Patterns and perceptions of ecstasy use among young, low-income women

Addictive Behaviors 31 (2006) 676 – 685

Patterns and perceptions of ecstasy use among young, low-income women Zhao Helen Wu a,*, Charles E. Holzer III b, Carmen Radecki Breitkopf a, James J. Grady c, Abbey B. Berenson a a

Department of Obstetrics and Gynecology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-0587, United States b Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX, United States c Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, United States

Abstract A significant number of young, low-income women experiment with ecstasy outside of club or rave settings. The current study examined patterns and risk factors of ecstasy use among this group of women. A cross-sectional survey was conducted among 696 women aged 18 to 31 who sought gynecological care from two university clinics in southeast Texas between December 1, 2001, and May 30, 2003. Fifteen percent of participants reported ever using ecstasy. Of those, over 90% used it at a friend’s home. Compared with women who used only marijuana or other illicit drugs, ecstasy users were more likely to be white, use a larger number of other drugs, be willing to use drugs in the future, and have more friends who used drugs. Fewer ecstasy users strongly disapproved of adult drug use than users of other illicit drugs. Future interventional efforts should target young, low-income women to prevent future experimentation with illicit drugs. D 2005 Elsevier Ltd. All rights reserved. Keywords: Methlenedioxy-methamphetamine; MDMA; Ecstasy; Risk factors; Low income; Women

Methlenedioxy-methamphetamine (MDMA) or ecstasy use in all-night dance parties or bravesQ became popular among American youth in the early 1990s and led to a startling increase in ecstasy use.

* Corresponding author. Tel.: +1 409 772 1021; fax: +1 409 747 0366. E-mail address: [email protected] (Z.H. Wu). 0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2005.05.051

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This increase was most prominent from 1998 to 2001 (Schwartz & Miller, 1997) and leveled off from 2002 to 2003 (Johnston, O’Malley, Bachman, & Schulenberg, 2003). Higher rates (50%–80%) were found among rave and club attendees (Gross, Barrett, Shestowsky, & Pihl, 2002) and juvenile detainees (16%–18%) (Yacoubian, Arria, Fost, & Wish, 2002), and lower rates were reported in the general populations (Substance Abuse and Mental Health Services Administration (SAMHSA), 2003). The most distinct characteristic of these ecstasy users was polydrug use (Scholey et al., 2004), particularly the greater use of illicit central nervous system stimulants and hallucinogens. In addition, the increased use of ecstasy has been related to the more intensive patterns of ecstasy use (Scholey et al., 2004). However, most studies have focused on students, rave/club attendees, and certain at-risk subgroups such as juvenile detainees or men who have sex with men (Gross et al., 2002; Yacoubian et al., 2002). Only a few studies of the general population outside the United States have reported a pattern of occasional ecstasy use; e.g., taking one or two ecstasy tablets on a typical-use occasion, with use often occurring several times per month (Degenhard, Barker, & Topp, 2003). Although these studies provided valuable information, few epidemiological studies have targeted at-risk populations other than students and rave/ club attendees. An important at-risk group that needs more study is women, particularly those from lower socioeconomic groups. These women have reported higher rates of illicit drug use (Comerci & Schwebel, 2000). These women also have low levels of literacy and may not be aware of the adverse consequences of ecstasy use (Comerci & Schwebel, 2000). For instance, ecstasy use has been shown to cause hyperthermia, seizures, hepatotoxicity, hyponatraemia, retinal hemorrhage, psychological problems and psychiatric disorders, and even death (Parrott et al., 2002; Parrott, Milani, Parmar, & Turner, 2001; Verheyden, Henry, & Curran, 2003). These adverse consequences were found to be especially detrimental to young women (Topp, Hando, Dillon, Roche, & Solowij, 1999). In addition to the adverse health effects to women themselves, ecstasy use may also increase infant congenital defects (McElhatton, Bateman, Evans, Pughe, & Thomas, 1999). Furthermore, children can suffer developmental problems from inadequate care and nurturing often found among drug-using mothers (Ornoy, Segal, Bar-Hamburger, & Greenbaum, 2001). Thus, maternal drug use has implications—not only for their own health but also for the health and well-being of their children. Despite these potential risks and consequences of ecstasy use among young, low-income women, the prevalence and perceptions of ecstasy use as well as other illicit drug use have not yet been adequately explored (Topp et al., 1999). Another known risk factor is social environment, where peer pressure can exert a negative influence on youth to use substances (Andrews, Tildesley, Hops, & Li, 2002; Urberg, Luo, Pilgrim, & Degirmencioglu, 2004). Among young, low-income women, a large percentage reported that they had lower levels of education, worked part-time or at a minimum wage, tended to be independent and lived on their own at a young age, and were abused physically or sexually (Wu, Berenson, & Wiemann, 2003). Their peers can be their main source of social support, which contributes to young adult substance use (Andrews et al., 2002; Urberg et al., 2004). Thus, we hypothesize that peer pressure – which constitutes a part of the social environment where young, low-income women reside – may be strongly associated with ecstasy use, as well as other illicit drug use. We assessed the extent and patterns of ecstasy use by sampling community-based low-income family planning clinics. We sought to determine differences between women who used ecstasy and those who used other illicit drugs with respect to risk factors such as knowledge and perceptions of drug use, and characteristics of the social environment.

