Trends in injection drug use behaviors over 10 years among street youth

OBJECTIVES: To determine the temporal trends of initiation into injection drug use, current injection, and recent receptive sharing of injection paraphernalia among street youth. DESIGN: Data from two cohort studies conducted between 1995 and 2005 were combined. METHODS: Recruitment was done on an ongoing basis. Interviews were performed semi-annually. Overall and annual drug injection incidence rates were calculated with the person-time method. Poisson regression was used to assess the predictive power of calendar year on incidence rate. Generalized estimating equations (GEE) were used to assess linear trends in current injection among street youth and in recent receptive sharing of syringe and other injection paraphernalia among current injection drug users. RESULTS: By 31 March 2005, 1633 subjects had completed 8875 questionnaires. Most subjects were born in Canada (94%), their mean age at entry was 20 years, 68% were boys and almost half (44%) had injected drugs before recruitment. Among 778 never injectors at entry, 130 subjects initiated injection in 1898 person-years of follow-up (incidence rate: 6.8 per 100 person-years). When controlling for age, calendar year was not a significant predictor of incidence rate. Prevalence of current injection was stable (around 30%). Odds of both sharing behaviors decreased by approximately 10% per year. CONCLUSIONS: In addition to injection paraphernalia sharing reduction efforts, interventions aimed at preventing initiation into injection drug use among high-risk youth are needed.     

A comparison of drug use and risk behavior profiles among younger and older street youth

Among 559 street youth recruited between 2005 and 2007 in Vancouver, Canada, young drug users (<21 years of age) were compared with older drug users (≥21 years) with regard to recent drug use and sexual practices using multiple logistic regression. Older youth were more likely to be male and of Aboriginal ancestry, to have more significant depressive symptoms, to have recently engaged in crack smoking, and to have had a recent history of injection drug use. Young drug users, by contrast, were more likely to have engaged in recent binge alcohol use. Efforts to reduce drug use-related harm among street youth may be improved by considering the highly prevalent use of "harder" drugs and risk for depression among older youth.     

Sequential Progression of Substance Use Among Homeless Youth: An Empirical Investigation of the Gateway Theory

We examined the sequence of substance-use initiation in 375 street youth (age 13–21) who were interviewed from 1994–99 in Seattle, Washington. Based on the “gateway theory,” participants were categorized into six profiles to describe the order in which they initiated use of various substances (i.e., alcohol, marijuana, other drugs), or classified as nonprogressors if they had not tried all three classes of drugs. Youth progressing in the hypothesized gateway order (i.e., alcohol preceding marijuana, followed by other drugs) initiated their use at an earlier age than youth who had not progressed through all three substance classes. However, there was no relationship between a substance initiation profile and current substance-use. Implications include the recognition that street youth may follow different patterns of use than normative groups, and that interventions geared toward youth who use substances heavily must include contextual factors, in addition to substance-use history.     

A Comparison of Drug Use and Risk Behavior Profiles Among Younger and Older Street Youth

Among 559 street youth recruited between 2005 and 2007 in Vancouver, Canada, young drug users (<21 years of age) were compared with older drug users (≥21 years) with regard to recent drug use and sexual practices using multiple logistic regression. Older youth were more likely to be male and of Aboriginal ancestry, to have more significant depressive symptoms, to have recently engaged in crack smoking, and to have had a recent history of injection drug use. Young drug users, by contrast, were more likely to have engaged in recent binge alcohol use. Efforts to reduce drug use-related harm among street youth may be improved by considering the highly prevalent use of “harder” drugs and risk for depression among older youth.     

