541661
research-article2014
IJOXXX10.1177/0306624X14541661International Journal of Offender Therapy and Comparative CriminologySaddichha et al.
Article
Stimulants and Cannabis Use Among a Marginalized Population in British Columbia, Canada: Role of Trauma and Incarceration
International Journal of Offender Therapy and Comparative Criminology 2015, Vol. 59(13) 1487–1498 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0306624X14541661 ijo.sagepub.com
Sahoo Saddichha1, Gregory R. Werker2, Christian Schuetz3, and Michael R. Krausz3
Abstract High rates of substance use, especially cannabis and stimulant use, have been associated with homelessness, exposure to trauma, and involvement with the criminal justice system. This study explored differences in substance use (cannabis vs. stimulants) and associations with trauma and incarceration among a homeless population. Data were derived from the BC Health of the Homeless Study (BCHOHS), carried out in three cities in British Columbia, Canada. Measures included sociodemographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ), and the Mini International Neuropsychiatric Interview (MINI) Plus. Stimulant users were more likely to be female (43%), using multiple substances (3.2), and engaging in survival sex (14%). Cannabis users had higher rates of lifetime psychotic disorders (32%). Among the incarcerated, cannabis users had been subjected to greater emotional neglect (p < .05) and one in two cannabis users had a history of lifetime depressive disorders (p < .05). Childhood physical abuse and Caucasian ethnicity were also associated with greater crack cocaine use. One explanation for the results is that a history of childhood abuse may lead to a developmental cascade of depressive symptoms and other psychopathology, increasing the chances of cannabis dependence and the development of psychosis.
1Melbourne
Health, Sunshine, Victoria, Australia for Health Evaluation and Outcome Sciences, University of British Columbia, Canada 3Department of Psychiatry, University of British Columbia, Canada 2Centre
Corresponding Author: Sahoo Saddichha, Senior Psychiatry Registrar, Melbourne Health, 4a Devonshire Road, Sunshine, Victoria, 3020, Australia. Email: [email protected]
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Keywords homeless, cannabis, stimulants, incarceration, trauma
Introduction Stimulants such as cocaine, amphetamines, and crystal methamphetamine, along with cannabis, are the most common drugs of abuse consumed worldwide (World Drug Report, 2011). Cannabis, in particular, is the most commonly used illicit substance among young adults, with a lifetime prevalence of 51.9% and about 18.1 million current users in the United States in 2011 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). The lifetime prevalence of cocaine use has been estimated at 12.4% among young adults in the United States (including crack use; SAMHSA, 2011). Corresponding lifetime prevalence for methamphetamine use was 8.5% in 2008 (SAMHSA, 2008) with significant cultural and regional differences having been observed. This phenomenon of drug use is further complicated by the fact that nearly 40% of all emergency drug-related visits today are accounted for by stimulants, which are also counted as among the top three causes of drug-related deaths (SAMHSA, 2006). Unfortunately, accompanying these substances’ high rates of use are their associations with criminal involvement and social marginalization (Greenberg & Rosenheck, 2010; Grinman et al., 2010; Hadland, Marshall, Kerr, Qi, Montaner, & Wood, 2011; McNiel, Binder, & Robinson, 2005). In addition, stimulants and cannabis have been linked to severe mental disorders (Fiorentini et al., 2011; Grant et al., 2012; Marshall & Werb, 2010; Moore et al., 2007; Saddichha, Sur, Sinha, & Khess, 2010; Smart, 1991). Yet both groups of drugs also differ in their effects, their associations with physical and mental disorders and their prevalence. To fully study all environmental impacts, one would need to evaluate such differences in epidemiological studies where natural history of the substance use in question can be studied. In addition, there is increasing appreciation of the fact that these drugs of abuse are intricately linked to the phenomenon of childhood trauma and living on the street (Cuellar, Snowden, & Ewing, 2007; Weitzman, Knickman, & Shinn, 1992; White, Chafetz, Collins-Bride, & Nickens, 2006). Previous literature on homeless populations indicates an estimated range of 41% to 84% of substance use disorder in this population (Gonzalez & Rosenheck, 2002; North, Eyrich, Pollio, & Spitznagel, 2004), among which stimulant use has been found in nearly 8% to 22% (Sara et al., 2012; Teesson, Hodder, & Buhrich, 2000) and cannabis use disorder in 22% to 78% (Sara et al., 2012; Teesson et al., 2000). Substance use and homelessness pose specific burdens due to rendering the victims vulnerable to abuse, poor mental and physical health, and increased victimization. This is more so, especially among the more vulnerable groups like women (Tyler & Cauce, 2002) and youth (Slesnick & Prestopnik, 2005). In fact, in recent times, the homeless demographic increasingly represents an epidemiological population untainted and unrepresented by previous studies and hence has little chance of showing overlap with other studies. Such an epidemiological
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population is important to study because it represents a group with minimal access to physical and mental health services, disability services and other rehabilitation services and in whom substance use frequently develops. However, studies of the homeless are difficult to conduct because these vulnerable urban populations represent a hidden and very mobile demographic that is not easily sampled by traditional research methods. Because of their high rates of residential instability and reduced access to health services, the homeless therefore are underserved and understudied. In addition, their typically high levels of substance use also tend to impact their options for reintegration and housing, and for recovery from their mental challenges. Many previous studies of the homeless have neither used standardized diagnostic instruments nor trained raters, which compromises the validity of the diagnoses and impedes replicability and comparisons of the results across studies. Even among those studies that have used assessments based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), there are wide variations, partly due to differences in recruitment procedures and populations, time of assessment, and inability or unwillingness to record substance use comprehensively. This article therefore evaluates substance use among a homeless population in Canada and attempts to (a) explore substance use differences—chiefly cannabis and stimulants—which are the two most common drugs of use and (b) identify links between these substances and the incarceration and trauma that are associated with the use of these drugs.
