Social relationships and intravenous drug use among methadone maintenance patients

Dual-substance use disorder couples: An integrative review and proposed theoretical model

Committed romantic relationships between two individuals with Substance Use Disorder (or dual-SUD couples) are prevalent. Dual-SUD couples have poor treatment engagement and outcomes. Research has established a reciprocal link between relationship dynamics (e.g., conflict, intimacy) and substance use. Thus, the couple's relationship presents a distinct social context for both partner's substance use. Dual-SUD couples face unique challenges due to substance use being a shared behavior that may serve as a rewarding source of compatibility, closeness, and short-term relationship satisfaction despite it being at the cost of other alternative sources of substance-free reinforcement. Yet, treatment options for these couples are scarce. Dual-maladaptive health behaviors (e.g., dual-substance use) are challenging to treat; however, theory and preliminary research suggests that transformation of couple's joint motivation toward adaptive health behavior change may result in a more satisfying relationship and improved treatment outcomes for both individuals. The current paper reviews the extant literature on dual-SUD couples from theoretical, empirical, and treatment research and proposes an expanded paradigm regarding how we understand dual-SUD couples with the aim of informing basic research and treatment development.

Substance Misuse Themes Among Women Living in Transitional Housing: Effects on Children, Intimate Partner Relationships, and Social Relationships

ABSTRACT

Traditional substance misuse treatments have not always taken women or marginalized populations into consideration. A holistic approach that addresses how drugs may be used to cope with trauma caused by violence, poverty, and neglect as well as employment of engagement strategies that connect populations with culturally relevant support systems are key, especially in treating African American women. As substance misuse rates rise among African American women, characterizing how this may influence or be influenced by relationships (such as with children, intimate partners, and social relations) is especially important in the context of effective treatment. The purpose of this qualitative study was to examine the themes surrounding substance misuse and close relationships among women previously enrolled in a transitional housing treatment program grounded in social support. Many women discussed how the program itself was an impetus in addressing not only their own substance use but also intergenerational substance use within their families. Women also noted how relationships with their children were vastly different pretreatment compared with during and after treatment, specifically emphasizing a positive improvement. Regarding intimate relationships, African American women learned to establish assertiveness and navigate healthier social relationships, all while sustaining drug abstinence. It is important to acknowledge the role of the healthcare professional in ensuring effective and culturally relevant treatment for African American women; nursing curricula should include evidence-based practice education and training on mental health and substance misuse specific to marginalized communities to more deeply understand the complex intersections of substance misuse, poverty, and social relationships in the lives of women.

Association Between Dual Partnership and Sexual and Injecting Behaviors Among Persons Who Inject Drugs in 23 US Cities, 2018

Persons who inject drugs (PWID) engaging in receptive syringe sharing with their sex partner (dual partnership) may have different behavior patterns than people who have only sex or syringe sharing partnerships. PWID from 23 US cities were recruited for the National HIV Behavioral Surveillance in 2018 using respondent-driven sampling, interviewed, and tested for HIV. Log-linked Poisson regression was conducted to examine the associations between injecting and sexual behaviors and dual partnership. A total of 3435 PWID reported receptive syringe sharing and 42% engaged in dual partnership with their last sharing injecting partner. PWID who reported condomless vaginal or anal sex at last sex were more likely to engage in dual partnership (aPR = 1.85, 95% CI = 1.65-2.08). PWID who reported having two or more sex partners (aPR = 0.67, 95% CI = 0.62-0.72) or two or more sharing injecting partners (aPR = 0.54, 95% CI = 0.50-0.59) were less likely to engage in dual partnership. Findings suggest opportunities for tailored prevention intervention, including couple-based HIV testing, pre-exposure prophylaxis, and access to syringe services programs coupled with safer injection education to help reduce HIV risk.

Associations between relationship quality and treatment-related stress among couples receiving methadone for opioid use disorder

BACKGROUND

Social relationships may buffer or exacerbate stress among patients receiving methadone treatment for opioid use disorder (OUD). Little is known, however, about how relationship quality is linked to treatment-related stress among couples in which both partners receive methadone. We considered the links between relationship quality and treatment-related stress among couples in methadone treatment for OUD.

METHODS

Participants for this cross-sectional observational study included 60 heterosexual married or cohabiting couples aged 18 and older drawn from two opioid treatment programs in Rhode Island and Massachusetts. Both partners completed a self-administered survey which assessed their sociodemographic information, relationship and treatment characteristics, and perceived treatment-related stress. We estimated actor-partner interdependence models to evaluate the links between each partner's perceptions of relationship quality (with their partner and their closest family member or friend) and treatment-related stress.

RESULTS

When their partners reported a more positive partner relationship, women had lower treatment-related stress. When women reported a more positive relationship with their own closest family member or friend, both women and their partners had lower treatment-related stress. When men perceived a more positive relationship with their closest family member or friend, their partners reported greater treatment-related stress. Negative relationship quality was not significantly linked to treatment-related stress.

CONCLUSIONS

This study highlights the importance of considering how social relationship quality might impact the experiences of couples receiving methadone for OUD. In particular, women's close relationships may help to mitigate treatment-related stress.

Sex differences in factors predicting post-treatment opioid use

BACKGROUND AND AIMS

Several reports have documented risk factors for opioid use following treatment discharge, yet few have assessed sex differences, and no study has assessed risk using contemporary machine learning approaches. The goal of the present paper was to inform treatments for opioid use disorder (OUD) by exploring individual factors for each sex that are most strongly associated with opioid use following treatment.

DESIGN

Secondary analysis of Global Appraisal of Individual Needs (GAIN) database with follow-ups at 3, 6 and 12 months post-OUD treatment discharge, exploring demographic, psychological and behavioral variables that predict post-treatment opioid use.

SETTING

One hundred and thity-seven treatment sites across the United States.

PARTICIPANTS

Adolescents (26.9%), young adults (40.8%) and adults (32.3%) in treatment for OUD. The sample (n = 1,126) was 54.9% male, 66.1% white, 20% Hispanic, 9.8% multi-race/ethnicity, 2.8% African American and 1.3% other.

MEASUREMENT

Primary outcome was latency to opioid use over 1 year following treatment admission.

RESULTS

For women, regularized Cox regression indicated that greater withdrawal symptoms [hazard ratio (HR) = 1.31], younger age (HR = 0.88), prior substance use disorder (SUD) treatment (HR = 1.11) and treatment resistance (HR = 1.11) presented the largest hazard for post-treatment opioid use, while a random survival forest identified and ranked substance use problems [variable importance (VI) = 0.007], criminal justice involvement (VI = 0.006), younger age (VI = 0.005) and greater withdrawal symptoms (VI = 0.004) as the greatest risk factors. For men, Cox regression indicated greater conduct disorder symptoms (HR = 1.34), younger age (HR = 0.76) and multiple SUDs (HR = 1.27) were most strongly associated with post-treatment opioid use, while a random survival forests ranked younger age (VI = 0.023), greater conduct disorder symptoms (VI = 0.010), having multiple substance use disorders (VI = 0.010) and criminal justice involvement (VI = 0.006) as the greatest risk factors.

