Social science contributions to understanding multiple drug use have lagged behind those from the natural sciences . The regular and combined use of multiple substances is disproportionately practiced by some minority and socially marginalized groups, such as gender minority individuals . The particular risks and benefits associated with multiple drug use demand a better understanding of its unique characteristics, including its specific patterns, combinations, intentions, and contexts . We use the term multiple drug use to encompass both ‘drug use repertoires’ and ‘drug use combinations’. Drug use repertoires refer to the variety of substances a person ingests during a particular time frame . ‘Drug use combinations’ refer to the ingestion of two or more substances at the same time or in close temporal proximity so that overlapping psychoactive effects are produced . Prominent methods for researching multiple drug use include retrospective surveys that inventory participants’ drug use repertoires over the past month or year, and in-depth interviews and ethnographic field work that examine practices and experiences of drug use combinations. Increasingly, mobile and geo-enabled technologies are being integrated with qualitative research methods to ground drug use practices and experiences in their social and physical environments . In the spirit of creative research methods like these ,hydroponic rack we integrated geo-enabled smartphone survey data collection with a qualitative mapping interview method and piloted it to explain tobacco use disparities among bisexual young adults.
The pilot study revealed smoking patterns and situations that reflect young adult smokers, generally, but also the unique roles that smoking plays for bisexual young adults as they navigate differently sexualized spaces in everyday life . This brief report draws from preliminary data to demonstrate how the method may also provide integrated insights into the unique patterns, intentions, and socio-structural contexts of multiple drug use for different groups of people.Smartphone apps that repeatedly administer surveys to participants and record their locations over time are often used to research recurring and episodic behaviours. These approaches can ‘reach into’ the fabric of everyday life to collect data within participants’ natural environments and routines . Smartphone ownership is increasingly ubiquitous even among low income and rural groups, making this approach feasible with diverse populations. Mobile health research methods, such as these, minimize the retrospective recall bias that occurs when participants are asked to characterize their behaviours or experiences, and can be integrated into spatial frameworks and analyses when geolocation data are also collected . The value of mHealth methods for researching tobacco use is established mHealth methods are now used to research patterns and situational predictors of use of other substances, including cannabis, opioids, cocaine, MDMA, and alcohol . Because mHealth surveys must be kept short to reduce participant burden and encourage data collection compliance, they cannot capture the richness of individuals’ experiences of use contexts and practices, nor how individuals make sense of their drug use within the context of their broader life narratives.
Integrating qualitative mapping methods with mHealth momentary assessements can provide reliable and ecologically valid measures of substance use behaviours while also revealing the richness of experiences and contexts of use. Qualitative mapping, also known as qualitative Geographic Information System , integrates mapping techniques with qualitative methods to explain the processes that produce spatial patterns, relationships, and behaviours . It has been used in research on substance use, including to understand place-based practices and norms of tobacco use , the impact of area restrictions on people who use drugs , and characteristics of drug overdose contexts . Our mixed method approach leverages the “productive complementarity” of multiple methods, acknowledging that different ways of knowing about social phenomena, like drug use, are all inherently partial and are shaped by the conditions and actors involved in the creation of knowledge . We integrate real time, smartphone-collected surveys, location tracking, and subsequent in-depth interviews that are guided by viewing maps of participants’ own mHealth data in an explanatory sequential mixed methods approach . Participants use a smartphone app for a period of time to report on the substances they used and the situations they used them in via participant-initiated real-time reports of use, prompted momentary surveys about use and non-use situations, and prompted daily diary surveys. The real-time reports and prompted surveys collected multiple choice responses with write-in options. Subsequently, real-time reports of use and location tracking data are visualized in mapping software and brought into in-depth interviews to guide and ground discussion of drug use experiences within everyday contexts and situations of use. The interviewer and/or participant toggle between map layers and zoom in and out of places in Google Earth. Together, they identify apparent spatial clusters of use of different substances and discuss what those places are, what they usually do and experience there, who they interact with, and how it is that use of particular substances fold into those experiences. This is similar to the use of travel and activity diaries to guide interviews, but further ‘grounds’ interview discussion by interacting with spatially-visualized representations of participant data.