Method Sample Data were derived from the BC Health of the Homeless Study (BCHOHS) which randomly sampled homeless populations from three cities in British Columbia, Canada: the large urban centre of Vancouver (n = 250), the midsized city and capital of the province Victoria (n = 150), and the more remote and rural northern city of Prince George (n = 100), between May and September 2009. These participants were at least 19 years of age, able to give informed consent, and self-identified as being homeless. Homelessness was defined as living on the street, in a shelter, couch surfing or having no fixed address, as has been used in previous studies originating from this region. A significant (15%+) portion of women, young people (aged 19-25), and Aboriginal participants were recruited through purposive sampling due to general vulnerabilities that these groups face. The first half of the sample was restricted to those termed “absolutely homeless,” or living on the streets. This group was recruited via street outreach, at drop-in centres, at food banks and through service staff. The second half of the sample was recruited randomly from shelters. Shelter beds were randomized, then selected shelter beds received a card with an invitation to participate in the study, and to book an appointment. To determine housing status of potential participants recruited from services and outreach centres, outreach staff was consulted.
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Procedure Face-to-face interviews were conducted for one session by trained interviewers. Interviews were administered primarily in a research office, although some interviews took place at the site of recruitment, where participants felt most comfortable. Existing homeless outreach and drop-in centre teams were contacted with a request to help with recruiting. To recruit individuals living in shelters, research assistants visited all available homeless shelters in Victoria and Prince George, and selected shelters in Vancouver. Recruitment was usually carried out Monday to Friday during the daytime and on occasional early nights and weekends. Research assistants trained as raters administered the interviews; most of the research assistants had previous experience surveying this population. Prior to participation, participants were given a detailed description of the study and were then given a choice to provide informed consent. All consenting participants received US$30 whether or not the interview was completed. The Behavioural Research Ethics Board of the University of British Columbia and the Providence Health Care Research Institute approved the ethics.
Measures Demographic information collected included age, marital status, housing situation, education, source of income, and social contacts. One of the questions asked was about the use of commercial sex as the only means of income which has been used as “survival sex” in this article. Participants were also asked whether they had ever been in prison, jail or juvenile detention overnight or longer. They were also asked to identify which ethnic group/descent they belonged to. The MINI Plus (Sheehan et al., 1998) is based on the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychological Association, 1994) and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Administered as a structured clinical interview, it is designed to assess Axis I substance use disorders and mental disorders and Axis II antisocial personality disorder. Reliability and validity of the MINI Plus has been demonstrated in several studies in North America and Europe (Sheehan et al., 1998). Lifetime and current mental and substance use disorders were derived from the MINI Plus. In addition, the Maudsley Addiction Profile (MAP; Marsden, Gossop, & Stewart, 1998) was used to determine further details of substance use including frequency, amount and mode of use. We also used the Childhood Trauma Questionnaire– Short Form (CTQ-SF; Bernstein et al., 2003), which is a retrospective self-report inventory that assesses different types of childhood maltreatment on five subscales: Physical Abuse, Emotional Abuse, Sexual Abuse, Physical Neglect, and Emotional Neglect. For this article, from the entire sample of the homeless (n = 500), we initially identified a group of participants who reported stimulants as their substance of preference, and a group that reported cannabis as their substance of preference. Although most
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participants had tried and had been using several substances, we only included the current, regular, and most problematic substance of use as the substance of choice. We combined cocaine, crack cocaine, amphetamines, and crystal methamphetamine use into a single group of Stimulant users (n = 220) and compared it with the other group of Cannabis users (n = 189), which were the two largest group of substance users in our sample.
Statistical Analyses The sociodemographic characteristics of the sample were described using frequencies and means with standard deviations (SD) for continuous variables and using counts and percentages for categorical variables. Prevalence rates for mental health disorders, substance use disorders, and childhood trauma were calculated using counts and percentages. Differences between the two groups were calculated using chi-square for categorical variables and t test for continuous variables.
