Risk factors associated with the transition from heroin sniffing to heroin injection: a street addict role perspective

Trends and distinct profiles of persons who inject drugs in the United States, 2015-2019

Drug injection represents a major health problem in the US, with severe health consequences including the transmission of blood-borne infections. An examination of the most recent trends in drug injection is warranted by the fast-evolving drug epidemic and recent policy changes such as the federal funding ban on needle exchange programs. This research examines current drug injection trends, patterns, and socioeconomic and behavioral profiles of people who inject drugs (PWID). Data were derived from the 2002 to 2019 National Survey on Drug Use and Health (NSDUH). After examining the annual prevalence of drug injection since 2002, a latent class analysis was conducted to identify drug injection and other substance misuse patterns among PWID using the latest (2015-2019) NSDUH datasets. Associations between class membership and behavioral health comorbidities and treatment receipt were also assessed. The drug injection prevalence among US adults aged 18-64 increased from 0.21% in 2002/2004 to 0.36% in 2017/2019. Three distinctive groups were identified: the heroin injection group (45.2%), the methamphetamine injection group (28.0%), and the multi-drug injection group (26.8%). The methamphetamine injection group reported greater risks of experiencing serious psychological distress, suicidality, and limited substance use treatment. Special attention is needed for those who primarily injected methamphetamine. Programs to promote harm reduction and increase access to addiction treatment need to be expanded in at-risk communities while accounting for their distinct socioeconomic and drug use/misuse profiles.

An Exploration of Factors Associated With Methamphetamine Injection Among Street-Involved Drug Users and Dealers in Los Angeles

Based on fieldwork and ethnographic interviews, this article explores the subjective meanings and processes of injecting methamphetamine and risk taking among 38 participants involved in a street drug scene, including long-term methamphetamine users and dealers recruited in an inner-city Los Angeles neighborhood, as a means of gaining insight into the factors facilitating injection. There were a multitude of individual, structural, social, and spatial factors that may influence injection as a mode of methamphetamine administration, including economic conditions, perceived cost, and efficiency of specific routes of use; social role and collective identification with a street scene; physical and social settings; drug policy and fear of arrest; social network factors, including the influence of sexual partners, peers, and the normalization of injection; other drug use, including individual drug histories and preferences for specific routes of administration among particular drug users (e.g., black tar heroin); and characteristics of the local drug market.

Circumstances and contexts of heroin initiation following non-medical opioid analgesic use in New York City

BACKGROUND

As the prevalence of opioid analgesic (OA) misuse and associated harms have increased in the United States, the prevalence of heroin use and rates of unintentional overdose have concurrently risen. Research has begun to identify connections between OA misuse and heroin use, although this relationship remains under explored. The present study explores the context of heroin initiation among persons with histories of OA misuse in New York City.

METHODS

In-depth interviews were conducted with 31 individuals with histories of OA misuse who initiated heroin use within the past five years. Data were collected between August 2013 and January 2015. All participants' OA misuse temporally preceded their heroin use. Interviews were coded and analyzed utilizing thematic qualitative methods.

RESULTS

Participants ranged in age from 18 to 44 years; 25 identified as male and 30 identified as non-Hispanic white and heterosexual. All participants had stable housing at the time of interview and all were high school graduates. Participants described several key points of transition along their trajectories from OA misuse to heroin initiation: dual- to single-entity OAs; oral to intranasal OA administration; and the development of physical opioid dependence. Participants described the breaking down of heroin-related stigma across social networks as new drug use permeated social groups.

CONCLUSION

Several points of transition were identified in participants' trajectories from OA misuse to heroin initiation. In particular the development of physical dependence was a critical factor as existing heroin stigma was rapidly overcome in the face of opioid withdrawal. The relatively short time to heroin initiation documented among new user groups serves as an added challenge to the development of interventions.

Transition to injecting drug use in Iran: A systematic review of qualitative and quantitative evidence

BACKGROUND

Injection drug use, a behavior associated with significant adverse health effects, has been increasing over the past decade in Iran. This study aims to systematically review the epidemiological and qualitative evidence on factors that facilitate or protect the transition to injection drug use in Iran.

