Needles in the haystacks: the social context of initiation to heroin injection in rural Ohio

Although there has been much research on the social context of heroin injection, little has been reported outside of major urban areas. This article examines contextual factors associated with initiation to heroin injection in rural Ohio, based on semistructured qualitative interviews and focus groups involving 25 recent heroin injectors (12 women, 13 men) recruited from three contiguous counties between June 2002 and February 2004. Curiosity about the drug's effects, the growing pressures of drug dependence and economic need, and the influence of intimate and group relations were all identified as factors that offset fears commonly associated with injection. This study complements other research on the social ecology of heroin injection and may contribute to improved services for injection drug users in rural areas and small communities.     

Heroin Sniffers: Between Two Worlds

Abstract

This article examines individual and social factors associated with initiation of illicit drug injection, with a focus on racial differences. Data were derived from a cross-sectional survey of young injection and noninjection drug users in Baltimore, Maryland. Participants were aged 15 to 30 and had initiated use of heroin, cocaine, and/or crack within the prior five years. Bivariate and multivariate logistic regression models were used to identify correlates of injection initiation. Of 579 drug users, 73% were injectors, 56% were male, and 41% were African American. In a multivariate model controlling for age, correlates of injection initiation were: being an African American male [Adjusted Odds Ratio (AOR): 0.08; 95% Confidence Interval (CI): 0.04, 0. 17] or female (AOR = 0.12; 95%CI: 0.06, 027) compared to being a White male; younger age of first use of alcohol, marijuana, or inhalants (AOR=0.73; 95%CI: 0.65, 0.82); shorter time between first use of alcohol, marijuana, or inhalants and first use of heroin, crack, or cocaine (per year decrease, AOR=0.63, 95%CI: 0.40, 0.87); parental drug use (AOR=0.54, 95%CI: 0.32, 0.92); seeing someone inject prior to injection, AOR=1.96, 95%CI: 1.0 1, 3.50); and crack smoking (AOR=1.77, 95%CI: 1.07, 2.99). Early drug use panems and drug expos we factors are associated with initiation injection. Interventions are needed that target noninjection drug users to prevent transition to injection drug use.     

Editorial

The increase in the number of non-fatal opioid overdoses in Melbourne, Australia has occurred concomitantly with the emergence of street heroin dealing / using areas across different parts of Melbourne. The aim of this study was to examine the social and environmental factors that contribute to the risk of illicit drug overdose in a street heroin dealing / using setting. A detailed examination of overdose experiences, and consultations with drug users, police and shop traders, suggests that the harm related to drug overdose and the factors which contribute to the risk of overdose in a street-using / dealing environment may be significantly underestimated. The clinical definition of drug overdose may underestimate the harm associated with illicit drug use. Through not fully understanding drug user's experiences of drug overdose, and thus incorrectly defining drug overdose, significant opportunities to intervene in what is a significant medical and social problem may be lost.     

Nonmedical Use of Promethazine Hydrochloride Among Heroin Injectors in Vietnam: Unrecognized Risks and Unintended Consequences

Background: Surveillance studies have noted intravenous injection of promethazine hydrochloride (PHC) among populations that use heroin in south and southeast Asia. However, little is known about onset and initiation of PHC use and its relationship to habitual heroin use. Methods: As part of a longitudinal study of heroin initiation, a sample of 179 new heroin users, aged 15–27 years, were interviewed between October 2005 and December 2006 in Hanoi, Vietnam. Cox proportional hazard regression analysis was used to characterize age at promethazine initiation and its association with relevant covariates. Results: 76%% reported lifetime use of PHC. Mean age of PHC initiation was 21.3 years, on average 6 months following onset of heroin injection. In multivariate analysis, lifetime use of diazepam [[HR == 1.69 (1.17, 2.44); p-value == .01]] and injecting heroin for more than 1.58 years [[HR == 1.46 (1.04, 2.06); p-value == .03]] were associated with PHC initiation. Conclusion: Intravenous injection of PHC is a relatively common practice among young injection heroin users in Hanoi, Vietnam who use it on a situational basis to substitute for heroin (when heroin is not available or when heroin is too costly) or to augment the effects of an inadequate heroin dosing (delaying onset of heroin withdraw). Existing drug prevention strategies in Vietnam are focused primarily on heroin and most new heroin users initiate PHC use without prior knowledge of its high risk for serious vein damage. Future research is needed on the PHC use among heroin users, including long-term medical consequences of PHC exposure.     