CONCLUSION

Risk factors for relapse to opioid use following opioid use disorder treatment appear to be, for women, greater substance use problems and withdrawal symptoms and, for men, younger age and histories of conduct disorder and multiple substance use disorder.

Dyadic associations between relationship quality and risk of opioid use among couples receiving methadone for opioid use disorder

BACKGROUND

Social relationships may serve as both protective factors and risk factors for opioid use (nonmedical prescription opioid or illicit opioid use) among patients receiving methadone for opioid use disorder (OUD). Yet little is known about how relationship quality is linked to outcomes among couples receiving methadone. We evaluated the links between relationship quality and risk of opioid use among couples in which both partners received methadone.

METHODS

Participants included 53 heterosexual married or cohabiting couples aged 18 and older who were drawn from two opioid treatment programs in Rhode Island and Massachusetts. Both members of the couple completed a self-administered survey assessing their sociodemographic information, relationship and treatment characteristics, and risk of opioid use.

RESULTS

Roughly half of women (47.2%) and men (52.8%) had a moderate to high risk of nonmedical prescription opioid use and almost two-thirds (64.2%) had a moderate to high risk of street opioid use. Risk of street opioid use was highly correlated within couples. Actor-partner interdependence models revealed that when women reported higher positive relationship quality, they had a lower risk of nonmedical prescription opioid use and their partners had a lower risk of street opioid use. Negative relationship quality was not significantly linked to risk of opioid use.

CONCLUSIONS

Couples in which both partners receive methadone for OUD may be at risk of return to use, and positive partner relationships may play a role in lowering this risk. Women's perceptions of relationship quality might be a particularly important target for clinical care and interventions.

Giving and receiving social support in online substance use disorder forums: How self-efficacy moderates effects on relapse

OBJECTIVE

Individuals in recovery for substance use disorders (SUDs) increasingly use online social support forums, necessitating research on how communicating through these forums can affect recovery. This study examines how giving and receiving support within an SUDs recovery forum predict substance use, and considers whether effects vary according to participants' self-efficacy.

METHODS

We applied content analysis to 3440 messages that were posted by 231 participants in an online SUDs forum. Surveys assessed social support reception and substance use at three timepoints. We assessed relationships between giving and receiving support and substance use (risky drinking days, illicit drug use days), and the interactions between self-efficacy and social support in predicting substance use outcomes.

RESULTS

Receiving more emotional support was associated with reduced illicit drug use at 6 and 12 months. For those with low self-efficacy, giving more emotional support predicted less risky drinking at month 12, whereas giving more informational support predicted more risky drinking at month 12.

CONCLUSION

These results suggest conditional benefits of exchanging support in an online SUDs forum, depending upon type of support (informational versus emotional), the participants' role (giver or receiver), and their self-efficacy.

PRACTICE IMPLICATIONS

We discuss implications for designing and using peer-to-peer support platforms.

What's the influence of social interactions on substance use and treatment initiation? A prospective analysis among substance-using probationers

INTRODUCTION

A person's social environment greatly affects the likelihood of substance use, which in turn affects risk for criminal behavior. This study examined how people's social environment early in probation contributed to later substance use and treatment outcome, both of which predict probation success.

METHODS

Data were analyzed from a randomized controlled trial of substance-using probationers (N = 316). Moderation analyses assessed the relationship between social support near the start of probation and substance use and treatment initiation after 2 and 6 months.

RESULTS

Abstinence at 2-months was associated with better baseline measures of support quality (more positive support, fewer negative interactions, and reduced conflict). Similar associations were identified for 6-month abstinence including better baseline quality, more positive support, and less family and peer conflict. There were no significant associations between the baseline social support and treatment initiation at 2-months. However, poorer baseline quality support and more negative interactions predicted increased treatment initiation at 6-months.

CONCLUSIONS

Social support and the quality of an offender's social network have important implications for substance use and treatment compliance. The criminal justice system emphasizes ways to minimize negative social influences among offenders (i.e., probation conditions that limit contact with other offenders). However, this study suggests that behavior change is a function of not only reducing negative influences but also increasing positive or good quality supports.

Loneliness and Illicit Opioid Use Among Methadone Maintenance Treatment Patients

Background: Loneliness has been linked to greater substance use, especially among women. Yet little is known about how loneliness is associated with treatment outcomes for patients with opioid use disorder (OUD). Objectives: We evaluated how patient reports of using illicit opioids (i.e. heroin or non-prescription pain medications) are linked to perceptions of loneliness in a sample of adults receiving methadone maintenance treatment (MMT), and whether this link varies by gender. Methods: Participants for this cross-sectional observational study included 371 MMT patients aged 18 and older drawn from four opioid treatment programs in Southern New England and the Pacific Northwest. Patients completed a self-administered survey assessing sociodemographic and health information, loneliness, illicit opioid use, and MMT characteristics. Logistic regressions were estimated to examine the link between patient odds of illicit opioid use in the past month and perceived loneliness. Results: Patient gender moderated the association between illicit opioid use and loneliness such that severe loneliness was associated with higher odds of using illicit opioids among women (OR = 3.00, 95% CI [1.19, 7.57], p=.020) but lower odds of using illicit opioids among men (OR = 0.35, 95% CI [0.14, 0.87], p=.024), accounting for age, marital status, work status, depressive symptoms, and MMT characteristics (treatment episode, treatment duration, and methadone dose). Conclusions/importance: This study underscores the importance of considering loneliness in the management of OUD. Routine clinical care and treatment may benefit from strategies to build and sustain social connections that support long-term recovery among MMT patients.

A pilot feasibility randomised controlled trial of an adjunct brief social network intervention in opiate substitution treatment services

BACKGROUND

Approximately 3% of people receiving opioid substitution therapy (OST) in the UK manage to achieve abstinence from prescribed and illicit drugs within three years of commencing treatment. Involvement of families and wider social networks in supporting psychological treatment may be an effective strategy in facilitating recovery, and this pilot study aimed to evaluate the impact of a social network-focused intervention for patients receiving OST.

