Drtlg and Alcohol Dependence,
Elsevier Scientific Publishers
27 (1991119-27 Ireland Ltd.
19
Licit and illicit drug initiations and alcohol-related problems amongst illicit drug users in Edinburgh Valerie Morrison, Martin Plant Alcohol Research
Group, Department
of Psychiatry,
University of Edinburgh. Scotland IlJ.K.I
Morningside
Park. Edinburgh
EHlO 5HF,
(Received June 6th. 19901 A non-random study group of one hundred and fifteen regular illicit drug users were interviewed in Edinburgh between January and July 1988. It was found that initiation to the use of alcohol and tobacco generally preceded the first use of illicit substances. The circumstances of initiation to alcohol use often differed from those of initiation to an illicit substance. Results from the first phase of this longitudinal study also indicate that the majority of current users of illicit drugs have experienced a wide range of problems attributed to alcohol consumption. Opiate users in particular, reported experiencing alcohol-related trouble with the police, being involved in alcohol-related violence and being banned from premises due to their drinking. Key words: drug initiation; poly drug use; alcohol related problems
Introduction
This paper reports findings from an ongoing longitudinal study of illicit drug users in the community. Results from 115 interviews conducted in Edinburgh, the main study area, are reported here. The main aims of this study are to assess changing patterns of illicit drug use in the community and to examine the influence of social, environmental, financial and legal factors on such changes. This paper presents results related to drug initiation and alcohol related problems. Other aspects of this study have been reported elsewhere [l-2]. Analysis of the follow-up data and findings related to changing patterns of use is underway. It has been widely reported that there is an association between the use of alcohol and tobacco and the use of illicit drugs such as cannabis, amphetamines and opiates [3- 51. Licit substance use, in the main precedes the use of illicit substances. Circumstances of initiation may vary from substance to substance and may be dependent on factors including availability, legality and peer pressures, for example. 0376-8716/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland
Problems resulting from the use of psychoactive substances are not confined to those substances which are illegal, neither do all illicit drug users necessarily experience adverse consequences resulting from their use. However, adverse consequences of drinking alcohol were found to have been experienced by the great majority of respondents, all of whom were regularly using illicit substances at the time of interview. Subjects and methods
The subjects of this study were ‘regular drug users’ defined as having used an illicit substance (including illicitly used prescribed drugs) on at least a monthly basis in the twelve months preceding the interview or twelve times minimum in the same period. Respondents were contacted by a non-random method known as “snowballing” or “networking”. This method has been described elsewhere and has been used in several previous studies of illicit drug use [2,6 - 81. Respondents were contacted in the community between January and July Ireland Ltd.
20
All interviews were conducted in locations suited to both interviewers and respondents such as cafes, youth centres, drug agencies and respondents’ homes. Respondents were assured that no details of their identities would be published or otherwise be disclosed. All respondents provided interviewers with their names and where possible, contact addresses were obtained in order to facilitate a follow-up interview 18 months after initial contact.
1988. The first author conducted 70 per cent of the interviews. The remaining 30 per cent (n = 351were carried out by three trained fieldworkers. Contacts were initially established with drug users in contact with a variety of agencies such as unemployed groups, drug advice centres and other agencies providing services for young people. Further details of the ‘networks’ contacted using this methodology have been described by Morrison and Plant 1990 121. Data were elicited by the administration of a face-to-face standardized interview, which took between forty and ninety minutes to complete and related to over two hundred variables. These related to biographical details (e.g. education, employment history, income and expenditure); the use of alcohol, tobacco, prescribed and illicit drugs; the use of services for drug users; the awareness of HIV/AIDS-related issues and any effect of such awareness on drug use and sexual behaviour practices and criminal history.
Table I.
Results The Study tics
Group
-
background
characteris-
As reported elsewhere [Z], the 115 respondents were divided into four subgroups defined on the basis of the nature and frequency of their illicit substance use. Alcohol and tobacco use were not included in this categorisation since the primary concern of this study was patterns of illicit substance use. Only one respondent in this study group had reportedly
Background characteristics.
Sex Male Female Age Mean (median) years S.D. Marital status Single Married/ cohabiting Divorced/ separated Currently employed Yes No Had prison sentence Yes Age left education Under 16 years Over 16 years
Sub-group 1 71 = 26
Sub-group 2 n = 32
Sub-group 3 n = 28
Sub-group 4 n = 27
20 8
20 12
18 10
21 6
28.6 (26) 5.92
26.8 (24) 8.01
21.8 (21) 4.99
25.7 (25) 5.18
15 11
20 9
21 7
18 5
2
3
0
4
21 7
21 11
8 20
0 27
x2 = 41.O;df = 3;p < 0.01
5
14
16
23
x2 = 2&l;@ = 3;p< 0.01
3 25
11 21
21 7
18 9
x2 = 29.9; df = 3; p < 0.01
21
never had an alcoholic drink and four respondents reported never having smoked cigarettes. The four sub-groups were as follows: Subgroup1 (n = 28lCannabisusers Subgroup 2 (n = 32) Cannabis use plus at least monthly use of one or more non-opiates (i.e., amphetamines, solvents, hallucinogens, benzodiazepines, cocaine). Subgroup 3 (n = 28) Cannabis use and/or at least one non-opiate plus opiates on a maximum of 149 days in the 12 months preceding interview. Subgroup 4 (n = 27) As Subgroup 3, but with opiate use on a minimum of 150 days in the preceding 12 months. The sex ratio was approximately 2:l (79 males, 36 females). Respondents’ ages ranged from 16- 41 years with the mean age of the total study group being 25.7 years. The majority of respondents in all subgroups were unmarried, although a larger proportion of the cannabis only users were married or cohabiting. Many respondents were, however, in ‘stable’ relationships, although this was a selfdefined term and did not necessarily indicate a longstanding association (Table Il. Table I also shows that a significant difference emerged between the numbers of those in each sub-group who were currently employed.