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1. Methods 1.1. Study design and sampling This cross-sectional study utilized a self-administered survey, supplemented by a face-to-face interview for a subgroup of respondents who reported using ecstasy. The sample consisted of women aged 18 to 31 years old who, between December 1, 2001 and May 30, 2003, sought gynecological care from two community-based family planning clinics operated by the University of Texas Medical Branch (UTMB). Using a protocol approved by the University’s Institutional Review Board, women who were pregnant or less than 6 months postpartum, those who refused, and those who were unable to provide informed consent were excluded. Trained bilingual (Spanish and English) research assistants approached and recruited potentially eligible patients. Each participant consented in writing to complete the survey and to allow investigators to review her medical record. All study materials were available in English or Spanish. The subset of women (n = 50) reporting ecstasy use was invited to discuss their perceptions and experience surrounding club drug use in face-to-face interviews. A total of 906 women were approached for this study. There were 141 (15.6%) women who refused to participate because of time constraints. Women who refused to participate did not differ from respondents with regard to age ( P = .08), but more black women (8.1%) refused to participate relative to white (4.3%) and Hispanic (3.2%) women ( P b 0.01). Of the 765 women who agreed to participate, 31 left the clinic before they finished the survey. An additional 38 participants did not respond to questions regarding drug use and were excluded from the analyses, leaving 696 participants in the final analyses. 1.2. Measurement 1.2.1. Drug use measures We used a modified version of the Drug History Questionnaire (DHQ) by Sobell, Kwan, and Sobell (1995), the Substance Abuse History Form by Huba, Melchior, Staff of The Measurement Group, and HRSA/HAB’s SPNS Cooperative Agreement Steering Committee (2001), and the drug instrument from the 1999 Monitoring The Future (MTF) study (Johnston & O’Malley, 2001) to assess self-reported use of 13 substances (e.g., tobacco, beer, or wine, as well as ecstasy, GHB, or rohypnol). A summary measure of the number of illicit drugs ever used was created by counting how many of the 13 drugs each respondent had ever used. Age at first use ranged from 5 to 29 years old. Respondents were asked to indicate any of 14 reasons for drug use in a multiple-choice format derived from the MTF survey (Johnston & O’Malley, 2001)—e.g., bto experiment in order to see what it is likeQ. Drug use was classified into four groups based on the type of drug or drugs each women reported ever using: 1) ecstasy, 2) other illicit drugs, 3) marijuana only, and 4) no drugs. The primary focus of this study was ecstasy use; therefore, women who reported ever using ecstasy were assigned to the first group, even though they may have reported using other types of drugs. The second drug-use group included women who used other hard drugs (even once) but never used ecstasy. Women who only used marijuana in their lifetime comprised the third group. These women were classified as a separate druguse group because marijuana may be the bgateway drug,Q which may predict other illicit drug (or hard drug) use (Morral, McCaffrey, & Paddock, 2002). Women who reported never using any drugs comprised the last group.