METHODS

A two-site, open feasibility trial randomised patients receiving OST for at least 12 months but still reporting illicit opiate use in the past 28 days to one of three treatments: 1) treatment as usual (TAU), 2) Brief Social Behaviour and Network Therapy (B-SBNT) + TAU, or 3) Personal Goal Setting (PGS) + TAU. The two active interventions consisted of 4 sessions. There were 3 aims: 1) test the feasibility of recruiting OST patients to a trial of B-SBNT, and following them up over 12 months; 2) test the feasibility of training clinicians to deliver B-SBNT; 3) test whether B-SBNT reduces heroin use 3 and 12 months after treatment, and to explore potential mediating factors. The primary outcome for aim 3 was number of days of heroin use in the past month, and a range of secondary outcome measures were specified in advance (level of drug dependence, mental health, social satisfaction, therapist rapport, treatment satisfaction, social network size and support).

RESULTS

A total of 83 participants were randomised, and 70 (84%) were followed-up at 12 months. Fidelity analysis of showed that B-SBNT sessions were clearly distinguishable from PGS and TAU sessions, suggesting it was possible to train clinical staff to an adequate level of competence. No significant differences were found between the 3 intervention arms in the primary or secondary outcome measures. Attendance at psychosocial treatment intervention sessions was low across all three arms (44% overall).

CONCLUSIONS

Patients receiving OST can be recruited into a trial of a social network-based intervention, but poor attendance at treatment sessions makes it uncertain whether an adequate dose of treatment was delivered. In order to achieve the benefits of psychosocial interventions, further work is needed to overcome poor engagement.

TRIAL REGISTRATION

ISRCTN Trial Registration Number: ISRCTN22608399 . Date of registration: 27/04/2012. Date of first randomisation: 14/08/2012.

Risk Factors for Substance Use Among Youth Experiencing Homelessness

Background

Youth experiencing homelessness are at high risk for frequent substance use. This study examines individual, interpersonal, and contextual factors associated with substance use among such youth, age 13-24.

Methods

Data were collected through computer-assisted structured interviews with participants (N=474) recruited at service agencies in Los Angeles.

Results

Youth had experienced over two years of homelessness on average. Almost a third used substances frequently; significant risk factors included delinquency, sensation seeking, and ongoing homelessness. Time spent in clubs and organizations was protective.

Conclusions

Providing housing and services to curb delinquency may help protect youth from becoming frequent substance users.

Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial

BACKGROUND

Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment.

OBJECTIVES

To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control.

DESIGN

A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London.

SETTING

NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016.

PARTICIPANTS

Current PWID, aged ≥ 18 years.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control).

MAIN OUTCOME MEASURES

Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability.

RESULTS

A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported.

CONCLUSIONS

As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs.

FUTURE WORK

The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female.

LIMITATIONS

Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.

The phenomenon of low-frequency heroin injection among street-based urban poor: drug user strategies and contexts of use

BACKGROUND

Dominant public health and medical discourse has relied on a pharmacocentric conception of heroin use-that is, the notion that heroin users inject compulsively to stave off physical and psychological withdrawal. Previous research disputes this claim suggesting that other patterns of heroin use, such as occasional, recreational, or controlled use are possible. In our previous cross-sectional epidemiological research, we identified the phenomenon of low frequency heroin injection (low-FHI), among street-based drug users. The goal of the current study was to qualitatively assess and contextualise this phenomenon over time among a sample of street-based low-FHI.

METHODS

29 low-FHI and 25 high frequency heroin injectors (high-FHI) were followed for 2 years, during which they participated in a series of in-depth interviews. Qualitative data were coded using an inductive analysis approach. As similarities and differences between participants were discovered, transcripts were queried for supportive quotations as well as negative cases.

RESULTS

We found the social context among low-FHI and high-FHI to be similar with the exception of their patterns of heroin use. Thus, we focused this analysis on understanding motivations for and management of low-FHI. Two major categories of low-FHI emerged from the data: maintenance and transitioning low-FHI. Maintenance low-FHI sustained low-FHI over time. Some of these heroin users were circumstantial low-FHI, who maintained low-FHI as a result of their social networks or life events, and others maintained low-FHI purposefully. Transitioning low-FHI did not sustain low use throughout the study. We found that heroin use patterns frequently shift over time and these categories help identify factors impacting drug use within particular moments in an individual's life.

CONCLUSIONS

Given the various patterns of heroin use that were identified in this study, when working with IDUs, one must assess the specifics of heroin use patterns including drug preferences, desire for substance abuse treatment, as well as basic physical and mental health care needs.

Predictors of non-prescribed opioid use after one year of methadone treatment: an attributable-risk approach (ANRS-Methaville trial)

BACKGROUND

The effectiveness of methadone as an opioid maintenance treatment (OMT) for opioid dependence has been widely demonstrated. However many patients continue to use other opioids while on methadone treatment. Studies assessing avoidable cases of continued non-prescribed opioid use during methadone treatment are sparse.

METHODS

At 12 months of treatment (M12), 158 subjects had available data on opioid use, measured using the Opiate Treatment Index. We identified variables associated with non-prescribed opioid use at M12, using a univariate logistic regression and two multivariate models, one incorporating only pre-treatment variables, the second adding the in-treatment variables. We also calculated attributable fractions for risk factors.

RESULTS

At M12, 32.3% of the patients had used non-prescribed opioids during the previous month. A good patient-physician relationship was the most influential factor associated with not using non-prescribed opioids after one year. Living with a heroin user after one year of treatment, using cocaine during treatment and hazardous alcohol consumption at enrolment were all associated with an increased risk of non-prescribed opioid use at M12. Analysis of attributable fractions indicated that living with a heroin user at M12 accounted for 21% of patients reporting non-prescribed opioid use at M12, while the lack of a good relationship with the physician accounted for 26%.

CONCLUSIONS

The attributable risk approach suggests that continued non-prescribed opioid use by a considerable proportion of individuals could potentially be reduced by improving patient-physician relationships, enhancing care for co-dependent patients and encouraging patients to modify their social network.

Pilot study of a social network intervention for heroin users in opiate substitution treatment: study protocol for a randomized controlled trial

Background

Research indicates that 3% of people receiving opiate substitution treatment (OST) in the UK manage to achieve abstinence from all prescribed and illicit drugs within 3 years of commencing treatment, and there is concern that treatment services have become skilled at engaging people but not at helping them to enter a stage of recovery and drug abstinence. The National Treatment Agency for Substance Misuse recommends the involvement of families and wider social networks in supporting drug users’ psychological treatment, and this pilot randomized controlled trial aims to evaluate the impact of a social network-focused intervention for patients receiving OST.