Table
II
Initiation
to licit and illicit substances
Opiate users - both moderate and heavy, were significantly more likely to be unemployed than were other respondents (x2 = 41.0, df = 3, P < 0.011. Opiate users were also significantly more likely than other respondents to have served a prison sentence (x2 = 28.1, df = 3, P< 0.011 and to have left full time education under 16 years of age (x2 = 29.9,df = 3,P< 0.011. Table II shows the ages at which respondents had been initiated into the use of thirteen substances, legal and illegal, and the numbers who had used each substance. The use of legal substances are seen to be initiated at a younger age and by a greater number of respondents than that of most illegal substances. All respondents had used cannabis. Fewer reported having used the other illicit drugs. Heroin had only ever been used by 43 individuals. The most commonly used substances (with the exception of alcohol and tobacco) were, in descending order: cannabis, amphetamines, tranquillisers, hallucinogens, analgesics (including Temgesic (buprenorphinel and DF118 (dihydrocodeine)), glue and other solvents, barbiturates, cocaine, heroin, and, finally, diconal/palfium and methadone. Table III indicates the mean age of drug initiations reported by those in the four subgroups. Few differences in the sequence of
(n = 115).
Substance
Valid 7~ (ever tried)
Cigarettes Alcohol
111 114
Glue/solvents Cannabis Tranquillisers Barbiturates
60 115 80 55
52 100 70 48
14.82 16.01 17.75 18.03
Amphetamines Hallucinogens Painkillers* Heroin
91 77 76 43
79 67 66 37
18.54 18.69 19.02 19.79
Cocaine Diconahpalfium Methadone
46 34 34
40 30 30
20.63 22.20 27.40
*Opiate-based
analgesics,
including
for example,
buprenorphine
%
96.5 99
and dihydrocodeine.
Mean age (years) 13.00 13.68
22 Table III.
Initiation to licit and illicit substances.
Cigarettes Alcohol Solvents Cannabis Tranquillisers Barbiturates Amphetamines Hallucinogens Painkillers** Heroin Cocaine Diconabpalfium Methadone
Sub-group 1 rl = 28
Sub-group 2 n = 32
Sub-group 3 n = 28
Sub-group 4 12= 27
mean (years)
n*
mean (years)
n*
mean n* (years)
mean n* (years)
14.9 14.7 15.6 17.1 18.7 18.9 19.1 19.0 18.9 20.8 22.5 22.5 28.0
26 28 5 28 7 7 16 22 9 5 17 2 1
14.2 13.5 14.8 16.3 18.9 19.3 18.4 18.8 20.1 22.2 22.3 28.5 35.0
32 31 18 32 20 10 26 18 13 5 15 2 1
10.9 13.3 13.9 15.5 16.7 17.3 18.4 18.7 18.0 18.5 17.7 18.6 24.4
12.1 13.3 15.0 15.1 16.7 16.7 18.2 18.3 19.1 17.6 20.0 19.2 22.3
26 28 20 28 26 15 24 16 27 8 7 5 10
27 27 17 27 27 23 25 21 27 25 20 25 22
*Number of respondents who had ever tried a substance. **Opiate-based analgesics, including, for example, Temgesics and DFIWs
Table IV.
Frequency of substance
Cigarettes Alcohol Cannabis Tranquillisers Painkillers Methadone DiconallPalfium Heroin Cocaine Amphetamines Solvents Hallucinogens
use in 12 months preceding interview. Sub-group 1 n = 28
Sub-group 2 n = 32
Sub-group 3 n = 28
Sub-group 4 n = 27
mean (days)
n*
mean (days)
n*
mean (days)
n*
mean (days)
n*
328 209 202 _ -
26 28 28 _
323 158 207 10 -
32 31 32 10 -
_ _
-
_
_
_ _ -
_ _
5 5 154 2
11 11 8 7
358 103 148 87 14 6 _ 6 5 9 83 5
26 28 28 22 27 7 4 3 15 5 9
362 58 178 289 231 89 77 43 35 21 17 7
27 27 27 27 27 18 15 13 8 16 2 3
*Number of respondents who had used a substance in the 12 months preceding interview. N.B. Barbiturates are omitted from this table due to their minimal usage amongst this subject group.
23
Table V.
Reasons
for initiation.
Valid responses
Curiosity To be sociable Friend said was good Persuaded/forced Relieve boredom To avoid withdrawal/substitute
“can’t remember”,
Cannabis N = 103
Opiates N = 27
?l
n
R
%
” to relieve
pressure”,
67 6
65 6
11 1
41 4
5 2 0
5 2 0 .19 3
15 3 2 _
15 3 2 -
10 -
10 -
3 0 1 8 3 _
11 0 4 30 11 _
and miscellaneous
patterns
Company
Valid responses
others.
use was also reported by the moderate opiate users in subgroup 3. Heavy opiate users (subgroup 41 reported frequent use of tranquilisers and other analgesic painkillers (mainly temgesic and DF1181. Many also reported regular use of other substances such as methadone or diconal (dipipanonel (For more details see Morrison and Plant 1990)[2]. Note that heroin does not appear as one of the most frequently used substances amongst the opiate users interviewed for this study.
Alcohol, tobacco and cannabis were the most commonly used substances amongst the study group as a whole. Table IV shows the frequency (mean days) of use in each subgroup, in the 12 months preceding interview. Subgroups 2 and 3 reported the highest levels of solvent use. A high level of tranquiliser Table VI.
O/O
56 16
events are evident. What is notable however, is that licit prescribed substances such as tranquillisers (most commonly diazepam and temazepaml and barbiturates (e.g. tuinal, seconal and nembutall had first been used at slightly earlier mean ages by current opiate users than by non-opiate users. Consumption
%
59 17
20 3
Other reasons* Don’t know why *Included
Alcohol N = 106
Reasons for initial use of alcohol, cannabis and opiates
Table V shows the reasons given for initial use of alcohol, cannabis and opiates. (Opiates
at first use. Opiates N = 27
Cannabis N = 103
Alcohol N = 106
N
%
N
Group of friends Sibling/relative
46 33
43 31
63 9
61 9
15 0
55 0
One friend Spouse/partner Alone Can’t remember Other company
11 2 4 7 3
10 2 4 7 3
22 5 2 1 1
21 5 2 1 1
6 3 1
22 11 4 0 8
N
%
%
2*
*These two respondents had first tried opiate-based painkillers with a cellmate during a period of imprisonment. There is some missing data on these items hence the ‘ns’ vary from table to table, the main reason for this being that although a respondent may have used a substance, if it had not been used on a least a monthly basis in the previous 12 months further details of the use of this substance were not collected.
