The families of problem drug users: a study of 50 close relatives

The research described in this paper resulted from a-collaborative multi-centre study of the relatives of problem drug users involving six practitioners and researchers, in four centres within the south-west of England. The objective of this research was simply to interview 50 close relatives of identified problem drug users, with the identification occurring through clinics and self-help groups. Quantitative and qualitative results show that large numbers of these relatives reported many negative experiences. The partners of illicit drug users reported both more and differently patterned problematic behaviours than those of prescribed tranquilliser users. The partners of illicit users also reported different problems to those of the parents. Relatives reported many negative effects in terms of how they viewed the drug user, and how the experiences had affected their health. They also described various coping mechanisms, and the extent of the support which they had received. The results are discussed in terms of coping, and similarity with research into the families of problem drinkers.     

The Relationship Between Crime and Opioid Use⋆

Accepting that opioid use and crime are associated and develop together, amongst opioid-using criminals the need for opioids may cause crime on a day-to-day basis or both may tend to be determined by some other set of factors. Previous studies have either failed to allow for such other factors, or have failed to compare opioid users to adequate control groups. From interviews with 151 Scottish prisoners and non-prisoners, divided into five drug-using groups: (1) alcohol only; (2) cannabis and alcohol; (3) other drugs but not opioids; (4) moderate opioids; (5) heavy opioids, data were obtained on drug use frequency, crime frequency and a variety of other variables. It was found that: (1) there were no differences between incarcerated and non-incarcerated opioid users, in fact incarceration had no substantial effects on other variables; (2) heavy opioid users committed crimes significantly more frequently than did moderate opioid users, non-opioid poly drug users, cannabis users or alcohol users. But, moderate opioid users did not commit crimes significantly more frequently than did the other groups; (3) other drugs were related to crime. Polydrug use (including cannabis use) was more related to theft and delinquency than was opioid use. Alcohol use was related to fraud; (4) there were larger explanations of crime than opioid use—criminal experience and polydrug use—and crime was a better explanation of opioid use variance than opioid use was of crime. It is concluded that need for opioids did not simply cause crime. Rather, crime and opioid use tended to influence each other. However, this relationship was not special to opioids but, depending on historical circumstances, could—and to some extent does—apply to any drug. In consequence, society's treatment of drug-using criminals needs to deal with drug use and crime together.     

Pulmonary effects of illicit drug use

The lungs are at considerable risk from the use of injected or inhaled illicit drugs. The extent and clinical significance of illicit drug induced lung damage is not known completely. Drug use leads to an increase in infectious pulmonary disease, historically in relation to nonsterile injection techniques, and, more recently, in relation to HIV infection and its pulmonary manifestations. Barotrauma related to "smoking topography" or errant injections also represents a real risk of drug use. Although granulomatous disease that involves the pulmonary vasculature and interstitium is probably common in injection drug users, the clinical consequence of such is difficult to estimate. What effect smoked or injected illicit drugs have on short- and long-term pulmonary function also is hard to ascertain. The ubiquitous use of tobacco among users of illicit drugs certainly has confounding effects. Given that illicit drug use is common and that the "popular" drugs of abuse change from generation to generation, the pulmonary physician must remain informed about, and alert for, the effects of drugs of abuse.     

Extent of illicit drug use and dependence, and their contribution to the global burden of disease

This paper summarises data for the prevalence, correlates, and probable adverse health consequences of problem use of amphetamines, cannabis, cocaine, and opioids. We discuss findings from systematic reviews of the prevalence of illicit drug use and dependence, remission from dependence, and mortality in illicit drug users, and evidence for acute and chronic effects of illicit drug use. We outline the regional and global distribution of use and estimated health burden from illicit drugs. These distributions are likely to be underestimates because they have not included all adverse outcomes of drug use and exclude those of cannabis--the mostly widely used illicit drug. In high-income countries, illicit drug use contributes less to the burden of disease than does tobacco but a substantial proportion of that due to alcohol. The major adverse health effects of cannabis use are dependence and probably psychotic disorders and other mental disorders. The health-related harms of cannabis use differ from those of amphetamine, cocaine, and opioid use, in that cannabis contributes little to mortality. Intelligent policy responses to drug problems need better data for the prevalence of different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas.     