Methods and design

In this two-site, early phase, randomized controlled trial, a total of 120 patients receiving OST will be recruited and randomized to receive one of three treatments: 1) Brief Social Behavior and Network Therapy (B-SBNT), 2) Personal Goal Setting (PGS) or 3) treatment as usual. Randomization will take place following baseline assessment. Participants allocated to receive B-SBNT or PGS will continue to receive the same treatment that is routinely provided by drug treatment services, plus four additional sessions of either intervention. Outcomes will be assessed at baseline, 3 and 12 months. The primary outcome will be assessment of illicit heroin use, measured by both urinary analysis and self-report. Secondary outcomes involve assessment of dependence, psychological symptoms, social satisfaction, motivation to change, quality of life and therapeutic engagement. Family members (n = 120) of patients involved in the trial will also be assessed to measure the level of symptoms, coping and the impact of the addiction problem on the family member at baseline, 3 and 12 months.

Discussion

This study will provide experimental data regarding the feasibility and efficacy of implementing a social network intervention within routine drug treatment services in the UK National Health Service. The study will explore the impact of the intervention on both patients receiving drug treatment and their family members.

Trial registration

Trial Registration Number: ISRCTN22608399

ISRCTN22608399 registration: 27/04/2012

Date of first randomisation: 14/08/2012

Low-frequency heroin injection among out-of-treatment, street-recruited injection drug users

In this paper, we explore the understudied phenomenon of "low-frequency" heroin injection in a sample of street-recruited heroin injectors not in drug treatment. We conducted a cross-sectional study of 2,410 active injection drug users (IDUs) recruited in San Francisco, California from 2000 to 2005. We compare the sociodemographic characteristics and injection risk behaviors of low-frequency heroin injectors (low-FHI; one to 10 self-reported heroin injections in the past 30 days) to high-frequency heroin injectors (high-FHI; 30 or more self-reported heroin injections in the past 30 days). Fifteen percent of the sample met criteria for low-FHI. African American race, men who have sex with men (MSM) behavior, and injection and noninjection methamphetamine use were independently associated with low-FHI. Compared to high-FHI, low-FHI were less likely to report syringe sharing and nonfatal heroin overdose. A small but significant proportion of heroin injectors inject heroin 10 or less times per month. Additional research is needed to qualitatively examine low-frequency heroin injection and its relationship to drug use trajectories.

Social network support for individuals receiving opiate substitution treatment and its association with treatment progress

BACKGROUND/AIMS

Social networks have been hypothesized to protect people from the harmful effects of stress, but may also provide dysfunctional role models and provide cues associated with drug use. This study describes the range, type and level of social support available to patients engaged in UK opiate substitution treatment (OST) programmes, and explores the association between network factors and continued use of illicit heroin.

METHODS

A cross-sectional survey of a randomly selected sample of OST patients (n = 118) utilised measures of current substance use and social network structure and support.

RESULTS

More than half of the participants had used heroin in the previous month, and most described networks that were both supportive and positive about treatment. Multivariate analysis showed that the substance use involvement of network members was higher in those patients still using heroin, even when other treatment factors were controlled for.

CONCLUSION

There was a strong association between ongoing contact with other drug users and continued use of illicit heroin in this treatment sample. Whilst there is potential for the involvement of social networks in treatment, future research needs to ascertain the exact nature of the relationship between social support and drug use.

The role of perceived belongingness to a drug subculture among opioid-dependent patients

Illicit drug use frequently occurs in a context of a drug subculture characterized by social ties with other drug users, feelings of excitement and effectiveness deriving from illicit activities, and alienation from mainstream society. Identification with this subculture is recognized anecdotally as a barrier to recovery, but clear quantification of individual differences in perceived belongingness to the drug subculture has been absent from the literature. The purpose of this study was to describe the development and psychometric properties of a brief self-report measure designed to assess this construct, the Belongingness to Drug Culture Questionnaire (BDCQ). Ninety-six opioid-dependent, methadone-maintained participants completed the BDCQ, related self-report measures, and assessment of drug use patterns. The BDCQ demonstrated high internal consistency (α = .88) and was significantly associated with self-reported days of drug use in the past 30 days, desire to quit, impulsivity, psychopathy, and social, enhancement, and coping drug use motives. These findings encourage continued psychometric evaluation of the BDCQ and study of the role of belongingness in the development and maintenance of substance use disorders.

The social support and social network characteristics of smokers in methadone maintenance treatment

BACKGROUND

Previous studies have shown social support and social network variables to be important factors in smoking cessation treatment. Tobacco use is highly prevalent among individuals in methadone maintenance treatment (MMT). However, smoking cessation treatment outcomes in this vulnerable subpopulation have been poor and social support and social network variables may contribute.

METHODS

The current study examined the social support and social network characteristics of 151 MMT smokers involved in a randomized clinical trial of smoking cessation treatments. Participants were 50% women and 78% Caucasian. A high proportion (57%) of MMT smokers had spouses or partners who smoke and over two-thirds of households (68.5%) included at least one smoker.

RESULTS

Our sample was characterized by relatively small social networks, but high levels of general social support and quitting support. The number of cigarettes per day was found to be positively associated with the number of smokers in the social network (r = .239, p < .05) and quitting self-efficacy was negatively associated with partner smoking (r = -.217, p < .001).

CONCLUSIONS

Findings are discussed in the context of developing smoking cessation interventions that address the influential role of social support and social networks of smokers in MMT.

Concurrent heroin use among methadone maintenance clients in China

BACKGROUND

The study examined concurrent illicit heroin use among methadone maintenance clients in China and its association with clients' demographic characteristics, treatment experience, and personal social network.

METHODS

Face-to-face surveys were conducted with 178 clients randomly recruited from six methadone maintenance treatment (MMT) clinics in Sichuan, China. Concurrent heroin use was measured based on self-report of heroin use during the past 30 days and a confirmatory urine morphine test. The participants' demographic characteristics and treatment factors were measured and examined. The drug use status of their family members and friends was also assessed.

RESULTS

A total of 80 participants (44.9%) who either reported illicit heroin use in the past 30 days or had a positive urine test were defined as using heroin concurrently. Having drug-using friends was significantly associated with increased concurrent heroin use. Longer length of treatment (2 years or longer) was associated with increased concurrent heroin use. Among those who had both drug-using family members and friends, more women (71.4%) than men (50.0%) used heroin. For those who had no drug-using family members or friends, more men (34.8%) than women (20.8%) used heroin.

DISCUSSION

Study findings indicate an urgent need to address concurrent illicit heroin use among MMT clients. Further examination of the influence of social networks on concurrent drug abuse behavior is encouraged. Results also highlight the importance of understanding gender differences in treatment seeking and behavioral changes, which is crucial to the development of gender-specific treatment strategies.

Barriers to drug treatment for IDU couples: the need for couple-based approaches

This qualitative study examines the interpersonal and structural barriers to drug treatment program entry, retention, and outcomes experienced by injection drug-using couples, and the program policies regarding injection drug-using couples seeking treatment in New York, New York. Our findings reveal a mismatch between the substantial need for concurrent and coordinated treatment for partnered injection-drug users and programmatic policies that are antithetical to such treatment approaches. This discrepancy can be attributed to the lack of viable options for couple-focused treatment approaches that fit within the current drug treatment system. We provide a rationale and a roadmap for the development of innovative approaches for couple-based drug treatment.