24 Table VII.
Alcohol was often used initially as a means of “being sociable” (16%). Only 6% and 4% respectively cited “being sociable” as reasons for cannabis and opiate initiation. Being “told by friends that it was good” was the reason for initiation to alcohol in 5% of cases, to cannabis in 15% and to opiates in 11%. No-one claimed to have been persuaded or forced to try opiates, with only small numbers giving this as a reason for first using alcohol or cannabis. “Boredom” was cited as a reason for trying cannabis by two respondents. One gave this as the reason for first opiate use. Groups of friends emerged as the most important influence for the first use of all substances. Slightly more illicit drug initiations reportedly took place with friends than was the case for first use of alcohol. Not surprisingly, alcohol initiations were more likely to have occurred in the company of a relative (Table VI).
Source of first use.
Valid responses
Cannabis 103 %
Opiates 26 %
Friend Relative
81 9
79 9
10 2
38 8
Dealer GP (prescribed) Other source*
12 -
12 -
7 -
27 12 15
4
*Two respondents received their first opiate from a cellmate during a period of imprisonment. Another claims to have been told where someone bad “hidden” a “stash” and had stolen them. The fourth first tried opiates by stealing from a parent’s prescribed supply.
here included any of the following; heroin, analgesic painkillers, e.g., DF118, Temgesic, Diconal or Palfium, opium, morphine). “Curiosity” was the most frequently cited reason for first use of these 3 substance types (56,65 and 41%. respectively). Opiates used in the previous 12 months were primarily prescribed substances, e.g. DF118’s or Temgesic, and although these may not have been the first opiate respondents had tried, they may be the only ones details were gathered on. Therefore, the 36% citing “withdrawal” as a reason for taking an opiate, generally referred to individuals who had first taken DF118’s or temgesics as a means of alleviating heroin withdrawals. Table VIII.
Drug initiations Table VII indicates the sources of each substance on the first occasion of use. It is obvious that cannabis most frequently came from a friend, whereas opiates were almost as likely to have been obtained from a dealer. This question was not included in the alcohol section. However, discussions with respondents sug-
Sex differences in adverse consequences resulting from alcohol consumption W = 102).
Problem reported
Males N = 72
Total N = 102
Females N = 30
n
O/c
n
%
rl
%
Involved in violence* Arguments with partner/s
49 38
68 53
14 18
47 60
63 56
62 55
Arguments with family Arguments with friends Trouble with police** Been banned from premises Financial problems Split up with partner/s Health problems Been imprisoned Problems at work Lost job
38 40 42 38 23 20 16 17 14 11
53 56 58 53 32 28 22 24 19 15
16 14 7 10 7 8 4 3 -
53 47 23 33 23 27 13 10 -
54 54 49 48 30 28 20 17 17 11
53 53 48 47 29 27 20 17 17 11
*Chi-squared test (df = 3) P < 0.05. **Chi-squared
test (df = 3) P < 0.01.
25
Opiate users were significantly more likely than other respondents to report having been banned from premises (x2 = 12.24, df = 3, P < 0.011, having had trouble with the police (x2 = 13.08, df = , 3, P < 0.011 and being involved in alcohol-related violence (x2 = 11.93, df = 3, P < 0.01). Respondents’ alcohol consumption, in terms of units* of alcohol consumed on the last drinking occasion, is seen to be fairly high amongst respondents as shown in Table X. Opiate using males drank substantially more alcohol on the last drinking occasion than nonopiate using males. The females who used opiates heavily also reported drinking larger quantities than did women in the other three sub-groups.
gest that alcohol was available in the homes of friends or relatives and was first used either with or without parental knowledge. Problems attributed to alcohol use The pattern of drug-related problems reported by this study group has been described elsewhere [2]. Attention is now focussed upon their self-reported levels of alcohol - related problems. Respondents were asked whether or not they had ever experienced any of a list of 12 adverse consequences which they attributed to their own drinking behaviour. The list varied greatly in the severity of consequences, as shown in Table VIII. The most frequently experienced ‘problem’ was violence (62%). Females were significantly less likely to report either involvement in violence or trouble with the police as a result of their drinking. Arguments with partners, family and friends were commonly experienced by both sexes. Seventeen respondents, all males, reported having been imprisoned as a result of their drinking. Table IX, divides respondents into the four drug using subgroups. Only three problems differed significantly according to subgroup.
Table IX.
Sub-group differences in adverse consequences
Problems reported
Arguments with family Arguments with friends Arguments with partners(s) Split up with partner(s) Health problems Money problems Problems at work Lost a job Beenbanned’ Trouble with police** Imprisoned Involved in violence***
Discussion The use of licit substances such as alcohol and tobacco is more prevalent in the United Kingdom than is the use of illicit substances. Furthermore illicit drug use is often preceded by the use of legal drugs [3,5,9 - 111. This is supported by the data obtained from the 115 respondents in this study. Alcohol and
resulting from alcohol consumption (n = 102).
Sub-group 1
Sub-group 2
Sub-group 3
Sub-group 4
It
%
12
o/o
n
%I
n
%
15 9 11 4 2 7
54 32 39 14 7 25
13 17 20 7 4 6
16 17 13 10 7 11
59 63 48 37 26 41
10 11 12 7 7 6
56 61 67 39 39 33
4 3 9 7 1 12
14 11 32 25 4 43
3 1 10 12 2 15
45 59 69 24 14 21 10 3 34 41 7 52
6 3 18 17 7 21
22 11 67 63 26 78
4 4 11 13 7 15
22 22 61 72 39 83
Chi-squared test: *12.24; **13.08; l**11.93 fdf = 3)P < 0.01.
