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Age and injecting drug use in Perth, Western Australia: the Australian National AIDS and injecting drug use study a
a
W. Loxley , A. Marsh & S. K. Lo
a
a
National Centre for Research Into the Prevention of Drug Abuse &Centre for Advanced Studies, Division of Health Sciences , Curtin University of Technology , Western Australia Published online: 25 Sep 2007.
To cite this article: W. Loxley , A. Marsh & S. K. Lo (1991) Age and injecting drug use in Perth, Western Australia: the Australian National AIDS and injecting drug use study, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 363-372, DOI: 10.1080/09540129108251592 To link to this article: http://dx.doi.org/10.1080/09540129108251592
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 3, NO. 4, 1991
363
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Age and injecting drug use in Perth, Western Australia: the Australian national AIDS and injecting drug use study W. LOXLEY, A. MARSH& S . K. Lo1 National Centre fm Research Into the Prevention of Drug Abuse & Centre fm Advanced Studies, Division of Health Sciences, Curtin University of Technology, Western Australia
Abstract Young injecting drug users (IDUs) in Australia are a group about whom little is known. It is suggested, however, that their drug using behaviours and life styles put them at particular risk for HIV/AIDS. Data collected in Perth from 195 respondents in the Australian National AIDS and Injecting Drug Use Study was analyzed with emphasis on the distinctions between young and older injecting drug users. It was found that, relative to those aged 23 or over, IDUs under 23 used more stimulants and LSD and fewer opiates and benzodiazepines; were more likely to inject all or most of their drugs; were less likely to have been in treatment; had more sex partners; were less likely to have changed their drug taking behaviour because of AIDS; were less likely to use alone; shared needles lessfiequently but shared at least some of the time; and had less knowledge of AIDS and were more pessimistic about the long term outcomes of AIDS. Such charactmktics need to be taken into account if effective intervention and prevention strategies for this group are planned.
The first case of AIDS was diagnosed in Australia in December 1982 and there were 2,347 reported cases of AIDS in Australia by 30 November 1990. Injecting drug use as the only risk behaviour accounted for 1.5% of cases (National Centre in HIV Epidemiology and Clinical Research, 1990), but there is a high risk of rapid spread of infection among injecting drug users (IDUs) given that there may be as many as 80,000 IDUs in Australia, three quarters of whom probably share needles (Gajanayake & Santow, 1990). The known seroprevalence rate among IDUs in Western Australia is estimated to be less than 1% but it is believed that the number of IDUs, many of them non-dependent or occasional users, is three or four times higher than the number known to treatment and law agencies (Watson, 1990). Young Australian IDUs are a group about whom relatively little is known. In one study it was found that 1 to 3% of people aged 16-24 had injected themselves with drugs within the last 12 months (NACAIDS, 1988): in national terms, this represents some 51,000 young people. Reilly and Home1 (1987) found that amphetamine was the most
Address for correspondence: Wendy Loxley, BA (Hons), M.Psych., National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology, PO Box U1987, Penh WA 6001, Australia.
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364 W.LOXLEY, A. MARSH & S. K. LO commonly used drug among 15 to 18 year old illicit drug users in Sydney: daily or weekly use was uncommon, with most of these young people using 1-3 times a month. Amphetamine use among young people has been increasing over the last few years (Loxley, 1990) and it has been suggested that this increase is related to effective law enforcement in limiting the supply of marijuana (Moore, Makkai & McAllister, 1989). Such a ‘displacement’ effect with adolescents turning to injectable drugs such as amphetamines which are now not so expensive or difficult to get as marijuana, raises particular concerns about the transmission of HIVIAIDS through needle sharing. But these are not the only concerns about recent trends in drug-taking. In Perth, for example, we have seen the emergence within the last 2 years of ‘homebake’ (a heroin substitute synthesized at home from codeine which is cheaper than heroin) which we are informed is often sold in preloaded needles, raising the possibility that needles are re-used. Experimental and recreational IDUs may not perceive that they are at personal risk from HIV (Health Promotion Unit, 1989). In an exploratory study Loxley (1990) found that many young IDUs had had no involvement with the law or with treatment agencies, and were anxious to keep their drug use a secret. They had a much greater stake in not being identified as drug users than those with a more established using ‘career’, which has a number of implications for safe(r) using such as the considerable suspicion among young IDUs of agencies such as needle-exchange schemes. Some were reluctant to store sterile injecting equipment in their homes because of a fear of police random checks and raids and future harassment and arrest and some lacked the social skills (or the money) necessary to purchase clean needles in chemists, and indicated that chemist staff often treated them with disdain. There is also need for concern about unsafe sexual practices among a group of people who are very sexually active, and among whom there are strong attitudes against the use of condoms (Health Promotion Unit, 1989). More extensive information about young IDUs is available through the Australian National AIDS and Injecting Drug Use Study (ANAIDUS). This is a multi-centre, multicity study, which is developing the most extensive database of information about Australian IDUs that has ever been established. The aims of the study are to investigate HIVIAIDS related knowledge, attitudes and behaviours among IDUs, to estimate seropositivity among IDUs, to identify hindrances and facilitators of behaviour change and to identify subgroups of IDUs for educational and interventional targetting. The ANAIDUS commenced in 1988 as a pilot project and in 1989 had five study centres (Sydney, Canberra, Brisbane, Melbourne and Perth). It has now just completed a second year of data collection. The data reported in this paper was collected for the ANAIDUS in Perth in 1989. The aim of the reported analysis was to compare young with older Perth IDUs in order to investigate those characteristics of young IDUs which put them at particular risk of HIV/AIDS.