A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals

BACKGROUND

Attention from researchers and health care workers to the quality of life (QoL) of opiate users is growing, but most studies are quantitative, giving limited attention to the consumer's perspective. No information is available on how opiate-dependent individuals themselves perceive QoL and what they see as the important components that contribute to a good QoL.

OBJECTIVES

This qualitative study aims to expand our knowledge concerning opiate-dependent individuals' perceptions of a good QoL and the impact of methadone on components of a good QoL.

METHODS

In-depth interviews were conducted with 25 opiate-dependent individuals aged between 26 and 46 years old who started a methadone maintenance treatment at least 5 years ago. Purposive sampling was used to recruit participants with different socio-demographic characteristics and drug use profiles. The interviews were audio-tape recorded, transcribed verbatim and analysed thematically.

RESULTS

Thematic analyses revealed five key themes contributing to a good QoL for opiate-dependent individuals: (1) having social relationships, (2) holding an occupation, (3) feeling good about one's self, (4) being independent and (5) having a meaningful life. Opiate-dependent individuals valued methadone's ability to help them function normally, overcome their psychological problems and dependence on illicit opiates, and support them in achieving certain life goals. On the other hand, stigmatisation, discrimination, dependence on methadone and the drug's paralysing effects on their emotions were mentioned as common negative consequences.

CONCLUSIONS

The findings of this study highlight the importance of supporting opiate-dependent individuals in their daily life by means of practical, social and environmental support (alongside pharmacological treatment) in order to improve their QoL. This study further illustrates the ambivalent influence of methadone on opiate-dependent individuals' QoL, and demonstrates how something commonly perceived as a 'good' can also be a 'bad' for some people. Efforts should be made to limit the negative consequences of methadone on opiate-dependent individuals' QoL, while increasing its potential benefits.

Confirmatory Factor Analysis and Test-Retest Reliability of the Alcohol and Drug Confrontation Scale (ADCS)

The addiction field lacks an accepted definition and reliable measure of confrontation. The Alcohol and Drug Confrontation Scale (ADCS) defines confrontation as warnings about the potential consequences of substance use. To assess psychometric properties, 323 individual entering recovery houses in U.S. urban and suburban areas were interviewed between 2003 and 2005 (20% women, 68% white). Analyses included test-retest reliability, confirmatory factor analysis, and measures of internal consistency. Findings support the ADCS as a reliable way of assessing two factors: Internal Support and External intensity. Confrontation was experienced as supportive, accurate and helpful. Additional studies should assess confrontation in different contexts.

Gender differences in social support and depression among injection drug users in Houston, Texas

BACKGROUND

Injection drug is the second most frequent HIV/AIDS exposure in the United States. Social support and depression may mediate risky behaviors among drug injectors.

OBJECTIVES

To describe differences in perceived social support and depressive symptoms between male and female injection drug users, and to describe factors associated with depressive symptoms.

METHODS

Using respondent-driven sampling, we recruited and interviewed injection drug users in Houston, Texas. Data were from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Program. We used the short Center for Epidemiologic Studies Depression Scale (CES-D 10) and scales for perceived social support from family, friends, and significant others from the Multidimensional Scale of Perceived Social Support. Four-hundred seventy-one participants had complete data and were included in this analysis.

RESULTS

Seventy-five percent of male and female participants had CES-D scores indicating depressive symptoms. In a multivariate logistic regression, depressive symptoms among men were positively associated with frequent use of speedballs (injecting heroin and cocaine together) and never having tested for HIV, and negatively associated with perceived social support from a special person. Among women, depressive symptoms were positively associated with currently smoking cigarettes, having no health insurance, and more years of injection drug use, and negatively associated with perceived social support from a special person.

CONCLUSIONS

Lack of social support from a special person or significant other was associated with depressive symptoms in both males and females. Our findings suggest that depression and social support should be addressed when developing HIV prevention programs among injection drug users.

Women's Early Recovery: Managing the Dilemma of Substance Abuse and Intimate Partner Relationships

Numerous studies have shown that women's patterns of substance use are strongly impacted by social relationships. Using a hermeneutic phenomenological method, this study examined the interplay between intimate partner relationships and substance abuse recovery through in-depth interviews with 17 women in a treatment program. Six essential themes about the dilemmas posed by recovery and relationships emerged from analysis: (a) experiencing themselves as damaged goods; (b) paying the price for both recovery and relationship choices made; (c) trading parts of self for relationships and drugs; (d) waking from the nightmare and realizing the impact of abuse; (e) hoping, but not always quite believing, in the possibility of recovery; (f) asking themselves “who's in charge of my life?” This study expands on previous findings by examining critical similarities in the dynamics of interpersonal relationships and recovery for women and the meanings they assign to each.

Gender differences in the impact of social support on crack use among African Americans

This article examines the influence of social support on crack use in a sample of 435 African American out-of-treatment crack users recruited through street outreach in Raleigh, North Carolina, between 2000 and 2002. Multivariate regression models indicated that social support was not a strong influence on crack use. For women, no social support variables predicted crack use, whereas for men, having a non-using partner was negatively associated with crack use. Findings indicate that existing social support is not strongly linked to drug use among African Americans, but African American men may be positively influenced by non-using sexual partners. Limitations of the sample and data are discussed. Further research is needed on the influence of social support for African American drug-using populations.

Individual and social factors associated with participation in treatment programs for drug users

Since only about one third of people who are dependent on drugs are in treatment, there is a need to promote both treatment entry and retention. Previous research has described the role of individual and social characteristics in drug user treatment participation, but little is known about the interaction of individual and social factors. Injecting and noninjecting drug users (2002-2004; N = 581) were recruited, as part of Self-Help in Eliminating Life-Threatening Diseases (SHIELD) study, in Baltimore, MD, and were administered a structured questionnaire. The mean age of participants was 43.6 years, out of which 41% were female, 50% had high school education, and 16% self-reported being HIV infected. Logistic regression analyses of interaction terms revealed that compared to those with no plans to stop and no friends encouraging them to enter treatment those who planned to cease drug use or whose friends encouraged treatment were more likely to attend a 12-step program. Furthermore, compared to those with no problems with drug use and no friends encouraging them to enter treatment those with greater perceived drug problem severity or with friends encouraging treatment were more likely to attend methadone maintenance, as were those who did not receive free drugs from others. The influence of friends may have a crucial modifying effect by getting into treatment less addicted individuals who have higher chances of successful recovery.

The importance of social networks in their association to drug equipment sharing among injection drug users: a review

AIM

To examine the scientific evidence regarding the association between characteristics of social networks of injection drug users (IDUs) and the sharing of drug injection equipment.