Quantitative and qualitative data are analysed separately and then integrated in a table. Visually organizing and juxtaposing the quantitative and qualitative data sets helps to identify threads of interest to explore across the data sets and to observe the convergence, complementarity, and/or dissonance between their depictions of participant’s everyday use of and experiences with substance use. We collected data in 2019-2020 with 32 young adults in California who regularly used both tobacco and cannabis with the mixed method . We draw from that study on tobacco and cannabis use to explore one participant’s data, which provided particularly informative insights into the complex patterns, intentions, and socio-structural contexts of multiple drug use repertoires and combinations. The participant did not respond to our request for feedback on the manuscript. To protect the participant’s identity, we use a pseudonym and have added fictional details about the participant that are not relevant to interpreting the data presented below. mHealth data were descriptively analysed using STATA statistical analysis software. Transcript analysis followed an inductive-deductive thematic approach . Transcripts were coded with NVIVO qualitative data analysis software. The initial transcript coding scheme was informed by our previous studies and the literature and was used to sort content by substance type, location, social identity, and roles/intensions of use. Emergent themes regarding roles and intensions of use were identified in a series of group readings of transcript excerpts, as we have done in the past .‘Jason’ was a transgender man in his mid-twenties who lived in a rural community, had a history of homelessness, and reported having autism spectrum disorder . He worked part-time in constrution and lived with his partner in a small house. Jason completed 70% of all prompted surveys during his 30 days of data collection. Jason’s mHealth survey data indicated that he smoked a daily average of 6.5 cigarettes. He most often smoked alone, and frequently smoked at home, in a vehicle, or at someone else’s home. On the minority of occasions that he smoked cigarettes with others,vertical growing systems it was usually with friends or his partner. Jason’s mHealth survey data indicated that he used cannabis almost every day ; 4.9 times per day, on average. He frequently used cannabis in his garage or backyard, someone else’s home, or in a vehicle. He was with friends or his partner during most of these sessions , and was alone for the rest. On most days of the study he reported using cannabis and cigarettes together some or most of the time. He used alcohol on only 15 days and most of those reports were for one drink. On only 5 days did he report using alcohol and cigarettes together some or most of the time. In short, Jason’s mobile data indicated that he used cigarettes and cannabis daily or almost daily, less regularly used alcohol, and that he often used cigarettes and cannabis at the same time.This one individual’s mHealth and map-led interview data set offered an integrated understanding of the complex use patterns, combinations, and intentions within his drug use repertoire , and linked these to his intersecting identities and the particular social and structural characteristics of his environment.
Specifically, it revealed relationships between how and why he uses multiple drugs and his day-to-day experiences as a transgender person with ASD living in a rural community. A key strength of this mixed method appears to be its capacity to go beyond examination of individual substances and individual drug use ‘risk factors’, to link use patterns and intentions of multiple drugs to the intersecting characteristics and place based experiences of different people. The perspective offered by integrating mHealth and qualitative mapping methods may help identify particular drug use patterns and combinations that increase risk of drug-related harm for priority groups, like gender minority individuals, as well as provide insight into the place embedded experiences that give rise to motives for those ‘risky’ drug use practices . Our findings suggest that participant narratives of multiple drug use patterns, intentions, and experiences can be enhanced and further grounded in context by viewing and discussing maps of participants’ own data during interviews. Maps that show where and how frequently participants use different drugs provide an avenue for the participant and interviewer to organize their discussion around the complexities and diverse factors related to multiple drug use. Moreover, similar to other creative methods that integrate images or other objects into interviews , the visual representation of drug use practices in map form may help depersonalize highly stigmatized use practices, like methamphetamine use, and reinforce the participant’s role as expert while cultivating an experience of discovery, reflection, and ownership over the interpreted ‘story’ of their data. This mixed method is limited, however, by being time-consuming and resource-intensive, especially with regards to participant and investigator time effort, as well as obtaining the smartphone data collection software and mapping software. Participant burden must be considered when designing the frequency and length of smartphone-collected surveys, the duration of data collection , and participant incentives. Moreover, great care must be taken to protect participant confidentiality when using any geo-enabled data collection method. This method could be used with a larger sample size by grouping participants for comparison rather than at the individual case level, and triangulating between the quantitative and qualitative data for each group. Future studies can build on research that has identified individual ‘risk factors’ related to multiple drug use , by gaining integrated and geographically-grounded insights into how these diverse and place-embedded factors intersect and interact with one another to shape drug use repertoires and combinations. In-depth knowledge like this can inform the resources and services directed toward and tailored to the needs of diverse groups of people who experience the unique pleasures, roles, and risks of multiple drug use.Over the past decade, perceptions of cannabis and cannabis use have changed radically, with 37 states and D.C. legalizing medical usage and 21 states and D.C. allowing adult recreational usage as of January of 2023. In 2019, Illinois became the 11th state to legalize recreational cannabis for adult use, and the first in the country to adopt a regulatory system for cannabis cultivation, testing, and sales. Texas is one of 13 states without a comprehensive medical cannabis law, only allowing patients with specific debilitating medical conditions to access low-THC medical cannabis products. In May of 2021 the U.S. House of Representative introduced the “Marijuana Opportunity Reinvestment and Expungement Act” that would legalize cannabis and expunge federal cannabis arrest and offenses from individuals’ records. This bill has huge implications for Black communities who are disproportionately impacted by incarceration for cannabis-related offenses. Recent reports estimate Black people are 3.64 times as likely as their white peers to be arrested for cannabis possession despite similar rates of cannabis consumption. Research has explored the risks associated with cannabis usage in Black men who have sex with men such as homelessness, incarceration, and high risk sexual behaviors. Cannabis and sexual risk behaviors maintain a complex relationship as cannabis is often coused with alcohol and other illicit substances. In one study people who used cannabis heavily were more likely to be unaware of their human immuno defficiency virus status; whereas, associations with other HIV outcomes were inconclusive.