Demographic and Clinical Features of Chinese Heroin Users Who Switch from Non-injection to Injection

Background: Injection drug users (IDUs) are at high-risk for acquiring human immunodeficiency virus, hepatitis C virus, and other infections, and delaying the switch from non-injection drug use to injection to drug use could reduce the spread of these infections. Objectives: To estimate the incidence of switching from non-injected heroin use (usually smoking or “chasing”) to injection and to investigate the risk factors for this change. Methods: We reviewed the socio-demographic and clinical data of 7305 heroin-dependent patients treated at a detoxification clinic of a university-affiliated psychiatric hospital in China from January 2000 to February 2009. Results: Within 1 year, the majority of non-injection drug users (NIDUs) transitioned to IDUs (59.4% within 6 months and 76.7% within 12 months). Multiple logistic regression analysis showed that marital status, years of education, employment status, age at onset of heroin use, duration of drug abuse, and initial dose were associated with the switch from NIDU to IDU. Being married (B = ?0.410, OR = 0.664), being employed (B = ?0.243, OR = 0.784), and older age at onset (B = ?0.040, OR = 0.961) were protective factors. More education (B = 0.120, OR = 1.128), longer duration of drug abuse (B = 0.010, OR = 1.010), and a higher dose at initial drug use (B = 0.234, OR = 1.264) were risk factors. Conclusions/Importance: The study has identified several risk factors for the switch to injection among heroin users. Understanding these factors can help design new approaches to more specifically target high-risk populations and high-risk behaviors to delay or prevent the transition to injection.     

Comparing Injection and Non-Injection Routes of Administration for Heroin,Methamphetamine, and Cocaine Users in the United States

ABSTRACT

Research examining the demographic and substance use characteristics of illicit drug use in the United States has typically failed to consider differences in routes of administration or has exclusively focused on a single route of administration—injection drug use. Data from National Survey on Drug Use and Health were used to compare past-year injection drug users and non-injection drug users' routes of administration of those who use the three drugs most commonly injected in the United States: heroin, methamphetamine, and cocaine. Injection drug users were more likely than those using drugs via other routes to be older (aged 35 and older), unemployed, possess less than a high school education, and reside in rural areas. IDUs also exhibited higher rates of abuse/dependence, perceived need for substance abuse treatment, and co-occurring physical and psychological problems. Fewer differences between IDUs and non-IDUs were observed for heroin users compared with methamphetamine or cocaine users.     

Prevalence and correlates of jugular injections among injection drug users

Background . Jugular injection of drugs has been reported, although little is known about the prevalence of and risk factors associated with this behaviour. We evaluated factors associated with jugular injection among a cohort of injection drug users (IDU) in Vancouver, Canada. Methods . We used univariate statistics and logistic regression to examine factors associated with jugular injection among participants in the Vancouver Injecting Drug Users Study (VIDUS), a large prospective cohort study of IDU recruited through snowball sampling methods in Vancouver, Canada. Findings . Between December 2004 and November 2005, 780 IDU were followed up as part of VIDUS and 198 (25%) reported jugular injection in the previous 6 months. In multivariate analyses, factors associated independently with jugular injection included: being of the female gender [adjusted odds ratio (aOR) = 1.72, 95% confidence interval (CI): 1.14–2.59; p = 0.010], daily heroin use (aOR = 2.89, 95% CI: 1.93–4.34; p < 0.001), daily cocaine use (aOR = 1.76, 95% CI: 1.12–2.76; p = 0.014], requiring help injecting (aOR = 4.44, 95% CI: 2.64–7.46; p < 0.001), and involvement in the sex‐trade (aOR = 2.71, 95% CI: 1.6–4.55; p < 0.001). Interpretation . Reporting a history of jugular injecting was alarmingly high in the cohort and was associated with several identifiable demographic and drug‐using characteristics. Given previous reports demonstrating the risk of infection and vascular trauma due to this behaviour, these populations should be considered seriously as a target for safer injecting education.     