Subjects and method
One hundred and ninety five IDUs were interviewed in Perth. Half of the sample were drawn from treatment and half from non-treatment populations. The treatment sample was representative of the drug treatment population in Perth in terms of gender and type of treatment. It is not known whether the non-treatment sample was representative of their population since the characteristics of this population in Perth are not known. Attempts were made, however, to obtain the sample from as wide a range of respondents as possible.
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AGE AND INJECTING DRUG USE IN PERTH
365
Respondents were recruited to the study through advertising, referrals by staff at treatment and other agencies, direct approach to individuals, and snowballing. A comprehensive questionnaire covered demographics, drug use, needle sharing, cleaning and disposal of needles, the social context of IV drug use, sexual behaviour, knowledge of and attitudes towards AIDS, and behaviour change. Respondents were interviewed individually and all interviews were conducted by one trained interviewer. The interview schedule was administered by the interviewer other than for the sexual behaviour section which was self-completed unless the respondent requested help. Upon completion of the questionnaire respondents were given feedback and information; asked if they were prepared to give a contact name and number for future follow-up; and encouraged to provide a fingerprick blood sample for HIV antibody testing. Blood samples were sent to Fairfield Hospital in Melbourne for analysis. Results were not returned to individual respondents as facilities for pre- and post-test counselling were not available, but respondents were told where they could be tested for HIV/AIDS if they requested it. Further details of the methodology and characteristics of the study sample are available in a separate report (Marsh & Loxley, 1991). Results Respondents were divided into two groups: under 23 (young), and 23 and over (older). Twenty three was selected as the cut-off point because Loxley (1990) found that drug using behaviour appeared to change at around this age. There were 44 respondents in the young, and 151 respondents in the older group. The mean age of the total sample was 27.9 years: for the young and 30.5 for the older group.
Drug Use There were two major measures of drug use-‘ever’ use and the number of occasions of use of each drug in the ‘most recent typical using month’ (as the question was worded). Opiates and non-opiates ever used by each group are shown in Table. 1. Significantly fewer young respondents (ranging from 18% to 59%) had ever used opiates compared to older respondents (ranging from 71% to 97%). The percentage of non-opiates ever used by the two age groups was not statistically significant except in the case of cocaine, barbiturates and benzodiazepines although a slightly higher (but not statistically significant) proportion of young than older respondents had ever used amphetamines and ecstasy. A majority of those surveyed had never used crack and a large proportion of the total sample had tried LSD and benzodiazepines. Figure 1 shows the percentage of young and older respondents who injected each drug at least once a month in the ‘most recent typical using month’. Only drugs which were injected by more than 10% of at least one group were included in the analysis. The difference in drug of choice is clear. Heroin was more frequently injected by the older group (83% vs 32%, xzl = 43.2, p = 0,000) and amphetamine more frequently by young respondents (91% vs. 35%, xZ1= 42.5, p = 0.000). Similar, though less striking patterns were found for LSD and ecstasy, which were favoured by the young. No significant difference in percentage of those injecting was found for palfium (5% vs 11%, xzl = 1.8, p = 0.186). Figure 2 shows a similar analysis of drugs that were smoked, snorted or swallowed. Older respondents were more likely to have used methadone (32% vs 5%, xzl = 13.3, p = 0.000) but LSD was preferred by the young group (16% vs 1%, xzl = 16.5,p = O.OO0). No significant differences in the patterns of ingestion of cocaine and benzodiazepines were
366
W. LOXLEY, A. MARSH & S. K. LO Table 1. Drug Use ‘Ewer’ By Age
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Opiates Heroin Methadone Morphine Opium Pethadine Codeine Palfium
Non- Opiates Amphetamine LSD Ecstasy Cocaine Crank Crack Barbiturates Benzodiazepines
Young n=44
Older n=151
56.8 20.5 34.1 34.1 31.8 59.1 18.2 100.0 86.4 59.1 36.4 25.0 4.5 3!.8 79.5
-
X21
P
97.4 80.8 82.8 70.9 78.8 88.1 74.2
53.81 56.26 39.89 19.67 34.69 19.02 45.13
0.001 0.001 0.001 0.001 0.001 0.001 0.001
92.1 90.1 43.0 84.1 39.1 6.6 72.2 92.1
3.73 0.49 3.52 39.71 2.93 0.26 23.84 5.55
0.054 0.486 0.060 0.001 0.087 0.614 0.001 0.019
Injection
FIG.1.Injection at least once a month by age, n = 195; Young = 44, Older = 151 @ young; 0 older).
found despite the fact that four older respondents claimed to have very large benzodiazepine habits. Total drug use and total injecting drug use These data are shown in Table 2. Total Drug Use is a composite score which represents the total number of occasions on which a drug was used in the ‘most recent typical using month‘, regardless of means of administration. Total Injecting is a composite score combining all occasions of injecting in the ‘most recent typical using month’. Table 2 shows that much of
AGE AND INJECTING DRUG USE IN PERTH
367
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7 "
Methadone
m Codeine
I
LSD
Benzodiazepine
Non-Injection FIG. 2.