Results Part 1: Differences Between Cannabis and Stimulant Users in the Entire Sample When the entire sample was compared for stimulant use versus cannabis use (Table 1), significant differences were observed mainly for gender and number of substances used, with females preferring stimulants over cannabis (43% vs. 31%), while males were nearly equally divided between both (p = .008). Moreover, stimulant users were all poly-substance users, with this group reporting use of three or more drugs, than the cannabis group (p < .001). Stimulant users also dealt with drugs in significantly larger amounts, both for personal use and as a source of income (p < .05), as well as engaged in survival sex more often (14% vs. 8%; p = .04). There were no differences in either childhood trauma or adult abuse rates between the two groups. However, among psychiatric diagnoses on the MINI, cannabis users were diagnosed with psychotic disorders more often than stimulant users (32% vs. 24%; p = .05). A nonsignificant trend was also observed for lifetime depressive disorders, with cannabis users developing depression (49%) more often than stimulant users (41%).
Part 2: Differences Between Cannabis and Stimulant Users Among the Incarcerated In the second part of the analysis, we explored possible links between incarceration, trauma and the substance being used, having observed a nonsignificant association earlier. Because previous studies have also found significant links between incarceration and substance use, we analysed differences between the two groups in relation to incarceration (Table 2). Once again, gender continued to play an important role, with females continuing to prefer stimulants (63%) over cannabis (36%). With regard to
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Table 1. Sociodemographic and Clinical Differences for Entire Sample (N = 409). All participants
Stimulants
Cannabis
p value
Age (in years) (M, SD) Gender Male Female Age of first use of drug (in years) (M, SD) Ethnicity Caucasians Aboriginals Number of substances used Selling drugs days Selling drugs times Engaging in unsafe sex (times) Survival sex No Yes Been in prison Used emergency rooms Times used emergency room Childhood trauma scores (M, SD) Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect Adult abuse Emotional abuse Physical abuse Sexual abuse Psychiatric diagnoses (lifetime) Psychotic disorders Bipolar disorder Depressive disorders Post-traumatic stress disorder Panic disorder Agoraphobia Generalised Anxiety Disorder
36.9 (10.5)
37.6 (11.7)
.572
124 (56.6%) 95 (43.4%) 12. 9 (14.3)
130 (68.8%) 59 (31.2%) 12.0 (17.5)
.008 .579
130 (59.0%) 90 (41.0%) 3.2 (1.5) 3.7 (9.1) 4.3 (15.5) 3.61 (13.3)
116 (61.4%) 73 (38.6%) 2.7 (1.2) 1.8 (6.6) 1.5 (12.5) 3.2 (12.7)
.63 .001 .017 .049 .724
190 (86.4%) 30 (13.6%) 154 (70.0%) 118 (53.6%) 02.3 (7.7)
174 (92.1%) 15 (07.9%) 128 (67.7%) 104 (55.0%) 1.4 (4.8)
.04 .67 .43 .19
14.20 (5.4) 12.04 (5.8) 11.04 (7.0) 13.88 (5.4) 11.04 (4.3)
13.70 (5.89 11.41 (5.7) 10.22 (6.5) 14.62 (5.5) 11.36 (4.6)
.37 .28 .22 .17 .47
170 (79.1%) 143 (66.8%) 66 (30.7%)
143 (76.5%) 129 (69.0%) 53 (28.3%)
.55 .67 .66
53 (24.1%) 50 (22.7%) 90 (40.9%) 44 (20.0%) 41 (18.6%) 90 (40.9%) 44 (20.0%)
60 (31.7%) 52 (27.5%) 92 (48.7%) 43 (22.8%) 39 (20.6%) 73 (38.6%) 38 (20.1%)
.05 .30 .07 .54 .87 .69 1.00
substance, stimulant users continued to use more substances than cannabis users (p = .003). However, when a history of childhood trauma was analysed on the CTQ, no significant differences were noted between the two groups with the exception of
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Saddichha et al. Table 2. Differences Among the Previously Incarcerated (n = 282). Participants—Previously Incarcerated (n = 282) Age (in years; M, SD) Gender Male Female Ethnicity Caucasians Aboriginals No of substances (M, SD) Adult abuse Emotional abuse Physical abuse Sexual abuse Childhood trauma scores (M, SD) Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect Psychiatric diagnoses Depressive disorders Psychotic disorders Bipolar disorders PTSD Panic disorder Agoraphobia GAD
Stimulants
Cannabis
37.4 (10.2)
38.5 (11.2)
p value .38
92 (49.7%) 61 (63.5%)
93(50.3%) 35 (36.5%)
.03
87 (52.7%) 70 (50.9%) 3.3 (1.5)
78 (47.3%) 50 (49.1%) 2.7 (1.3)
.35 .003
123 (82.0%) 101 (67.8%) 46 (30.7%)
97 (76.4%) 90 (70.9%) 41 (32.3%)
.29 .60 .79
14.3 (5.2) 11.9 (5.7) 11.4 (7.3) 13.8 (5.3) 11.1 (4.2) 57 (37.0%) 36 (23.4%) 32 (20.8%) 33 (21.4%) 28 (18.2%) 64 (41.6%) 33 (21.4%)
14.4 (5.5) 11.9 (5.7) 10.5 (6.5) 15.2 (5.1) 11.7 (4.7) 64 (50.0%) 35 (27.3%) 33 (25.8%) 24 (18.8%) 26 (20.3%) 43 (33.6%) 24 (18.8%)
.91 .99 .28 .02 .25 .03 .49 .32 .65 .60 .18 .65
emotional neglect (p = .02) which was higher among cannabis users than stimulant users. Similarly, on the psychiatric diagnosis on the MINI, only lifetime depressive disorders was higher among cannabis users (p = .03) when compared with stimulant users.
