Pregnancy and sexual health among homeless young injection drug users

Substance use typologies among young people experiencing homelessness in seven cities across the United States: A latent class analysis

BACKGROUND

Substance use and other health-risk risk factors, including mental health, trauma, and sexual-risk behaviors, often co-occur among youth experiencing homelessness (YEH). The present study aimed to identify subgroups of YEH based on polysubstance use and the linkages to sociodemographic and health-risk characteristics.

METHODS

From June 2016 to July 2017, 1,426 YEH (aged 18-26 years) were recruited from seven cities (Houston, Los Angeles, Denver, Phoenix, New York City, St. Louis, San Jose). Participants provided information via a self-administered electronic survey on substance use, mental health, trauma, sexual risk behaviors, and sociodemographic characteristics. The majority of YEH identified as Black (37.3%), cisgender (92.8%), and heterosexual (69.2%). On average, YEH were 20.9 years (SD = 2.1). This study employed latent class analysis (LCA) to identify subgroups of YEH according to their substance use. Multinomial logistic regression analyses were conducted to identify sociodemographic and health-risk characteristics associated with class-membership.

RESULTS

Four latent classes of YEH substance use were identified: (1) high polysubstance use; (2) moderate stimulant and high marijuana, alcohol, and prescription drug use; (3) high marijuana, alcohol, and prescription drug use; (4) low/moderate marijuana and alcohol use. Multinomial logistic regression models indicated that geographic location, gender, race/ethnicity, mental health, trauma history, and sexual risk behaviors were significant correlates of substance use class membership among YEH.

CONCLUSIONS

These findings offer important implications for the prevention and treatment of substance use among YEH. Screening protocols should consider co-occurring risk factors such as traumatic experiences, sexual risk behaviors, and mental health history as indicators of polysubstance use.

Barriers to and facilitators of hormonal and long-acting reversible contraception access and use in the US among reproductive-aged women who use opioids: A scoping review

Existing research has found that women who use opioids (WWUO) experience challenges to hormonal and long-acting reversible contraception (HC-LARC) access and use. Facilitators of such use are unclear. We conducted a scoping review to comprehensively map the literature on barriers to and facilitators of HC-LARC access and use in the United States among reproductive-aged WWUO. In accordance with the JBI Manual of Evidence Synthesis, we conducted literature searches for empirical articles published from 1990 to 2021. Independent reviewers screened references, first by titles and abstracts, then by full-text, and charted data of eligible articles. We coded and organized HC-LARC barriers and facilitators according to a four-level social-ecological model (SEM) and categorized findings within each SEM level into domains. We screened 4,617 records, of which 28 articles focusing on HC-LARC (n = 18), LARC only (n = 6), or testing an intervention to increase HC-LARC uptake (n = 4) met inclusion criteria. We identified 13 domains of barriers and 11 domains of facilitators across four SEM levels (individual, relationship, community, societal). The most frequently cited barriers and facilitators were methods characteristics, partner and provider relations, transportation, healthcare availability and accessibility, cost, insurance, and stigma. Future studies would benefit from recruiting participants and collecting data in community settings, targeting more diverse populations, and identifying neighborhood, social, and policy barriers and facilitators. Reducing barriers and improving equity in HC-LARC access and use among WWUO is a complex, multifaceted issue that will require targeting factors simultaneously at multiple levels of the social-ecological hierarchy to effect change.

Risk of delivery complications among pregnant people experiencing housing insecurity

BACKGROUND

Housing insecurity is increasingly being recognized as an important social determinant of health. Pregnant individuals experiencing housing insecurity may represent a particularly vulnerable subset of this population, but few studies have examined this population nationally. In particular, racial and ethnic minority individuals may be at risk for poor outcomes within this group because of structural racism and discrimination. The introduction of the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes related to social determinants of health represent a new opportunity to identify patients with housing insecurity nationally.

OBJECTIVE

This study aimed to evaluate the prevalence of and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race and ethnicity.

STUDY DESIGN

This was a retrospective cohort study using data from the 2016 to 2018 National Inpatient Sample. Delivery hospitalizations for people experiencing housing insecurity were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code Z59. Among hospitals that coded at least 1 delivery for a patient with housing insecurity, logistic regression models were used to assess the odds of severe maternal morbidity associated with housing insecurity, adjusting for clinical risk and pregnancy characteristics.