Non-injection at least once a month by age, n = 195; Young = 44, Older = 151 @ young 0 older).
the young respondents' use was by injection, while much of the older respondents' use was non-injected. Table 2. Drug use and injecting by age
Occasions of use
Young ( n = 44) Mean SD
Older ( n = 151) Mean SD
Total drug use Total injecting
47.7 30.8
105.1 46.2
(77.3) (45.2)
(192.7) (69.5)
Dism'minant Analysis Stepwise discriminant analysis was used to identify the variables that most reliably distinguished young from older IDUs. Variables were first included in one of four discriminant analyses, representing different aspects of the questionnaire as follows: Function Function Function Function
1. Demographics, drug use patterns, treatment status. 2. Injecting, sharing, cleaning and social context of drug use. 3. Sexual Behaviour. 4. Knowledge of, and attitudes towards AIDS.
Significant variables from each of the four functions were then included in another discriminant function. This approach was adopted in order to maximize the power by minimizing the number of cases excluded because of missing data. The effective sample size for the final discriminant function was 170: 37 young and 133 older respondents. Variables found to be significant in the final discriminant function are presented in Table 3. The order of significance was Treatment, Total LSD, and so on up to AIDS
368
W. LOXLEY, A. MARSH & S. K. LO
Knowledge. High discriminating power was obtained for the final model: using only the 10 variables in Table 3,91% of the 133 older respondents and 89% of the 37 young respondents could be correctly classified. Table 3. Final discriminantfinction
Step
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1
2 3 4 5 6 7 8 9 10
Variable In Treatment Total LSD No.sex partners Age of first injection Drug behaviour change Injecting alone Total stimulants Totalcocaine Sharing AIDS knowledge
Improvement F df
D*
1.525 1.8704 2.5845 2.9697 3.4872 3.8821 4.3170 4.5956 4.8656 5.1433
33.36 17.24 15.54 7.58 9.67 6.93 7.27 4.43 4.15 4.14
1,168 1,167 1,166 1,165 1,164 1,163 1,162 1,161 1,160 1,159
P O.OOO1 O.OOO1
O.OOO1
0.0066 0.0022 0.0093 0.0078 0.0369 0.0433 0.0435
Final Model: Mahalanobis D2 = 5.143, F = 14.09,~ = 0.OOO Classification Rate-Young: 89%; Older: 91% n = Young 37, Older 133, Total 170
The correlation matrix of the 10 variables identified in the final discriminant function demonstrated that there were no major relationships between them. Below is a description of how the young IDUs were different from the older IDUs on each of the 10 variables.
Treatment. Although this variable was dichotomized according to whether or not the IDU was in treatment at the time of interview, a more detailed examination showed that more than half of the older respondents were in treatment for at least the second time, while a majority of the young respondents had never been in treatment. Only small proportions of both groups had previously been in treatment, but were not currently, or were in treatment for the first time. Total LSD. Although the majority of the young respondents had not injected or ingested LSD in the most recent month, only one of the older respondents had done so. Number of sex partners (Figure 3) This is a summary variable which computes the number of sexual partners respondents have had in the last 12 months. Figure 3 shows that more than 80% of the older respondents had had 1-5 partners in the previous 12 months. Young respondents were equally as likely to have had 6-10 as 1-5 partners, and more than 10% of the young group had had more than 20 partners. (The influence of prostitution on these figures has not yet been examined). Age ofjrst injection. On average the young respondents began to inject drugs 2 years earlier than the older group.
AGE AND INJECTING DRUG USE IN PERTH
369
100
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a,
20
6-10
11-15
16-20
S O
Partners FIG.3. Number of sex partners in last 12 months by age, n = 195; Young = 44, Older = 151 @d young; 0 older).
Lh-ug behaviour change. Respondents were asked whether or not they had changed their drug taking behaviour since hearing about AIDS. The majority (72%) of older respondents had changed at least some of the aspects of their behaviour since hearing about AIDS, but only a few (37%) of young respondents had done so. Injecting alone. Respondents were asked to estimate the proportion of total injecting occasions on which they were alone. Young respondents estimated that they injected alone, on average, 16% of the time, while older respondents estimated that they were alone an average of 33% of the time. Total stimulants. This is a composite variable composed of the number of occasions during the ‘most recent typical using month’ when respondents used amphetamines or ecstasy by any means of administration. While 63.6% of the older group had not used stimulants in the typical month, only 9.1% of the young group had not done so. At the other extreme, 31.8% of the young group compared to 3.3% of the older group had used stimulants more than 20 times in the typical month. Total cocaine. This is a composite score composed of all occasions of cocaine, crack and crank use during the ‘most recent typical using month’. No young respondent had used cocaine products at least once a month. Six older respondents had used cocaine once in the most recent month. Needle sharing. This measured the respondent’s estimate of the proportion of drug use occasions on which needle sharing took place. While almost equal proportions of older and younger respondents said they never shared needles, young respondents were slightly more likely than older respondents to share 1-10% of the time. No young respondent (vs more
370 W.LOXLEY, A. MARSH & S. K. LO than 7% of the older group) said they shared 51-100% of the time. The influence of regular sexual partnerships on consistent sharing by older people has yet to be examined.