Sequential progression of substance use among homeless youth: an empirical investigation of the gateway theory

We examined the sequence of substance-use initiation in 375 street youth (age 13-21) who were interviewed from 1994-99 in Seattle, Washington. Based on the "gateway theory," participants were categorized into six profiles to describe the order in which they initiated use of various substances (i.e., alcohol, marijuana, other drugs), or classified as nonprogressors if they had not tried all three classes of drugs. Youth progressing in the hypothesized gateway order (i.e., alcohol preceding marijuana, followed by other drugs) initiated their use at an earlier age than youth who had not progressed through all three substance classes. However, there was no relationship between a substance initiation profile and current substance-use. Implications include the recognition that street youth may follow different patterns of use than normative groups, and that interventions geared toward youth who use substances heavily must include contextual factors, in addition to substance-use history.     

Trajectories of initiation for the heroin-based drug whoonga – qualitative evidence from South Africa

BackgroundWhoonga is a smoked heroin-based street drug that first emerged in South Africa a decade ago. While previous scientific reports suggest that use is growing and youth are particularly vulnerable, trajectories of initiation are not well characterized.MethodsIn 2015, 30 men undergoing residential addiction treatment for this smoked heroin drug in KwaZulu-Natal, South Africa participated in semi-structured interviews about their experiences using the drug. Interview data were coded using qualitative content analysis.ResultsParticipant trajectories to initiating smoked heroin were “vertical” in the context of marijuana use or “horizontal” in the context of other hard drug use. Participants reporting vertical trajectories began smoking heroin as youth at school or in other settings where people were smoking marijuana. Several participants with horizontal trajectories started smoking heroin to address symptoms of other drug or alcohol addiction. Social influences on initiation emerged as an overarching theme. Members of participants’ social networks who were smoking or distributing heroin figured prominently in initiation narratives. Surprisingly, references to injection drug use were absent from initiation narratives. Participants reported people who smoke heroin differ from those who inject heroin by race.ConclusionConsistent with theories implicating social and structural influences on substance use initiation, people who started smoking heroin had social contacts who smoked heroin and frequented places where substance use was common. Smoked heroin initiation for several participants with horizontal trajectories may have been averted if they accessed evidence-based treatments for stimulant or alcohol use disorders. With increasing reports of heroin use across Africa, a coordinated approach to address this growing epidemic is needed. However, because smoked heroin and injection heroin use occur in distinct risk environments, interventions tailored to people who use smoked heroin will be needed to prevent smoked heroin use, prevent transition to injection use, and mitigate other social harms.     

Transition to injection drug use among street youth--a qualitative analysis

OBJECTIVES: To examine social contexts and processes influencing transition to drug injection among street youth. METHODS: 42 street youth participated in in-depth interviews. A typology of experiences was built founded on youth's street life and drug use trajectories. The transition to drug injection was examined through these experiences. RESULTS: We identified five types of mutually exclusive experiences. The "downtowner's" experience is characterised by early street life and drug consumption trajectories, and a strong identification with the downtown milieu. These youth progress from one drug to another and, in a milieu where drug injection is omnipresent, this escalation culminates in transition to injection. The "tripper" street life and substance use trajectories begin later and are less intense. Most "tripper" youth are already chronic hallucinogens users when they arrive in downtown Montréal. Although they judge "junkies" severely, they show some ambivalence towards injection. The "on the go" experience is characterised by trajectories of drug use and street life that are intermingled, leading to a loss of control. These youth, who often have serious delinquent behaviours, come to downtown Montréal to party and consume drugs, mostly stimulants. Their drug use pattern and network make them at high risk of starting cocaine injection. The "hard-luck's" experience is characterised by a lack of identification with the downtown milieu. These youth who use drugs recreationally, end up in the streets accidentally, often because of unemployment. The "alcoholic' experience is related to alcohol misuse. These youth usually end up in the streets due to this dependence. Their street involvement is mostly an experience of solitude. The risk of transitioning to injection for both these types is low. CONCLUSIONS: Some combinations of street life and drug use trajectories seem to contribute to injection among street youth. Some important factors interact and increase the risk of street youth transitioning to injection: poor personal assets; early rupture with primary social institutions; social integration into subcultures where both street life and "drug trips" are fashionable, drug preferences and the local drug market.     