RESULTS

Of 539,950 delivery hospitalizations, 1820 hospitalizations (0.3%) were for patients with housing insecurity. Compared to deliveries for patients with housing security, deliveries for patients with housing insecurity were more likely for patients who identified as Black (34.8% vs 18.1%; P<.001) and who had Medicaid insurance (83.5% vs 46.2%; P<.001). People with housing insecurity were more likely to have comorbidities and higher-risk pregnancies, including higher rates of substance use disorders (54.0% vs 6.9%), major mental health disorders (37.5% vs 8.7%), preeclampsia with severe features (7.4% vs 4.3%), and preterm birth <37 weeks gestation (23.7% vs 11.6%) (all P<.001). In regression analyses, patients with housing insecurity had more than twice the odds of severe maternal morbidity than patients with housing security during the delivery hospitalization (odds ratio, 2.17; 95% confidence interval, 1.75-2.68). After adjusting for clinical risk and pregnancy characteristics, the differences were attenuated overall (adjusted odds ratio, 1.17; 95% confidence interval, 0.94-1.47) and among racial and ethnic groups (White patients: adjusted odds ratio, 1.39; 95% confidence interval, 0.95-2.03; Black patients: adjusted odds ratio, 1.05; 95% confidence interval, 0.73-1.52; Hispanic patients: adjusted odds ratio, 1.04; 95% confidence interval, 0.59-1.84; Asian or Pacific Islander or Native American or other race patients: adjusted odds ratio, 1.08; 95% confidence interval, 0.45-2.58).

CONCLUSION

Pregnant individuals experiencing housing insecurity were more likely to be from groups that have been marginalized historically, had higher rates of comorbidities, and worse delivery outcomes. After risk adjustment, differences in the odds of severe maternal mortality were attenuated. Screening for housing insecurity may identify these patients earlier and connect them to services that could improve disparities in outcomes.

Counter-Narratives of Structural Oppressions, Stigma and Resistance, and Reproductive and Sexual Health Among Youth Experiencing Homelessness

Youth experiencing homelessness (YEH) face myriad injustices regarding their reproductive and sexual health and rights. Reproductive and sexual health research with YEH often explores condom-use and sexually transmitted infections, potentially contributing to narrow conceptualizations of YEH as "unclean" or in need of disease-screening. A narrative theory perspective was applied to this study, which allowed for the emergence of alternative storylines, or counter-narratives, which attend to manifestations of power and oppression within the lives of marginalized individuals. Qualitative interviews engaged 30 young people (ages 18-21) accessing shelter services. Narrative analyses identified YEHs' documentations of dominant narratives related to structural oppressions, stigma, and numerous dimensions of reproductive and sexual health including how they create, through their resistance, counter-narratives that include their preferred futures. YEH emphasized systemic sources of stigma and outlined their criticisms of the state. Within-group stigma emerged as a noteworthy theme, with YEH showing both empathy and ambivalence towards other YEH, along with internalization of stigmatizing narratives about pregnancy and homelessness. Approaches to service provision that further amplify youths' voices in naming and challenging the many oppressions and stigmas they face should be prioritized. Moreover, policies should be implemented to dismantle the actual root causes of challenges faced by YEH, rather than perpetuating them through measures rooted in interlocking oppressions of discrimination, inequity, and judgment.

Perceived barriers and facilitators to accessing and utilising sexual and reproductive healthcare for people who experience homelessness: a systematic review

INTRODUCTION

People who experience homelessness face disproportionately poor reproductive health and adverse pregnancy outcomes, including but not limited to unintended pregnancy, abortion, low birth weight and preterm birth, as well as a higher risk of sexually transmitted infections (STIs). Precarious living conditions are known to contribute to poor uptake and engagement with sexual and reproductive healthcare (SRH) for this population.

AIM

To identify and understand the perceived barriers and facilitators for accessing and utilising SRH for people who experience homelessness from their perspective, and the perspective of support staff/volunteers and healthcare professionals.

METHODS

Electronic databases and online sources were searched. Two reviewers independently carried out the screening, data extraction, critical appraisal, data synthesis and thematic analysis of findings.

RESULTS

Following deduplication and screening, 23 papers/reports were considered eligible for the review. Barriers for people experiencing homelessness to accessing and utilising SRH were identified within the themes of complexity, feelings and knowledge (ie, individual-level factors), as well as patient/provider interaction and healthcare system (ie, organisational factors). Facilitators were identified within all of the above themes except for complexity.

