The transition from injection to non-injection drug use: long-term outcomes among heroin and cocaine users in New York City

AIMS: To characterize heroin and cocaine users in New York City who have changed from injection to non-injection drug administration and to identify factors associated with long-term non-injection use. DESIGN: Two cross-sectional studies of heroin and cocaine users in New York City. SETTINGS AND PARTICIPANTS: New admissions were recruited at drug abuse treatment programs (2000-04) and respondent-driven sampling was used to recruit drug users from the community (2004). Both injecting and non-injecting drug users participated in each study. 'Former injectors' were defined operationally as people who had used heroin and/or cocaine in the 6 months prior to the interview and who had injected illicit drugs in the past, but whose most recent injection was more than 6 months before the study interview. 'Current' injectors were defined as people who had injected heroin and/or cocaine in the 6 months prior to the interview. MEASUREMENTS: A structured interview on drug use history was administered, and a serum sample was collected and tested for the human immunodeficiency virus (HIV). FINDINGS: A total of 104 former injectors was recruited for the drug abuse treatment program study, and 229 current injectors were recruited for the community recruitment study; 160 former injectors and 1731 current injectors were recruited from the drug abuse treatment study. Compared with the current injectors, former injectors were older and more likely to be African American. The former injectors reported long intervals since their most recent injection, a mean of 8 years in the drug abuse treatment program study and a mean of 12 years in the community recruitment study. The most common reasons for stopping injection drug use included concerns about health, social stigmatization and self-image, and preference for intranasal use as a route of drug administration. The results were highly consistent across the two studies. CONCLUSIONS: The transition from injection to non-injection use appears to be relatively stable behavior change for many former injectors, who report a decade or more without injecting. Developing a greater understanding of the transition from injection to stable non-injection drug use may provide insights into the natural histories of drug use and addiction.     

Readiness for change and drug use outcomes after treatment

AIMS: The present study represents the first large-scale test of the capacity to predict illicit drug treatment outcomes of an instrument [Stages of Change and Treatment Eagerness Scale (SOCRATES)] purporting to measure processes underlying stages of change. The main hypothesis was that 'taking steps' should be predictive of less frequent use of illicit opiates (heroin and non-prescribed methadone) at follow-up. DESIGN: The sample comprised 1075 people seeking treatment for drug abuse problems in 54 treatment agencies in England. The study uses a longitudinal, prospective cohort design. Structured interviews were conducted at treatment intake and at 1-year follow-up. Data were collected about illicit drug use (frequency of use of heroin, non-prescribed methadone, cocaine and amphetamines, and non-prescribed benzodiazepines) and other problems. FINDINGS: Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake. CONCLUSIONS: Readiness for change measures were not associated with illicit drug use outcomes. Of the 12 hypothesized relationships between readiness for change measures and outcomes, our results show only one 'hit' and 11 'misses'.     

Social Networks,Norms, and 12-Step Group Participation

In a sample of active drug users, we assessed the associations between frequency of attending a 12-step program, perceived social norms, and social network structure. Participants who reported that most or all of their drug partners attended 12-step groups were over ten times more likely to be frequent attenders compared to individuals who did not go to Narcotics Anonymous (NA). While social network structure of number of cocaine and heroin users and number of members in treatment was associated with frequent attendance, there was no association among individuals who infrequently went to a 12-step program. Individuals who are trying to control their drug use should be encouraged to affiliate with others in recovery or attending a 12-step program.     

Social networks, norms, and 12-step group participation

In a sample of active drug users, we assessed the associations between frequency of attending a 12-step program, perceived social norms, and social network structure. Participants who reported that most or all of their drug partners attended 12-step groups were over ten times more likely to be frequent attenders compared to individuals who did not go to Narcotics Anonymous (NA). While social network structure of number of cocaine and heroin users and number of members in treatment was associated with frequent attendance, there was no association among individuals who infrequently went to a 12-step program. Individuals who are trying to control their drug use should be encouraged to affiliate with others in recovery or attending a 12-step program.     

Stimulant use and HIV risk behavior: the influence of peer support group participation.