Motives for and Against Injecting Drug Use Among Young Adults in Amsterdam: Qualitative Findings and Considerations for Disease Prevention

To elucidate injection initiation and risky injection practices among young drug users (YDUs) in Amsterdam, this study identifies self-reported motives for injecting and not injecting to inform interventions to be targeted at issues personally relevant for this population. A qualitative study was performed using in-depth interviews to obtain retrospective drug use histories. Recruitment took place both directly (by street outreach, outreach at methadone outposts) and indirectly (by respondent-driven sampling). The study started in the year 2001 and included 50 YDUs, aged 18–30, of which 18 had a history of injecting. Reasons for not starting injection were fears of needles, overstepping a limit, damage to appearance, fears of missing veins and causing abscesses, and illnesses. Reasons for starting injection were stronger effect or rush, curiosity, economy, knowing injectors, and perceived lack of danger to health. Motives for injecting and not injecting can differ widely individually. Some strong motives are hardly addressed by prevention programs and should inform new prevention initiatives. Users’ own motives for not injecting should be promoted, whereas their motives for initiation should be counter-balanced with factual information.     

Evaluation of a media campaign aimed at preventing initiation into drug injection among street youth

Aims: A campaign to prevent initiation into drug injecting among street youth who have never injected drugs (NIDUs) was carried out in Montréal, Canada in 2005. Evaluation objectives were (1) to assess the campaign's ability to reach NIDU street youth and (2) to understand the campaign's effects on this population.

Methods: A survey was conducted, as well as semi-structured interviews.

Findings: The campaign enjoyed a high degree of visibility. It spoke to young NIDUs, causing them to reflect on both drug injecting and their own non-injection drug use. The campaign had a positive impact in terms of their views on drug injecting. Despite its limited scope, young NIDUs also considered the campaign to be a tool with the potential to contribute to preventing initiation into drug injecting among their peers.

Conclusions: Media prevention campaigns are able to reach hidden populations through the use of bold and innovative techniques. Such campaigns can also contribute to influencing the attitudes and perceptions of these populations. However, more comprehensive injection prevention programs need to be established.     

Motives for and against injecting drug use among young adults in Amsterdam: qualitative findings and considerations for disease prevention

To elucidate injection initiation and risky injection practices among young drug users (YDUs) in Amsterdam, this study identifies self-reported motives for injecting and not injecting to inform interventions to be targeted at issues personally relevant for this population. A qualitative study was performed using in-depth interviews to obtain retrospective drug use histories. Recruitment took place both directly (by street outreach, outreach at methadone outposts) and indirectly (by respondent-driven sampling). The study started in the year 2001 and included 50 YDUs, aged 18-30, of which 18 had a history of injecting. Reasons for not starting injection were fears of needles, overstepping a limit, damage to appearance, fears of missing veins and causing abscesses, and illnesses. Reasons for starting injection were stronger effect or rush, curiosity, economy, knowing injectors, and perceived lack of danger to health. Motives for injecting and not injecting can differ widely individually. Some strong motives are hardly addressed by prevention programs and should inform new prevention initiatives. Users' own motives for not injecting should be promoted, whereas their motives for initiation should be counter-balanced with factual information.     

Initiation to drug injection among street youth: a gender-based analysis

Objective(s)

To estimate the incidence rate of initiation into drug injection and to identify predictors of initiation into drug injection separately among street girls and boys.

Design

Data from two consecutive prospective street youth cohort studies (1995-2001 and 2001-2005) were used to conduct these analyses, stratified by gender.

Methods

Data were collected using semi-annual interviewer-administered questionnaires. Variables from the following domains were considered in Cox regression models: socio-demographic characteristics, early and current substance abuse, marginalization, childhood traumatic sexual events and injection exposure.