Taming demons: the reduction of harm resulting from use of illicit drugs

Restricting availability is the major response to illicit drugs in most Western countries including Australia. Prohibition may reduce harm when the drug in question is in low demand, controls are difficult to subvert, and when similar drugs are less toxi; or unavailable. However, the health, social and economic costs of supply reduction are substantial and increasing for both injecting drug users and the general community. Population adjusted mortality of heroin users has doubled in Australia in the last decade. The possible impact of supply reduction policy on the spread of HIV infection among IDUs is an important but largely neglected consideration. The effectiveness of supply restriction policy in decreasing the availability of drugs or in reducing drug-related harm is unlikely to be increased significantly by more vigorous implementation of supply reduction or adoption of new technology. Conversely, on the basis of existing data, greater availability of HIV prevention measures attractive to the target population (including especially drug treatment such as methadone maintenance) is likely to be effective and cost-effective. The costs and benefits of innovative methods of providing currently illicit drugs to those who are determined to use them requires careful evaluation and comparison with existing policies. Policy on illicit drugs in most countries including Australia is still dominated by concern about drug use rather rhan focused on the need to reduce drug-related problems which is the agreed aim of national drug policy. (Aust NZ 3 Med 1992; 22: 204–208.)     

The criminality of new drug users in Glasgow

The drug use and crime of 210 teenage licit and illict drug users were examined. Over 90% of the sample, including non-users, soft drug users, opioid users and injectors, were obtained via the same ‘snowball’ of friends and acquaintances. None had been injecting for more than 2 years. It was found that the frequency of use of all licit and illict drugs and the frequency of all crimes were intercorrelated. However, even many of the opioid injectors in this sample were not near-daily users and ‘addiction’ did not explain the results of regression equations predicting crime and drug use; crime explained drug use more than drug use explained crime and drug use was not a major unique predictor of theft. The criminal drug-using teenagers in this sample were better regarded as ‘delinquents’ than as ‘drug-abusers’ or ‘drug addicts’. Delinquent behaviour of all kinds appeared to be increased by prior criminal experience, having delinquent friends and lack of conventional social support (notably including having spent time in care). Implications of these findings for theories of delinquency and the practice of treatment and prevention are discussed.     

When is alcohol just another drug? Some thoughts on research and policy

AIM: To reflect on the divergence and overlap between alcohol and illicit drugs with respect to both current policies and policy research. RESULTS: For demand reduction, there is considerable overlap in programs and services for prevention and even more clearly for treatment. For supply controls there is mostly divergence, reflecting the difference in legal status. Research generally follows the same pattern. However, a cross-cutting research agenda on the supply side has merit. CONCLUSION: Even in a prohibition regime, law-enforcement agencies have considerable discretion. A systematic, pragmatic, 'evidence-based' use of that discretion to reduce harm is possible. It can be accomplished only by a continuing program of policy research that measures the harms of drug use and drug enforcement, assesses the effects of current policies on both these sources of social cost and explores alternative strategies. There is a similarly important project for alcohol and tobacco control policy. The goal for research on alcohol and tobacco is to document the extent to which supply controls can be effective in reducing harm; the additional goal for illicit drugs is to document just how much the current ideologically driven approach is costing the public.     

Crystal methamphetamine use among young adults in the USA

AIMS: To examine the prevalence and correlates of crystal methamphetamine use among young adults in the USA. DESIGN: Cross-sectional analyses of nationally representative data of young adults from the National Longitudinal Study of Adolescent Health (Add Health). SETTING: In-home interviews conducted in 2001-02. PARTICIPANTS: A total of 14,322 respondents aged 18-26 years. Measurements: Past year and 30-day crystal methamphetamine use; crime/violence (ever arrested, past year drug selling, past year violent behavior) and sexual risk behaviors (multiple partners, poor condom use, regretted sex, sex for money). FINDINGS: Prevalence of past year crystal methamphetamine use was 2.8%; past month was 1.3%. White or Native American race, residence in the west or south, having an ever-incarcerated father, marijuana, cocaine, intravenous drug use and high novelty seeking were associated with greater likelihood of past year use in multivariate analyses. Compared to marijuana and cocaine users, crystal methamphetamine users were more likely to be male, unemployed, reside in the west or south, have an ever-incarcerated father and less likely to be black or Hispanic. Frequent users were no different from occasional users, except being more likely to have dropped out of school. Although crystal methamphetamine use was associated with crime and risky sex, controlling for covariates greatly diminished this relationship. CONCLUSIONS: Most users are occasional users, but any past year use is associated with risky and antisocial behaviors, including other illicit drug use. Further research is needed to examine how other drug addiction is associated with methamphetamine use, and to identify longitudinal antecedents for prevention.     