This study examines 12-step groups for recovery from methamphetamine and cocaine use that are attended by men having sex with men and the impact of attendance on HIV risk behavior. Participants in Crystal Meth Anonymous and other 12-step groups were interviewed up to 3 months since their last substance use. Sixty-two initial interviews, and ethnographic observations, were conducted. With entry into the program, mean reported sexual partners fell from around seven to one per month and the proportion having unprotected anal intercourse declined from 70% to 24%. HIV-positive men were more likely than HIV-negative men to report unprotected anal intercourse when using stimulants but less likely in recovery. Qualitative data suggest a transition from cocaine to methamphetamine in Chicago, and that reduction in partners is due to fear of relapsing in sexual situations rather than program teachings. These programs do however facilitate discussions around drug use and sexual issues.     

Identification of substance use and dependence among patients with viral hepatitis

BackgroundAs drug abuse and addiction have been shown to decrease adherence to treatment of hepatitis C virus (HCV) or HIV, screening for substance use should be standard clinical practice in those undergoing an evaluation for these diseases.AimsTo assess the effectiveness of the Kreek–McHugh–Schluger–Kellogg (KMSK) scale to quantify substance use and dependence among patients with viral hepatitis.MethodsThe KMSK scale, a validated instrument that quantifies lifetime use of alcohol, cocaine, heroin, and tobacco, was distributed to 161 consecutive patients referred to a hepatology clinic at an academic, tertiary-care center over a 1-year period.ResultsOf the 159 patients who returned the KMSK scale, 62% reported illicit drug use and 30% met defined criteria for lifetime dependence on cocaine or heroin. We found that 15% of our population at some time had been co-dependent on cocaine and heroin. The KMSK scale identified significantly more cocaine, heroin, and alcohol use than that detected through the medical record (χ² = 7.61, p < 0.01, χ² = 9.66, p < 0.002, respectively). Cocaine dependence was significantly higher among HCV/HIV co-infected than among mono-infected patients (χ² = 5.46, p < 0.02).ConclusionsThe KMSK scale may be useful to diagnose drug and alcohol use and dependence among patients undergoing evaluation for treatment of viral hepatitis.     

Heroin‐Related Deaths in Sydney,Australia. How Common Are They?

The objective of this article was to determine the number of recent deaths caused by accidental illicit drug overdoses seen at the NSW Institute of Forensic Medicine, Glebe (Sydney). All Forensic cases (3559) were reviewed during the period July 1995-February 1997. Any that were classified as accidental illicit drug overdose were followed up, and demographic and toxicological data were collected for analysis. Our results found that one hundred and forty three accidental illicit drug overdoses were identified from 3359 autopsies during the 20 month data collection period (4%). Male to female ratio was 5:1, but females predominated in the methadone toxicity group. Most of the cases were under 40 years of age. Toxicological results showed that 80% of the deaths were associated with morphine (heroin) levels in the toxic range, although 91% had morphine present at some level. Only 35% of cases had significant levels of bile morphine, suggesting "chronic" usage. In many cases, multiple illicit substances and/or alcohol were thought to be important contributing factors. Cocaine was found in 13% of cases, and all of these had morphine (heroin) in their blood. Methadone was found in 13% of cases, and 13/19 had toxic levels--9/19 also had morphine in their blood. Only two cases had amphetamines or methamphetamines in their blood. The authors conclude that Heroin overdose is by far the most common cause of accidental illicit drug overdose. Those at greatest risk are naive users and those who are not tolerant. There is an urgent need for increased awareness and further education concerning the dangers of heroin use, particularly of multiple drug use (including alcohol). Only about one-third of these cases appear to be "chronic" users.     

Gender,Drug Use,and Perceived Social Support Among HIV Positive Patients

We investigated the relationships among gender, drug use, and perceived social support in 176 HIV positive patients recruited with their informal caregivers in HIV clinics. Perceived caregiver support, emotional support, tangible support, and conflict were assessed. Current drug use was defined as heroin and/or cocaine use within 6 months prior to baseline. Gender was not significantly associated with any of the four outcomes. Current drug users reported significantly higher conflict in social relationships than nonusers, but was not significantly associated with the other three outcomes. However, significant heroin/cocaine use by gender interactions were observed; specifically, the negative associations between current drug use and perceived caregiver and emotional support were stronger among females than males. We concluded that recent heroin/cocaine use may be associated with dissatisfaction in perceived social support from most sources, with the strongest relationships amongst drug using females.     