26
Table X.
Male Female
Units*
of alcohol
consumed
on last drinking
occasion
(trimmed
mean).
Sub-group 1
Sub-group 2
Sub-group 3
Sub-group 4
6.3 5.1
6.8 7.8
16.4 7.1
18.7 18.0
*“Unit” defined as either half a pint of ordinary beer, lager, stout Each unit contains approximately 1 centilitre of absolute alcohol.
tobacco use were first experienced at an early age with the use of one or both tending to continue to become part of later multiple substance use. Other drugs, such as solvents, were often reported to have been used at an earlier stage in respondents drug use “careers” but were generally discarded either as individuals aged (i.e., maturing out), or as they were initiated in the use of other substances [12- 131. “Curiosity” was given most frequently as the reason for first using alcohol, cannabis and opiates. Alcohol was more often used on the first occasion as a means of “being sociable”. Slightly higher percentages of initiations to cannabis and opiates took place whilst in the company of friends, than did alcohol initiations. In addition, friends were most often the source of cannabis on the first occasion, whereas opiates were almost as likely to come from a dealer. Peer group pressure can play an active role not only in drug initiations but also in switching substances in preference of another, or in ceasing to use a drug altogether. These data are similar to that reported in many other studies [4,14- 191. The availability of legal substances such as alcohol and tobacco provide greater opportunities for use and their social acceptability explains why, for most young persons, they will be the first, if not the only, psychoactive substances tried. Amongst opiate users in Edinburgh, there has been a marked reduction in the availability of street heroin over the past few years [20]. This has, in part, led to an increased reliance on prescribed substances such as Valium, Temazepam, Temgesic and DF118. These substances are obtained through either legitimate pre-
or cider,
or a single
measure
of spirits
or a glass
of wine.
scriptions or on the black market. The first use of these substances was, for some respondents out of a need to alleviate withdrawals, mainly from heroin. Therefore, the main role of such drugs was initially that of substitutes. This has also been noted in other areas of Britain [2123]. A high level of adverse consequences (social, financial, legal, etc.1 resulting from alcohol use were reported by this study group. It has been suggested [18,24 - 251 that since the majority of illicit substance users are poly-drug users (including both licit and illicit psychoactive substances) it is difficult to distinguish negative effects caused by any single drug. However, this paper is concerned with the negative effects respondents themselves attributed to their alcohol consumption. It is interesting that within this study group alcohol was blamed by respondents for a greater number of adverse experiences than were illicit drugs [2]. Twentysix respondents reported having experienced no negative consequences of drinking. However, over half of the 25 respondents who reported no negative consequences of illicit drug use were cannabis-only users. Females across each of the four sub-groups were significantly less likely to report involvement in violence or trouble with the police as a result of their drinking behaviour. Opiate users on the other hand were more likely to report having been involved in alcohol-related violence, trouble with the police, and having been banned from premises. It has been noted that young males, particularly those in manual occupations, are often the heavist drinking group in a community and that
27
problem drinking is increasing among females [ll]. Amongst this study group it would appear that although drinking occasions may be fewer, opiate-using males drink in substantially larger quantitities than non-opiate using males. The two females using opiates on a “heavy” basis also showed unusually high levels of alcohol consumption [26 - 271.
References 1 2 3 4 5 6
Conclusions
These results confirm the commonplace use of a multiplicity of legal and illegal drugs amongst regular users of illicit substances. Multiple substances were being consumed on a regular basis by both opiate and non opiate users. A limitation of the data is that specific time periods were not identified for the experiences reported; accordingly, the adverse effects of alcohol use discussed could have occurred at any stage in the drug users life. It must also be remembered that the experience of drug problems (whether alcohol or illicit drugs) is not necessarily a permanent state. Many people may experience adverse effects due to drinking or drug use without necessarily developing chronic problems [ll]. The phenomenon of ‘maturing out’ of drug problems is well documented [12 - 131 and is to be assessed during the follow-up phase of this study. These results lend weight to the view that preventive responses to illicit drug use should take account of the social influences upon drug use in addition to the experience of negative consequences which may result from such use. Negative reinforcement activated within ones peer group possibly using exusers or more responsible users could be an effective means of educating users towards safer, less problematic modes of substance use. Acknowledgements
7 8 9
10
11 12 13 14
15
16
17
18
19 20
21
22 23 24
This study was funded by the Scottish Home and Health Department with additional support from the Scotch Whisky Association. Any opinions expressed are those of the authors and are not necessarily representative of those of the funding bodies.
25 26 27
V.L. Morrison, Drug Alcohol Depend., 23 (1989195. V.L. Morrison and M.A. Plant, Rr. J. Addict., 85 119901 547. E. Goode, Drugs in American Society, Alfred A. Knopf, New York, 1972. M.A. Plant, D.F. Peck and E. Samuels, Alcohol, and School Leavers. Tavistock, London, 1985. G. Bagnall, Drug Alcohol Depend., 22 (19881241.
Drugs
M.A. Plant, Drugtakers in an English Town, Tavistack, London, 1975. V.L. Morrison, Sot. Pharmacol., 2 (1988) 247. R. Power, Br. J. Addict., 84 (1989143. R. Jessor and S.L. Jessor. Problem Behaviour and Psychosocial Development, Academic Press, New York 1977. D.B. Kandel ted), Longitudinal Research Empirical Findings and Methodological stead, New York, 1978.