Factors associated with high-frequency illicit methadone use among rural Appalachian drug users

Abstract

Background: In recent years there has been a sharp increase in the use of illicit methadone as well as methadone-related overdose deaths. Objective: The purpose of this study was to describe factors associated with low- and high-frequency methadone use in a cohort of rural Appalachian drug users. Methods: Interviews assessing sociodemographics, illicit drug use and drug treatment, psychiatric disorders, health and sociometric drug network characteristics were conducted with 503 rural drug users between 2008 and 2010. A two-level mixed effects regression model was utilized to differentiate low- (one use per month or less in the past six months) versus high-frequency (daily or weekly use in the past six months) illicit methadone users. Results: The lifetime prevalence of illicit methadone use in this population was 94.7% (n?=?476) and slightly less than half (46.3%) were high-frequency users. In the mixed effects regression model, initiating illicit methadone use at a younger age was associated with high-frequency illicit methadone use. Taking a prescribed medication for a physical problem, undergoing additional weeks of outpatient drug free treatment, daily OxyContin® use in the past month, and having fewer ties and second-order connections in the drug network reduced the odds of high-frequency illicit methadone use. Conclusions: Rates of illicit methadone use and high-frequency illicit methadone use among this sample of rural drug users were considerably higher than those previously reported in the literature. Health practitioners in rural areas should routinely screen for illicit opioid use, including methadone.     

Policy and environment assessment on illicit drug use and HIV risk in Cambodia

Research on the extent of illicit drug use and its consequences for HIV risk in Cambodia has revealed that government, NGO, and health care systems in that country are unequipped to deal with HIV/AIDS epidemics among injecting drug users.     

The introduction of a methadone prescribing programme to a drug-free treatment service: implications for harm reduction

In 1990, a National Health drug treatment service with a non-opiate prescribing policy introduced an oral methadone treatment programme for problem opiate users, in addition to existing counselling services. The present study aimed to evaluate the implications of this policy change by comparing two client groups in terms of defined harm reduction variables. The groups consisted of 39 clients presenting to the service prior to methadone prescribing (pre-methadone group), and 41 clients who attended for treatment after methadone prescribing had commenced (post-methadone group). Data analysis revealed that 83% of the post-methadone group remained in treatment for longer than 6 months, in comparison with 13% of clients in the pre-methadone group (p< 0.00001). Other significant differences were noted in treatment outcome, where findings indicated that clients in the post-methadone group were more likely to report cessation of injecting behaviour and continued illicit drug use. Detected crime in the post-methadone group was reduced, and greater positive change in terms of personal relationships was reported. The study concludes that the introduction of a methadone treatment programme appears to have improved treatment outcome significantly for problem opiate users presenting in the service.     

Detection of Illicit Opioid and Cocaine Use in Methadone Maintenance Treatment

Urine toxicology is the gold standard for estimating the prevalence of illicit drug use in methadone maintenance treatment (MMT). The frequency of urine testing may be crucial for establishing accurate use rates. Infrequent testing may lead programs to undercount active drug users and to target interventions too narrowly. This study compared results from frequent testing (twice per week) versus less frequent testing of 166 patients at four MMT programs. As part of a research study, all patients were tested by research staff for opioid and cocaine use twice per week on a fixed schedule for 10 weeks. During the same period, the four MMT programs tested the patients according to their standard protocols, approximately weekly (one program) or every 3–4 weeks (three programs). The research tests identified approximately 50% more illicit opioid users and 70% more cocaine users than the less frequent program tests. Patients who were drug positive according to the research tests but drug negative according to the program tests tended to be infrequent users. The data suggest that standard urine testing practices in MMT programs may result in underestimates of the prevalence of opioid and cocaine use. More frequent testing, even for time-limited periods, should produce more accurate depictions of drug use prevalence and help indicate the direction of interventions.     