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AIDS knowledge. This is a composite score composed of two TrueIFalse questions: “Once you have the virus, is there anything you can do to improve your chances of survival?” and “Once you have the symptoms is there anything you can do to improve your chances of survival?” Two supplementary questions asking for ways in which survival could be improved were also included. Although older respondents were more knowledgeable about the progression and symptoms of HIV/AIDS than were young respondents, neither group could be considered as particularly knowledgeable. Discussion A number of points can be made about individual results. In terms of drug use, the reduced likelihood of young IDUs to have used opiates might be considered explicable in terms of the number of years in which people may ever have used, but this does not account for the increased likelihood of their use of amphetamines unless there is a progression from amphetamine to heroin use as is discussed below. Much of the young users’ use was by injection, while much of the older users’ use was non-injected. This presumably reflects the influence of treatment-based methadone as well as the high (oral) benzodiazepine use of some older IDUs. More generally, these analyses can be used to typify young as compared to older IDUs as follows. Young IDUs used more stimulants and LSD and fewer opiates and benzodiazepines; were more likely to inject all or most of their drugs; were less likely to have been in treatment; had more sex partners; were less likely to have changed their drug taking behaviour because of AIDS; were less likely to use alone; shared needles less frequently, but a majority shared at least some of the time; and had less knowledge of AIDS and were more pessimistic about the long term outcomes of AIDS. These characteristics add up to a composite picture of young IDUs who use amphetamine and LSD, usually in groups with friends, inject most of the time, have multiple sexual partners and share needles occasionally. Most of these behaviours put them at risk of HIV infection. Unfortunately, they are not likely to have contact with treatment services for education, and perhaps fail to realise which aspects of their behaviour put them at risk. These results fit well with those found by Reilly and Home1 (1987) and Moore, Makkai and McAllister (1989) as well as the qualitative data collected by Loxley (1990). Young IDUs have consistently been found to prefer amphetamine to heroin, to inject most of their drugs (probably as a cost-saving measure) and to have had little contact with treatment agencies. These characteristics raise a number of implications for health promotion and education. There is a public stereotype of all IDUs as ‘heroin junkies’: degraded, addicted, desperate, dying. The young IDUs do not fit this stereotype (indeed, only some of the older IDUs fit it) and their motivation for using may be much more about having fun than about addiction. It is important that we target some of our health education messages about AIDS specifically at these young people. Because they are not presenting for treatment, where they can be counselled and advised, strategies for them would have to encompass much more outreach and street work. These young people may think they know all about AIDS when they started injecting, but the evidence presented here suggests that many of them are engaging in risky behaviour.
AGE AND INJECTING DRUG USE IN PERTH
371
It is also important to know more about drug using progression. The pattern of drug use described for young IDUs can be explained by at least two separate hypotheses:
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1. In the last 12-18 months there has been a dramatic increase in Perth in the availability of relatively cheap amphetamine, such that those young people who have an inclination to take risks are attracted to it in a way they have not been in the past. Linked to this, the same people deal in amphetamine and marijuana and amphetamine is offered as a substitute for marijuana when there is a marijuana drought. 2. Amphetamine use is an early stage in a drug taking career which, if it continues, may progress to opiate addiction. The implications of these two hypotheses are quite different. If the first is correct, the young IDUs described here are a different group of people from those who may have been seen as IDUs in the past; if the second, then these young people may later end up in treatment clinics with opiate addictions. We need to know who progresses to this point and why, and who does not. Either way, interventions that precede drug treatment are necessary. There are two clear implications of this analysis, both of which have been alluded to. In the first place, health promotion about the AIDS virus needs to be targetted carefully if it is to reach all injecting drug users: the ‘heroin screws you up’ type of message does not reach the young amphetamine user. At the same time there needs to be a consideration of whether ‘safe sex’ messages aimed at young sexually active teenagers should not include some ‘safe using’ messages too. Finally, as always, we need more information. While it may be better understood now than it was at the start of the AIDS epidemic, that injecting drug users are not a homogeneous group, and that sub-populations need to be investigated independently, there has been little detailed research looking at the world of the very young injecting drug user. A new project along these lines has commenced in Perth, and it is to be hoped that other researchers will recognize the need to focus some attention on those IDUs who are not to be found in treatment centres and on whom so little of the research in the past has been based. Acknowledgements
This research is supported by the Commonwealth AIDS Research Grants Committee. We acknowledge the assistance and support of Professor David Hawks and Dr Alan Quigley in the preparation of this paper. References GAJANAYAKE, I. & SANTOW, G . (1990) Intravenous drug use in Australia, in: P. J. SOLOMON, C. F A Z E U S DE ST GROTH& S. R. WILSON(Eds) Projections of Acquired Immune Deficiency Syndrome in Australia Using Data to the End of September 1989 (Canberra, National Centre for Epidemiology and Population Health, Australian National University). HEUTH PROMOTION UNIT (1989) Communications Study for Phase 11 Illicit Drug Use Campaign (Health Department, Victoria). LOXLEY,W. (1990) Psychosocial Antecedents of Needle-Sharing and Unsafe Sexual Practices in Australian Injecting Drug Users: Perceptions of Law Enfmcement and Unsafe Practice. Paper presented at the 4th National Conference on HIV/AIDS; 8-1 1 August, Canberra. W n , A. & LOXLEY, W. (1991) The Australian National AIDS and Injecting Drug Use Study: Perch, 1989 (Perth, Western Australia, National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology). MOORE, R., MAKKAI, T., & MCALLISTER, I. (1989) Perceptions and Patterns of Drug Use: Changes Since the Drug Ofeensiwe (Canberra, Department of Community Services and Health).
372 W.LOXLEY,A. MARSH & S. K. LO
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NACAIDS (1988) National AIDS Education Campaign, Benchmark Survey 1986-1987 (Canberra, Commonwealth Department of Community Services and Health). AND CLINICAL RBSEARCH(1990) Australian HIV Surveillance Repon, 6 , NATIONAL CENTRe IN HIV EPIDEMIOLOGY 12, November. REILLY,C. & HOMEL,P. (1987) 1986 Suruey of Recreational Drug Use and Attuudes of 15 to 18 Year OIds in Sydney (Sydney, New South Wales Drug and Alcohol Authority). WATSON,J. (1990) Repon to the Select Committee Appointed to Inquire into the National HIVIAIDS Strategy White Paper (Canberra, Australian Government Publishing Service).
