Psychopathology and HIV risk behaviors among injection drug users in and out of treatment

DEPENDENCE ELSEVIER

Drug and Alcohol Dependence 43 (1996) 1~ 11

Psychopathology

and HIV risk behaviors among injection in and out of treatment

Stephen H. Dinwiddie *, Linda Cottler, Wilson Compton, Washin#on

IJniwrsity

School of Medicine. Department of Psychiatry,

drug users

Arbi Ben Abdallah

4940 Children’s Place, St. Louis,

MO

13llO.

1093, UsA

Received 20 December 1995; accepted 15 July 1996

Abstract

To replicate prior descriptions of injection drug users (IDUs), 158 ID1Js recruited via a street-outreach program were compared to 320 non-IDUs on measures of substance use, lifetime psychopathology, and HIV risk behavior. IDUs were more likely to receive a diagnosis of antisocial personality disorder, but not other psychiatric diagnoses, and to report dependence on multiple substances. IDUs reported more HIV risk behaviors, but perceived HIV risk did not differ from non-IDUs. Compared to IDUs who declined treatment, IDUs willing to accept treatment did not differ on drug-related problems, lifetime psychopathology, or 1. perceived HIV risk. Keywords; Antisocial

personality

disorder; Human immunodeficiency

1. Introduction

The decision to inject psychoactive drugs further adds to the substantial health consequences associated with illicit substance abuse (Haverkos and Lange, 1990). In particular, injection drug use (IDU) is a major contributor to the spread of the human immunodeficiency virus (HIV), and accounts for approximately one in four new cases of AIDS (Schnittman and Fauci, 1994). Deeper understanding of the psychological characteristics and drug use histories of injection drug users (IDUs) may ultimately improve clinical ability to identify those at risk for initiating drug injection, either before significant substance use begins or before the transition between significant (but non-injection) drug use and the onset of IDU (Dinwiddie et al., 1992a). Such descriptive study might potentially also lead to better ways of treating IDUs, for example by improved retention in treatment or more specific matching of program orientation to patient characteristics, as is beginning to occur in treatment of alcoholism (Litt et al., 1992). * Corresponding author.

Although it is often assumed that IDU is equivalent to opiate (particularly heroin) use, there is evidence to suggest that, in fact, stimulants are more commonly injected. Indeed, even when subjects are not ascertain& through treatment settings, any history of drug injection indicates very substantial lifetime involvement in illicit substance USC, and, consequently, high lifetime rates of dependence on alcohol and multiple other psychoactive substances. Though onset of drug injection frequently begins by late adolescence, fairly early in the individual’s addiction carier, the .ndividual has by that time already had substantial exposure to a variety of psychoactive substances. Thus, for this group, basing treatment on addiction to one specific class. of drug (e.g. opiates, cocaine, etc.) is likely to inappropriately limit the interventions needed for adequate substance use treatment (Dinwiddie et al., 1992b). Moreover,

while

such pervasive

substance

exposure

undoubtedly promotes involvement in a variety of antisocial behaviors simply because of the illegality and cost of the drugs, such behaviors are often more than simply a consequence of drug use: those who report any

0376-8716/96/F%] 5.00 0 1996 Elsevier Science Ireland Ltd. All rights reserved PI1 SO376-87 16(96)0 1290-2

virus; Injection drug users

2

S.H. Dinwiddir

et ul. i Drug und Alcohol Depmrknce 43 (1996) I-l

lifetime IDU are also much more likely to have had a history of school disciplinary problems, fighting, running away, chronic lying, and juvenile arrest, with the onset of these behaviors substantially predating (and perhaps promoting) initiation of IDU (Tomas et al., 1990; Dinwiddie et al., 1992b). Presence of such behaviors is likely to be a marker for substantially elevated risk for subsequent IDU; moreover, given such early problems, on a lifetime basis those with any lifetime IDU demonstrate high rates of antisocial personality disorder (ASPD), which has been diagnosed in 35-69% of IDUs (Brooner et al., 1992; Dinwiddie et al., 1992~). While other forms of psychopathology, primarily symptoms of mood and anxiety disorders, have also been identified in this population (Stenbacka et al., 1992; Brooner et al., 1993; Lipsitz et al., 1994), manifestations of psychiatric comorbidity in this population appear to be related most closely to the presence of ASPD. Selection through treatment potentially introduces significant sampling bias, since more severe cases may be differentially represented and one might therefore expect elevated rates of comorbidity among such populations. On the other hand, because studies of IDUs not selected through treatment indicate comparable rates and kinds of lifetime psychopathology to those reported among IDUs selected through treatment, effects of treatment bias may be less pronounced. However, this issue remains unsettled because little has been reported comparing IDUs who accept treatment to those who do not. In this study, we examine drug use history and lifetime psychiatric diagnoses in a demonstration project wlllere community subjects were recruited to treatmeirt through street outreach. A unique aspect of this study is the inclusion of subjects with substzntial drug use histories who declined treatment offered thro,ugh this program, thus allowing further compar;.5on between injection drug users willing to enter treatnrent and those declining it. Specifically, this sample allowed for comparisons (a) between IDUs and ITO~-IDUS and (b) between IDUs who accepted and
2. I. Subjects and assessment The methodology of the effort to reduce the spread of AIDS (ERSA) program has been reported

