
Acknowledgements
This research was funded by the Faculty Development Scheme of the Hong Kong Research Grants Council under the Project Reference Number UGC/FDS16/H04/22. The author appreciates the older mixed users who contributed to this study and thanks Professor Sida Liu, Jianhua Xu, and Dr Tiffany Ip for their valuable comments and suggestions on an earlier draft of the paper. The author also gives thanks for the support of the Centre for Criminology of The University of Hong Kong and the Public and Social Policy Research Centre of The Hong Kong Metropolitan University in this work.
Open access