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Age and injecting drug use in Perth, Western Australia: the Australian National AIDS and injecting drug use study a
a
W. Loxley , A. Marsh & S. K. Lo
a
a
National Centre for Research Into the Prevention of Drug Abuse &Centre for Advanced Studies, Division of Health Sciences , Curtin University of Technology , Western Australia Published online: 25 Sep 2007.
To cite this article: W. Loxley , A. Marsh & S. K. Lo (1991) Age and injecting drug use in Perth, Western Australia: the Australian National AIDS and injecting drug use study, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 363-372, DOI: 10.1080/09540129108251592 To link to this article: http://dx.doi.org/10.1080/09540129108251592
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 3, NO. 4, 1991
363
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Age and injecting drug use in Perth, Western Australia: the Australian national AIDS and injecting drug use study W. LOXLEY, A. MARSH& S . K. Lo1 National Centre fm Research Into the Prevention of Drug Abuse & Centre fm Advanced Studies, Division of Health Sciences, Curtin University of Technology, Western Australia
Abstract Young injecting drug users (IDUs) in Australia are a group about whom little is known. It is suggested, however, that their drug using behaviours and life styles put them at particular risk for HIV/AIDS. Data collected in Perth from 195 respondents in the Australian National AIDS and Injecting Drug Use Study was analyzed with emphasis on the distinctions between young and older injecting drug users. It was found that, relative to those aged 23 or over, IDUs under 23 used more stimulants and LSD and fewer opiates and benzodiazepines; were more likely to inject all or most of their drugs; were less likely to have been in treatment; had more sex partners; were less likely to have changed their drug taking behaviour because of AIDS; were less likely to use alone; shared needles lessfiequently but shared at least some of the time; and had less knowledge of AIDS and were more pessimistic about the long term outcomes of AIDS. Such charactmktics need to be taken into account if effective intervention and prevention strategies for this group are planned.
The first case of AIDS was diagnosed in Australia in December 1982 and there were 2,347 reported cases of AIDS in Australia by 30 November 1990. Injecting drug use as the only risk behaviour accounted for 1.5% of cases (National Centre in HIV Epidemiology and Clinical Research, 1990), but there is a high risk of rapid spread of infection among injecting drug users (IDUs) given that there may be as many as 80,000 IDUs in Australia, three quarters of whom probably share needles (Gajanayake & Santow, 1990). The known seroprevalence rate among IDUs in Western Australia is estimated to be less than 1% but it is believed that the number of IDUs, many of them non-dependent or occasional users, is three or four times higher than the number known to treatment and law agencies (Watson, 1990). Young Australian IDUs are a group about whom relatively little is known. In one study it was found that 1 to 3% of people aged 16-24 had injected themselves with drugs within the last 12 months (NACAIDS, 1988): in national terms, this represents some 51,000 young people. Reilly and Home1 (1987) found that amphetamine was the most
Address for correspondence: Wendy Loxley, BA (Hons), M.Psych., National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology, PO Box U1987, Penh WA 6001, Australia.
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364 W.LOXLEY, A. MARSH & S. K. LO commonly used drug among 15 to 18 year old illicit drug users in Sydney: daily or weekly use was uncommon, with most of these young people using 1-3 times a month. Amphetamine use among young people has been increasing over the last few years (Loxley, 1990) and it has been suggested that this increase is related to effective law enforcement in limiting the supply of marijuana (Moore, Makkai & McAllister, 1989). Such a ‘displacement’ effect with adolescents turning to injectable drugs such as amphetamines which are now not so expensive or difficult to get as marijuana, raises particular concerns about the transmission of HIVIAIDS through needle sharing. But these are not the only concerns about recent trends in drug-taking. In Perth, for example, we have seen the emergence within the last 2 years of ‘homebake’ (a heroin substitute synthesized at home from codeine which is cheaper than heroin) which we are informed is often sold in preloaded needles, raising the possibility that needles are re-used. Experimental and recreational IDUs may not perceive that they are at personal risk from HIV (Health Promotion Unit, 1989). In an exploratory study Loxley (1990) found that many young IDUs had had no involvement with the law or with treatment agencies, and were anxious to keep their drug use a secret. They had a much greater stake in not being identified as drug users than those with a more established using ‘career’, which has a number of implications for safe(r) using such as the considerable suspicion among young IDUs of agencies such as needle-exchange schemes. Some were reluctant to store sterile injecting equipment in their homes because of a fear of police random checks and raids and future harassment and arrest and some lacked the social skills (or the money) necessary to purchase clean needles in chemists, and indicated that chemist staff often treated them with disdain. There is also need for concern about unsafe sexual practices among a group of people who are very sexually active, and among whom there are strong attitudes against the use of condoms (Health Promotion Unit, 1989). More extensive information about young IDUs is available through the Australian National AIDS and Injecting Drug Use Study (ANAIDUS). This is a multi-centre, multicity study, which is developing the most extensive database of information about Australian IDUs that has ever been established. The aims of the study are to investigate HIVIAIDS related knowledge, attitudes and behaviours among IDUs, to estimate seropositivity among IDUs, to identify hindrances and facilitators of behaviour change and to identify subgroups of IDUs for educational and interventional targetting. The ANAIDUS commenced in 1988 as a pilot project and in 1989 had five study centres (Sydney, Canberra, Brisbane, Melbourne and Perth). It has now just completed a second year of data collection. The data reported in this paper was collected for the ANAIDUS in Perth in 1989. The aim of the reported analysis was to compare young with older Perth IDUs in order to investigate those characteristics of young IDUs which put them at particular risk of HIV/AIDS.