Pregnancy and birth rates among HIV-infected women in the United States: the confounding effects of illicit drug use

OBJECTIVE: To determine the effect of HIV infection on pregnancy and birth rates and assess the potentially confounding effect of illicit drug use. DESIGN: A retrospective record review of matched cohorts examining pregnancy outcomes for HIV-positive women and two HIV-negative comparison groups (one matched by drug use). METHODS: Ninety HIV-positive women who gave birth in a US city between 1989 and 1993 were matched to HIV-negative women by race, age, parity and date of index birth (group 1, N = 180) and also by the type of illicit drug used (group 2, N = 90). Data were abstracted on tubal ligations and pregnancies occurring before April 1996. RESULTS: A total of 63% of HIV-positive women used cocaine during the index pregnancy and 26% also used opiates. HIV-positive women had fewer tubal ligations than group 1 (38.9% versus 51.1%, P = 0.058), but there was no difference when matching included drug use (38.9% in group 2). HIV infection was associated with a decrease in the number of pregnancies; this decrease was most marked when matching included drug use (18.0 versus 32.1 pregnancies per 100 woman-years,P < 0.01). There were no significant differences in spontaneous or therapeutic terminations. Poisson regression analysis demonstrated that HIV infection and older age were associated with fewer pregnancies, and cocaine use with an increased pregnancy rate. CONCLUSION: This study confirms that HIV infection is associated with a decrease in the number of pregnancies, but also illustrates the confounding effects of illicit drug use among women in the United States.     

HIV risk among women injecting drug users who are in jail

Female offender populations and females in jail include large proportions of injecting drug users (IDUs), who are at high risk of contracting or transmitting HIV. Women IDUs (n = 165) were recruited and interviewed at New York City's central jail facility for women. The study examined these women's patterns of HIV risk behaviors related to drugs and sex and identified behavioral and attitudinal correlates of HIV serostatus. The women typically used both injectable and non-injectable drugs prior to arrest, primarily heroin, cocaine powder, crack, and illicit methadone. Self-reported HIV seropositivity was 43%. Variables correlated with HIV serostatus in the bivariate analysis were: cocaine injection frequency; lifetime injection risk behavior; providing oral sex during male crack use; Hispanic ethnicity; sharing of needles/syringes; sharing of cookers; sharing injection equipment with friends; heroin smoking (negative); injection risk acceptance; peer norms and behavior; lifetime sexual risk behavior; frequency of sex with men; provision of sex for money or drugs; and knowing people with AIDS. The first four variables listed retained statistical significance in a multiple logistic regression analysis. The paper considers the need to tailor AIDS prevention interventions for woman IDUs in jail, including taking into account risk behaviors that occur within frequently reported same-sex partnerships.     

Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users

BACKGROUND: Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined. OBJECTIVE: To estimate the frequency and risk factors for use of street methadone. METHODS: Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression. RESULTS: Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment. CONCLUSION: The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.     

Drug use and perceived treatment need among newly sentenced prisoners in England and Wales

Aims   To investigate pre-custody levels of drug use among newly sentenced prisoners and factors associated with perceived drug treatment need.
Design, setting and participants   A sample of 1457 prisoners was recruited to a general purpose longitudinal survey of convicted prisoners starting a new sentence.
Measurements   Data were collected by structured interviews on reception to prison. Measures were taken of illicit drug use, drug treatment history, current treatment needs, psychological health and a range of social problems.
Findings   Life-time use of heroin, crack cocaine, cocaine powder, amphetamines or cannabis was reported by 79% of prisoners. Cannabis was the drug reported most commonly, but approximately a third had used heroin or crack cocaine during the year before custody. Nearly half of recent drug users reported wanting help or support with a drug problem during their sentence. Dependence on heroin and cocaine, previous drug treatment, employment, accommodation and psychological health problems were all associated positively with perceived treatment need.
Conclusions   The prevalence of pre-custody drug use among this sample of newly sentenced prisoners was high. Because treatment need was associated with a range of drug, health and social factors, assessment and referral to appropriate interventions should occur as soon as possible on reception. Treatment should be coordinated with other services and support.