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.     

Drug use and initiation in prison: results from a national prison survey in England and Wales

Aims  To investigate heroin and cocaine use in a sample of British prisoners, and to explore the characteristics of inmates who use these drugs for the first time while in prison.
Design, participants  A cross-sectional survey of all prisons in England and Wales conducted as part of a major national study of psychiatric morbidity. A total of 3142 prisoners (88.2% of those selected) completed a structured interviewer-administered questionnaire.
Measurements  Interview measures of personal demographics, social history, psychiatric morbidity and drug use. Personality disorders were diagnosed via the Structured Clinical Interview for DSM-IV (SCID-II) and neurotic symptoms were assessed using the revised Clinical Interview Schedule (CIS-R).
Findings  More than 60% of the heroin users and cannabis users reported that they had used these drugs in prison compared with less than a quarter of the life-time cocaine users. More than a quarter of the heroin users reported that they had initiated use of this drug in prison. The extent of an individual's experience of prison was related more consistently to heroin and/or cocaine use in and out of prison than other personal background, social history or psychiatric variables assessed.
Conclusions  The findings indicate that prisons are a high-risk environment for heroin and other drug initiation and use. Although related to drug use, psychiatric variables were not generally associated with initiation in prison, which was dominated by prison exposure. There is a need to explore ways of reducing heroin initiation in prison as part of a broader risk-prevention strategy.     

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.     

Drug use patterns and infection with sexually transmissible agents among young adults in a high-risk neighbourhood in New York City

Aims To determine relationships between drug use ‘hardness’ (defined in increasing order of hardness as no drug use, marijuana use, non‐injected heroin or cocaine use, crack smoking and injection drug use) and prevalences of several sexually transmissible infections among young adults in a high‐risk neighbourhood. Drug users, particularly injection drug users and crack smokers, may be a core group for some sexually transmitted infections. Design Cross‐sectional survey and assays of young adults from (a) a household probability sample and (b) a targeted sample of youth who have used injected drugs, crack, other cocaine or heroin. Setting Bushwick, an impoverished New York City minority neighbourhood with major drug markets. Participants A total of 363 18–24‐year‐olds from a household probability sample; 165 Bushwick 18–24‐year‐olds who have used injected drugs, crack, other cocaine or heroin. Measurements Drug use by self‐report; serum‐ and urine‐based assays for HIV, hepatitis B and C, syphilis, gonorrhoea, chlamydia and herpes simplex (type 2). Findings Household‐sample prevalences: HIV, hepatitis C and syphilis, 1%; gonorrhoea 3%; chlamydia 5%; past or present hepatitis B infection 8%; herpes simplex (type 2) 18%. In combined household and targeted samples, hepatitis C and HIV were concentrated among drug injectors. Herpes simplex (type 2), syphilis and hepatitis B increased among women with ‘hardest drug ever used’. Conclusions Using ‘harder’ drugs is associated with some but not all of these infections. Prevention efforts should help youth avoid unsafe sex and higher‐risk drugs.     

Changes and predictors of change in the physical health status of heroin users over 24 months

Aims   (i) To describe the course of physical health among the ATOS cohort over 24 months; and (ii) to examine the effects of treatment, drug use patterns and social and psychological factors on health status over 24 months.
Design   Longitudinal cohort.
Setting   Sydney, Australia.
Participants   A total of 615 heroin users recruited for the Australian Treatment Outcome Study (ATOS).
Findings   The general health of the cohort improved significantly over 24 months. Significant predictors of poor health over 24 months were: being older, being female, past month heroin, other opiate and tobacco use, past month unemployment and current major depression. Spending a greater proportion of time in residential rehabilitation (RR) was associated with better health over 24 months. No other treatment factors demonstrated a significant, independent relationship with health.
Conclusions   The physical health of dependent heroin users is affected by drug use and psychosocial problems. RR treatment appears to be particularly beneficial to the health of heroin users, suggesting the importance of a comprehensive approach to improving health among this group.     

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.     