METHODS

We conducted electronic searches in five international (Medline, Web of Science, EMBASE, CINAHL, PsycINFO), one regional (IMEMR) and three Iranian (Iranmedex, Iranpsych, IranDoc) databases, as well as contacting experts in the field. Two trained researchers screened documents to identify relevant studies and independently dual-extracted data following pre-specified protocol. We applied principles of thematic analysis for qualitative data and applied a random effect meta-analysis model for age of first injection.

RESULTS

A total of 38 documents from 31 studies met eligibility criteria, from which more than 50% were implemented from 2006 to 2008. The weighted mean age of first injection was 25.8 (95% Confidence Interval: 25.3-26.2). Between 1998 and 2011, the age of first injection was relatively stable. Overall, drug users had used drugs for 6-7 years before they started injection use. Heroin was the first drug of injection in the majority of the cases. We identified factors influencing the initiation of or transition to injection use at various levels, including: (1) individual (pleasure-seeking behavior, curiosity and development of drug dependency commonly reported), (2) social and environmental (role of peer drug users in the first injection use, the economic efficiency associated with injections and the wide availability of injectable form of drugs in the market).

CONCLUSION

Harm reduction policies in Iran have almost exclusively focused on drug injectors in Iran. However, given the extent of the non-injection drug use epidemic, evidence from this study can provide insight on points of interventions for the prevention of the transition to injection use.

Correlates and contexts of US injection drug initiation among undocumented Mexican migrant men who were deported from the United States

Preventing the onset of injection drug use is important in controlling the spread of HIV and other blood borne infections. Undocumented migrants in the United States face social, economic, and legal stressors that may contribute to substance abuse. Little is known about undocumented migrants' drug abuse trajectories including injection initiation. To examine the correlates and contexts of US injection initiation among undocumented migrants, we administered quantitative surveys (N = 309) and qualitative interviews (N = 23) on migration and drug abuse experiences to deported male injection drug users in Tijuana, Mexico. US injection initiation was independently associated with ever using drugs in Mexico pre-migration, younger age at first US migration, and US incarceration. Participants' qualitative interviews contextualized quantitative findings and demonstrated the significance of social contexts surrounding US injection initiation experiences. HIV prevention programs may prevent/delay US injection initiation by addressing socio-economic and migration-related stressors experienced by undocumented migrants.

What are Differences between Non-injecting and Injecting Drug Addicts?

BACKGROUND

This study aims to identify the differences between Injecting Drug Users (IDUs) and non-IDUs, with regard to some potential factors. This could be useful to design effective interventions for harm reduction, which is one of the priority areas in reducing the burden of addiction.

METHODS

Sixty cases and 60 controls participated in this pair-matched case-control study, which was conducted in Tehran. The cases were IDUs who were asked to introduce two friends; one IDU and the other non-IDU as the paired control. In addition to demographic variables, onset age of cigarette smoking, dropping out of school, imprisonment, history of being sexually abused for money, and family history of using illegal drugs were obtained from the cases and controls via an interview. Pair Odds Ratio (OR) was estimated through McNemar and conditional multivariable logistic regression analysis.

RESULTS

Eighty-three % of the IDUs and 92% the controls were male. The mean for onset age of cigarette smoking was 16 in the cases and 20 in the controls, which was significantly different between cases and controls (P<0.001). In the multivariate analysis, dropping out from school was significantly different between cases and controls (OR=4.22 95% CI: 2.23 - 14.0). Imprisonment was more frequent in IDUs compared to non-IDUs (OR=3.70 95% CI: 1.09 - 11.08). The cases had more sexual relationship for earning money compared to the controls (OR=3.14 95% CI: 1.24 - 13.70). Onset age of cigarette smoking was significantly (P<0.001) sooner in the IDUs compared to the non-IDUs (15.9 and 20.1 years, respectively). IDUs reported 5.5 times more that non-IDUs of having an addict in their family (P value=0.04).

CONCLUSION

The finding of this study can be useful in identifying the persons who are at risk of IDU. Therefore, people who involve with risk factors recognized in this study should be triggered for harm reduction prevention strategies.

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.