Subjects and method
One hundred and ninety five IDUs were interviewed in Perth. Half of the sample were drawn from treatment and half from non-treatment populations. The treatment sample was representative of the drug treatment population in Perth in terms of gender and type of treatment. It is not known whether the non-treatment sample was representative of their population since the characteristics of this population in Perth are not known. Attempts were made, however, to obtain the sample from as wide a range of respondents as possible.
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Respondents were recruited to the study through advertising, referrals by staff at treatment and other agencies, direct approach to individuals, and snowballing. A comprehensive questionnaire covered demographics, drug use, needle sharing, cleaning and disposal of needles, the social context of IV drug use, sexual behaviour, knowledge of and attitudes towards AIDS, and behaviour change. Respondents were interviewed individually and all interviews were conducted by one trained interviewer. The interview schedule was administered by the interviewer other than for the sexual behaviour section which was self-completed unless the respondent requested help. Upon completion of the questionnaire respondents were given feedback and information; asked if they were prepared to give a contact name and number for future follow-up; and encouraged to provide a fingerprick blood sample for HIV antibody testing. Blood samples were sent to Fairfield Hospital in Melbourne for analysis. Results were not returned to individual respondents as facilities for pre- and post-test counselling were not available, but respondents were told where they could be tested for HIV/AIDS if they requested it. Further details of the methodology and characteristics of the study sample are available in a separate report (Marsh & Loxley, 1991). Results Respondents were divided into two groups: under 23 (young), and 23 and over (older). Twenty three was selected as the cut-off point because Loxley (1990) found that drug using behaviour appeared to change at around this age. There were 44 respondents in the young, and 151 respondents in the older group. The mean age of the total sample was 27.9 years: for the young and 30.5 for the older group.
Drug Use There were two major measures of drug use-‘ever’ use and the number of occasions of use of each drug in the ‘most recent typical using month’ (as the question was worded). Opiates and non-opiates ever used by each group are shown in Table. 1. Significantly fewer young respondents (ranging from 18% to 59%) had ever used opiates compared to older respondents (ranging from 71% to 97%). The percentage of non-opiates ever used by the two age groups was not statistically significant except in the case of cocaine, barbiturates and benzodiazepines although a slightly higher (but not statistically significant) proportion of young than older respondents had ever used amphetamines and ecstasy. A majority of those surveyed had never used crack and a large proportion of the total sample had tried LSD and benzodiazepines. Figure 1 shows the percentage of young and older respondents who injected each drug at least once a month in the ‘most recent typical using month’. Only drugs which were injected by more than 10% of at least one group were included in the analysis. The difference in drug of choice is clear. Heroin was more frequently injected by the older group (83% vs 32%, xzl = 43.2, p = 0,000) and amphetamine more frequently by young respondents (91% vs. 35%, xZ1= 42.5, p = 0.000). Similar, though less striking patterns were found for LSD and ecstasy, which were favoured by the young. No significant difference in percentage of those injecting was found for palfium (5% vs 11%, xzl = 1.8, p = 0.186). Figure 2 shows a similar analysis of drugs that were smoked, snorted or swallowed. Older respondents were more likely to have used methadone (32% vs 5%, xzl = 13.3, p = 0.000) but LSD was preferred by the young group (16% vs 1%, xzl = 16.5,p = O.OO0). No significant differences in the patterns of ingestion of cocaine and benzodiazepines were
366
W. LOXLEY, A. MARSH & S. K. LO Table 1. Drug Use ‘Ewer’ By Age
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Opiates Heroin Methadone Morphine Opium Pethadine Codeine Palfium
Non- Opiates Amphetamine LSD Ecstasy Cocaine Crank Crack Barbiturates Benzodiazepines
Young n=44
Older n=151
56.8 20.5 34.1 34.1 31.8 59.1 18.2 100.0 86.4 59.1 36.4 25.0 4.5 3!.8 79.5
-
X21
P
97.4 80.8 82.8 70.9 78.8 88.1 74.2
53.81 56.26 39.89 19.67 34.69 19.02 45.13
0.001 0.001 0.001 0.001 0.001 0.001 0.001
92.1 90.1 43.0 84.1 39.1 6.6 72.2 92.1
3.73 0.49 3.52 39.71 2.93 0.26 23.84 5.55
0.054 0.486 0.060 0.001 0.087 0.614 0.001 0.019
Injection
FIG.1.Injection at least once a month by age, n = 195; Young = 44, Older = 151 @ young; 0 older).
found despite the fact that four older respondents claimed to have very large benzodiazepine habits. Total drug use and total injecting drug use These data are shown in Table 2. Total Drug Use is a composite score which represents the total number of occasions on which a drug was used in the ‘most recent typical using month‘, regardless of means of administration. Total Injecting is a composite score combining all occasions of injecting in the ‘most recent typical using month’. Table 2 shows that much of
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7 "
Methadone
m Codeine
I
LSD
Benzodiazepine
Non-Injection FIG. 2.