METHODS

A search was performed on MEDLINE, EMBASE, BIOSIS, Current Contents, PsycINFO databases and other sources to identify published studies on social networks of IDUs. Papers were selected based on their examination of social network factors in relation to the sharing of syringes and drug preparation equipment (e.g. containers, filters, water). Additional relevant papers were found from the reference list of identified articles.

RESULTS

Network correlates of drug equipment sharing are multi-factorial and include structural factors (network size, density, position, turnover), compositional factors (network member characteristics, role and quality of relationships with members) and behavioural factors (injecting norms, patterns of drug use, severity of drug addiction). Factors appear to be related differentially to equipment sharing.

CONCLUSIONS

Social network characteristics are associated with drug injection risk behaviours and should be considered alongside personal risk behaviours in prevention programmes. Recommendations for future research into the social networks of IDUs are proposed.

Suicide attempts among individuals with opiate dependence: the critical role of belonging

This study explored the role of three theoretically important interpersonal variables in attempted suicide and unintentional overdose using a diverse sample of one hundred thirty-one (69 women) methadone patients at an urban university hospital. Subjects completed a standardized interview including self-report measures of perceived 1) belonging 2) burdensomeness, and 3) loneliness. In separate multivariate logistic regression analyses, individuals with a history of attempted suicide were compared to non-attempters, and individuals with a history of unintentional overdose were compared to individuals without such a history. As hypothesized, low belonging distinguished suicide attempters but not individuals with a history of unintentional overdose, after accounting for covariates. Results concerning burdensomeness and suicide attempt were also suggestive. Findings underscore the relevance of a sense of belonging to vulnerability to suicidal behavior, and lend further support to the notion that suicide attempts and unintentional overdose have dissimilar correlates.

Theory-based processes that promote the remission of substance use disorders

Four related theories about the personal and social resources that shield individuals from developing substance use disorders and foster the process of remission from these disorders are described. These theories are social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. Next, the social processes specified by these theories are highlighted, including the provision of support, goal direction, and monitoring; engagement in rewarding activities other than substance use, exposure to abstinence-oriented norms and models, and attempts to build self-efficacy and coping skills. Then, a review of the literature considers evidence about the association between the personal and social resources specified by the four theories and remission from substance use disorders. The discussion highlights several issues that need to be addressed to enhance our understanding of the protective resources involved in stable remission, such as how to develop integrated measures of the key resources and specify their associations with substance use outcomes, the extent to which the resources amplify or compensate for the influence of treatment, and how treatment and continuing care can be tailored to strengthen the protective resources that promote remission.

Reliability of the UCLA Loneliness Scale in Opiate Dependent Individuals

The purpose of this study was to examine the internal consistency and test-retest reliability of the self-report University of California, Los Angeles, Loneliness Scale (UCLA LS; Russell, 1996) in methadone maintenance patients at an urban university hospital. A diverse sample of 117 patient volunteers completed a standardized interview that included the UCLA LS. A total of 67 participants returned after a minimum of 14 days for a follow-up session to complete an identical assessment but with a different researcher. We examined internal consistency and test-retest reliability in the total sample and in groups stratified by gender, race, ethnicity, and education. Across strata, the UCLA LS showed adequate to high internal consistency and good to excellent test-retest reliability. The UCLA LS was highly correlated with a measure of perceived belonging, supporting criterion validity. Findings support the use of the UCLA LS with methadone maintenance patients.

Patients in long-term maintenance therapy for drug use in Italy: analysis of some parameters of social integration and serological status for infectious diseases in a cohort of 1091 patients

BACKGROUND

Heroin addiction often severely disrupts normal social functioning. The aims of this multi-centre study of heroin users in long-term replacement treatment were: i) to provide information on aspects of social condition such as employment, educational background, living status, partner status and any history of drug addiction for partners, comparing these data with that of the general population; ii) to assess the prevalence of hepatitis, syphilis and HIV, because serological status could be a reflection of the social conditions of patients undergoing replacement treatment for drug addiction; iii) to analyse possible relationships between social conditions and serological status.

METHODS

A cross-sectional study was carried out in sixteen National Health Service Drug Addiction Units in northern Italy. The data were collected from February 1, 2002 to August 31, 2002. Recruitment eligibility was: maintenance treatment with methadone or buprenorphine, treatment for the previous six months, and at least 18 years of age. In the centres involved in the study no specific criteria or regulations were established concerning the duration of replacement therapy. Participants underwent a face-to-face interview.

RESULTS

The conditions of 1091 drug treatment patients were evaluated. The mean duration of drug use was 14.5 years. Duration was shorter in females, in subjects with a higher educational background, and in stable relationships. Most (68%) had completed middle school (11-14 years of age). Seventy-nine percent were employed and 16% were unemployed. Fifty percent lived with their parents, 34% with a partner and 14% alone. Males lived more frequently with their parents (55%), and females more frequently with a partner (60%). Sixty-seven percent of male patients with a stable relationship had a partner who had never used heroin. HCV prevalence was 72%, HBV antibodies were detected in 42% of patients, while 30% had been vaccinated; 12.5% of subjects were HIV positive and 1.5% were positive for TPHA.

CONCLUSION

A significant percentage of heroin users in treatment for opiate addiction in the cohort study have characteristics which indicate reasonable integration within broader society. We posit that the combination of effective treatment and a setting of economic prosperity may enhance the social integration of patients with a history of heroin use.

The impact of a social network intervention on retention in Belgian therapeutic communities: a quasi-experimental study

BACKGROUND

Although numerous studies recognize the importance of social network support in engaging substance abusers into treatment, there is only limited knowledge of the impact of network involvement and support during treatment. The primary objective of this research was to enhance retention in Therapeutic Community treatment utilizing a social network intervention.

AIMS

The specific goals of this study were (1) to determine whether different pre-treatment factors predicted treatment retention in a Therapeutic Community; and (2) to determine whether participation of significant others in a social network intervention predicted treatment retention.

DESIGN, SETTING AND PARTICIPANTS

Consecutive admissions to four long-term residential Therapeutic Communities were assessed at intake (n = 207); the study comprised a mainly male (84.9%) sample of polydrug (41.1%) and opiate (20.8%) abusers, of whom 64.4% had ever injected drugs. Assessment involved the European version of the Addiction Severity Index (EuropASI), the Circumstances, Motivation, Readiness scales (CMR), the Dutch version of the family environment scale (GKS/FES) and an in-depth interview on social network structure and perceived social support. Network members of different cohorts were assigned to a social network intervention, which consisted of three elements (a video, participation at an induction day and participation in a discussion session).