Factors associated with abstinence,lapse or relapse to heroin use after residential treatment: protective effect of coping responses

Aims   This study investigates factors associated with abstinence, lapse or relapse to heroin use after residential treatment and, specifically, the extent to which changes in cognitive, avoidance and distraction coping responses were related to heroin use and other drug use outcomes.
Design, setting, participants  The sample comprised 242 clients from 23 residential programmes in the NTORS project, who used heroin before treatment and who were followed-up after treatment during the first 12 months of the study.
Measurements   Data on client characteristics and problems, coping responses, drug use and other outcomes, were collected by structured face-to-face interviews.
Findings   Many clients (60%) used heroin after treatment, with the first occasion of heroin use usually occurring very soon after leaving treatment: 40% remained abstinent from heroin. Analyses were conducted for three groups based upon heroin outcome status (abstinent, lapsed, relapsed). Clients who avoided a full relapse to heroin use (abstinent and lapse groups) consistently made more use of cognitive, avoidance and distraction coping strategies at follow-up than at intake. Treatment completion was related to better outcome. The lapse and relapse groups reported higher rates of use of illicit drugs other than heroin after treatment than the abstinent group.
Conclusions  Despite generally satisfactory drug use outcomes, the lapses and relapses to heroin use give rise to concern. Treatment services should develop further and strengthen relapse prevention and relapse coping skills among drug misusers.     

Problematic heroin use incidence trends in Spain

Aims   To estimate the annual incidence of heroin use in Spain.
Participants and design   Data on individuals' year of first heroin use (from 1971 to 2005), year of first heroin treatment between 1991 and 2005 and most frequent route of heroin administration when presenting to treatment were obtained from the Spanish Drug Observatory Register and used to calculate the delay between onset and treatment. By using a log-linear model approach it was possible to correct for missing observations (heroin users who presented for treatment before 1991 and those who had still not presented by the end of 2005) and to estimate heroin incidence over time.
Findings   The estimated incidence of problematic heroin use in the population aged 15–44 peaked at 190 per 100 000 in 1980—after rising rapidly from less than 40 per 100 000 in 1971—and fell subsequently to about 8 per 100 000 in 2005. On average, incidence was five times higher in men. Injecting heroin incidence peaked and declined rapidly from 1980; as heroin smoking did not decline as rapidly, from 1985 onwards its estimated incidence has remained above that of heroin injecting. The delay between starting heroin use and entering treatment had a median of 3 years.
Conclusions   We demonstrate the utility of a method to estimate heroin incidence from analysis of observed trends in presentations at specialist drug treatment facilities. The estimates suggest that incidence of heroin use, especially injecting, has fallen since 1980 and is now lower than in the early 1970s.     

Drug withdrawal, cocaine and sedative use disorders increase the need for mechanical ventilation in medical patients

Aims   Alcohol use disorders increase the need for mechanical ventilation (MV) in critically ill medical, surgical and trauma patients. Studies examining other drug use disorders (DUD) in trauma patients have not demonstrated heightened rates of intensive care unit (ICU) complications. Patients with asthma and concurrent cocaine or heroin use disorders have an increased need for MV. The objective of this study is to determine if the presence of DUD and drug withdrawal syndromes are associated with increased need for MV in medical patients.
Design   Analysis of a national database.
Setting   The Nationwide Inpatient Sample, the largest all-payer in-patient database was utilized for the years 2002–2004.
Participants   Adult patients with one of the six common diagnoses associated with medical ICU admission were included.
Intervention   None.
Measurements   Univariate analysis and multivariate logistic regression were performed to determine if DUD and drug withdrawal were associated independently with the use of MV.
Findings   A total 1 218 875 patients fulfilled one of the six diagnoses; 22 827 (1.9%) had DUD, and 102 841 (8.4%) underwent MV. Independent of the medical diagnosis, DUD was associated with an increased risk for requiring MV by univariate analysis (relative risk = 1.50, P  < 0.0001). By multivariate analyses, sedative and cocaine use disorders remained associated with increased need for MV. Independent of medical diagnosis and substance, drug withdrawal was associated with increased odds of MV by both univariate and multivariate analysis (odds ratio = 2.94, P  < 0.0001).
Conclusions   DUD are associated with increased need for MV in medical patients. This study demonstrates the importance of screening all medical patients for DUD.     

Changes in women's use of illicit drugs following imprisonment

Aim   To provide data on changes in illegal drug use in women following imprisonment.
Design   Prospective cohort study.
Setting   Recruitment took place in two prisons in the Midlands and South-East England and follow-up in 13 prisons across England.
Participants   A total of 505 women prisoners participated, a response rate of 82%.
Measurements   Questions about drug use were contained within a questionnaire which examined broad aspects of health. On entry into prison, women answered questions about daily drug use and injecting drug use prior to imprisonment. One month later the questionnaires examined drug use during this period of imprisonment.
Findings   Prior to imprisonment, 53% [95% confidence interval (CI): 49–58%] of women took at least one illegal drug daily and 38% (CI: 34–42%) said they had ever injected drugs. Following imprisonment, some women continued to use drugs; 14% (CI: 10–20%) of women reported using at least one illegal drug daily and 2% (CI: 0.7–5%) of women had injected drugs. There were important changes in the types of drugs used; there was a change in use from crack and heroin to benzodiazepines and opiate substitutes. Prior to imprisonment, women most commonly used crack and heroin, but in prison the two most commonly used illegal drugs were benzodiazepines and opiate substitutes.
Conclusions   The study provides quantitative evidence of the impact of imprisonment on drug use among women. It highlights the need for enhanced drug treatment services and stronger measures to reduce the availability of illegal drugs to women in prison.     