CONCLUSIONS

Both population characteristics and attributes of the healthcare system influence access and utilisation of SRH by people experiencing homelessness. Given the complexity of living conditions associated with homelessness, greater efforts to improve access should be placed on healthcare systems and aspects of care delivery. This systematic review highlights current gaps in the literature and provides recommendations for enhancing future research and practice to meet the needs of this vulnerable group more effectively.

Access experiences and attitudes toward abortion among youth experiencing homelessness in the United States: A systematic review

Objectives

We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States.

Methods

We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options.

Results

Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences.

Conclusions

Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

Substance Use among Homeless Reproductive Age People in Southern Ethiopia

Introduction

Substance use by homeless reproductive age people may result to anxiety, involvement of risky sexual behaviors, and increasing the likelihood of unwanted pregnancy and sexually transmitted diseases (STDs). Therefore, this study assessed the magnitude of alcohol use, sexual intercourse after alcohol use, and its associated factors among homeless reproductive age people in southern Ethiopia.

Methods

Community-based cross-sectional study design was conducted among homeless reproductive age people. The snowball sampling technique was used to recruit 842 participants. Pretested and structured interviewer-administered questionnaire was used to collect the data. Data were entered into Epidata version 3.1 and exported to SPSS version 23 for analysis. Binary logistic regression was used to determine the association of independent variables with the outcome variables. Odds ratio with their 95% confidence interval and P value was used to identify the significant variables.

Results

More than half 423 (53.2%) of the respondents had taken a drink that contains alcohol in the last one year of the study period. Out of 324 khat chewers, 190 (58.64%) had sex after chewing khat. More than one-thirds, 323(38.4%) homeless people were smoking cigarette during the study period. Factors associated with alcohol use were age 19-25 years (AOR: 0.49; CI: 0.34, 0.72), ≥26 years (AOR: 0.40; CI: 0.25, 0.65), level of education (AOR: 0.61; CI: 0.39, 0.94), place of residence: major urban (AOR: 0.31; CI: 0.18, 0.51), small town (AOR: 0.38; CI: 0.23, 0.63), ever heard about STDs (AOR: 0.14; CI: 0.07, 027), and being a cigarette smoker (AOR: 2.67; CI: 1.94, 3.71).

Conclusions

In this study, significant percentage of respondents had taken a drink that contains alcohol. Age, level of education, place of residence, ever heard about STDs, and smoking cigarette were variables significantly associated with alcohol use. Awareness creation on the effect and outcome of substance use is recommended.

Understanding the Family Planning Needs of Female Participants in a Syringe Exchange Program: A Needs Assessment and Pilot Project

OBJECTIVES

To describe the reproductive health needs of women who inject drugs (WWID) and are participants in a syringe exchange program (SEP) in Hawaii. Our secondary objective was to develop and pilot services in response to those needs.

METHODS

We conducted a reproductive health needs-assessment of women participating in the SEP. We also documented the perspectives and recommendations of key informants who work closely with women in this program. This needs-assessment informed a pilot contraceptive project at the SEP.

RESULTS

We received surveys from 50 syringe exchange participants and hosted 1 focus group with 6 participants. We completed 8 key informant interviews. The majority of survey respondents indicated that they did not want to become pregnant in the next year, but most were not using a reliable method of contraception. Additionally, for most respondents, prevention of pregnancy was a lower priority than other health and wellness needs. Focus group participants and key informants emphasized the importance of developing a network of accessible providers to address reproductive health needs, and also the importance of using the principles of trauma-informed care when developing a service. We developed a pilot program to offer contraceptive injections at the syringe exchange program. In the first 6 months of offering the service, 1 participant elected to use the injection.

CONCLUSIONS

WWID participating in this SEP may not prioritize their family planning needs when other health and safety needs are unmet. A pilot program to offer contraceptive injections at SEP had almost zero uptake.

Contraceptive use in Appalachian women who use drugs and were recruited from rural jails

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.