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1.2.2. Demographic variables Age, race/ethnicity, marital status, education, and employment were assessed using standard questionnaire wording. 1.2.3. Knowledge of drug use Adapted from the SAMHSA (2004b), respondents chose btrueQ or bfalseQ for each of five general drug knowledge items. Items included: 1) bThe term dclub drugsT describes drugs that are used at night clubs and raves.Q (False); 2) bThe effect of ecstasy lasts for about 3 to 6 h; however, anxiety and paranoia have been reported to occur weeks after the drug is taken.Q (True); 3) bThere are no long-term effects from using ecstasy.Q (False); 4) bIf you were in a club or bar and someone slipped one of these club drugs into your drink without your consent, you would be able to recognize a difference in your drink immediately.Q (False); and 5) bLow doses of ketamine can result in impaired attention, learning ability, and memory.Q (True). One point was given for each correct response, and correct responses were tallied to compute a total score as recommended (SAMHSA, 2004b). 1.2.4. Perception of drug use Using an item from the MTF survey (Johnston & O’Malley, 2001), women were asked to report how much they approved of people aged 18 or older using each of the drugs either occasionally or regularly. Responses were dichotomized as bstrongly disapproveQ vs. bdon’t disapproveQ or bdisapproveQ because stronger expressions about opinions or attitudes may be better able to discriminate acceptance of deviant behaviors, such as substance use, among young individuals due to their cognitive–developmental stage and broader acceptance of a wide range of beliefs than adults. For the same reasons, responses of intention to use each drug 5 years from now were dichotomized for analysis as bdefinitely will not useQ vs. bdefinitely will use,Q bprobably will use,Q or bprobably will not useQ. 1.2.5. Social environment Social environment was assessed by asking respondents the number of close friends (Achenbach, 1997) and the number of friends who had engaged in certain substance use behaviors, e.g., smoking (Johnston & O’Malley, 2001). For analytic purposes and for assessing any exposure to peer substanceuse behavior, the responses were recoded as bnoneQ vs. bany friendQ. Responses to two neighborhood items related to substance use were coded as bagreeQ vs. bdisagreeQ. 1.3. Statistical analyses When explanatory variables were categorical, v 2 tests were used to assess group differences among types of substance use. Means are reported as mean F standard deviation. Analysis of variance (ANOVA) was used to test for group differences for continuous variables. When the assumptions for ANOVA were not met, a Kruskal–Wallis test was used. After controlling for covariates of interest, two exploratory multivariable logistic regression analyses were used to model two dichotomous outcomes: 1) ecstasy use vs. other illicit drug use (Model 1) and 2) ecstasy use vs. marijuana use only (Model 2). Variables that were statistically significant at P b 0.05 in the bivariate analyses were entered into the multivariable logistic regression analyses, which employed a forward-selection approach. Odds ratios (OR) and 95% confidence intervals (95% CI) were reported from the final models. SAS for Windows, Version 8.02, was used to conduct analyses (SAS Institute Inc., 2001).