Change in the Scenery

Abstract

Though still largely perceived as an “inner city” drug, crack cocaine has become increasingly available in many areas of the United States. However, little research has been conducted on the phenomenon of crack cocaine use outside of urban areas. This paper draws on qualitative interviews with 50 recent and former crack-cocaine users to explore patterns of use and distribution in three counties in rural Ohio. The findings show that variable patterns of crack use previously documented among urban crack users are evident in rural areas as well, though these are modified by the context of the rural small town. It is postulated that local social networks are the primary means by which these patterns are both transmitted and translated. Implications of these exploratory findings and possible directions for future research are discussed.     

Drug Initiation of Female Detainees in a Compulsory Drug Treatment Institution in China

This study explored drug initiation among 46 Chinese women in a compulsory drug treatment institution. The study adopted a mixed method with a strong emphasis on qualitative techniques to capture the perspectives of women in long-term treatment regarding their drug initiation experiences. A complementary analysis of quantitative data was used to help interpret, refine, deepen, and extend qualitative findings. Participants were divided into two groups according to their main drug of choice: 27 used methamphetamines and 19 used heroin (11 of them used methamphetamines occasionally). Four main themes were identified in the analysis of participants’ drug initiation narratives: (1) involvement in high-risk social networks; (2) lack of family love and support; (3) relationship problems; and (4) male partner influence. Findings indicate that the younger generation preferred starting their drug career with methamphetamines rather than heroin, due to the changes in the drug market and broader changes related to globalization. A lack of family love and support had a strong effect on the initiation of methamphetamine but not heroin users; however, male intimate partners and relationship issues showed strong influence on heroin initiation. Having high-risk social networks was a common narrative in the drug use initiation of Chinese women across methamphetamine and heroin groups.     

海洛因依赖者的社会支持与主观幸福感及其相关性分析

目的:调查和研究海洛因依赖者的社会支持和主观幸福感的状况及其关系。方法:对60名正常人群(对照组)及60名海洛因依赖者(海洛因依赖组)进行社会支持评定量表及总体幸福感量表(GWBS)测评,并分析其相关性。结果:两组各量表评分比较,海洛因依赖者得分显著低于正常人群,差异具有显著性(P<0.001);主观幸福感与社会支持呈正相关,即海洛因依赖者获得的社会支持越高,其主观幸福感就越好;主观幸福感与负性情绪呈显著负相关。结论:社会支持与主观幸福感密切相关,海洛因依赖者社会支持和主观幸福感状况较差,开展戒毒工作,应该重视社会支持系统,对提高海洛因依赖者生活满意度有重要作用。     

Injection Risk Behavior among Women Syringe Exchangers in San Francisco

Women who inject drugs in cities where syringe exchange programs (SEPs) are well established may have different risks for HIV infection. In 1997, we interviewed 149 female syringe exchangers in San Francisco, CA, a city with high rates of injection drug use that is home to one of the largest and oldest SEPs in the United States. In this report, we describe their sociodemographics, health, and risk behavior, and we examine factors associated with recent syringe sharing. Fifty percent of respondents were women of color and the median age was 38 years. Most (86%) injected heroin and nearly half were currently homeless or had recently been incarcerated. One-third of all women reported needle sharing in the prior month. This was higher than the rate of needle sharing reported by a mixed gender sample of San Francisco exchangers in 1993, although it resembled the rate reported by a mixed gender sample in 1992. In a multivariate analysis, syringe sharing was associated with age, housing status, and sexual partnerships. Syringe sharers were more likely to be young, homeless, or have a sexual partner who was also an injection drug user. While wide access to sterile syringes is an important strategy to reduce HIV transmission among injection drug users (IDU), syringe exchange alone cannot eradicate risky injection by female IDU. Additional efforts to reduce risky injection practices should focus on younger and homeless female IDU, as well as address selective risk taking between sexual partners.     

Personal Social Network Factors Associated with Overdose Prevention Training Participation

We investigated social network factors associated with participation in overdose prevention training among injection drug users (IDUs). From 2008 to 2010, 106 IDUs who had witnessed an overdose in the past year from two syringe exchange programs in Los Angeles provided data on overdose prevention training status (trained vs. untrained), social networks, history of overdose, and demographics. In multivariate logistic regression, naming at least one network member who had been trained in overdose prevention was significantly associated with being trained (Adjusted Odds Ratio 3.25, 95% Confidence Interval 1.09, 9.68). Using social network approaches may help increase training participation. Limitations are noted.     