"It seems kinda like a different language to us": Homeless youths' attitudes and experiences pertaining to condoms and contraceptives

Homeless youth become pregnant or involved in pregnancies at high rates. There are many ways by which unintended pregnancies may be prevented, including the use of condoms and other contraceptives. However, there is a dearth of research regarding contraceptive use among this vulnerable youth population, and especially through lenses that consider homeless youths' diverse gender identities, expressions, and sexualities. This study qualitatively explores homeless youths' attitudes and experiences regarding condom and other contraceptive use. Data were obtained from interviews with 30 youth experiencing homelessness, ages 18-21. Youth reported inconsistent use of condoms and other contraceptives, which youth often attributed to their perceptions of contraceptive inaccessibility and exorbitant cost. Most youth also did not know where to obtain contraceptive information and services, and reported transportation barriers and fear of being stigmatized in health care settings, particularly in relation to their gender identities and sexualities. Findings suggest that reproductive and sexual health information and services are urgently needed by all homeless young people, and from low-barrier, non-judgmental, and empathetic sources.

Behavioural risk factors for sexually transmitted infections and health seeking behaviour of street youths in Ibadan, Nigeria

BACKGROUND

Street youths are faced with a number of health challenges that could be linked to their exposure to the risk elements, accessing medical care including motivation and /or ignorance to utilise available health care.

OBJECTIVE

This qualitative study therefore aimed at determining the behavioural risks for sexually transmitted infections (STIs) and health seeking behaviour of street youths in Ibadan.

METHODS

Sixteen focus group discussion (FGD) sessions were conducted among 160 street youths aged between 15-24 years.

RESULT

The result showed that most of the respondents had low perception of risk of contracting STIs in spite of their risky behaviours which included multiple sexual partnering, sharing of personal effects, malnourishment and sexual harassment. Most of the street youth could not identify the various types however; Gonorrhea and HIV were commonly mentioned by them. The major treatment regimen for STIs was traditional remedies and drugs obtained from patent medicine vendors. Traditional remedies were preferred by most of the participants and considered to be more effective.

CONCLUSION

Majority of the street youths were sexually active, engaged in high risk sexual behaviours and had inappropriately treated sexually transmitted infections. Development of risk reduction and appropriate sexual health interventions targeted at prevention and appropriate treatment is recommended.

Reproductive health rights and survival: The voices of mothers experiencing homelessness

Women experiencing homelessness report higher rates of reproductive health-related traumas, including unplanned pregnancy, miscarriage, and abortion than their non-homeless peers. Using phenomenological hermeneutic methods, we sought to understand the reproductive health histories of women currently experiencing homelessness (N = 20, 25-61 years old, Mage = 38.33, SDage = 9.33) analyzing data collected between June 2014 and July 2015 in north central Texas. Three key themes highlight the essence of the women's experiences: (1) unexpected pregnancy-pregnancy just happened, (2) loss of reproductive health rights-I was broken, and (3) resilience-giving back and looking forward to good things. Many of the women became mothers through unexpected pregnancies, and overnight found that their lives were transformed irrevocably. Often unexpected pregnancy was the result or cause of a lack of ownership over their reproductive health and led to prolonged health-related traumas. Over time, though, many of the women whom we interviewed re-expressed resilience through social support, housing assistance, and a sense of giving back to society. Results indicate that reproductive health care providers require training to identify the relationship among unexpected pregnancy, reproductive health-related traumas, and housing insecurity. Providers can help preserve women's reproductive health rights through education and empowerment.

The paradox of homeless youth pregnancy: a review of challenges and opportunities

Compared to their housed counterparts, homeless youth become pregnant at exceptionally high rates. Causes of such pregnancies are multifaceted, while a paradoxically high proportion of these pregnancies are intended. This review discusses causes and risk factors associated with homeless youth pregnancies, and notes experiences of pregnancy decision-making discord, challenges encountered during and following pregnancy, and difficulties faced by homeless youth when or if they become parents. Because homeless youth face a wide array of unique risks, future research would benefit from exploring alternative approaches to prevention to reduce pregnancies and improve sexual and reproductive health outcomes among this population.

Substance use and risky sexual behaviours among street connected children and youth in Accra, Ghana

BACKGROUND

Research on street children and youth has shown that this population is at high risk for substance use. Though risky sexual behaviours have been investigated and widely reported among street youth in resource constrained-settings, few studies have explored the relationship between substance use and other risk behaviours. This study was therefore conducted to examine the association between substance use and risky sexual behaviours among homeless youth in Ghana.

METHOD

A cross-sectional survey of a convenient sample of 227 (122 male and 105 female) street connected children and youth was conducted in Ghana in 2012. Using self-report measures, the relationship between substance use and risky sexual behaviours was examined using logistic regression.