Detection of illicit opioid and cocaine use in methadone maintenance treatment.

Urine toxicology is the gold standard for estimating the prevalence of illicit drug use in methadone maintenance treatment (MMT). The frequency of urine testing may be crucial for establishing accurate use rates. Infrequent testing may lead programs to undercount active drug users and to target interventions too narrowly. This study compared results from frequent testing (twice per week) versus less frequent testing of 166 patients at four MMT programs. As part of a research study, all patients were tested by research staff for opioid and cocaine use twice per week on a fixed schedule for 10 weeks. During the same period, the four MMT programs tested the patients according to their standard protocols, approximately weekly (one program) or every 3-4 weeks (three programs). The research tests identified approximately 50% more illicit opioid users and 70% more cocaine users than the less frequent program tests. Patients who were drug positive according to the research tests but drug negative according to the program tests tended to be infrequent users. The data suggest that standard urine testing practices in MMT programs may result in underestimates of the prevalence of opioid and cocaine use. More frequent testing, even for time-limited periods, should produce more accurate depictions of drug use prevalence and help indicate the direction of interventions.     

How well do international drug conventions protect public health?

The Single Convention on Narcotic Drugs in 1961 aimed to eliminate the illicit production and non-medical use of cannabis, cocaine, and opioids, an aim later extended to many pharmaceutical drugs. Over the past 50 years international drug treaties have neither prevented the globalisation of the illicit production and non-medical use of these drugs, nor, outside of developed countries, made these drugs adequately available for medical use. The system has also arguably worsened the human health and wellbeing of drug users by increasing the number of drug users imprisoned, discouraging effective countermeasures to the spread of HIV by injecting drug users, and creating an environment conducive to the violation of drug users' human rights. The international system has belatedly accepted measures to reduce the harm from injecting drug use, but national attempts to reduce penalties for drug use while complying with the treaties have often increased the number of drug users involved with the criminal justice system. The international treaties have also constrained national policy experimentation because they require nation states to criminalise drug use. The adoption of national policies that are more aligned with the risks of different drugs and the effectiveness of controls will require the amendment of existing treaties, the formulation of new treaties, or withdrawal of states from existing treaties and re-accession with reservations.     

Effects of a sustained heroin shortage in three Australian States

BACKGROUND: In early 2001 in Australia there was a sudden and dramatic decrease in heroin availability that occurred throughout the country that was evidenced by marked increases in heroin price and decreases in its purity. AIM: This study examines the impact of this change in heroin supply on the following indicators of heroin use: fatal and non-fatal drug overdoses; treatment seeking for heroin dependence; injecting drug use; drug-specific offences; and general property offences. The study was conducted using data from three Australian States [New South Wales (NSW), Victoria (VIC) and South Australia (SA)]. METHODS: Data were obtained on fatal and non-fatal overdoses from hospital emergency departments (EDs), ambulance services and coronial systems; treatment entries for heroin dependence compiled by State health departments; numbers of needles and syringes distributed to drug users; and data on arrests for heroin-related incidents and property-related crime incidents compiled by State Police Services. Time-series analyses were conducted where possible to examine changes before and after the onset of the heroin shortage. These were supplemented with information drawn from studies involving interviews with injecting drug users. RESULTS: After the reduction in heroin supply, fatal and non-fatal heroin overdoses decreased by between 40% and 85%. Despite some evidence of increased cocaine, methamphetamine and benzodiazepine use and reports of increases in harms related to their use, there were no increases recorded in the number of either non-fatal overdoses or deaths related to these drugs. There was a sustained decline in injecting drug use in NSW and VIC, as indicated by a substantial drop in the number of needles and syringes distributed (to 1999 levels in Victoria). There was a short-lived increase in property crime in NSW followed by a sustained reduction in such offences. SA and VIC did not show any marked change in the categories of property crime examined in the study. CONCLUSIONS: Substantial reductions in heroin availability have not occurred often, but in this Australian case a reduction had an aggregate positive impact in that it was associated with: reduced fatal and non-fatal heroin overdoses; reduced the apparent extent of injecting drug use in VIC and NSW; and may have contributed to reduced crime in NSW. All these changes provide substantial benefits to the community and some to heroin users. Documented shifts to other forms of drug use did not appear sufficient to produce increases in deaths, non-fatal overdoses or treatment seeking related to those drugs.     