on Drug Issues,
Use: Hal-
M.A. Plant, Drugs in Perspective, Hodder and Stough~ ton, London, 1987. J. Blackwell, J. Drug Issues., 12 (19831219. R. Stall and P. Biernacki, Int. J. Addict., 21 (198611. J. Miller et al.. National Survey on Drug Abuse: Main Findings, NIDA Research Monograph Series, Washington D.C., 1982. N.E. Zinberg, Drug, Set and Setting: The Basis for Controlled Intoxicant Use, IJniversity Press, Yale, 1984. B. Glassner and J. Loughlin, Drugs in Adolescent Worlds: Burnouts to Straights, Macmillan Press, New York, 1987. R.C. Stephens, Mind Altering Drugs: Use, Abuse and Treatment, Criminal Justice Series Vol. 9. Sage Publications, Beverley Hills, 1987. R.H. Hammersley et al., Heroin Use and Crime, Report to Criminological Research Div., Scottish Home and Health Dept., 1988. 0. Teck-Hong, Br. J. Addict., 84 (19891631. J.R. Robertson and C. Skidmore, AIDS in The Family, 2nd Report to Scottish Home and Health Department, 1989. A. Jamieson, A. Glanz and S. Macgregor, Dealing with Drug Misuse: Crisis Intervention in the City, Tavis tack, London, 1984. K.M.H. Perera, M. Tulley and F.A. Jenner. Br. J. Addict., 82 (19871511. C.R. Stark, R. Sykes and P.J. Mullin. Lancet., II (19871 802. R.H. Hammersley and V.L. Morrison. Br. J. Addict., 82 (19871899. R.H. Hammersley and V.L. Morrison, Med and Law., 7 (19881185. P. Wilson, Drinking in England and Wales, H.M.S.O., London, 1980. E. Breeze, 1985.
Women
and
Drinking
H.M.S.O.,
London,
Elsevier Scientific Publishers
27 (1991119-27 Ireland Ltd.
19
Licit and illicit drug initiations and alcohol-related problems amongst illicit drug users in Edinburgh Valerie Morrison, Martin Plant Alcohol Research
Group, Department
of Psychiatry,
University of Edinburgh. Scotland IlJ.K.I
Morningside
Park. Edinburgh
EHlO 5HF,
(Received June 6th. 19901 A non-random study group of one hundred and fifteen regular illicit drug users were interviewed in Edinburgh between January and July 1988. It was found that initiation to the use of alcohol and tobacco generally preceded the first use of illicit substances. The circumstances of initiation to alcohol use often differed from those of initiation to an illicit substance. Results from the first phase of this longitudinal study also indicate that the majority of current users of illicit drugs have experienced a wide range of problems attributed to alcohol consumption. Opiate users in particular, reported experiencing alcohol-related trouble with the police, being involved in alcohol-related violence and being banned from premises due to their drinking. Key words: drug initiation; poly drug use; alcohol related problems
Introduction
This paper reports findings from an ongoing longitudinal study of illicit drug users in the community. Results from 115 interviews conducted in Edinburgh, the main study area, are reported here. The main aims of this study are to assess changing patterns of illicit drug use in the community and to examine the influence of social, environmental, financial and legal factors on such changes. This paper presents results related to drug initiation and alcohol related problems. Other aspects of this study have been reported elsewhere [l-2]. Analysis of the follow-up data and findings related to changing patterns of use is underway. It has been widely reported that there is an association between the use of alcohol and tobacco and the use of illicit drugs such as cannabis, amphetamines and opiates [3- 51. Licit substance use, in the main precedes the use of illicit substances. Circumstances of initiation may vary from substance to substance and may be dependent on factors including availability, legality and peer pressures, for example. 0376-8716/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland
Problems resulting from the use of psychoactive substances are not confined to those substances which are illegal, neither do all illicit drug users necessarily experience adverse consequences resulting from their use. However, adverse consequences of drinking alcohol were found to have been experienced by the great majority of respondents, all of whom were regularly using illicit substances at the time of interview. Subjects and methods
The subjects of this study were ‘regular drug users’ defined as having used an illicit substance (including illicitly used prescribed drugs) on at least a monthly basis in the twelve months preceding the interview or twelve times minimum in the same period. Respondents were contacted by a non-random method known as “snowballing” or “networking”. This method has been described elsewhere and has been used in several previous studies of illicit drug use [2,6 - 81. Respondents were contacted in the community between January and July Ireland Ltd.
20
All interviews were conducted in locations suited to both interviewers and respondents such as cafes, youth centres, drug agencies and respondents’ homes. Respondents were assured that no details of their identities would be published or otherwise be disclosed. All respondents provided interviewers with their names and where possible, contact addresses were obtained in order to facilitate a follow-up interview 18 months after initial contact.
1988. The first author conducted 70 per cent of the interviews. The remaining 30 per cent (n = 351were carried out by three trained fieldworkers. Contacts were initially established with drug users in contact with a variety of agencies such as unemployed groups, drug advice centres and other agencies providing services for young people. Further details of the ‘networks’ contacted using this methodology have been described by Morrison and Plant 1990 121. Data were elicited by the administration of a face-to-face standardized interview, which took between forty and ninety minutes to complete and related to over two hundred variables. These related to biographical details (e.g. education, employment history, income and expenditure); the use of alcohol, tobacco, prescribed and illicit drugs; the use of services for drug users; the awareness of HIV/AIDS-related issues and any effect of such awareness on drug use and sexual behaviour practices and criminal history.
Table I.
Results The Study tics
Group
-
background
characteris-
As reported elsewhere [Z], the 115 respondents were divided into four subgroups defined on the basis of the nature and frequency of their illicit substance use. Alcohol and tobacco use were not included in this categorisation since the primary concern of this study was patterns of illicit substance use. Only one respondent in this study group had reportedly
Background characteristics.