RESULTS

Substance use was relatively high as 12% and 16.2% reported daily use of alcohol and marijuana respectively. There were age and sex differences in substance use among the sample. As compared to males, more females had smoked cigarettes, used alcohol and marijuana. While alcohol use decrease with age, marijuana use on the other hand increases with age. Results from multivariate analysis revealed that having ever drunk alcohol and alcohol use in the past one month were independently associated with all the four indices of risky sexual behaviour (ever had sex, non-condom use, multiple sexual partners and survival sex). Both marijuana use and smoking of cigarettes were associated with having ever had sex, multiple sexual partners and survival sex. Other drug use was independently associated with non-condom use.

CONCLUSION

Substance use seems to serve as a possible risk factor for sexual risk behaviours among homeless youth. Harm reduction interventions are needed to prevent street children and youth from engaging in substance use and risky sexual behaviours. Such programmes should pay special attention to females and younger children who are highly susceptible to the adverse conditions on the street.

Pregnancy attitudes, contraceptive service utilization, and other factors associated with Los Angeles homeless youths' use of effective contraception and withdrawal

STUDY OBJECTIVE

This study aims to understand the associations of contraceptive service utilization (ie, accessing condoms or birth control), pregnancy attitudes, and lifetime pregnancy history among male and female homeless youth in relation to use of effective contraception and withdrawal.

DESIGN, SETTING, AND PARTICIPANTS

Between October 2011 and February 2012, homeless youth (14-27 years old) from 2 drop-in centers in Los Angeles (N = 380) were recruited and completed a questionnaire. The data in this paper are restricted to those who reported vaginal sex at last sex (N = 283).

MAIN OUTCOME MEASURES

Analyses examined history of foster care, sexual abuse, exchange sex, pregnancy, lifetime homelessness duration, current living situation, contraceptive service utilization, and pregnancy attitudes in predicting use of effective contraception and withdrawal at last sex.

RESULTS

Over 62% of females and 43% of males report having ever been pregnant or impregnating someone. There are no gender-based differences in pregnancy attitudes; 21% agree they would like to become pregnant within the year. Additionally, there are no gender-based differences in reported contraceptive use at last vaginal sex. In the multivariable model, high school education, contraceptive service utilization (Relative Risk Ratio [RRR]: 4.0), and anti-pregnancy attitudes (RRR: 1.3) are significant positive predictors of using effective contraception; anti-pregnancy attitudes (RRR: 1.2) and gender (RRR: 0.3) are significantly associated with using withdrawal.

CONCLUSIONS

Health professionals should acknowledge that some homeless youth desire pregnancy; for those that do not, access to effective contraception is important. Programs must continue to promote pregnancy prevention, and include discussions of healthy pregnancy habits for pregnancy-desiring youth.

Characteristics of natural mentoring relationships from the perspectives of homeless youth

PROBLEM

Homeless youth experience high risks for poor mental health outcomes. The purpose of this qualitative study was to explore the characteristics of natural mentoring relationships among homeless youth and to identify possible mechanisms that can enhance social support for this population.

METHODS

Semi-structured interviews were conducted with 23 homeless youth aged 14-21 who had natural mentors. The interviews focused on how youth met their natural mentors, the function of these relationships, and how natural mentoring relationships differed from other relationships in the youth's social networks.

FINDINGS

Main themes that emerged from the interviews included parental absence, natural mentors as surrogate parents, and social support from mentors.

CONCLUSIONS

Findings suggest that social supports provided by mentors enhance youth's adaptive functioning and may promote resilience, thus the use of natural mentors may be an important untapped asset in designing interventions to improve outcomes for homeless youth.

Prescription drug misuse and risk behaviors among young injection drug users

Prescription drug misuse among young adults, especially opioids, is a substantial public health problem in the United States. Although risks associated with injection of illicit drugs are well established, injection and sexual risks associated with misuse of prescription drugs are under-studied. Forty young injection drug users aged 16 to 25 who reported injection of a prescription drug were recruited in 2008-09 in Los Angeles and New York City. Descriptive quantitative and qualitative data were analyzed to illustrate risky injection and sexual behaviors reported in this sample. Over half of participants engaged in risky injection behavior, three-quarters engaged in risky sexual behavior, nearly half reported both risky behaviors, and five did not report either risk behavior while misusing a prescription drug. Prescription opioids, tranquilizers, and stimulants were misused in the context of risky sexual behaviors while only opioids were misused in the context of injection risk behaviors. Access to clean syringes, attitudes and beliefs regarding hepatitis C, and risk reduction through partner selection were identified as key themes that contextualized risk behaviors. Although these findings help identify areas to target educational campaigns, such as prevention of sexually transmitted infections, risk behaviors specifically associated with prescription drug misuse warrant further study.