Non-injection at least once a month by age, n = 195; Young = 44, Older = 151 @ young 0 older).
the young respondents' use was by injection, while much of the older respondents' use was non-injected. Table 2. Drug use and injecting by age
Occasions of use
Young ( n = 44) Mean SD
Older ( n = 151) Mean SD
Total drug use Total injecting
47.7 30.8
105.1 46.2
(77.3) (45.2)
(192.7) (69.5)
Dism'minant Analysis Stepwise discriminant analysis was used to identify the variables that most reliably distinguished young from older IDUs. Variables were first included in one of four discriminant analyses, representing different aspects of the questionnaire as follows: Function Function Function Function
1. Demographics, drug use patterns, treatment status. 2. Injecting, sharing, cleaning and social context of drug use. 3. Sexual Behaviour. 4. Knowledge of, and attitudes towards AIDS.
Significant variables from each of the four functions were then included in another discriminant function. This approach was adopted in order to maximize the power by minimizing the number of cases excluded because of missing data. The effective sample size for the final discriminant function was 170: 37 young and 133 older respondents. Variables found to be significant in the final discriminant function are presented in Table 3. The order of significance was Treatment, Total LSD, and so on up to AIDS
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W. LOXLEY, A. MARSH & S. K. LO
Knowledge. High discriminating power was obtained for the final model: using only the 10 variables in Table 3,91% of the 133 older respondents and 89% of the 37 young respondents could be correctly classified. Table 3. Final discriminantfinction
Step
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1
2 3 4 5 6 7 8 9 10
Variable In Treatment Total LSD No.sex partners Age of first injection Drug behaviour change Injecting alone Total stimulants Totalcocaine Sharing AIDS knowledge
Improvement F df
D*
1.525 1.8704 2.5845 2.9697 3.4872 3.8821 4.3170 4.5956 4.8656 5.1433
33.36 17.24 15.54 7.58 9.67 6.93 7.27 4.43 4.15 4.14
1,168 1,167 1,166 1,165 1,164 1,163 1,162 1,161 1,160 1,159
P O.OOO1 O.OOO1
O.OOO1
0.0066 0.0022 0.0093 0.0078 0.0369 0.0433 0.0435
Final Model: Mahalanobis D2 = 5.143, F = 14.09,~ = 0.OOO Classification Rate-Young: 89%; Older: 91% n = Young 37, Older 133, Total 170
The correlation matrix of the 10 variables identified in the final discriminant function demonstrated that there were no major relationships between them. Below is a description of how the young IDUs were different from the older IDUs on each of the 10 variables.
Treatment. Although this variable was dichotomized according to whether or not the IDU was in treatment at the time of interview, a more detailed examination showed that more than half of the older respondents were in treatment for at least the second time, while a majority of the young respondents had never been in treatment. Only small proportions of both groups had previously been in treatment, but were not currently, or were in treatment for the first time. Total LSD. Although the majority of the young respondents had not injected or ingested LSD in the most recent month, only one of the older respondents had done so. Number of sex partners (Figure 3) This is a summary variable which computes the number of sexual partners respondents have had in the last 12 months. Figure 3 shows that more than 80% of the older respondents had had 1-5 partners in the previous 12 months. Young respondents were equally as likely to have had 6-10 as 1-5 partners, and more than 10% of the young group had had more than 20 partners. (The influence of prostitution on these figures has not yet been examined). Age ofjrst injection. On average the young respondents began to inject drugs 2 years earlier than the older group.
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100
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a,
20
6-10
11-15
16-20
S O
Partners FIG.3. Number of sex partners in last 12 months by age, n = 195; Young = 44, Older = 151 @d young; 0 older).
Lh-ug behaviour change. Respondents were asked whether or not they had changed their drug taking behaviour since hearing about AIDS. The majority (72%) of older respondents had changed at least some of the aspects of their behaviour since hearing about AIDS, but only a few (37%) of young respondents had done so. Injecting alone. Respondents were asked to estimate the proportion of total injecting occasions on which they were alone. Young respondents estimated that they injected alone, on average, 16% of the time, while older respondents estimated that they were alone an average of 33% of the time. Total stimulants. This is a composite variable composed of the number of occasions during the ‘most recent typical using month’ when respondents used amphetamines or ecstasy by any means of administration. While 63.6% of the older group had not used stimulants in the typical month, only 9.1% of the young group had not done so. At the other extreme, 31.8% of the young group compared to 3.3% of the older group had used stimulants more than 20 times in the typical month. Total cocaine. This is a composite score composed of all occasions of cocaine, crack and crank use during the ‘most recent typical using month’. No young respondent had used cocaine products at least once a month. Six older respondents had used cocaine once in the most recent month. Needle sharing. This measured the respondent’s estimate of the proportion of drug use occasions on which needle sharing took place. While almost equal proportions of older and younger respondents said they never shared needles, young respondents were slightly more likely than older respondents to share 1-10% of the time. No young respondent (vs more
370 W.LOXLEY, A. MARSH & S. K. LO than 7% of the older group) said they shared 51-100% of the time. The influence of regular sexual partnerships on consistent sharing by older people has yet to be examined.