Results

Of the 946 youth who had never injected drugs at study entry, 86.4% completed at least two questionnaires representing 243 girls and 574 boys. Incidence rates of injection of 7.0 and 5.9 per 100 person-years were observed among these girls and boys respectively. Among girls, cocaine or crack use (adjusted hazard ratio (AHR) = 1.97), heroin use (AHR = 2.86), homelessness (AHR = 2.49) and hanging out regularly with people who inject (AHR = 4.46) all independently increased risk of first injection. Among boys, age decreased risk of initiating injection (AHR = 0.90/year), while cocaine or crack use (AHR = 2.14), heroin use (AHR = 3.56), homelessness before age 16 (AHR = 1.68), incest or rape before age 14 (AHR = 1.98) and hanging out regularly with people who inject (AHR = 1.66) all independently increased this risk.

Conclusions

Our findings suggest similar rates of initiation among girls and boys; however, factors associated with initiation vary by gender. This might lead to the design of more effective programs to prevent initiation into drug injection.     

Neighborhood of residence and risk of initiation into injection drug use among street-involved youth in a Canadian setting

Background

While research has suggested that exposure to environments where drug use is prevalent may be a key determinant of drug-related risk, little is known regarding the impact of such exposure on the initiation of illicit injection drug use. We assessed whether neighborhood of residence predicted rates of injecting initiation among a cohort of street-involved youth in Vancouver, British Columbia.

Methods

We followed street-involved injecting naïve youth aged 14–26 and compared rates of injecting initiation between youth residing in Vancouver's Downtown Eastside (DTES) neighborhood (the site of a large street-based illicit drug market) to those living in other parts of the city. Univariate and multivariate Cox regression analyses were employed to determine whether residence in the DTES was independently associated with increased risk of initiation of injection drug use.

Results

Between September, 2005 and November, 2011, 422 injection-naïve individuals were followed, among whom 77 initiated injecting for an incidence density of injecting of 10.3 (95% confidence interval [CI] 5.0–18.8) per 100 person years. In a multivariate model, residence in the DTES was independently associated with initiating injection drug use (adjusted hazard ratio [AHR] = 2.16, 95% CI: 1.33–3.52, p = 0.002).

Conclusions

These results suggest neighborhood of residence affects the risk of initiation into injection drug use among street-involved youth. The development of prevention interventions should target high-risk neighborhoods where risk of initiating into injecting drug use may be greatest.     

Knowledge, attitudes, and substance use practices among street children in Western kenya

The study describes the knowledge of and attitudes toward substance use among street-involved youth in Kenya, and how they relate to their substance use practices. In 2011, 146 children and youth ages 10-19?years, classified as either children on the street or children of the street were recruited to participate in a cross-sectional survey in Eldoret, Kenya. Bivariate analysis using χ(2) or Fisher's Exact Test was used to test the associations between variables, and multiple logistic regression analysis was used to identify independent covariates associated with lifetime and current drug use. The study's limitations and source of funding are noted.     

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 (? = -0.22, p < .001) and earlier alcohol initiation was associated with greater frequency of recent heroin use (? = -0.12, p < .05). Academic failure was directly related to greater frequency of recent heroin injection (? = 0.15, p < .01). The results expand research investigating the relationship between adolescent behavior and illicit drug use in adulthood.     

Knowledge,Attitudes, and Substance Use Practices Among Street Children in Western Kenya

The study describes the knowledge of and attitudes toward substance use among street-involved youth in Kenya, and how they relate to their substance use practices. In 2011, 146 children and youth ages 10–19 years, classified as either children on the street or children of the street were recruited to participate in a cross-sectional survey in Eldoret, Kenya. Bivariate analysis using χ² or Fisher's Exact Test was used to test the associations between variables, and multiple logistic regression analysis was used to identify independent covariates associated with lifetime and current drug use. The study's limitations and source of funding are noted.     