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2. Results The mean age of the total sample (n = 696) was 24.2 F 3.6 years. Overall, 15.2% of women reported using ecstasy at least once during their lifetime; 7.2% reported using it in the last 12 months. Among women 18 to 24 years old, lifetime use was 8.9% and use in the last year was 4.7%. Compared with the two other illicit drug groups (women who used any other illicit drugs and women who used only marijuana but no other illicit drugs), ecstasy users did not differ by age, marital status, education, or employment status. However, differences were observed by race/ethnicity; more non-Hispanic whites used ecstasy ( P b 0.01), while more non-Hispanic blacks used marijuana ( P b 0.01). Among those women who used ecstasy at least once, 53.0% last used the drug N 12 months prior to the survey, while 26.0% had used it within the last year but not in the last month; 21.0% had used it within the last 20 days. Women reported using 0.5 to 4 pills on each occasion. Many users also reported smoking cigarettes (82.1%), drinking beer and wine (91.5%), drinking hard liquor (84.9%), smoking marijuana (87.7%), and using crack cocaine (53.8%) or LSD (34.0%) in their lifetime. Initiation of ecstasy use occurred from 14 to 29 years old (mean = 19.9 F 2.9 years) (Fig. 1). Overall, ecstasy users reported first use of cigarettes, beer/wine, hard liquor, or marijuana at a younger age than the other two groups of illicit drug users. Ecstasy users, if they used crack cocaine, initiated its use at the same age as the group who used other illicit drugs. Face-to-face interview responses from 41 ecstasy users (from 50 invited survey participants who reported using ecstasy during their lifetime) revealed that principal use was at a friend’s home; specifically, 93.7% reported using it at their friends’ home compared with only 48.8% reporting using it at a bar or night club, and 34.2% at a rave. In addition, 37.5% reported using ecstasy at other places such as a beach, and 34.2% used it in their own home. Ecstasy users were more likely to report using a larger number of illicit drugs relative to the two other drug groups (Table 1). They also initiated use of other illicit substances, except crack cocaine, at earlier ages. Among users of ecstasy, the three most frequently identified reasons for using the drug were to: experiment, have a good time with friends, and relax or relieve tension (data not shown). These same reasons were cited by ecstasy users as their top reasons for use of other illicit drugs.

Mean age at 1st use

19.5 18.5 17.5 16.5 15.5 14.5 Cig

Beer/wine Hard Liquor Marijuana

LSD

Crake Cocaine

Ecstasy

Types of substances used

Ecstasy

Other Illicit Drugs

Marijuana

None

Fig. 1. Mean age at 1st use of substance by ecstasy, marijuana, and other illicit drug users, as well as nonusers.

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Table 1 Substance use history in young, low-income women, by drug-use status (N = 696) Substance use

Drug-use status

Cigarette use in the last 30 days Beer drinking in the last 30 days Hard liquor use in the last 30 days Marijuana in the last 12 months Ecstasy Marijuana Cocaine LSD Barbiturates Amphetamine Other narcotics Tranquilizers PCP Rohypnol Heroin

Ecstasy (n = 106, %)

Other illicit drugs (n = 64, %)

Marijuana only (n = 173, %)

None (n = 353, %)

66.4 68.6 51.9 65.4 100.0 91.4 56.3 36.4 34.0 31.1 30.7 23.8 17.4 16.5 5.8

47.6 53.1 37.5 42.2 0.0 75.0 46.9 28.1 29.5 25.0 23.8 11.5 17.2 7.7 9.4

42.2 45.9 29.7 41.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

9.1 23.7 8.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

No significant differences were detected with respect to knowledge of club drug use by the paired comparisons of drug use groups, except that ecstasy users were more likely to know that bclub drugsQ were not limited to night clubs and raves ( P = 0.02). Compared with the two other drug groups, fewer ecstasy users strongly disapproved of other adults using illicit drugs either occasionally or regularly (Table 2). They also expressed a greater intention to use ecstasy, marijuana, and cocaine within 5 years. Table 2 Women’s perceptions of drug use by others and their own future use of drugs among young, low-income women, by drug-use status (N = 696) Perceptions

Drug-use status Ecstasy (n = 106, %)

Other illicit drugs (n = 64, %)

Marijuana (n = 173, %)

None (n = 353, %)

% Women who strongly disapproved of people aged 18 or older using the following drugs occasionally Ecstasy 32.4 80.9 81.9 Marijuana 17.3 33.3 28.6 Cocaine 61.5 84.4 93.0

86.6 74.7 86.9

% Women who strongly disapproved of people aged 18 or older using the following drugs regularly Ecstasy 64.7 88.7 90.8 Marijuana 31.4 53.2 52.7 Cocaine 84.3 91.8 94.6