Drug network characteristics as a predictor of cessation of drug use among adult injection drug users: a prospective study.

Few studies have examined recovery from opiate and cocaine dependence without treatment, referred to as "natural recovery," "spontaneous recovery," and "spontaneous remission." The present study examined the relationship between network characteristics and cessation of heroin, cocaine, and crack use in a sample of underclass inner-city injection drug users in Baltimore, Maryland. Participants were enrolled in an experimental human immunodeficiency virus (HIV) preventive intervention. Between the baseline and follow-up interviews, which averaged 5.2 months, 24 (7%) of 335 participants reported ceasing to use heroin, cocaine, and crack. Individuals who had reported cessation of drug use at follow-up had reported at baseline a smaller proportion of their network members with whom they used drugs (p < .02). Using multiple logistic regression analyses and adjusting for baseline drug use, enrollment in drug treatment, and demographic and background variables, cessation of drug use was associated with a lower proportion of personal network members in one's drug network (odds ratio [OR] = 25.4, p < .05). The data from this study suggest that network members have potential for social influence on the cessation of drug use.     

A Bayesian model for estimating the effects of drug use when drug use may be under-reported

Aims   We present a statistical model for evaluating the effects of substance use when substance use might be under-reported. The model is a special case of the Bayesian formulation of the 'classical' measurement error model, requiring that the analyst quantify prior beliefs about rates of under-reporting and the true prevalence of substance use in the study population.
Design   Prospective study.
Setting   A diversion program for youths on probation for drug-related crimes.
Participants   A total of 257 youths at risk for re-incarceration.
Measurements   The effects of true cocaine use on recidivism risks while accounting for possible under-reporting.
Findings   The proposed model showed a 60% lower mean time to re-incarceration among actual cocaine users. This effect size is about 75% larger than that estimated in the analysis that relies only on self-reported cocaine use. Sensitivity analysis comparing different prior beliefs about prevalence of cocaine use and rates of under-reporting universally indicate larger effects than the analysis that assumes that everyone tells the truth about their drug use.
Conclusion   The proposed Bayesian model allows one to estimate the effect of actual drug use on study outcome measures.     

Drug Network Characteristics as a Predictor of Cessation of Drug Use Among Adult Injection Drug Users: A Prospective Study

Few studies have examined recovery from opiate and cocaine dependence without treatment, referred to as “natural recovery,” “spontaneous recovery,” and “spontaneous remission.” The present study examined the relationship between network characteristics and cessation of heroin, cocaine, and crack use in a sample of underclass inner-city injection drug users in Baltimore, Maryland. Participants were enrolled in an experimental human immunodeficiency virus (HIV) preventive intervention. Between the baseline and follow-up interviews, which averaged 5.2 months, 24 (7%) of 335 participants reported ceasing to use heroin, cocaine, and crack. Individuals who had reported cessation of drug use at follow-up had reported at baseline a smaller proportion of their network members with whom they used drugs (p <. 02). Using multiple logistic regression analyses and adjusting for baseline drug use, enrollment in drug treatment, and demographic and background variables, cessation of drug use was associated with a lower proportion of personal network members in one's drug network (odds ratio [OR] = 25.4, p. 05). The data from this study suggest that network members have potential for social influence on the cessation of drug use.     