Sex Male Female Age Mean (median) years S.D. Marital status Single Married/ cohabiting Divorced/ separated Currently employed Yes No Had prison sentence Yes Age left education Under 16 years Over 16 years
Sub-group 1 71 = 26
Sub-group 2 n = 32
Sub-group 3 n = 28
Sub-group 4 n = 27
20 8
20 12
18 10
21 6
28.6 (26) 5.92
26.8 (24) 8.01
21.8 (21) 4.99
25.7 (25) 5.18
15 11
20 9
21 7
18 5
2
3
0
4
21 7
21 11
8 20
0 27
x2 = 41.O;df = 3;p < 0.01
5
14
16
23
x2 = 2&l;@ = 3;p< 0.01
3 25
11 21
21 7
18 9
x2 = 29.9; df = 3; p < 0.01
21
never had an alcoholic drink and four respondents reported never having smoked cigarettes. The four sub-groups were as follows: Subgroup1 (n = 28lCannabisusers Subgroup 2 (n = 32) Cannabis use plus at least monthly use of one or more non-opiates (i.e., amphetamines, solvents, hallucinogens, benzodiazepines, cocaine). Subgroup 3 (n = 28) Cannabis use and/or at least one non-opiate plus opiates on a maximum of 149 days in the 12 months preceding interview. Subgroup 4 (n = 27) As Subgroup 3, but with opiate use on a minimum of 150 days in the preceding 12 months. The sex ratio was approximately 2:l (79 males, 36 females). Respondents’ ages ranged from 16- 41 years with the mean age of the total study group being 25.7 years. The majority of respondents in all subgroups were unmarried, although a larger proportion of the cannabis only users were married or cohabiting. Many respondents were, however, in ‘stable’ relationships, although this was a selfdefined term and did not necessarily indicate a longstanding association (Table Il. Table I also shows that a significant difference emerged between the numbers of those in each sub-group who were currently employed.
Table
II
Initiation
to licit and illicit substances
Opiate users - both moderate and heavy, were significantly more likely to be unemployed than were other respondents (x2 = 41.0, df = 3, P < 0.011. Opiate users were also significantly more likely than other respondents to have served a prison sentence (x2 = 28.1, df = 3, P< 0.011 and to have left full time education under 16 years of age (x2 = 29.9,df = 3,P< 0.011. Table II shows the ages at which respondents had been initiated into the use of thirteen substances, legal and illegal, and the numbers who had used each substance. The use of legal substances are seen to be initiated at a younger age and by a greater number of respondents than that of most illegal substances. All respondents had used cannabis. Fewer reported having used the other illicit drugs. Heroin had only ever been used by 43 individuals. The most commonly used substances (with the exception of alcohol and tobacco) were, in descending order: cannabis, amphetamines, tranquillisers, hallucinogens, analgesics (including Temgesic (buprenorphinel and DF118 (dihydrocodeine)), glue and other solvents, barbiturates, cocaine, heroin, and, finally, diconal/palfium and methadone. Table III indicates the mean age of drug initiations reported by those in the four subgroups. Few differences in the sequence of
(n = 115).
Substance
Valid 7~ (ever tried)
Cigarettes Alcohol
111 114
Glue/solvents Cannabis Tranquillisers Barbiturates
60 115 80 55
52 100 70 48
14.82 16.01 17.75 18.03
Amphetamines Hallucinogens Painkillers* Heroin
91 77 76 43
79 67 66 37
18.54 18.69 19.02 19.79
Cocaine Diconahpalfium Methadone
46 34 34
40 30 30
20.63 22.20 27.40
*Opiate-based
analgesics,
including
for example,
buprenorphine
%
96.5 99
and dihydrocodeine.
Mean age (years) 13.00 13.68
22 Table III.
Initiation to licit and illicit substances.
Cigarettes Alcohol Solvents Cannabis Tranquillisers Barbiturates Amphetamines Hallucinogens Painkillers** Heroin Cocaine Diconabpalfium Methadone
Sub-group 1 rl = 28
Sub-group 2 n = 32
Sub-group 3 n = 28
Sub-group 4 12= 27
mean (years)
n*
mean (years)
n*
mean n* (years)
mean n* (years)
14.9 14.7 15.6 17.1 18.7 18.9 19.1 19.0 18.9 20.8 22.5 22.5 28.0
26 28 5 28 7 7 16 22 9 5 17 2 1
14.2 13.5 14.8 16.3 18.9 19.3 18.4 18.8 20.1 22.2 22.3 28.5 35.0
32 31 18 32 20 10 26 18 13 5 15 2 1
10.9 13.3 13.9 15.5 16.7 17.3 18.4 18.7 18.0 18.5 17.7 18.6 24.4
12.1 13.3 15.0 15.1 16.7 16.7 18.2 18.3 19.1 17.6 20.0 19.2 22.3
26 28 20 28 26 15 24 16 27 8 7 5 10
27 27 17 27 27 23 25 21 27 25 20 25 22
*Number of respondents who had ever tried a substance. **Opiate-based analgesics, including, for example, Temgesics and DFIWs
Table IV.
Frequency of substance
Cigarettes Alcohol Cannabis Tranquillisers Painkillers Methadone DiconallPalfium Heroin Cocaine Amphetamines Solvents Hallucinogens
use in 12 months preceding interview. Sub-group 1 n = 28
Sub-group 2 n = 32
Sub-group 3 n = 28
Sub-group 4 n = 27
mean (days)
n*
mean (days)
n*
mean (days)
n*
mean (days)
n*
328 209 202 _ -
26 28 28 _
323 158 207 10 -
32 31 32 10 -
_ _
-
_
_
_ _ -
_ _
5 5 154 2
11 11 8 7
358 103 148 87 14 6 _ 6 5 9 83 5
26 28 28 22 27 7 4 3 15 5 9
362 58 178 289 231 89 77 43 35 21 17 7
27 27 27 27 27 18 15 13 8 16 2 3
*Number of respondents who had used a substance in the 12 months preceding interview. N.B. Barbiturates are omitted from this table due to their minimal usage amongst this subject group.
23
Table V.
Reasons
for initiation.
Valid responses
Curiosity To be sociable Friend said was good Persuaded/forced Relieve boredom To avoid withdrawal/substitute
“can’t remember”,
Cannabis N = 103
Opiates N = 27
?l
n
R
%
” to relieve
pressure”,
67 6
65 6
11 1
41 4
5 2 0
5 2 0 .19 3
15 3 2 _
15 3 2 -
10 -
10 -
3 0 1 8 3 _
11 0 4 30 11 _
and miscellaneous
patterns
Company
Valid responses
others.
use was also reported by the moderate opiate users in subgroup 3. Heavy opiate users (subgroup 41 reported frequent use of tranquilisers and other analgesic painkillers (mainly temgesic and DF1181. Many also reported regular use of other substances such as methadone or diconal (dipipanonel (For more details see Morrison and Plant 1990)[2]. Note that heroin does not appear as one of the most frequently used substances amongst the opiate users interviewed for this study.