The relationship between drug use settings,roles in the drug economy,and witnessing a drug overdose in Baltimore,Maryland

Background: There has been a dramatic increase in drug overdose deaths in the United States. In the current study, the authors examined factors associated with witnessing a drug overdose. Methods: A sample of 450 substance users in Baltimore, Maryland, were recruited for a behavioral intervention and were administered a survey. Multinomial logistic regression models were used to compare participants who never witnessed a drug overdose with those who witnessed one in the prior 6 months and those who witnessed an overdose over 6 months ago. Results: Most (58%) participants were male, 40% experienced homelessness in the prior 6 months, 63% reported a history of heroin injecting, 84% had snorted heroin, 75% reported witnessing a drug overdose, and 38% experienced an overdose. In multinomial logistic regression models, witnessing an overdose in the past 6 months was associated with number of different types of places where drugs were used (adjusted odds ratio [aOR] = 1.34), history of experiencing an overdose (aOR = 1.80), injecting heroin and/or speedball (aOR = 1.78), and snorting heroin (aOR = 1.54). Witnessing an overdose more than 6 months ago was associated with number of different places where drugs were used (aOR = 1.25), history of experiencing an overdose (aOR = 1.61), snorting heroin (aOR = 1.42), and injecting heroin or speedball (aOR = 1.47). Conclusions: These data suggest that people who engage in more public and frequent drug use, and hence are more likely to witness an overdose, should be targeted for interventions to prevent and treat drug overdose.     

Predictors of injection drug use cessation and relapse in a prospective cohort of young injection drug users in San Francisco,CA (UFO Study)

Background

Studies of injection drug use cessation have largely sampled adults in drug treatment settings. Little is known about injection cessation and relapse among young injection drug users (IDU) in the community.

Methods

A total of 365 HCV-negative IDU under age 30 years were recruited by street outreach and interviewed quarterly for a prospective cohort between January 2000 and February 2008. Participants were followed for a total of 638 person-years and 1996 visits. We used survival analysis techniques to identify correlates of injection cessation (≥3 months) and relapse to injection.

Results

67% of subjects were male, median age was 22 years (interquartile range (IQR) 20–26) and median years injecting was 3.6 (IQR 1.3–6.5). 28.8% ceased injecting during the follow-up period. Among those that ceased injecting, nearly one-half resumed drug injection on subsequent visits, one-quarter maintained injecting cessation, and one-quarter were lost to follow-up. Participating in a drug treatment program in the last 3 months and injecting less than 30 times per month were associated with injection cessation. Injecting heroin or heroin mixed with other drugs, injecting the residue from previously used drug preparation equipment, drinking alcohol, and using benzodiazepines were negatively associated with cessation. Younger age was associated with relapse to injection.

Conclusion

These results suggest that factors associated with stopping injecting involve multiple areas of intervention, including access to drug treatment and behavioral approaches to reduce injection and sustain cessation. The higher incidence of relapse in the younger subjects in this cohort underscores the need for earlier detection and treatment programs targeted to adolescents and transition-age youth.     

38例顽固性药物滥用者情况调查分析

本文对４３８例药物依赖者多次戒断多次复吸的心理因素及社会因素进行调查分析,结果发现药物滥用者对毒品的心理依赖无法纠正,即心瘾难消,戒断症状迁延不愈以及本身又无戒断毅力,是造成吸毒－戒毒－复吸－戒毒－复吸的恶性循环的主观因素;毒源难清,毒友引诱是客观因素。因此“对症下药”寻找抗复吸的对策十分必要     

Prevalence and Correlates of Former Injection Drug Use Among Young Noninjecting Heroin Users in Chicago

Noninjecting heroin users (NIHU) that were 16–30 years old were street recruited in Chicago between 2002 and 2005 to examine factors associated with having ever injected. Participants completed computerized self-administered interviews and provided specimens for HIV and hepatitis serotesting. Of 689 NIHU, 51.2% were non-Hispanic Black, 64.4% were male, and the median age was 25 years. Former injection was reported by 17.9%; of those, 66.7% injected <10 times. Multivariable analysis identified individual and social factors that place young NIHU at increased risk of injection. Targeted interventions are necessary to prevent transitions to injection and reduce transmission of HIV and viral hepatitis infections. The study's limitations are noted.     