Part 3: Within-Group Differences Among Stimulant Users With Past History of Incarceration (Data Not Shown) We further pursued a within-group analysis in the largest group among the incarcerated participants—the stimulant users—to find any other differences between cocaine users and methamphetamine users. Within this group, an ethnic effect was seen (p = .018) with Caucasians preferring crack cocaine (n = 86; 76.1%) to methamphetamine
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(n = 27; 23.9%) when compared with other ethnicities (predominantly Aboriginal, in our sample). No differences were noted in other sociodemographic characteristics including age, gender, service use, or survival sex. On the CTQ, only a history of physical abuse (p = .05) was also linked to greater crack cocaine use (78.5%) than methamphetamine use (21.5%). Other domains of childhood trauma on the CTQ and psychiatric diagnoses on the MINI were insignificant.
Discussion This study presents significant differences between stimulant and cannabis use in a homeless population and also observes links between incarceration, trauma, psychiatric illness, and substance use. The most significant finding of this study was that stimulant users were more likely to be female and also more likely to be poly-substance users. Similar high use of stimulants among the female gender has been observed in other studies (Pope, Falck, Carlson, Leukefeld, & Booth, 2011). In line with earlier studies that have found links between survival sex and stimulant use (Chettiar, Shannon, Wood, Zhang, & Kerr, 2010; Semple, Strathdee, Zians, & Patterson, 2011), we observed that stimulant users were twice as likely to be engaging in survival sex, than cannabis users. We also observed cannabis use to be strongly associated with the existence of psychotic disorders (Fiorentini et al., 2011; Moore et al., 2007) as is commonly known. Interestingly, stimulant users were more likely to be dealing with drugs—both buying and selling—than cannabis users. We believe that the effects of cannabis (a depressant), compared with stimulants, as well as the time taken to recover from the effects of cannabis use may be responsible for this observed difference (Saddichha et al., 2010). When we analysed the group of participants that had been previously incarcerated, cannabis use was linked to a diagnosis of lifetime depressive disorders and to a past history of childhood trauma, specifically emotional neglect. Unlike psychosis, however, the evidence for links between depression and cannabis is equivocal. While some studies have observed an increased prevalence of depression among cannabis users (Degenhardt, Hall, & Lynskey, 2003; Gilder & Ehlers, 2012) others have found no such link (Manrique-Garcia, Zammit, Dalman, Hemmingsson, & Allebeck, 2012; Moore et al., 2007). Although our study also suggests a link between depression and cannabis use, there are several confounding factors in our study sample, which make derivation of causal relationships impossible. However, it has been suggested that prolonged intake of cannabis can result in depression through the effects of tetrahydrocannabinol (THC) on serotonin and other neurotransmitters (Degenhardt et al., 2003), or through changes in hippocampal and amygdala volumes (Yucel et al., 2008). In addition, we also observed an association between childhood emotional neglect and cannabis use. This association supports the fact that in several clinical samples of substance use disorders, between one third and two thirds of individuals evince histories of childhood abuse and neglect (Fergusson, Boden, & Horwood, 2008; Harrison, Fulkerson, & Beebe, 1997; Rodgers et al., 2004; Schaefer, Sobieraj, & Hollyfield, 1988). A similar model has also been suggested for cannabis use disorder, where
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childhood maltreatment may lead to a cascade of psychopathology including cannabis dependence (Rogosch, Oshri, & Cicchetti, 2010). However, we believe that a history of emotional neglect may have led to a developmental cascade of depressive symptoms and other psychopathology, further leading to cannabis dependence. Within the incarcerated group using stimulants, we observed a significant association between crack cocaine use and both physical abuse and ethnicity. The link between childhood trauma and crack cocaine use has been supported by several studies that noted an increased risk of cocaine use with a past history of childhood physical abuse (Ducci et al., 2009; Dunlap, Golub, Johnson, & Benoit, 2009). Many crack cocaine users often refer to their use as “To Numb Out and Start to Feel Nothing” (Dunlap et al., 2009). To summarize, this study observed significant differences between stimulant and cannabis users in a homeless sample in Canada, noteworthy of which were the preference among females for stimulants and males for cannabis. Cannabis use was linked to the increased presence of childhood emotional neglect and to a comorbid diagnosis of both psychotic disorders and depressive disorders. Furthermore, within the stimulant group, crack cocaine use was significantly associated with a past history of childhood physical abuse. Our findings, however, must be taken in light of several limitations. In selecting our sample, we used street-based outreach and snowball sampling, approaches that may result in some degree of selection bias. However, the importance of studying the homeless justifies the less-than-perfect sampling techniques required. Finally, it is important to bear in mind that our results draw on cross-sectional rather than longitudinal data. As such, it is inappropriate to draw conclusions regarding temporality and causality regarding the associations between drug use and psychiatric illnesses based on the findings of our study alone. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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research-article2014
IJOXXX10.1177/0306624X14541661International Journal of Offender Therapy and Comparative CriminologySaddichha et al.