FINDINGS

Hierarchical regression analyses showed that client-perceived social support (F1,198 = 10.9, P = 0.001) and treatment motivation and readiness (F1,198 = 8.8; P = 0.003) explained a significant proportion of the variance in treatment retention (model fit: F7,197 = 4.4; P = 0.000). By including the variable 'significant others' participation in network intervention' (network involvement) in the model, the fit clearly improved (F1,197 = 6.2; P = 0.013). At the same time, the impact of perceived social support decreased (F1,197 = 2.9; P = 0.091).

CONCLUSIONS

Participation in the social network intervention was associated with improved treatment retention controlling for other client characteristics. This suggests that the intervention may be of benefit in the treatment of addicted individuals.

The interplay between interpersonal dynamics, treatment barriers, and larger social forces: an exploratory study of drug-using couples in Hartford, CT

BACKGROUND

The drug treatment field tends to place emphasis on the individual rather than the individual in social context. While there are a growing number of studies indicating that drug-using intimate partners are likely to play an important role in determining treatment options, little attention has been given to the experience and complex treatment needs of illicit drug-using (heroin, cocaine, crack) couples.

METHODS

This exploratory study used in-depth interviews and ethnographic engagement to better understand the relationship between interpersonal dynamics and the treatment experience of ten relatively stable drug-using couples in Hartford, CT. Semi-structured and open-ended qualitative interviews were conducted with each couple and separately with each partner. Whenever possible, the day-to-day realities and contexts of risk were also observed via participant and non-participant observation of these couples in the community. A grounded theory approach was used to inductively code and analyze nearly 40 transcripts of 60-90 minute interviews as well as fieldnotes.

RESULTS

This study builds on a concept of complex interpersonal dynamics among drug users. Interpersonal dynamics of care and collusion were identified: couples cared for each other and colluded to acquire and use drugs. Care and collusion operate at the micro level of the risk environment. Treatment barriers and inadequacies were identified as part of the risk environment at the meso or intermediate level of analysis, and larger social forces such as gender dynamics, poverty and the "War on Drugs" were identified at the macro level. Interpersonal dynamics posed problems for couples when one or both partners were interested in accessing treatment. Structural barriers presented additional obstacles with the denial of admittance of both partners to treatment programs which had a sole focus on the individual and avoided treating couples.

CONCLUSION

Detoxification and treatment facilities need to recognize the complex interplay between interpersonal dynamics which shape the treatment experience of couples, and which are also shaped by larger structural dynamics, including barriers in the treatment system. Improvements to the treatment system in general will go a long way in improving treatment for couples. Couples-specific programming also needs to be developed.

Social contextual factors associated with entry into opiate agonist treatment among injection drug users

We tested hypotheses that social living arrangement and drug use in one's network are independently associated with entry into opiate agonist treatment modalities. Injection drug users (IDUs) attending the Baltimore Needle Exchange Program who received a referral for drug abuse treatment were studied. Baseline interviews, HIV testing, and the Addiction Severity Index (ASI) were administered. Agency records were used to confirm entry into a treatment program offering opiate agonist maintenance therapy within 30 days of the baseline interview. Logistic regression was used to identify predictors of treatment entry. To date, of 245 IDUs, 39% entered such a program. Multivariate logistic regression models controlling for age and intervention status revealed that compared to individuals who lived alone, in a controlled, or nonstable environment (e.g., streets, abandoned house, transitional housing program, or boarding house), individuals who lived with a sexual partner were 3 times more likely to enter treatment (adjusted Odds Ratio [aOR]=3.04; p=0.013) and those who lived with family or friends were almost 3 times more likely to enter treatment (aOR=2.72; p=0.016). In the bivariate analyses, a marginal association was observed between being responsible for children or others and entry into treatment (p=0.066); however, this association was not significant in the multivariate model. Findings from this study suggest that supportive living environments may facilitate entry into treatment and may be helpful in devising appropriate and targeted interventions to encourage drug treatment entry.

Social support and HIV-related injection risk among Puerto Rican migrant and nonmigrant injection drug users recruited in New York City

This study compared the associations between social support and HIV injection risk among Puerto Rican migrant (n = 221) and nonmigrant (n = 340) injection drug users in New York City. Practical and emotional support scales were developed from 8 items and examined by migrant status as predictors of risk. Bivariate and regression analysis were conducted with drug shooting gallery use, sharing needles, paraphernalia, and number of monthly injections as dependent variables. Migrants had lower emotional (2.82 vs. 3.19, p = .002) and practical (1.87 vs. 2.05; p = .051) support than nonmigrants. Controlling for age, sex and homelessness, emotional support was negatively associated to injection frequency and (standardized coefficient = -.168, p = .020) gallery use (adjusted odds ration [AOR] = .76, confidence interval [CI] = .62-.94, p = .011) among migrants and to an almost two fold increase in sharing syringes (AOR= 1.87, CI = 1.02-3.43; p = .041) among nonmigrants. The findings suggest that though migrants have less support than nonmigrants do, their support reduces risk and thus their likelihood of injection-related HIV infection.

The Effects of Peer Group Network Properties on Drug Use Among Homeless Youth

The authors examine how the properties of peer networks affect amphetamine, cocaine, and injection drug use over 3 months among newly homeless adolescents, aged 12 to 20 in Los Angeles (n = 217; 83% retention at 3 months) and Melbourne (n = 119; 72% retention at 3 months). Several hypotheses regarding the effects of social network properties on the peer influence process are developed. Multivariate logistic regression analyses show that higher concentrations of homeless peers in networks at recruitment were associated with increased likelihood of amphetamine and cocaine use at 3-month follow-up. Higher concentrations of injecting peers were associated with increased risk of injection drug use 3 months later. Change in network structure over time toward increased concentrations of homeless peers was associated with increased risk of cocaine use and injecting. Higher density networks at baseline were positively associated with increased likelihood of cocaine and amphetamine use at 3 months.

The Community Assessment Inventory--client views of supports to drug abuse treatment

A measure assessing client views of the community supports available to them was developed and tested with entrants to outpatient drug free treatment. Items for a Community Assessment Inventory (CAI) fell into four areas of potential social support for treatment entry and engagement: (1) partner and/or family with whom living; (2) family living outside the home; (3) friends; and (4) the community itself. Based on 241 study participants, it was found that internal consistency alphas for the four scales ranged between .79 and .88. Both total CAI score and individual scales assessing support from friends and from partner/spouse were found capable of predicting treatment readiness as assessed using the TCU Motivation Scale. Evidence of construct validity was suggested by differences in CAI total score between participants reporting and not reporting involvement in discussions with others regarding crime and regarding drugs. Findings are also provided regarding leisure time activities and social relations of treatment entrants.

