Estimating the Number of Heroin Users: A Review of Methods and Empirical Findings from the Netherlands

This article reviews major methods applied to estimate the number of heroin users in a community, predominantly urban areas. The main focus is on applicability of methods to the available data. Methodologies are evaluated with regard to reliability, validity, and feasibility from the perspective of empirical findings, in particular in the Netherlands. Findings from Amsterdam and Rotterdam are presented in more detail in order to discuss major criteria for application of the capture/recapture and the nomination techniques.     

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

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

Factors for Employment: A Case-Control Study of Fully Employed and Unemployed Heroin Users

The purpose of this article is to characterize fully employed users of heroin, compare them with their unemployed counterparts, and identify demographic, human, and social capital and drug misuse factors that are differentially associated with full employment. A nested case-control research design was used to identify 122 fully employed users (cases) and 466 unemployed users (controls) from a larger study of African American, Hispanic, and non-Hispanic White men and women who were active heroin injectors and sniffers and recruited from the streets of Miami–Dade County, Florida, between July 1997 and February 2000. Multivariate logistic regression techniques were used to analyze data from the Modified AIDS Risk Behavior Questionnaire. Findings indicated that employed users were more likely to possess human capital and social capital and less likely to use crack cocaine than unemployed users. Intervention to increase and sustain the employability of persons who misuse heroin is essential. Protocols that enhance human capital and social capital and reduce the misuse of drugs will benefit programs that seek to improve the employment status of persons who misuse heroin. The study's limitations are noted.     

Heroin Use,Dependence, and Attitudes to Treatment in Non-Treatment-Seeking Heroin Users: A Pilot Study

Much research examining heroin users utilizes treatment samples; non-treatment-seeking heroin users are not well understood. It is unclear whether this group can avoid impaired control or negative sequelae commonly observed in treatment-seeking populations. During 2000 and 2001, we recruited 69 non-treatment-seeking heroin users with no treatment history. Heroin use, management strategies, treatment attitudes, and risk behaviors were assessed; the DSM-IV checklist and severity of dependence scale were completed. Study limitations and implications for heroin use and its treatment are discussed. This study was funded by Prince Charles Hospital Foundation.     

Estimating the Number of Drug Injectors from Needle Exchange Data

Background. Information on the size of a drug injecting population is required for resource allocation and health service evaluation. The truncated Poisson (tP) estimator is a method of prevalence estimation which, in contrast to the capture-recapture method, can be used when only a single data source is available. Objective. We present a study on the size of a drug injecting population to illustrate how the tP estimator can be calculated and how some of its underlying assumptions can be checked. Results. Although 647 individuals attended the needle exchange in 1997, the total number of drug injectors was estimated to be 1041 within a 95% confidence interval of 960 ～ 1137. Discussion. The truncated Poisson estimator can be an easy and quick method of providing a prevalence estimate of drug injecting and may produce valid estimates of relative changes in prevalence rates over time.     

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

ABSTRACT

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

Impact of Substance Dependence and Dual Diagnosis on the Quality of Life of Heroin Users Seeking Treatment

In 189 opioid-dependent subjects on methadone maintenance treatment in Barcelona (Spain), we assessed the prevalence of co-occurrence substance use and non-substance-use disorders (dual diagnosis) by the Psychiatric Research Interview for Substance and Mental Disorders [PRISM], and the impact on quality of life (HRQoL) by the SF-12 (PCS-12 and MCS-12 scales). Rates of substance and non-substance-use diagnoses were 59% and 32%, respectively. Mean scores for PCS-12 and MCS-12 were 44.1 ± 10.1 and 39.9 ± 11.7, without differences by presence or absence of dual diagnosis. Heroin users on methadone treatment showed a high prevalence of dual diagnosis and a very impaired HRQoL.     

Characteristics of Cities and their Relationship to Heroin Use: An Analysis of Heroin Use Correlates in Metropolitan Areas

The problem addressed in this study was stated in general terms as follows: What are the factors related to differences between cities in heroin use levels? The explanatory power of five alternative conceptual models of heroin use was tested via multiple regression, using the Heroin Problem Index as the measure of heroin use prevalence. The results indicated that while several of the models had some validity, no single model provided a complete explanation of heroin use variability, suggesting that the ultimate explanation of heroin use includes elements from several models. Results were interpreted as supporting the notion that both supply and demand factors are important in heroin use.     