Drug Injecting, AIDS, and Risk Behaviour: potential for change and intervention strategies

The sharing of unsterile needles and syringes is a primary means by which drug users who inject put themselves at risk of HIV infection. This paper examines a sample of 127 regular illicit drug users (both in and out of treatment) in terms of injecting and needle sharing patterns, and investigates the impact of concern about AIDS upon these behaviours. Amongst those that had ever injected, it was found that 54% had substantially reduced their risk behaviour, in that they either no longer injected, or else no longer shared injecting equipment. A further 32% had to some extent reduced their risk behaviour, and only 14% staled that they had been unaffected by concern about AIDS. Those who were in contact with agencies were more likely to have substantially reduced their risk behaviour than those not in contact with agencies. Regarding the impact of HIV testing, the data suggest that it may be associated with reduced rather than increased risk behaviours, though the differences only approach significance. In two consecutive time periods, similar proportions reported that they were still sharing; but by the second time period almost all reported some attempt at change. In general, the results confirm other studies, from the USA and Britain, that have shown that drug users are not inherently irrational, and are capable of modifying their risk behaviour. Availability of clean injecting equipment was given as the prime reason for sharing, and the free supply of needles and syringes is advocated as a complement to effective health education. Aggressive outreach work is to be encouraged so as to reach those individuals unlikely to use established schemes.     

Type and pattern of illicit drug use and access to health care services for HIV-infected people

Approximately 28% of HIV-infected people in treatment in the United States report using illicit drugs. Illicit drug users have poorer course of HIV disease than non-drug users, which is thought to be due to their irregular use of HIV medical services. We examined associations between type (cocaine versus opioids) and pattern of drug use (drug use at baseline, 6-month follow-up, both periods, and nonuse) and health care utilization for a large sample of HIV-infected individuals drawn from a multisite project that evaluated the impact of medical outreach interventions for populations at risk of poor retention in HIV care. Across all types and patterns of drug use, drug users were more likely to have suboptimal ambulatory care, miss scheduled appointments, use the emergency department, have unmet support services needs, and were less likely to take antiretroviral medications. Additionally, while people who started using drugs during the follow-up period and consistently used drugs across both periods differed from nonusers on missed appointments (odds ratio [OR] = 2.20 for starters versus nonusers, OR = 2.92 for consistent users versus nonusers), emergency department use (OR = 4.93 for starters versus nonusers, OR = 2.24 for consistent users versus nonusers), and antiretroviral medication use at follow-up (OR = 0.23 starters versus nonusers, OR = 0.19 for consistent users versus nonusers), those who stopped using drugs after the baseline period did not differ from nonusers. We conclude that health care utilization is poorer for people who use illicit drugs than those who do not, and stopping drug use may facilitate improvements in health care utilization and HIV outcomes for this population.     

Marginality among older injectors in today's illicit drug culture: assessing the impact of ageing

Aims  As conceptualized by Robert Park in 1928, the 'marginal man' occupies simultaneously an intermediate point between two distinct cultures that embody some level of contradictory normative expectations, behaviors and beliefs. This paper explores the influence of ageing and social change on the creation of marginality among injection drug users over age 50 who have been chronic heroin users since their youth.
Design  Our data are drawn from in-depth interviews with 40 (28 male and 12 female) not-in-drug-treatment, active injecting drug users between the ages of 18 and 68.
Setting  Our sample was recruited using street outreach as part of a larger, community-based study conducted from a converted storefront in a high crime, economically depressed neighborhood on the west side of Chicago.
Findings  As they aged, and under the pressures of social change, the older users whom we studied moved from center positioning in the illicit drug culture of their youth to the margins of a differing drug culture of today where they participate largely unseen by others. Nostalgic for the 'Old School' mores of the past, and unable to transcend or assimilate fully into the cultural practices and norms of the 'New', they respond to their predicament by embracing 'poise' in the face of loneliness, stress and fear of victimization.
Conclusions  Our respondents' experiences draw attention to the need to refine the field's theoretical and practical understandings of what it means to be marginal and its consequences for older drug users and people in general. The results also point to what happens when society changes but some of its members do not.