Previous literature has identified several factors associated with the initiation of injection drug use; we add to this literature by focussing on the biological, psychosocial, socio-cultural and socio-structural processes that play a role in injection initiation. We identified three necessary processes. Firstly, one must already have developed a conception of drugs as creating desired effects. Secondly, initiation is born out of a social context through interaction with injection drug users. Lastly, the medical mismanagement of pain was a necessary process for a small number of participants. This article also sheds some light on how and why such necessary processes develop. In general, the majority of the participants indicated backgrounds of intense psychosocial and socio-structural hardship. An unstable family life, childhood abuse and environments where drug use is prominent all helped to reinforce a sense of inevitability in some participants.
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