Alcohol, tobacco and cannabis were the most commonly used substances amongst the study group as a whole. Table IV shows the frequency (mean days) of use in each subgroup, in the 12 months preceding interview. Subgroups 2 and 3 reported the highest levels of solvent use. A high level of tranquiliser Table VI.
O/O
56 16
events are evident. What is notable however, is that licit prescribed substances such as tranquillisers (most commonly diazepam and temazepaml and barbiturates (e.g. tuinal, seconal and nembutall had first been used at slightly earlier mean ages by current opiate users than by non-opiate users. Consumption
%
59 17
20 3
Other reasons* Don’t know why *Included
Alcohol N = 106
Reasons for initial use of alcohol, cannabis and opiates
Table V shows the reasons given for initial use of alcohol, cannabis and opiates. (Opiates
at first use. Opiates N = 27
Cannabis N = 103
Alcohol N = 106
N
%
N
Group of friends Sibling/relative
46 33
43 31
63 9
61 9
15 0
55 0
One friend Spouse/partner Alone Can’t remember Other company
11 2 4 7 3
10 2 4 7 3
22 5 2 1 1
21 5 2 1 1
6 3 1
22 11 4 0 8
N
%
%
2*
*These two respondents had first tried opiate-based painkillers with a cellmate during a period of imprisonment. There is some missing data on these items hence the ‘ns’ vary from table to table, the main reason for this being that although a respondent may have used a substance, if it had not been used on a least a monthly basis in the previous 12 months further details of the use of this substance were not collected.
24 Table VII.
Alcohol was often used initially as a means of “being sociable” (16%). Only 6% and 4% respectively cited “being sociable” as reasons for cannabis and opiate initiation. Being “told by friends that it was good” was the reason for initiation to alcohol in 5% of cases, to cannabis in 15% and to opiates in 11%. No-one claimed to have been persuaded or forced to try opiates, with only small numbers giving this as a reason for first using alcohol or cannabis. “Boredom” was cited as a reason for trying cannabis by two respondents. One gave this as the reason for first opiate use. Groups of friends emerged as the most important influence for the first use of all substances. Slightly more illicit drug initiations reportedly took place with friends than was the case for first use of alcohol. Not surprisingly, alcohol initiations were more likely to have occurred in the company of a relative (Table VI).
Source of first use.
Valid responses
Cannabis 103 %
Opiates 26 %
Friend Relative
81 9
79 9
10 2
38 8
Dealer GP (prescribed) Other source*
12 -
12 -
7 -
27 12 15
4
*Two respondents received their first opiate from a cellmate during a period of imprisonment. Another claims to have been told where someone bad “hidden” a “stash” and had stolen them. The fourth first tried opiates by stealing from a parent’s prescribed supply.
here included any of the following; heroin, analgesic painkillers, e.g., DF118, Temgesic, Diconal or Palfium, opium, morphine). “Curiosity” was the most frequently cited reason for first use of these 3 substance types (56,65 and 41%. respectively). Opiates used in the previous 12 months were primarily prescribed substances, e.g. DF118’s or Temgesic, and although these may not have been the first opiate respondents had tried, they may be the only ones details were gathered on. Therefore, the 36% citing “withdrawal” as a reason for taking an opiate, generally referred to individuals who had first taken DF118’s or temgesics as a means of alleviating heroin withdrawals. Table VIII.
Drug initiations Table VII indicates the sources of each substance on the first occasion of use. It is obvious that cannabis most frequently came from a friend, whereas opiates were almost as likely to have been obtained from a dealer. This question was not included in the alcohol section. However, discussions with respondents sug-
Sex differences in adverse consequences resulting from alcohol consumption W = 102).
Problem reported
Males N = 72
Total N = 102
Females N = 30
n
O/c
n
%
rl
%
Involved in violence* Arguments with partner/s
49 38
68 53
14 18
47 60
63 56
62 55
Arguments with family Arguments with friends Trouble with police** Been banned from premises Financial problems Split up with partner/s Health problems Been imprisoned Problems at work Lost job
38 40 42 38 23 20 16 17 14 11
53 56 58 53 32 28 22 24 19 15
16 14 7 10 7 8 4 3 -
53 47 23 33 23 27 13 10 -
54 54 49 48 30 28 20 17 17 11
53 53 48 47 29 27 20 17 17 11
*Chi-squared test (df = 3) P < 0.05. **Chi-squared
test (df = 3) P < 0.01.
25
Opiate users were significantly more likely than other respondents to report having been banned from premises (x2 = 12.24, df = 3, P < 0.011, having had trouble with the police (x2 = 13.08, df = , 3, P < 0.011 and being involved in alcohol-related violence (x2 = 11.93, df = 3, P < 0.01). Respondents’ alcohol consumption, in terms of units* of alcohol consumed on the last drinking occasion, is seen to be fairly high amongst respondents as shown in Table X. Opiate using males drank substantially more alcohol on the last drinking occasion than nonopiate using males. The females who used opiates heavily also reported drinking larger quantities than did women in the other three sub-groups.
gest that alcohol was available in the homes of friends or relatives and was first used either with or without parental knowledge. Problems attributed to alcohol use The pattern of drug-related problems reported by this study group has been described elsewhere [2]. Attention is now focussed upon their self-reported levels of alcohol - related problems. Respondents were asked whether or not they had ever experienced any of a list of 12 adverse consequences which they attributed to their own drinking behaviour. The list varied greatly in the severity of consequences, as shown in Table VIII. The most frequently experienced ‘problem’ was violence (62%). Females were significantly less likely to report either involvement in violence or trouble with the police as a result of their drinking. Arguments with partners, family and friends were commonly experienced by both sexes. Seventeen respondents, all males, reported having been imprisoned as a result of their drinking. Table IX, divides respondents into the four drug using subgroups. Only three problems differed significantly according to subgroup.