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AIDS knowledge. This is a composite score composed of two TrueIFalse questions: “Once you have the virus, is there anything you can do to improve your chances of survival?” and “Once you have the symptoms is there anything you can do to improve your chances of survival?” Two supplementary questions asking for ways in which survival could be improved were also included. Although older respondents were more knowledgeable about the progression and symptoms of HIV/AIDS than were young respondents, neither group could be considered as particularly knowledgeable. Discussion A number of points can be made about individual results. In terms of drug use, the reduced likelihood of young IDUs to have used opiates might be considered explicable in terms of the number of years in which people may ever have used, but this does not account for the increased likelihood of their use of amphetamines unless there is a progression from amphetamine to heroin use as is discussed below. Much of the young users’ use was by injection, while much of the older users’ use was non-injected. This presumably reflects the influence of treatment-based methadone as well as the high (oral) benzodiazepine use of some older IDUs. More generally, these analyses can be used to typify young as compared to older IDUs as follows. Young IDUs used more stimulants and LSD and fewer opiates and benzodiazepines; were more likely to inject all or most of their drugs; were less likely to have been in treatment; had more sex partners; were less likely to have changed their drug taking behaviour because of AIDS; were less likely to use alone; shared needles less frequently, but a majority shared at least some of the time; and had less knowledge of AIDS and were more pessimistic about the long term outcomes of AIDS. These characteristics add up to a composite picture of young IDUs who use amphetamine and LSD, usually in groups with friends, inject most of the time, have multiple sexual partners and share needles occasionally. Most of these behaviours put them at risk of HIV infection. Unfortunately, they are not likely to have contact with treatment services for education, and perhaps fail to realise which aspects of their behaviour put them at risk. These results fit well with those found by Reilly and Home1 (1987) and Moore, Makkai and McAllister (1989) as well as the qualitative data collected by Loxley (1990). Young IDUs have consistently been found to prefer amphetamine to heroin, to inject most of their drugs (probably as a cost-saving measure) and to have had little contact with treatment agencies. These characteristics raise a number of implications for health promotion and education. There is a public stereotype of all IDUs as ‘heroin junkies’: degraded, addicted, desperate, dying. The young IDUs do not fit this stereotype (indeed, only some of the older IDUs fit it) and their motivation for using may be much more about having fun than about addiction. It is important that we target some of our health education messages about AIDS specifically at these young people. Because they are not presenting for treatment, where they can be counselled and advised, strategies for them would have to encompass much more outreach and street work. These young people may think they know all about AIDS when they started injecting, but the evidence presented here suggests that many of them are engaging in risky behaviour.
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It is also important to know more about drug using progression. The pattern of drug use described for young IDUs can be explained by at least two separate hypotheses:
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1. In the last 12-18 months there has been a dramatic increase in Perth in the availability of relatively cheap amphetamine, such that those young people who have an inclination to take risks are attracted to it in a way they have not been in the past. Linked to this, the same people deal in amphetamine and marijuana and amphetamine is offered as a substitute for marijuana when there is a marijuana drought. 2. Amphetamine use is an early stage in a drug taking career which, if it continues, may progress to opiate addiction. The implications of these two hypotheses are quite different. If the first is correct, the young IDUs described here are a different group of people from those who may have been seen as IDUs in the past; if the second, then these young people may later end up in treatment clinics with opiate addictions. We need to know who progresses to this point and why, and who does not. Either way, interventions that precede drug treatment are necessary. There are two clear implications of this analysis, both of which have been alluded to. In the first place, health promotion about the AIDS virus needs to be targetted carefully if it is to reach all injecting drug users: the ‘heroin screws you up’ type of message does not reach the young amphetamine user. At the same time there needs to be a consideration of whether ‘safe sex’ messages aimed at young sexually active teenagers should not include some ‘safe using’ messages too. Finally, as always, we need more information. While it may be better understood now than it was at the start of the AIDS epidemic, that injecting drug users are not a homogeneous group, and that sub-populations need to be investigated independently, there has been little detailed research looking at the world of the very young injecting drug user. A new project along these lines has commenced in Perth, and it is to be hoped that other researchers will recognize the need to focus some attention on those IDUs who are not to be found in treatment centres and on whom so little of the research in the past has been based. Acknowledgements
This research is supported by the Commonwealth AIDS Research Grants Committee. We acknowledge the assistance and support of Professor David Hawks and Dr Alan Quigley in the preparation of this paper. References GAJANAYAKE, I. & SANTOW, G . (1990) Intravenous drug use in Australia, in: P. J. SOLOMON, C. F A Z E U S DE ST GROTH& S. R. WILSON(Eds) Projections of Acquired Immune Deficiency Syndrome in Australia Using Data to the End of September 1989 (Canberra, National Centre for Epidemiology and Population Health, Australian National University). HEUTH PROMOTION UNIT (1989) Communications Study for Phase 11 Illicit Drug Use Campaign (Health Department, Victoria). LOXLEY,W. (1990) Psychosocial Antecedents of Needle-Sharing and Unsafe Sexual Practices in Australian Injecting Drug Users: Perceptions of Law Enfmcement and Unsafe Practice. Paper presented at the 4th National Conference on HIV/AIDS; 8-1 1 August, Canberra. W n , A. & LOXLEY, W. (1991) The Australian National AIDS and Injecting Drug Use Study: Perch, 1989 (Perth, Western Australia, National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology). MOORE, R., MAKKAI, T., & MCALLISTER, I. (1989) Perceptions and Patterns of Drug Use: Changes Since the Drug Ofeensiwe (Canberra, Department of Community Services and Health).
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NACAIDS (1988) National AIDS Education Campaign, Benchmark Survey 1986-1987 (Canberra, Commonwealth Department of Community Services and Health). AND CLINICAL RBSEARCH(1990) Australian HIV Surveillance Repon, 6 , NATIONAL CENTRe IN HIV EPIDEMIOLOGY 12, November. REILLY,C. & HOMEL,P. (1987) 1986 Suruey of Recreational Drug Use and Attuudes of 15 to 18 Year OIds in Sydney (Sydney, New South Wales Drug and Alcohol Authority). WATSON,J. (1990) Repon to the Select Committee Appointed to Inquire into the National HIVIAIDS Strategy White Paper (Canberra, Australian Government Publishing Service).