88.9 80.3 88.3

% Women who definitely would not use the following drugs 5 years from now Ecstasy 57.6 95.2 Marijuana 38.4 67.2 Cocaine 81.4 98.4

97.0 94.4 96.4

94.5 61.8 97.6

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Table 3 Social environment of young, low-income women, by drug-use status Social environment

Has at least two close friends Contacts friends at least 3 times/week Invites friends to home more than 3 times/month Has friends who Smoke marijuana or hashish Use bcrackQ cocaine Take cocaine powder Take club drugs including ecstasy, ketamine, etc. Bring drugs to parties Get drunk at least once a week Get bored at parties when no alcohol is served Cut work a lot to drink or get high Drive a car while drunk or high Have ever had an arrest in their lifetime Lives in a neighborhood where A lot of drug selling goes on in the neighborhood People move in and out of the neighborhood often

Drug-use status Ecstasy (n = 106, %)

Other illicit drugs (n = 64, %)

Marijuana (n = 173, %)

None (n = 353, %)

85.8 80.0 60.0

78.1 79.7 59.4

71.5 77.1 40.7

75.6 66.4 36.9

93.4 21.9 55.0 80.2 77.1 87.4 76.4 30.2 87.7 79.2

67.2 11.1 31.2 36.5 47.6 79.7 70.3 21.9 64.1 73.4

86.7 9.3 13.4 32.7 43.9 72.1 57.9 16.8 57.1 70.2

28.3 4.0 3.9 9.4 11.7 48.6 36.7 6.0 26.8 39.3

42.6 31.4

34.4 39.1

42.9 35.2

52.0 50.3

More ecstasy users reported having friends who used cocaine and club drugs, brought drugs to parties, and drove while drunk or high (Table 3). There were no differences between the three drug groups in geographic environment as discussed earlier (including selling drugs and people moving in and out of the neighborhood). In the first multivariable logistic model, after controlling for demographics and other characteristics (data not shown), ecstasy users were more likely than marijuana users to: (a) be non-Hispanic white (OR = 3.54; 95% CI: 1.62, 7.73) or Hispanic (OR = 6.03; 95% CI: 2.05, 17.90); (b) not strongly disapprove of other’s use of ecstasy on a regular basis (OR = 3.99; 95% CI: 1.73, 9.18); (c) intend to use ecstasy 5 years from now (OR = 5.18; 95% CI: 1.89, 14.16); and (d) have friends using many different substances (OR = 1.23; 95% CI: 1.08, 1.41). In the second multivariable logistic model, ecstasy users were more likely than those using other illicit drugs to: (a) use other illicit drugs (OR = 1.58; 95% CI: 1.21, 2.05); (b) not strongly disapprove other’s use of ecstasy on a regular basis (OR = 2.79; 95% CI: 1.12, 6.95); and (c) intend to use ecstasy 5 years from now (OR = 9.52; 95% CI: 2.38, 38.03).

3. Conclusions In our study, the rate (7.2%) of ecstasy use in the last 12 months among young, low-income women is slightly higher than the rate (5.6%) reported for women of the same age in the 2001 National Household Survey of Drug Abuse (NHSDA) (SAMHSA, 2003). Our results confirm the findings of other studies that young, low-income women are at high risk of substance use (Delva, Neumark, Furr, & Anthony, 2000; Jayakody, Danziger, & Pollack, 2000) and, in particular, of trying newer drugs that emerge such as ecstasy. Consistent with reports in previous population-based studies (Degenhard et al., 2003; Topp et