Interaction Effects of Client and Treatment Program Characteristics on Retention: An Exploratory Analysis Using Hierarchical Linear Models

This paper applied a hierarchical linear modeling approach to explore the interaction effects of treatment program and client characteristics on client retention in treatment for drug users. Program characteristics included services provision, funding sources, and staff-client gender congruence, and client characteristics included gender, age at admission, and drug use level prior to admission. The same model was applied separately to three modalities: residential, methadone maintenance, and outpatient drug-free programs. Data were obtained from 59 treatment programs and 3,764 of their clients who had discharge records. The most noteworthy significant interaction effect detected was program's funding source and client's gender on treatment retention in the outpatient drug-free modality. for example, female clients remained less time in the programs that accepted only public funding than in the programs that accepted both public and private funding. Male clients remained in the treatment an average of 25.3 fewer days than female clients in drug-free programs that only accepted public fund, but stayed about the same time as females if the programs received mixed funding.     

Nonmedical Opioid Use in Relation to Recency of Heroin Use in a Nationally Representative Sample of Adults in the United States

Nonmedical opioid use has been linked to lifetime heroin use; however, research is needed to examine associations between nonmedical opioid use and current or recent heroin use, as current users appear to be at highest risk for harm. Data were from a nationally representative sample of non-institutionalized adults (age 18–64) in households participating in the National Survey of Drug Use and Health who reported lifetime heroin use (2005–2014, N = 7,111). We examined associations between frequency and recency of nonmedical opioid use and recency of heroin use. Most (86.7%) lifetime heroin users reported no heroin use in the last 12 months, while 6.1% reported current use (use in the last 30 days). The majority of the sample (69.3%) reported lifetime nonmedical opioid use; 14.3% reported nonmedical use in the last 30 days. Adjusted odds for current heroin use increased as frequency of past-year nonmedical opioid use increased, with a quarter (24.7%) of current heroin users reporting nonmedical opioid use on 157–365 days in the last year. Over half (54.7%) of current heroin users reported current nonmedical opioid use. Prevention efforts should consider that high-frequency and current nonmedical opioid use is a robust correlate of continued heroin use.     

Entangled in Big Events: Rise of Heroin Use Among Children of Ex-Gurkhas in Hong Kong

Big event models have been developed to demonstrate the relationships between wars and socioeconomic political transitions, and between rise of drug use and HIV epidemic outbreaks. This ethnographic interview-based study of a Nepali, Hong Kong community, carried out between 2009 and 2011, explored increased heroin use among the children of Hong Kong's Nepali ex-Gurkhas since its political transition in 1997. Data from its 59 informants were coded and analyzed using the grounded-theory approach. Three derived themes influencing drug use among ex-Gurkha children were identified: (1) reorganization of social networks, (2) redefinition of social norms, and (3) renegotiation of self-identity. Their associated processes crossed the boundaries of time and space. These findings document that big event modeling variables can and do overlap, are interconnected in many different ways, and their relationships are dialectical and are culturally shaped even as individuals may and do influence these processes and outcomes. Study's limitations are noted.     

Gender Differences in Heroin Addiction and Treatment: Results from the VEdeTTE Cohort

Background: Gender differences strongly affect heroin addiction, from risk factors to patterns of consumption, access to treatments, and outcomes. Objectives: To investigate gender differences in the VEdeTTE cohort of heroin addicts. Methods: VEdeTTE is a cohort of 10,454 heroin users enrolled between 1998 and 2001 in 115 public drug treatment centres in Italy. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Gender differences were explored with regard to characteristics at intake, treatments, and retention in methadone maintenance and therapeutic community. Cox Proportional models were carried out to identify risk factors for treatment abandon. Results: Compared with men, at their first access to treatment women with drug addiction were younger, more frequently married, legally separated, divorced or widow, unemployed though better educated, HIV+; more frequently they lived with their partner and sons. They reported a higher use of sedatives, but a lower use of alcohol; more frequently they had psychiatric comorbidity, including depression, self-injuries, and suicide attempts. Psychotherapy was more frequently prescribed to women, pharmacological treatments to men. Methadone maintenance was less frequently abandoned by women. Drug abuse severity factors predicted abandon of methadone among women. High methadone doses and the combination with psychotherapy improved treatment retention in both genders. Low education level and severity factors among women and young age among men predicted abandon of therapeutic community. Conclusions: Gender differences in the VEdeTTE cohort suggest the need of a gender sensitive approach to improve treatment outcomes among heroin addicts.     

Disordered Gambling in Residential Substance Use Treatment Centers: An Unmet Need

This study examined prevalence and potential impact of disordered gambling in a sample of individuals (N = 684) undergoing residential treatment for substance use disorders at 13 facilities. Lifetime disordered gambling prevalence was 20.2%, as identified by South Oaks Gambling Screen. Within individuals who screened positive for disordered gambling, few had sought help for gambling (15.9%) and only 14.3% reported having gambling addressed in their current substance use disorder treatment. Meanwhile, 30.4% identified gambling as a concern in their recovery efforts. The presence of a gambling problem, either historical or current, potentially affects residential treatment outcomes and warrants clinical attention within these programs.     