Article
Stimulants and Cannabis Use Among a Marginalized Population in British Columbia, Canada: Role of Trauma and Incarceration
International Journal of Offender Therapy and Comparative Criminology 2015, Vol. 59(13) 1487–1498 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0306624X14541661 ijo.sagepub.com
Sahoo Saddichha1, Gregory R. Werker2, Christian Schuetz3, and Michael R. Krausz3
Abstract High rates of substance use, especially cannabis and stimulant use, have been associated with homelessness, exposure to trauma, and involvement with the criminal justice system. This study explored differences in substance use (cannabis vs. stimulants) and associations with trauma and incarceration among a homeless population. Data were derived from the BC Health of the Homeless Study (BCHOHS), carried out in three cities in British Columbia, Canada. Measures included sociodemographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ), and the Mini International Neuropsychiatric Interview (MINI) Plus. Stimulant users were more likely to be female (43%), using multiple substances (3.2), and engaging in survival sex (14%). Cannabis users had higher rates of lifetime psychotic disorders (32%). Among the incarcerated, cannabis users had been subjected to greater emotional neglect (p < .05) and one in two cannabis users had a history of lifetime depressive disorders (p < .05). Childhood physical abuse and Caucasian ethnicity were also associated with greater crack cocaine use. One explanation for the results is that a history of childhood abuse may lead to a developmental cascade of depressive symptoms and other psychopathology, increasing the chances of cannabis dependence and the development of psychosis.
1Melbourne
Health, Sunshine, Victoria, Australia for Health Evaluation and Outcome Sciences, University of British Columbia, Canada 3Department of Psychiatry, University of British Columbia, Canada 2Centre
Corresponding Author: Sahoo Saddichha, Senior Psychiatry Registrar, Melbourne Health, 4a Devonshire Road, Sunshine, Victoria, 3020, Australia. Email: [email protected]
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Keywords homeless, cannabis, stimulants, incarceration, trauma
Introduction Stimulants such as cocaine, amphetamines, and crystal methamphetamine, along with cannabis, are the most common drugs of abuse consumed worldwide (World Drug Report, 2011). Cannabis, in particular, is the most commonly used illicit substance among young adults, with a lifetime prevalence of 51.9% and about 18.1 million current users in the United States in 2011 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). The lifetime prevalence of cocaine use has been estimated at 12.4% among young adults in the United States (including crack use; SAMHSA, 2011). Corresponding lifetime prevalence for methamphetamine use was 8.5% in 2008 (SAMHSA, 2008) with significant cultural and regional differences having been observed. This phenomenon of drug use is further complicated by the fact that nearly 40% of all emergency drug-related visits today are accounted for by stimulants, which are also counted as among the top three causes of drug-related deaths (SAMHSA, 2006). Unfortunately, accompanying these substances’ high rates of use are their associations with criminal involvement and social marginalization (Greenberg & Rosenheck, 2010; Grinman et al., 2010; Hadland, Marshall, Kerr, Qi, Montaner, & Wood, 2011; McNiel, Binder, & Robinson, 2005). In addition, stimulants and cannabis have been linked to severe mental disorders (Fiorentini et al., 2011; Grant et al., 2012; Marshall & Werb, 2010; Moore et al., 2007; Saddichha, Sur, Sinha, & Khess, 2010; Smart, 1991). Yet both groups of drugs also differ in their effects, their associations with physical and mental disorders and their prevalence. To fully study all environmental impacts, one would need to evaluate such differences in epidemiological studies where natural history of the substance use in question can be studied. In addition, there is increasing appreciation of the fact that these drugs of abuse are intricately linked to the phenomenon of childhood trauma and living on the street (Cuellar, Snowden, & Ewing, 2007; Weitzman, Knickman, & Shinn, 1992; White, Chafetz, Collins-Bride, & Nickens, 2006). Previous literature on homeless populations indicates an estimated range of 41% to 84% of substance use disorder in this population (Gonzalez & Rosenheck, 2002; North, Eyrich, Pollio, & Spitznagel, 2004), among which stimulant use has been found in nearly 8% to 22% (Sara et al., 2012; Teesson, Hodder, & Buhrich, 2000) and cannabis use disorder in 22% to 78% (Sara et al., 2012; Teesson et al., 2000). Substance use and homelessness pose specific burdens due to rendering the victims vulnerable to abuse, poor mental and physical health, and increased victimization. This is more so, especially among the more vulnerable groups like women (Tyler & Cauce, 2002) and youth (Slesnick & Prestopnik, 2005). In fact, in recent times, the homeless demographic increasingly represents an epidemiological population untainted and unrepresented by previous studies and hence has little chance of showing overlap with other studies. Such an epidemiological
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population is important to study because it represents a group with minimal access to physical and mental health services, disability services and other rehabilitation services and in whom substance use frequently develops. However, studies of the homeless are difficult to conduct because these vulnerable urban populations represent a hidden and very mobile demographic that is not easily sampled by traditional research methods. Because of their high rates of residential instability and reduced access to health services, the homeless therefore are underserved and understudied. In addition, their typically high levels of substance use also tend to impact their options for reintegration and housing, and for recovery from their mental challenges. Many previous studies of the homeless have neither used standardized diagnostic instruments nor trained raters, which compromises the validity of the diagnoses and impedes replicability and comparisons of the results across studies. Even among those studies that have used assessments based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), there are wide variations, partly due to differences in recruitment procedures and populations, time of assessment, and inability or unwillingness to record substance use comprehensively. This article therefore evaluates substance use among a homeless population in Canada and attempts to (a) explore substance use differences—chiefly cannabis and stimulants—which are the two most common drugs of use and (b) identify links between these substances and the incarceration and trauma that are associated with the use of these drugs.