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al., 1999), these women reported occasional use of ecstasy but were usually polydrug users. However, compared with the women who used other illicit drugs (LSD, PCP, crack cocaine, etc.) but not ecstasy, these ecstasy users differed from our expectations. They tended to use even more illicit drugs besides ecstasy. The locations where these young, low-income women used ecstasy were different from those found in other studies (Gross et al., 2002; Pedersen & Skrondal, 1999; SAMHSA, 2003). Previous reports have stated that ecstasy use occurs primarily at clubs, rave parties, or other dance-related scenes. We found that almost all ecstasy users in our sample reported using it at a friend’s home, which is consistent with a previous report from Australia (Degenhard et al., 2003). These habits are consistent with the financial status of these young women, who may not have much discretionary money to attend raves or clubs. Previous research focusing primarily on students or rave or party attendees may have missed a substantial proportion of ecstasy users. With respect to stages of drug use (Pedersen & Skrondal, 1999), our study reported a slightly different sequence of drug use—cigarettes, beer and wine, marijuana, hard liquor, other illicit drugs except ecstasy, and finally ecstasy. Marijuana use was initiated at an earlier age than hard liquor use. This finding may indicate that an increasingly large volume of American youth, particularly younger women, are using or trying marijuana, or the results may suggest that it is easier to get marijuana than alcohol (Morral et al., 2002; SAMHSA, 2004a). As ecstasy has only recently gained popularity, it is logical that its initiation might appear later than that of other illicit drugs such as crack cocaine or LSD (Landry, 2002; Rosenbaum, 2002). Most importantly, ecstasy users initiated almost all substances (including tobacco and alcohol) earlier than their peers in the other drug use groups. The very early initiation of cigarette smoking or alcohol use may indicate that these women may tend to be risk-takers or pleasureseekers (De Micheli & Formigoni, 2002) or to have experienced other problems at an early age, resulting in self-medication through substance use (Najavits, Weiss, & Shaw, 1997). Many young women in this study who used ecstasy reported favorable attitudes towards other people’s use and intention to use illicit drugs in the future. Compared with marijuana users and other illicit drug users, fewer ecstasy users reported that they were strongly against other people’s use of ecstasy, marijuana, and cocaine, and they more often reported their intention to use these drugs within 5 years. We speculate that this subgroup of young women may be at high risk to continue their drug use or try new drugs as they appear on the market. Consistent with previous studies of other illicit drug use (Andrews et al., 2002; Urberg et al., 2004), peer association plays an important role in substance use in young people. Due to the cross-sectional feature of our study, we found that young, low-income ecstasy users reported having more friends who used more licit and illicit drugs. They may tend to choose a social network or environment that can foster their habit or reflect their similar interest. The current study has methodological limitations. First, the data are self-reported and are subject to recall bias and socially desirable response tendencies. Further, because ecstasy is an illicit drug and the study was conducted in a medical setting, it is possible that women underreported their use. Second, this is a cross-sectional study and therefore the causal relationships between the risk factors of interest and ecstasy use cannot be determined. Third, this study used a convenience sample. The results from this study may not be generalized to other populations with similar characteristics in different settings. Despite these limitations, this study describes the characteristics of low-income female ecstasy users. In general, ecstasy users perceived themselves using illicit drugs in the future and were at higher risk of continuing to use these drugs than respondents who used marijuana only or other illicit drugs. These

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results suggest that future interventions may be more cost-effective if they target this high-risk subgroup of young women. In addition, if young women who started using substances at very young ages have already tried a variety of illicit drugs, the next step may be for them to try newer, popular drugs available on the market. Future longitudinal studies are necessary to identify trends of new drug use among young, low-income women.

Acknowledgements This study was funded by the National Institute of Drug Abuse (R03DA14841), with additional support from the General Clinical Research Center at the University of Texas Medical Branch (UTMB) (Protocol No. 567). Dr. Berenson is supported by the National Institute of Health (K24HD043659). The authors express their appreciation to Ms. Areli Duran, Ms. Lindsay Maurer, and Mr. Liu Mouyong, the members of the UTMB Regional Maternal and Child Health Program, Pathology Outreach Services, Ms. Kimberly Bufton, and the laboratory technicians of the Pathology Laboratory. We also thank the members of The Writing Effectiveness Group (Center for Interdisciplinary Research in Women’s Health, UTMB) for their critique of this manuscript.

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