Prevention of deaths from harmful drinking in the United States: the potential effects of tax increases and advertising bans on young drinkers

OBJECTIVE: Harmful alcohol consumption is a leading cause of death in the United States. The majority of people who die from alcohol use begin drinking in their youth. In this study, we estimate the impact of interventions to reduce the prevalence of drinking among youth on subsequent drinking patterns and alcohol-attributable mortality. METHOD: We first estimated the effect of public health interventions to decrease harmful drinking among youth from literature reviews and used life table methods to estimate alcohol-attributable years of life lost by age 80 years among the cohort of approximately 4 million U.S. residents aged 20 in the year 2000. Then, from national survey data on transitions in drinking habits by age, we modeled the impact of interventions on alcohol-attributable mortality. RESULTS: A tax increase and an advertising ban were the most effective interventions identified. In the absence of intervention, there would be 55,259 alcohol-attributable deaths over the lifetime of the cohort. A tax-based 17% increase in the price of alcohol of dollar 1 per six pack of beer could reduce deaths from harmful drinking by 1,490, equivalent to 31,130 discounted years of potential life saved or 3.3% of current alcohol-attributable mortality. A complete ban on alcohol advertising would reduce deaths from harmful drinking by 7,609 and result in a 16.4% decrease in alcohol-related life-years lost. A partial advertising ban would result in a 4% reduction in alcohol-related life-years lost. CONCLUSIONS: Interventions to prevent harmful drinking by youth can result in reductions in adult mortality. Among interventions shown to be successful in reducing youthful drinking prevalence, advertising bans appear to have the greatest potential for premature mortality reduction.     

Street careers: homelessness, drug use, and sex work among young men who have sex with men (YMSM)

"Hustling" or sex work is a common means of surviving on the streets and paying for drugs among homeless youth. In this article, we formulate the concepts of "street capital" and "street competencies" to describe how 10 young men who have sex with men (YMSM) in New York City accumulated various knowledge and skills throughout their childhood and adolescence, and later entered into homelessness and the street economy as sex workers. While half of these young men described themselves as gay or bisexual, sexual identity was not a primary consideration amongst these youth. All were homeless and/or users of illegal drugs, and all survived through intimate involvement in the "street economy"-an informal system of exchange that circulates drugs, sex, and money across a range of settings and participants. Based upon an analysis of life history accounts gained through ethnographic interviews, we describe common pathways into the street economy with an emphasis on understanding how these 10 young men of diverse backgrounds became involved in homelessness, drugs, and sex work. In doing this, we document the differential sources of knowledge and particular childhood experiences that launched these youth into coherent street careers.     

Risk factors for progression to regular injection drug use among street-involved youth in a Canadian setting

Background

Street-involved youth are at high risk for experimenting with injection drug use; however, little attention has been given to identifying the factors that predict progression to on-going injecting.

Methods

Logistic regression was used to identify factors associated with progression to injecting weekly on a regular basis among a Canadian cohort of street-involved youth.

Results

Among our sample of 405 youth who had initiated injecting at baseline or during study observation, the median age was 22 years (interquartile range [IQR] = 21–24), and 72% (293) reported becoming a regular injector at some point after their first injection experience. Of these, the majority (n = 186, 63%) reported doing so within a month of initiating injection drug use. In multivariate analysis, the drug used at the first injection initiation event (opiates vs. cocaine vs. methamphetamine vs. other; all p > 0.05) was not associated with progression; however, younger age at first injection (adjusted odds ratio [AOR] = 1.13), a history of childhood physical abuse (AOR = 1.81), prior regular use of the drug first injected (AOR = 1.77), and having a sexual partner present at the first injection event (AOR = 2.65) independently predicted progression to regular injecting.

Conclusion

These data highlight how quickly youth progress to become regular injectors after experimentation. Findings indicate that addressing childhood trauma and interventions such as evidence-based youth focused addiction treatment that could prevent or delay regular non-injection drug use, may reduce progression to regular injection drug use among this population.