Method Sample Data were derived from the BC Health of the Homeless Study (BCHOHS) which randomly sampled homeless populations from three cities in British Columbia, Canada: the large urban centre of Vancouver (n = 250), the midsized city and capital of the province Victoria (n = 150), and the more remote and rural northern city of Prince George (n = 100), between May and September 2009. These participants were at least 19 years of age, able to give informed consent, and self-identified as being homeless. Homelessness was defined as living on the street, in a shelter, couch surfing or having no fixed address, as has been used in previous studies originating from this region. A significant (15%+) portion of women, young people (aged 19-25), and Aboriginal participants were recruited through purposive sampling due to general vulnerabilities that these groups face. The first half of the sample was restricted to those termed “absolutely homeless,” or living on the streets. This group was recruited via street outreach, at drop-in centres, at food banks and through service staff. The second half of the sample was recruited randomly from shelters. Shelter beds were randomized, then selected shelter beds received a card with an invitation to participate in the study, and to book an appointment. To determine housing status of potential participants recruited from services and outreach centres, outreach staff was consulted.
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Procedure Face-to-face interviews were conducted for one session by trained interviewers. Interviews were administered primarily in a research office, although some interviews took place at the site of recruitment, where participants felt most comfortable. Existing homeless outreach and drop-in centre teams were contacted with a request to help with recruiting. To recruit individuals living in shelters, research assistants visited all available homeless shelters in Victoria and Prince George, and selected shelters in Vancouver. Recruitment was usually carried out Monday to Friday during the daytime and on occasional early nights and weekends. Research assistants trained as raters administered the interviews; most of the research assistants had previous experience surveying this population. Prior to participation, participants were given a detailed description of the study and were then given a choice to provide informed consent. All consenting participants received US$30 whether or not the interview was completed. The Behavioural Research Ethics Board of the University of British Columbia and the Providence Health Care Research Institute approved the ethics.
Measures Demographic information collected included age, marital status, housing situation, education, source of income, and social contacts. One of the questions asked was about the use of commercial sex as the only means of income which has been used as “survival sex” in this article. Participants were also asked whether they had ever been in prison, jail or juvenile detention overnight or longer. They were also asked to identify which ethnic group/descent they belonged to. The MINI Plus (Sheehan et al., 1998) is based on the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychological Association, 1994) and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Administered as a structured clinical interview, it is designed to assess Axis I substance use disorders and mental disorders and Axis II antisocial personality disorder. Reliability and validity of the MINI Plus has been demonstrated in several studies in North America and Europe (Sheehan et al., 1998). Lifetime and current mental and substance use disorders were derived from the MINI Plus. In addition, the Maudsley Addiction Profile (MAP; Marsden, Gossop, & Stewart, 1998) was used to determine further details of substance use including frequency, amount and mode of use. We also used the Childhood Trauma Questionnaire– Short Form (CTQ-SF; Bernstein et al., 2003), which is a retrospective self-report inventory that assesses different types of childhood maltreatment on five subscales: Physical Abuse, Emotional Abuse, Sexual Abuse, Physical Neglect, and Emotional Neglect. For this article, from the entire sample of the homeless (n = 500), we initially identified a group of participants who reported stimulants as their substance of preference, and a group that reported cannabis as their substance of preference. Although most
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participants had tried and had been using several substances, we only included the current, regular, and most problematic substance of use as the substance of choice. We combined cocaine, crack cocaine, amphetamines, and crystal methamphetamine use into a single group of Stimulant users (n = 220) and compared it with the other group of Cannabis users (n = 189), which were the two largest group of substance users in our sample.
Statistical Analyses The sociodemographic characteristics of the sample were described using frequencies and means with standard deviations (SD) for continuous variables and using counts and percentages for categorical variables. Prevalence rates for mental health disorders, substance use disorders, and childhood trauma were calculated using counts and percentages. Differences between the two groups were calculated using chi-square for categorical variables and t test for continuous variables.