Modeling initiation into drug injection among street youth

This study aimed at examining the predictors of initiation into drug injection among street youth using social cognitive theory framework. A prospective cohort study based on semi-annual interviews was carried out. Psychosocial determinants referred to avoidance of initiation. Other potential predictors were: sociodemographic characteristics, relationships with injectors, parent's substance misuse, drug use patterns, homelessness, survival sex, sexual abuse. Independent predictors were identified using Cox proportional hazards regression models. Among the 352 participants, high control beliefs about avoidance of initiation was protective while younger age, daily alcohol consumption, heroin use, cocaine use, and survival sex all increased risk of initiation. Preventive strategies targeting street youth should both enhance youth's control beliefs and actual control over their substance use and improve their life conditions.

Comparison of HIV risk by duration of injection drug use

Early studies documented an inverse association between the HIV risk and duration of injection among injection drug users (IDUs). Results from subsequent studies have been inconsistent. To examine this issue, we conducted interviews with 395 street-recruited active IDUs from 38 neighborhoods in New York City during 2005 and 2008. We observed no significant differences in drug or risky sex behaviors by duration of drug use among these IDUs. Despite this, continuing to tailor HIV prevention programs for these recent-onset IDUs is prudent. The study's limitations are noted.

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.

DRUG RISK: A CROSS-SECTIONAL EXPLORATION OF THE INFLUENCE OF FAMILY-OF-ORIGIN AND CURRENT SITUATIONAL CIRCUMSTANCES

The main objective of this paper is to investigate potential predictors of drug risk among a community-based sample of individuals who are exposed to illicit drugs. The four domains of interest are individual socio-demographic and social-psychological attributes, current situational circumstances and family-of-origin characteristics. Interviews were conducted with 242 individuals who were recruited in Atlanta, Georgia. Initial descriptive analyses were followed by multivariate analyses. The final model predicted 60% of the variance in drug risk. Current situational circumstances were statistically significant regarding drug risk. Family-of-origin characteristics also were significant, even when entered into the predictive model after current situational circumstances. In addition to individual social-psychological characteristics such as depression and self-esteem, the impact of childhood emotional abuse is noted. The findings indicate a need for considering proximal as well as more distal influences on drug risk behavior when designing drug use prevention and intervention programs.

THE FIRST INJECTION EVENT: DIFFERENCES AMONG HEROIN, METHAMPHETAMINE, COCAINE, AND KETAMINE INITIATES

This article describes how the drug type injected at the first injection event is related to characteristics of the initiate, risk behaviors at initiation, and future drug-using trajectories. A diverse sample (n=222) of young injection drug users (IDUs) were recruited from public settings in New York, New Orleans, and Los Angeles during 2004 and 2005. The sample was between 16 and 29 years old, and had injected ketamine at least once in the preceding two years. Interview data was analyzed both quantitatively and qualitatively. Young IDUs initiated with four primary drug types: heroin (48.6%), methamphetamine (20.3%), ketamine (17.1%), and cocaine (14%). Several variables evidenced statistically significant relationships with drug type: age at injection initiation, level of education, region of initiation, setting, mode of administration, patterns of self-injection, number of drugs ever injected, current housing status, and their hepatitis C virus (HCV) status. Qualitative analyses revealed that rationale for injection initiation and subjective experiences at first injection differed by drug type.

Religiosity, Drug Use, and HIV-Related Risk Behaviors among Heroin Injectors

The association between religiosity and reduced alcohol and drug use in the general population is commonly recognized, but research about the relationship between religiosity and drug-related risk behaviors among illicit drug users has received considerably less attention. This study explores the role of religiosity in explaining heavy polydrug use and other HIV-related risk behaviors among a tri-ethnic sample of 600 male and female active heroin injectors who were recruited from the streets of Miami-Dade County Florida. The effects of three dimensions of religiosity on heavy alcohol use, daily crack-cocaine use, and five HIV-related injection and sex risk behaviors were assessed using multivariate logistic regression techniques that controlled for demographics and self-reported HIV serostatus. The majority of heroin injectors reported some degree of religiosity as expressed by religious intentionality, worship attendance, and religious self-perception. Strong religious intentionality was associated with a decreased likelihood of reusing needles/syringes, but the regression results suggest that religiosity for the most part did not influence heavy polydrug use or other HIV-related risk behaviors of active heroin injectors.