Patterns of prescription drug misuse among young injection drug users

Misuse of prescription drugs and injection drug use has increased among young adults in the USA. Despite these upward trends, few studies have examined prescription drug misuse among young injection drug users (IDUs). A qualitative study was undertaken to describe current patterns of prescription drug misuse among young IDUs. Young IDUs aged 16-25 years who had misused a prescription drug, e.g., opioids, tranquilizers, or stimulants, at least three times in the past 3 months were recruited in 2008 and 2009 in Los Angeles (n = 25) and New York (n = 25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analyzed both quantitatively and qualitatively. Most IDUs sampled were both homeless and transient. Heroin, prescription opioids, and prescription tranquilizers were frequently misused in the past 30 days. Qualitative results indicated that young IDUs used prescription opioids and tranquilizers: as substitutes for heroin when it was unavailable; to boost a heroin high; to self-medicate for health conditions, including untreated pain and heroin withdrawal; to curb heroin use; and to reduce risks associated with injecting heroin. Polydrug use involving heroin and prescription drugs resulted in an overdose in multiple cases. Findings point to contrasting availability of heroin in North American cities while indicating broad availability of prescription opioids among street-based drug users. The results highlight a variety of unmet service needs among this sample of young IDUs, such as overdose prevention, drug treatment programs, primary care clinics, and mental health services.

Denial of prescription opioids among young adults with histories of opioid misuse

OBJECTIVES

An exploratory study was undertaken to examine how being denied prescription opioids to treat pain impacted the drug-using careers of young adults with a history of misuse of prescription drugs.

DESIGN

Ethno-epidemiological methodology utilizing a cross-sectional design, semi-structured interviews, and qualitative/quantitative data analysis. Settings.  Non-clinical participants were recruited from natural settings, such as streets, parks, beaches, and college campuses, in New York City and Los Angeles during 2008 and 2009.

PARTICIPANTS

One hundred fifty participants aged 16 to 25 who had misused a prescription opioid, tranquilizer, or stimulant in the past 90 days. Outcome Measures.  Analyses focused on denial of opioids and associated consequences, including self-medication with prescription opioids and heroin.

RESULTS

Thirty-four participants (22.7%) described being denied prescription opioids for the treatment of a painful condition. Current opioid misuse and current pain problems were higher in this group compared to those who had never been denied prescription opioids. Reasons for denial included being identified as a drug user by a physician, lack of health insurance, and having medication withheld by a parent or authority figure. Approximately half reported self-medicating pain with either illegally obtained prescription opioids or heroin. Self-medication often coincided with initiation of new risk behaviors and more intensive drug use.

CONCLUSION

Being denied prescription opioids was an important moment in the drug using careers of many study participants. Results suggest that effective pain management techniques are needed to prevent high-risk young adults with pain problems from engaging in escalated opioid misuse and risk behaviors.

The mental and physical health of homeless youth: a literature review

Youth homelessness is a growing concern in the United States. Despite difficulties studying this population due to inconsistent definitions of what it means to be a youth and homeless, the current body of research indicates that abuse, family breakdown, and disruptive family relationships are common contributing factors to youth homelessness. Moreover, the experience of homelessness appears to have numerous adverse implications and to affect neurocognitive development and academics, as well as mental and physical health. Substance use, sexually transmitted infections, and psychiatric disorders are particularly prevalent in this population. Whereas some of these problems may be short-lived, the chronic stress and deprivation associated with homelessness may have long-term effects on development and functioning. Further, difficulties accessing adequate and developmentally-appropriate health care contribute to more serious health concerns. Suggestions for future research and interventions are discussed.