Injection and sexual risk practices among young heroin users in Hanoi,Vietnam

Abstract

Epidemiological data in Vietnam shows high HIV prevalence rates among injection drug users, especially in urban centres. However, there are limited data on specific practices used to prepare and inject drugs or on sexual practices among Vietnamese injectors. A street-based cross-sectional interview was conducted with 862 heroin injectors in Hanoi, Vietnam, to collect such data. Variability was seen in both injection and sexual risk, with 12.9% of current injectors reporting at least one unsafe method of drug sharing and 57.1% reporting unsafe sex in the past 30 days. These risks were strongly associated with those who engaged in unsafe injection significantly more likely to engage in unsafe sex (69.4% vs. 55.3%) and those engaging in unsafe sex significantly more likely to engage in unsafe injection (15.7% vs. 9.2%). These findings highlight the overlap of injection and sexual risk practices among Vietnamese heroin users and suggest the need for strong, broadly targeted HIV prevention activities among this population.     

Is inhalant use a risk factor for heroin and injection drug use among adolescents in the United States?

PURPOSE: We examined whether inhalant use was associated with heroin and injection drug use (IDU) among adolescents aged 12 to 17 in the United States. METHODS: Data were drawn from the 2002/2003 administrations of the National Survey on Drug Use and Health (NSDUH). We conducted logistic regression analyses to estimate associations of inhalant use with heroin use, heroin injection, and IDU, respectively, among adolescent drug users (N=8161). RESULTS: Approximately 30.9% of adolescents had ever used at least one illicit drug. More than one-fifth (22.2%) of adolescents were past-year or recent drug users. Among past-year adolescent drug users, 1.4% had progressed to heroin use and 1.2% reported IDU. Adolescents who had used inhalants and marijuana were 2.8 and 2.9 times as likely as adolescents who had used marijuana but not inhalants to report heroin use and any IDU, respectively. Adolescents who had used inhalants or other drugs but not marijuana were unlikely to use heroin. However, inhalant users, irrespective of their marijuana use histories, had greater odds of IDU than drug users who had not used inhalants. Adolescent drug users who were females, school dropouts, whites, or delinquents had significantly increased odds of heroin use and IDU. Cigarette smoking before the age of 15 was strongly associated with heroin use, and a history of foster care placement was associated with IDU. CONCLUSIONS: This national study of American adolescents identifies several subgroups of recent drug users, such as females, school dropouts, and youth who have used inhalants and marijuana, which have substantially increased odds of heroin use and IDU. Screening, prevention, and treatment interventions targeted to these groups might reduce medical and social complications of heroin use and IDU.     

Adoption of injection practices in heroin users in Guangxi Province, China

This preliminary study collected data from 326 heroin users in Guangxi Province, China, in 1997. Logistic regression analysis was performed to identify the risk factors for injection. Survival analysis identified factors independently associated with time from initiation of heroin use to adoption of injection. Four factors were independently associated with injection: number of friends who used heroin in the last year, duration of heroin use, dose of heroin consumed, and total number of times detoxified in drug treatment and rehabilitation centers. Only gender and duration of heroin use were independently associated with time to first injection. Median time to first injection was 11 months for males and 22 months for females. Median time to first injection varied by age. Median time to injection for those who used heroin for more than one year was 8.1 months; it was 19.1 months for on to five years of use, and 40.5 months for more than five years of use. This study's preliminary findings suggest that younger, more recent heroin users, and males are at increased risk of becoming injectors, a major risk behavior for HIV acquisition.     

A Model of School Problems,Academic Failure,Alcohol Initiation,and the Relationship to Adult Heroin Injection

The current study uses structural equation modeling to investigate factors associated with alcohol initiation and injection heroin use. Baseline data from the NEURO-HIV Epidemiologic Study in Baltimore, Maryland, were used. Participants were 404 injection heroin users (M_age = 32.72) with a history of regular injection in their lifetime. Latent variables were created for self-reported school problems and academic failure. The final model indicated that greater school problems were associated with earlier alcohol initiation (ß = ?0.22, p < .001) and earlier alcohol initiation was associated with greater frequency of recent heroin use (ß = ?0.12, p < .05). Academic failure was directly related to greater frequency of recent heroin injection (ß = 0.15, p < .01). The results expand research investigating the relationship between adolescent behavior and illicit drug use in adulthood.