Hair testing and self-report of cocaine use by heroin users

Aim Failure to disclose cocaine use can have a negative impact on medical care and research validity. This study was performed to identify predictors of cocaine non‐disclosure among individuals who self‐reported heroin use during a medical care encounter. Design A prospective comparison of self‐report of cocaine use among heroin users and hair analysis for cocaine. Setting Four health‐care clinics at an academic, inner‐city hospital. Participants Patients presenting for a health‐care visit who were willing to self‐report use of heroin and were not engaged in any form of drug treatment. Measurements (1) Self‐report using standardized instruments: the Drug Addiction Severity Test (DAST), the Addiction Severity Index (ASI) and quantity/frequency questions for heroin and cocaine use. (2) Biochemical evidence: analysis of hair by radioimmunoassay (RIA) for cocaine and opiate levels. Findings Among 336 heroin users who tested positive for cocaine in hair, 34.2% did not report their recent cocaine use. The mean cocaine level for discordant individuals was significantly lower than for concordant individuals (109.6 ng/10 mg versus 470.57 ng/10 mg; P < 0.0001). Multivariate predictors of disclosure included opiate and cocaine levels in hair and the ASI drug severity subscore. Conclusions Although self‐report has been validated for treatment system patients, almost a third of the out‐of‐treatment heroin users in this medical clinic study failed to disclose concomitant cocaine use. The likelihood of non‐disclosure was greatest for heavy users of heroin and light users of cocaine. Confirmation of self‐report with biochemical analysis in the medical setting may be necessary to improve both clinical care and research validity.     

Persistence of drug use during imprisonment: relationship of drug type, recency of use and severity of dependence to use of heroin, cocaine and amphetamine in prison

AIM: To investigate the persistence of use of heroin, cocaine and amphetamine drugs during imprisonment, and to identify factors associated with increased levels of persistence. DESIGN: The use of heroin, cocaine and amphetamine by current prison inmates has been examined and, in particular, the relationship between drug use within prison and the type of drug used prior to imprisonment, recency of use and severity of dependence. SETTING AND PARTICIPANTS: A randomly selected sample of 1009 adult male prisoners in 13 prisons in England and Wales during 1994/95; structured confidential interviews conducted by independent research staff. Enquiry about prior use of heroin, cocaine or amphetamine focused on three time-periods (ever, last year and last month pre-prison) and the use of these drugs during the first month of imprisonment. FINDINGS: A total of 557 (55%) of the 1009 prisoners had used previously one of the three drugs selected for study: 58% had used heroin, 69% cocaine and 75% amphetamine. More than half (59%; 327/557) had used these drugs in the month before the current imprisonment. Drug use in prisons was most likely to occur among those who had used in the month prior to imprisonment. The persistence of heroin use in prison occurred more frequently (70%) than use of cocaine (20%) or amphetamine (15%). Of those using heroin pre-imprisonment, 67% considered they were dependent, compared to 15% and 22%, respectively, for cocaine and amphetamine users. CONCLUSIONS: Changes in the drug-taking behaviour of drug users after imprisonment vary according to the type of drug being taken. Prisoners were much more likely to continue to use heroin than either cocaine or amphetamines while in prison. Heroin was most likely to be used by those who had been using heroin during the immediate pre-imprisonment period, and particularly by the two-thirds of heroin users who considered themselves dependent. In view of the high prevalence of prior use of these drugs by individuals currently imprisoned, continuing attention is required to study of their behaviour and of the impact of interventions that may be introduced during or following their incarceration.     

The effects of cocaine and heroin use on intubation rates and hospital utilization in patients with acute asthma exacerbations

BACKGROUND: The use of both heroin and cocaine has been associated with asthma exacerbations. However, the magnitude of this effect has not been adequately described. The purpose of this study was to examine the association between cocaine or heroin use and asthma severity. METHODS: We conducted a retrospective chart review of adult patients who had been admitted to an inner-city hospital and who subsequently had received a hospital discharge diagnosis of acute asthma exacerbation. Patients were classified as cocaine users if they had admitted to using cocaine within 24 h of symptom onset, or if a positive drug screen result was obtained. A similar classification was employed for heroin. The severity of asthma exacerbations among cocaine and heroin users was compared to severity among nonusers (ie, individuals without evidence of having used either drug within the 24 h preceding symptom onset). RESULTS: One hundred sixty-six unique patient encounters were identified, and 152 patient records were analyzed. Of these, 27.6% (42 of 152 patients) used cocaine with or without heroin and were classified as cocaine users, while 30.9% (47 of 152 patients) used heroin with or without cocaine and were classified as heroin users. Cocaine users had longer mean lengths of hospital stay than nonusers (3.4 days vs 2.5 days; p < 0.049). Intubation and ICU admission were more common among cocaine users than nonusers (21.4% vs 2.3%, respectively [p = 0.0006]; 31.0% vs 11.5%, respectively [p = 0.0068]). Heroin users were also intubated more frequently than nonusers (17.0% vs 2.3%, respectively; p = 0.0036). Neither the length of hospital stay nor the percentage of ICU admissions was significantly different between heroin users and nonusers. CONCLUSION: Heroin and cocaine use are common among adult asthmatic patients admitted to an inner-city hospital. Both cocaine and heroin are significantly associated with the need for intubation. Based on these findings, it may be prudent to screen adults with asthma presenting to an urban emergency department for cocaine and heroin use.     