Multi-city assessment of lifetime pregnancy involvement among street youth, Ukraine

Although street youth are at increased risk of lifetime pregnancy involvement (LPI), or ever becoming or getting someone pregnant, no reports to date describe the epidemiology of LPI among systematically sampled street youth from multiple cities outside of North America. The purpose of our assessment was to describe the prevalence of and risk factors associated with LPI among street youth from three Ukrainian cities. We used modified time-location sampling to conduct a cross-sectional assessment in Odesa, Kyiv, and Donetsk that included citywide mapping of 91 public venue locations frequented by street youth, random selection of 74 sites, and interviewing all eligible and consenting street youth aged 15-24 years found at sampled sites (n = 929). Characteristics of youth and prevalence of LPI overall and by demographic, social, sexual, and substance use risk factors, were estimated separately for males and females. Adjusted odds ratios (AORs) were calculated with multivariable logistic regression and effect modification by gender was examined. Most (96.6%) eligible youth consented to participate. LPI was reported for 41.7% of females (93/223) and 23.5% of males (166/706). For females, LPI was significantly elevated and highest (>70%) among those initiating sexual activity at ≤12 years and for those reporting lifetime anal sex and exchanging sex for goods. For males, LPI was significantly elevated and highest (>40%) among those who reported lifetime anal sex and history of a sexually transmitted infection. Overall, risk factors associated with LPI were similar for females and males. Among the total sample (females and males combined), significant independent risk factors with AORs ≥2.5 included female gender, being aged 20-24 years, having five to six total adverse childhood experiences, initiating sex at age ≤12 or 13-14 years, lifetime anal sex, most recent sex act unprotected, and lifetime exchange of sex for goods. Among street youth with LPI (n = 259), the most recent LPI event was reported to be unintended by 63.3% and to have ended in abortion by 43.2%. In conclusion, our assessment documented high rates of LPI among Ukrainian street youth who, given the potential for negative outcomes and the challenges of raising a child on the streets, are in need of community-based pregnancy prevention programs and services. Promising preventive strategies are discussed, which are likely applicable to other urban populations of street-based youth as well.

Initiation into prescription opioid misuse amongst young injection drug users

BACKGROUND

Prescription opioids are the most frequently misused class of prescription drugs amongst young adults. Initiation into prescription opioid misuse is an important public health concern since opioids are increasingly associated with drug dependence and fatal overdose. Descriptive data about initiation into prescription opioid misuse amongst young injection drug users (IDUs) are scarce.

METHODS

An exploratory qualitative study was undertaken to describe patterns of initiation into prescription opioid misuse amongst IDUs aged 16-25 years. Those young IDUs who had misused a prescription drug at least three times in the past three months were recruited during 2008 and 2009 in Los Angeles (n=25) and New York (n=25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analysed both quantitatively and qualitatively.

RESULTS

Initiation into prescription opioid misuse was facilitated by easy access to opioids via participant's own prescription, family, or friends, and occurred earlier than misuse of other illicit drugs, such as heroin. Nearly all transitioned into sniffing opioids, most injected opioids, and many initiated injection drug use with an opioid. Motives for transitions to sniffing and injecting opioids included obtaining a more potent high and/or substituting for heroin; access to multiple sources of opioids was common amongst those who progressed to sniffing and injecting opioids.

CONCLUSION

Prescription opioid misuse was a key feature of trajectories into injection drug use and/or heroin use amongst this sample of young IDUs. A new pattern of drug use may be emerging whereby IDUs initiate prescription opioid misuse before using heroin.

Street-based adolescents at high risk of HIV in Ukraine

Background

Ukraine has the highest HIV prevalence in Europe, with young people disproportionately represented among populations at high risk. One particularly vulnerable group comprises adolescents who live or work on the streets. This study aimed to measure the extent and distribution of HIV risk behaviours among street-based adolescents in four Ukrainian cities as part of a regional UNICEF HIV prevention programme for most-at-risk adolescents.

Methods

A cross-sectional behavioural survey was conducted of 805 adolescents (aged 10–19 years) in the cities of Kiev, Donetsk, Dnepropetrovsk and Nikolaev. Using location-based network and convenience sampling, 200 adolescents were reached in each site and were administered a standardised questionnaire on drug use, sexual behaviour, condom use, HIV knowledge, access to prevention services, experience of violence and contact with state institutions and police.

Results

Considerable levels of HIV risk behaviour were found, including injecting drug use among 15.5% of the sample. Almost three-quarters of adolescents had experienced sexual debut, most before the age of 15 years. Male-to-male sexual behaviour was reported by just under 10% of boys. Condom use was low although varied by partner type. There were high rates of forced sex, and 75.5% of respondents reported police harassment.

Conclusions

Street-based adolescents in Ukraine are at significant risk of contracting HIV due to involvement in injecting drug use and unprotected sex in personal and commercial exchanges, including male-to-male sex. This group initiates risk behaviours at early ages, and does not appear to have good access to prevention and other health services.

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.