Heterosexual relationships among heroin users in Italy

This study investigated how many stable partners of drug users (DUs) had a history of drug use or were current DUs. Of 589 DUs interviewed, 41% reported that they had a partner with current or previous experience of drug addiction. A strong gender difference emerged: 77% of female DUs reported a stable relationship with partners with a history of addiction, versus only 30% for male DUs. Partners with a history of drug dependence are more likely to be: male, older, with a lower educational level and a lower rate of stable employment than partners without a history of drug addiction. Logistic regression analysis indicated that the characteristics of heroin users who have current partners with histories of drug use include: female gender, older age, living with a partner, lengthy duration of the relationship and HIV positive status. Fewer subjects are married if the partner has a history of addiction, and there is an association between lengthy drug use and partner without drug addiction history. The high percentage (59%) of subjects who were in stable relationships with partners without histories of heroin addiction and the relatively long duration of these relationships, raises the issue of possible transmission of blood-borne viruses from the DUs to their sexual partners. The study does suggest the need for consideration of sexual partnerships and gender differences in providing drug abuse treatment for heroin users.

Drug injection cessation among HIV-infected injecting drug users

This article reports findings from a cohort study that investigated drug injection cessation over an 18-month period among HIV-infected injecting drug users followed up in a clinical setting. At 18th month visit, individuals reporting persistent injection practices were compared with individuals who reported drug injection cessation for at least 12 months. Crude and adjusted odds ratios were used to assess the impact of change in addictive and sexual behaviors, contacts with the drug network, depression, negative life events, clinical status, HIV therapy, and drug maintenance treatment (DMT) on drug injection cessation. After multiple adjustment, a general decrease of addiction practices (alcohol and cannabis) and of unsafe sexual behaviors significantly accompanied injection cessation. Individuals with higher education level, still in contact with the drug network, and not yet treated for their HIV disease were significantly more likely to persist injecting behaviors. These results underscore the importance and the need of monitoring addiction practices and unsafe sexual behaviors among HIV-positive individuals to properly address primary and secondary prevention in the era of highly active antiretroviral treatments (HAART).

Drug injection practices among high-risk youths: the first shot of ketamine

Ketamine, a "club drug" commonly administered intranasally among youths for its disassociative properties, has emerged as a drug increasingly common among a new hidden population of injection drug users. Because of a scarcity of epidemiological data, little is known about ketamine injection practices, associated risk behaviors, or the demographic characteristics of ketamine injectors. Using an ethno-epidemiological methodology, we interviewed 40 young (<25 years old) ketamine injectors in New York during 2000-2002 and asked detailed questions about ketamine injection initiation as well as histories of other injection drug use and involvement in the street economy. Our analysis, utilizing descriptive statistics and narrative accounts, compared two groups: ketamine initiates (youths who initiated injection drug use with ketamine) and other initiates (youths who initiated injection drug use with another drug, such as heroin, and later transitioned into ketamine injection). Results indicated that intramuscular injections were more common among ketamine initiates, whereas intravenous injections were more common among other initiates. Drug form and local knowledge within injection groups were important factors underpinning this relationship: liquid ketamine was injected primarily intramuscularly; powder ketamine was injected primarily intravenously virtually irrespective of injection drug use history. In addition, the comparison between ketamine initiates and other initiates revealed differences regarding knowledge about injecting drugs; risk behaviors at initiation; involvement in the street economy, including homelessness and experience dealing drugs; and city or location of ketamine injection initiation. These findings suggest that ketamine injection is an emerging practice among a new hidden population of injection drug users in cities throughout North America.

The influence of partner drug use and relationship power on treatment engagement

Substance-using intimate partners negatively influence individuals' substance abuse treatment engagement and drug use, but little else is known about effects of intimate relationships on treatment. We examine how relationship dynamics (power, control, dependence, insecurity and decision-making power) influence treatment engagement, and whether this differs by gender and partner drug use. Sixty-four heroin users (42 men, 22 women) receiving methadone detoxification treatment in Los Angeles were interviewed at treatment entry and submitted daily diaries of drug use throughout the 21-day treatment. Total number of reported heroin-free days in the first eight treatment days was the dependent variable. Bivariate analyses revealed, that compared to men, women were more likely to have substance-using partners, reported greater power over a partner and greater household decision-making power in their relationships. Multivariate analysis indicated that individuals whose partners had more control over them reported fewer days abstinent. Among individuals with heroin-using partners, greater household decision-making power was associated with more days abstinent, but there was no association for individuals with non-using partners. Relationship power dynamics may be important influences on the treatment process, and some dimensions of power may interact with partner drug use status.

Predictive factors of persisting illicit drug use in hospitalized heroin addicts

The efficacy of methadone treatment in reducing the rate of positive urinalyses for opiates has been repeatedly assessed in outpatient intravenous heroin users (IHUs), but not in IHUs hospitalized for coexisting diseases. The aim of the present study, performed on 83 IHUs, was to assess the rate of drug-free urinalyses for addictive drugs over a 13-day period of hospitalization. The rate of drug-free urinalyses was then related to the intensity of withdrawal symptoms, the level of dependence (as measured by the severity of dependence scale (SDS)) and of heroin craving (as measured by a visual analogical scale, (VAS)), assessed on admission and on days 4, 7, 10, and 13. All but nine patients received methadone upon hospitalization. The results show that positive urinalyses for morphine and/or cocaine dropped over the period of observation from 67 to 7%. On admission, patients who persisted in the illicit use of heroin did not differ significantly from the rest in terms of abstinence scores or daily methadone dose, but scored higher at the SDS and yielded urinalyses which all tested positive for morphine and/or cocaine. In conclusion, in the hospital setting low methadone doses (32.5 mg per die on average) induce a drug-free condition in the majority of patients and high SDS scores associated with positive urinalysis for morphine and/or cocaine are predictive of persistent drug abuse during hospitalization.

Social support and zero sharing risk among hazardously drinking injection drug users

We compared the sociodemographic, drug use, and social support characteristics of injection drug users (IDUs) who reported at least 6 months having not "shared needles or works" (zero sharing risk) with those who reported recent equipment sharing. 187 AUDIT-positive (>8), active IDUs were recruited between February 1998 and October 1999 from a needle exchange program in Providence, RI. The sample was 64% male and 87% white, with a mean age of 36 years, and 32% of subjects reported zero sharing risk in the prior 6 months. Variables having significant (P<.05) associations with zero sharing risk included: older age, lower heroin use frequency, lower cocaine use, and increased frequency of needle exchange visits. As social support from friends increased, the likelihood of sharing decreased. Subjects with substance-using friends or partners were significantly more likely to share than those without such associations (OR = 9.4; P<.05). Social support and social network composition influenced sharing behaviors in active, out-of-treatment drug injectors. Interventions that mobilize social support may increase the possibility of zero sharing, an important public health goal.