Results Part 1: Differences Between Cannabis and Stimulant Users in the Entire Sample When the entire sample was compared for stimulant use versus cannabis use (Table 1), significant differences were observed mainly for gender and number of substances used, with females preferring stimulants over cannabis (43% vs. 31%), while males were nearly equally divided between both (p = .008). Moreover, stimulant users were all poly-substance users, with this group reporting use of three or more drugs, than the cannabis group (p < .001). Stimulant users also dealt with drugs in significantly larger amounts, both for personal use and as a source of income (p < .05), as well as engaged in survival sex more often (14% vs. 8%; p = .04). There were no differences in either childhood trauma or adult abuse rates between the two groups. However, among psychiatric diagnoses on the MINI, cannabis users were diagnosed with psychotic disorders more often than stimulant users (32% vs. 24%; p = .05). A nonsignificant trend was also observed for lifetime depressive disorders, with cannabis users developing depression (49%) more often than stimulant users (41%).
Part 2: Differences Between Cannabis and Stimulant Users Among the Incarcerated In the second part of the analysis, we explored possible links between incarceration, trauma and the substance being used, having observed a nonsignificant association earlier. Because previous studies have also found significant links between incarceration and substance use, we analysed differences between the two groups in relation to incarceration (Table 2). Once again, gender continued to play an important role, with females continuing to prefer stimulants (63%) over cannabis (36%). With regard to
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Table 1. Sociodemographic and Clinical Differences for Entire Sample (N = 409). All participants
Stimulants
Cannabis
p value
Age (in years) (M, SD) Gender Male Female Age of first use of drug (in years) (M, SD) Ethnicity Caucasians Aboriginals Number of substances used Selling drugs days Selling drugs times Engaging in unsafe sex (times) Survival sex No Yes Been in prison Used emergency rooms Times used emergency room Childhood trauma scores (M, SD) Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect Adult abuse Emotional abuse Physical abuse Sexual abuse Psychiatric diagnoses (lifetime) Psychotic disorders Bipolar disorder Depressive disorders Post-traumatic stress disorder Panic disorder Agoraphobia Generalised Anxiety Disorder
36.9 (10.5)
37.6 (11.7)
.572
124 (56.6%) 95 (43.4%) 12. 9 (14.3)
130 (68.8%) 59 (31.2%) 12.0 (17.5)
.008 .579
130 (59.0%) 90 (41.0%) 3.2 (1.5) 3.7 (9.1) 4.3 (15.5) 3.61 (13.3)
116 (61.4%) 73 (38.6%) 2.7 (1.2) 1.8 (6.6) 1.5 (12.5) 3.2 (12.7)
.63 .001 .017 .049 .724
190 (86.4%) 30 (13.6%) 154 (70.0%) 118 (53.6%) 02.3 (7.7)
174 (92.1%) 15 (07.9%) 128 (67.7%) 104 (55.0%) 1.4 (4.8)
.04 .67 .43 .19
14.20 (5.4) 12.04 (5.8) 11.04 (7.0) 13.88 (5.4) 11.04 (4.3)
13.70 (5.89 11.41 (5.7) 10.22 (6.5) 14.62 (5.5) 11.36 (4.6)
.37 .28 .22 .17 .47
170 (79.1%) 143 (66.8%) 66 (30.7%)
143 (76.5%) 129 (69.0%) 53 (28.3%)
.55 .67 .66
53 (24.1%) 50 (22.7%) 90 (40.9%) 44 (20.0%) 41 (18.6%) 90 (40.9%) 44 (20.0%)
60 (31.7%) 52 (27.5%) 92 (48.7%) 43 (22.8%) 39 (20.6%) 73 (38.6%) 38 (20.1%)
.05 .30 .07 .54 .87 .69 1.00
substance, stimulant users continued to use more substances than cannabis users (p = .003). However, when a history of childhood trauma was analysed on the CTQ, no significant differences were noted between the two groups with the exception of
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Saddichha et al. Table 2. Differences Among the Previously Incarcerated (n = 282). Participants—Previously Incarcerated (n = 282) Age (in years; M, SD) Gender Male Female Ethnicity Caucasians Aboriginals No of substances (M, SD) Adult abuse Emotional abuse Physical abuse Sexual abuse Childhood trauma scores (M, SD) Emotional abuse Physical abuse Sexual abuse Emotional neglect Physical neglect Psychiatric diagnoses Depressive disorders Psychotic disorders Bipolar disorders PTSD Panic disorder Agoraphobia GAD
Stimulants
Cannabis
37.4 (10.2)
38.5 (11.2)
p value .38
92 (49.7%) 61 (63.5%)
93(50.3%) 35 (36.5%)
.03
87 (52.7%) 70 (50.9%) 3.3 (1.5)
78 (47.3%) 50 (49.1%) 2.7 (1.3)
.35 .003
123 (82.0%) 101 (67.8%) 46 (30.7%)
97 (76.4%) 90 (70.9%) 41 (32.3%)
.29 .60 .79
14.3 (5.2) 11.9 (5.7) 11.4 (7.3) 13.8 (5.3) 11.1 (4.2) 57 (37.0%) 36 (23.4%) 32 (20.8%) 33 (21.4%) 28 (18.2%) 64 (41.6%) 33 (21.4%)
14.4 (5.5) 11.9 (5.7) 10.5 (6.5) 15.2 (5.1) 11.7 (4.7) 64 (50.0%) 35 (27.3%) 33 (25.8%) 24 (18.8%) 26 (20.3%) 43 (33.6%) 24 (18.8%)
.91 .99 .28 .02 .25 .03 .49 .32 .65 .60 .18 .65
emotional neglect (p = .02) which was higher among cannabis users than stimulant users. Similarly, on the psychiatric diagnosis on the MINI, only lifetime depressive disorders was higher among cannabis users (p = .03) when compared with stimulant users.