The Needs of Crack-cocaine Users: lessons to be learnt from a study into the needs of crack-cocaine users

This article examines the findings that emerged from a study into the needs of crack-cocaine users in two inner city areas of northern England. The findings are contextualized within a review of current research around street use of crack cocaine. The authors argue that the local research indicates that current government policies militate against services being able to provide a comprehensive and flexible response to meeting the needs of crack-cocaine users, by putting an emphasis on criminalizing and medicalizing the problem. The ensuing service developments undoubtedly net some crack-cocaine users and address their unmet need, but the authors argue they fall short of addressing the underlying causes of problematic crack-cocaine use. Not only do they fall short but they also mask recognition of the underlying causes--namely the experience of multiple social deprivation.     

Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore,MD

Since 2001, heroin-related overdose deaths in the United States have risen six-fold, a rise unaccounted for by the expanding user population. Has heroin become a more dangerous drug? Reports of fentanyl and its analogs, often concealed in or sold as heroin, have also increased sharply. This article investigates heroin injectors’ perceptions and experiences of changes in the heroin supply in the East Coast city of Baltimore, Maryland, currently facing an epidemic in heroin- and fentanyl-related overdose deaths. Unusually, Baltimore’s heroin market is divided between two types: “Raw,” believed to be Colombian in origin and relatively pure, and the more adulterated “Scramble” (raw heroin traditionally blended with quinine and lactose). Users reported that Scramble heroin, while gaining market share, has become a highly unstable product, varying dramatically in appearance, intensity of onset, duration of action, and effect. Some considered that Scramble was no longer “heroin,” but was heavily adulterated or even replaced, mentioning fentanyl, benzodiazepines, and crushed opioid pills as additives. There was intense awareness of overdose as a present danger in users’ lives, which they linked to the recent adulteration of the heroin supply. Responses to this perceived adulteration varied, including information gathering, attraction, avoidance, taking precautions, and acceptance.     

新疆乌鲁木齐市吸毒人群首次吸毒的影响因素分析

目的:了解乌鲁木齐市吸毒人群首次吸毒的发生情况。方法:于2004年9―10月,应用结构式问卷调查乌鲁木齐市吸毒者性别、年龄、民族、文化程度,首次吸毒时间、方式及种类,首次吸毒前调查对象的吸烟、饮酒,家庭成员、朋友和亲戚吸毒情况。结果:提供知情同意书的509名吸毒者中,研究对象从出生到首次吸毒的发生率为4.90/100人年(95%CI为4.48-5.33),发生首次吸毒的中位时间为19.7(95%CI为19.1-20.4)岁。在多因素Cox比例风险回归模型分析中,维族(HR值为1.50;95%CI为1.25-1.80)、15岁以前开始吸烟(HR值为2.12,95%CI为1.77-2.55)及亲戚吸毒(HR值为1.36;95%CI为1.05-1.75)与发生首次吸毒的关系有统计学意义。结论:本调查提示青少年早期吸烟干预的健康教育对预防毒品滥用有必要,维族应该是当地干预的重点对象。     

Effectiveness of Therapies for Heroin Addiction in Retaining Patients in Treatment: Results From the VEdeTTE Study

Treatment is effective in reducing heroin use and clinical and social problems among heroin addicts. The effectiveness is related to the duration of treatment. “VEdeTTE” is an Italian longitudinal study funded by the Ministry of Health to evaluate the effectiveness of treatments provided by the National Health Services. The study involved 115 drug treatment centers and 10,454 heroin users. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Survival analysis and Cox Proportional Hazard model were used to evaluate treatment retention. Five thousand four hundred and fifty-seven patients who started a treatment in the 18 months of the study were included in the analysis: 43.2% received methadone maintenance therapy (MMT), 10.5% therapeutic community, and 46.3% abstinence-oriented therapy (AOT). The likelihood of remaining in treatment was 0.5 at 179 days. The median daily dose of methadone was 37 mg. Psychotherapy was provided in 7.6% of patients receiving methadone and 4.9% of those in therapeutic community. Type of therapy was the strongest predictor of retention, with AOT showing the lowest retention. In MMT patients, retention improved according to dose. Living alone, psychiatric comorbidity and cocaine use increased the risk of dropout. Psychotherapy associated halved the risk of dropout.     

Estimating the Size of Subpopulations of Heroin Users: Applications of Log-Linear Models to Capture/Recapture Sampling

This article reviews two of the major methodologies applied to estimation of the number of heroin abusers: survey research methods and the capture/recapture technique. The main focus of the paper is to show the flexibility of the capture/recapture approach in handling not only the dependence of samples of heroin users but also the nonhomogeneity of sampling probabilities, allowing estimation in populations which are mixtures of qualitatively different heroin user types. Models with these features are illustrated using both simulated and real heroin abuse data.