Opiates,cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98

Aims  Accidental drug overdose contributes substantially to mortality among drug users. Multi-drug use has been documented as a key risk factor in overdose and overdose mortality in several studies. This study investigated the contribution of multiple drug combinations to overdose mortality trends.
Design  We collected data on all overdose deaths in New York City between 1990 and 1998 using records from the Office of the Chief Medical Examiner (OCME). We standardized yearly overdose death rates by age, sex and race to the 1990 census population for NYC to enable comparability between years relevant to this analysis.
Findings  Opiates, cocaine and alcohol were the three drugs most commonly attributed as the cause of accidental overdose death by the OCME, accounting for 97.6% of all deaths; 57.8% of those deaths were attributed to two or more of these three drugs in combination. Accidental overdose deaths increased in 1990–93 and subsequently declined slightly in 1993–98. Changes in the rate of multi-drug combination deaths accounted for most of the change in overdose death rates, whereas single drug overdose death rates remained relatively stable. Trends in accidental overdose death rates within gender and racial/ethnic strata varied by drug combination suggesting different patterns of multi-drug use among different subpopulations.
Conclusions  These data suggest that interventions to prevent accidental overdose mortality should address the use of drugs such as heroin, cocaine and alcohol in combination.     

Cocaine use and the utilisation of drug help services by consumers of the open drug scene in Hamburg.

In order to describe the patterns of use in the open drug scene in Hamburg, a study was carried out among 616 drug users in the drug scene and in or in the vicinity of low-threshold institutions close to the drug scene in summer 2000. The special focus was on the prevalence of cocaine and crack use as well as on the utilisation of help services for drug users. 80% of the interviewed persons were male, the average age was 32.6 years. They had been using drugs such as heroin or cocaine for an average of 11 years. 84% had used heroin and 74% cocaine within the last 24 h. Use was intravenous for 66%. 57% used cocaine intravenously, the percentage of crack smokers was 22%. Compared to previous studies, an increase in cocaine use can be noted among the scene users in Hamburg, mainly related to intravenous cocaine use. Crack smoking has only increased slightly over the past few years. Based on cluster analysis, four consumption pattern groups can be established. The largest group (38%) mainly uses cocaine and heroin. The second group (26%) consists of polyvalent drug consumers using methadone in addition to heroin and cocaine, as well as, partially, benzodiazepines, cannabis or alcohol. Group 3 (19%) mainly uses heroin only, some of them also using methadone and/or cannabis. The fourth group (17%) is mainly related to alcohol, the greater part of them additionally using heroin. On the whole, it appears that those users who currently do not use cocaine (or crack) are in a better health and social situation. The group using only heroin (cluster 3) also compares favourably with the other three consumption pattern groups with regard to the intensity of use, consumption in public and risk behaviour. Almost all the interviewed persons are in contact with general practitioners. However, the increasing cocaine use has not been met by sufficient intervention and treatment programmes so far.     

Mortality associated with illegal drug use among adults in the United States

Objectives: To examine all-cause and cause-specific mortality over a 15-year follow-up period in relation to at-baseline reported lifetime use of illegal drugs from five classes (marijuana, cocaine, heroin, hallucinogens, and inhalants) among adults in the United States (US) household population. Methods: The study involved 20,983 sample adults who responded to the 1991 National Health Interview Survey Drug and Alcohol Use supplemental questionnaire and also met the eligibility criteria for mortality follow-up. Cox proportional hazards models were estimated to examine the relationships. Results: Adults who at baseline reported lifetime heroin use were at significantly higher risk of all-cause death over the follow-up period (hazard rate ratio or HR?=?2.02; 95% confidence interval or CI 1.26–3.23), compared with those who did not report using drugs from any of the five classes, even after adjusting for age, sex, race, education, marital status, cigarette smoking status, and alcohol use status. Those who at baseline reported lifetime cocaine (no heroin) use had a significantly higher rate of death associated with human immunodeficiency virus diseases over the follow-up period than nonusers of drugs from any of the five classes. Several limitations of the analysis are discussed. Conclusions: Further research is needed to understand and track the elevated mortality associated with illegal drug use and the correlates of drug-poisoning deaths.