Part 3: Within-Group Differences Among Stimulant Users With Past History of Incarceration (Data Not Shown) We further pursued a within-group analysis in the largest group among the incarcerated participants—the stimulant users—to find any other differences between cocaine users and methamphetamine users. Within this group, an ethnic effect was seen (p = .018) with Caucasians preferring crack cocaine (n = 86; 76.1%) to methamphetamine
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(n = 27; 23.9%) when compared with other ethnicities (predominantly Aboriginal, in our sample). No differences were noted in other sociodemographic characteristics including age, gender, service use, or survival sex. On the CTQ, only a history of physical abuse (p = .05) was also linked to greater crack cocaine use (78.5%) than methamphetamine use (21.5%). Other domains of childhood trauma on the CTQ and psychiatric diagnoses on the MINI were insignificant.
Discussion This study presents significant differences between stimulant and cannabis use in a homeless population and also observes links between incarceration, trauma, psychiatric illness, and substance use. The most significant finding of this study was that stimulant users were more likely to be female and also more likely to be poly-substance users. Similar high use of stimulants among the female gender has been observed in other studies (Pope, Falck, Carlson, Leukefeld, & Booth, 2011). In line with earlier studies that have found links between survival sex and stimulant use (Chettiar, Shannon, Wood, Zhang, & Kerr, 2010; Semple, Strathdee, Zians, & Patterson, 2011), we observed that stimulant users were twice as likely to be engaging in survival sex, than cannabis users. We also observed cannabis use to be strongly associated with the existence of psychotic disorders (Fiorentini et al., 2011; Moore et al., 2007) as is commonly known. Interestingly, stimulant users were more likely to be dealing with drugs—both buying and selling—than cannabis users. We believe that the effects of cannabis (a depressant), compared with stimulants, as well as the time taken to recover from the effects of cannabis use may be responsible for this observed difference (Saddichha et al., 2010). When we analysed the group of participants that had been previously incarcerated, cannabis use was linked to a diagnosis of lifetime depressive disorders and to a past history of childhood trauma, specifically emotional neglect. Unlike psychosis, however, the evidence for links between depression and cannabis is equivocal. While some studies have observed an increased prevalence of depression among cannabis users (Degenhardt, Hall, & Lynskey, 2003; Gilder & Ehlers, 2012) others have found no such link (Manrique-Garcia, Zammit, Dalman, Hemmingsson, & Allebeck, 2012; Moore et al., 2007). Although our study also suggests a link between depression and cannabis use, there are several confounding factors in our study sample, which make derivation of causal relationships impossible. However, it has been suggested that prolonged intake of cannabis can result in depression through the effects of tetrahydrocannabinol (THC) on serotonin and other neurotransmitters (Degenhardt et al., 2003), or through changes in hippocampal and amygdala volumes (Yucel et al., 2008). In addition, we also observed an association between childhood emotional neglect and cannabis use. This association supports the fact that in several clinical samples of substance use disorders, between one third and two thirds of individuals evince histories of childhood abuse and neglect (Fergusson, Boden, & Horwood, 2008; Harrison, Fulkerson, & Beebe, 1997; Rodgers et al., 2004; Schaefer, Sobieraj, & Hollyfield, 1988). A similar model has also been suggested for cannabis use disorder, where
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childhood maltreatment may lead to a cascade of psychopathology including cannabis dependence (Rogosch, Oshri, & Cicchetti, 2010). However, we believe that a history of emotional neglect may have led to a developmental cascade of depressive symptoms and other psychopathology, further leading to cannabis dependence. Within the incarcerated group using stimulants, we observed a significant association between crack cocaine use and both physical abuse and ethnicity. The link between childhood trauma and crack cocaine use has been supported by several studies that noted an increased risk of cocaine use with a past history of childhood physical abuse (Ducci et al., 2009; Dunlap, Golub, Johnson, & Benoit, 2009). Many crack cocaine users often refer to their use as “To Numb Out and Start to Feel Nothing” (Dunlap et al., 2009). To summarize, this study observed significant differences between stimulant and cannabis users in a homeless sample in Canada, noteworthy of which were the preference among females for stimulants and males for cannabis. Cannabis use was linked to the increased presence of childhood emotional neglect and to a comorbid diagnosis of both psychotic disorders and depressive disorders. Furthermore, within the stimulant group, crack cocaine use was significantly associated with a past history of childhood physical abuse. Our findings, however, must be taken in light of several limitations. In selecting our sample, we used street-based outreach and snowball sampling, approaches that may result in some degree of selection bias. However, the importance of studying the homeless justifies the less-than-perfect sampling techniques required. Finally, it is important to bear in mind that our results draw on cross-sectional rather than longitudinal data. As such, it is inappropriate to draw conclusions regarding temporality and causality regarding the associations between drug use and psychiatric illnesses based on the findings of our study alone. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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