Table IX.
Sub-group differences in adverse consequences
Problems reported
Arguments with family Arguments with friends Arguments with partners(s) Split up with partner(s) Health problems Money problems Problems at work Lost a job Beenbanned’ Trouble with police** Imprisoned Involved in violence***
Discussion The use of licit substances such as alcohol and tobacco is more prevalent in the United Kingdom than is the use of illicit substances. Furthermore illicit drug use is often preceded by the use of legal drugs [3,5,9 - 111. This is supported by the data obtained from the 115 respondents in this study. Alcohol and
resulting from alcohol consumption (n = 102).
Sub-group 1
Sub-group 2
Sub-group 3
Sub-group 4
It
%
12
o/o
n
%I
n
%
15 9 11 4 2 7
54 32 39 14 7 25
13 17 20 7 4 6
16 17 13 10 7 11
59 63 48 37 26 41
10 11 12 7 7 6
56 61 67 39 39 33
4 3 9 7 1 12
14 11 32 25 4 43
3 1 10 12 2 15
45 59 69 24 14 21 10 3 34 41 7 52
6 3 18 17 7 21
22 11 67 63 26 78
4 4 11 13 7 15
22 22 61 72 39 83
Chi-squared test: *12.24; **13.08; l**11.93 fdf = 3)P < 0.01.
26
Table X.
Male Female
Units*
of alcohol
consumed
on last drinking
occasion
(trimmed
mean).
Sub-group 1
Sub-group 2
Sub-group 3
Sub-group 4
6.3 5.1
6.8 7.8
16.4 7.1
18.7 18.0
*“Unit” defined as either half a pint of ordinary beer, lager, stout Each unit contains approximately 1 centilitre of absolute alcohol.
tobacco use were first experienced at an early age with the use of one or both tending to continue to become part of later multiple substance use. Other drugs, such as solvents, were often reported to have been used at an earlier stage in respondents drug use “careers” but were generally discarded either as individuals aged (i.e., maturing out), or as they were initiated in the use of other substances [12- 131. “Curiosity” was given most frequently as the reason for first using alcohol, cannabis and opiates. Alcohol was more often used on the first occasion as a means of “being sociable”. Slightly higher percentages of initiations to cannabis and opiates took place whilst in the company of friends, than did alcohol initiations. In addition, friends were most often the source of cannabis on the first occasion, whereas opiates were almost as likely to come from a dealer. Peer group pressure can play an active role not only in drug initiations but also in switching substances in preference of another, or in ceasing to use a drug altogether. These data are similar to that reported in many other studies [4,14- 191. The availability of legal substances such as alcohol and tobacco provide greater opportunities for use and their social acceptability explains why, for most young persons, they will be the first, if not the only, psychoactive substances tried. Amongst opiate users in Edinburgh, there has been a marked reduction in the availability of street heroin over the past few years [20]. This has, in part, led to an increased reliance on prescribed substances such as Valium, Temazepam, Temgesic and DF118. These substances are obtained through either legitimate pre-
or cider,
or a single
measure
of spirits
or a glass
of wine.
scriptions or on the black market. The first use of these substances was, for some respondents out of a need to alleviate withdrawals, mainly from heroin. Therefore, the main role of such drugs was initially that of substitutes. This has also been noted in other areas of Britain [2123]. A high level of adverse consequences (social, financial, legal, etc.1 resulting from alcohol use were reported by this study group. It has been suggested [18,24 - 251 that since the majority of illicit substance users are poly-drug users (including both licit and illicit psychoactive substances) it is difficult to distinguish negative effects caused by any single drug. However, this paper is concerned with the negative effects respondents themselves attributed to their alcohol consumption. It is interesting that within this study group alcohol was blamed by respondents for a greater number of adverse experiences than were illicit drugs [2]. Twentysix respondents reported having experienced no negative consequences of drinking. However, over half of the 25 respondents who reported no negative consequences of illicit drug use were cannabis-only users. Females across each of the four sub-groups were significantly less likely to report involvement in violence or trouble with the police as a result of their drinking behaviour. Opiate users on the other hand were more likely to report having been involved in alcohol-related violence, trouble with the police, and having been banned from premises. It has been noted that young males, particularly those in manual occupations, are often the heavist drinking group in a community and that
27
problem drinking is increasing among females [ll]. Amongst this study group it would appear that although drinking occasions may be fewer, opiate-using males drink in substantially larger quantitities than non-opiate using males. The two females using opiates on a “heavy” basis also showed unusually high levels of alcohol consumption [26 - 271.
References 1 2 3 4 5 6
Conclusions
These results confirm the commonplace use of a multiplicity of legal and illegal drugs amongst regular users of illicit substances. Multiple substances were being consumed on a regular basis by both opiate and non opiate users. A limitation of the data is that specific time periods were not identified for the experiences reported; accordingly, the adverse effects of alcohol use discussed could have occurred at any stage in the drug users life. It must also be remembered that the experience of drug problems (whether alcohol or illicit drugs) is not necessarily a permanent state. Many people may experience adverse effects due to drinking or drug use without necessarily developing chronic problems [ll]. The phenomenon of ‘maturing out’ of drug problems is well documented [12 - 131 and is to be assessed during the follow-up phase of this study. These results lend weight to the view that preventive responses to illicit drug use should take account of the social influences upon drug use in addition to the experience of negative consequences which may result from such use. Negative reinforcement activated within ones peer group possibly using exusers or more responsible users could be an effective means of educating users towards safer, less problematic modes of substance use. Acknowledgements
7 8 9
10
11 12 13 14
15
16
17
18
19 20
21
22 23 24
This study was funded by the Scottish Home and Health Department with additional support from the Scotch Whisky Association. Any opinions expressed are those of the authors and are not necessarily representative of those of the funding bodies.
25 26 27
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and
Drinking
H.M.S.O.,
London,