I

in detail elsewhere (Cottler et al., 1993, 1995). In brief, as part of a demonstration project funded by the National Institute on Drug Abuse (NIDA), subjects in two high-risk areas were recruited into the study by street-outreach personnel subcontracted by the St. Louis City Health Department. Community health outreach workers were trained to approach individuals on the street and engage them in conversation about AIDS and drugs, followed (when appropriate) by priority referral to one of two outreach centers. Alternatively, individuals could present as ‘walk-ins’, having heard about the program via advertising or word of mouth. At the centers, a variety of free health services (including flu shots and screening for diabetes and hypertension) were offered, and information regarding the reason for the visit, source of referral, and sociodemographic data were gathered. As part of this intake, potential respondents were asked about their use of illicit psychoactive substances within the past 12 months; those who reported regular use were informed about the ERSA project and asked to participate. Participation included being offered no-cost drug treatment. Those who were interested were then referred to area programs, including either a methadone maintenance program or a drug-free program for opiate addicts and a drug-free program for other users. Users who did not desire treatment were recruited into the study as a comparison sample. Those who requested treatment were considered part of the ‘treatment’ group if they entered a treatment program within 30 days and stayed at least 7 days; those who requested treatment but did not fulfill these criteria, as well as treatment decliners, were placed in the ‘comparison’ group. Informed consent to participate in this study was obtained from all enrolled subjects. Baseline information included interview by trained research assistants using the diagnostic interview schedule, version III-R (DIS) (Robins et al., 1981), the composite international diagnostic interviewsubstance abuse module (SAM) (Cottler et al., 1991) and the NIDA AIDS risk behavior assessment (Cottler et al., 1993). Subjects were followed up at 3, 6, 9, 12, and 18 months (in fact 95% of the baseline sample could be located and reinterviewed at 18 months), but only baseline data were used for these analyses. Psychiatric diagnoses reported here are lifetime conditions based on the DIS. A total of 158 subjects reported any lifetime history of IDU and were contrasted to 320 subjects who denied ever injecting. IDUs were further subdivided for analyses based on whether they accepted (n = 96) or declined (n = 62) treatment offered at time of entry into the study.

S.H. Dinwiddie et al. / Drug and Alcohol Dependence 43 (1996) l-l

2.2. Statistical

analysis

Statistical analyses were performed using SAS Version 6.09. For categorical data, x2 tests, with continuity correction where appropriate, were used; for continuous data, t-tests were used, with the approximate T statistic and approximation of degrees of freedom reported where sample variances were found to be significantly different. For all tests, two-tailed probabilities are reported. Further analysis used logistic regression, with all models including age, gender, marital status, ethnicity, and employment status as well as the independent variable of interest; reported odds ratios are adjusted for these effects. Because many of the variables examined are known to be closely related, use of Bonferroni correction was considered to be overly restrictive. However, many comparisons are reported, and ‘significant’ results therefore should be regarded with caution, with the understanding that some may represent Type 1 error. 3. Results 3.1. Demographic features

Overall, the sample was predominantly AfricanAmerican (89%) and male (72%); at intake, 36% were employed. Compared to non- IDUs, IDUs were somewhat older and perhaps consequently were more likely to have been married. IDUs were also less likely to be African-American and less likely to be currently employed. Although members of both groups reported high rates of prior substance abuse treatment, IDUs were more likely than non-IDUs to have had such treatment. Comparison of IDUs accepting treatment to those who declined showed little difference except that those accepting treatment were more likely to be women and to have been married. However, substantially more of those accepting treatment had undergone treatment in the past (Table 1). The relationship between IDU and prior treatment persisted after adjustment for gender, ethnicity, marital and employment status, and age, with IDU increasing the odds of reporting prior substance abuse treatment by a factor of 2.2 (95% confidence interval 1.1-4.3, P = 0.0166). 3.2. Lifetime psychopathology

and conduct disturbance

Comparison of IDUs to non-IDUs showed no significant differences in lifetime rates of psychopathology, except that IDUs more often met DSM-III-R

I

3

diagnostic criteria for antisocial personality disorder (ASPD). After adjustment for age, gender, ethnicity, current marital and employment status, this difference remained, with odds for the diagnosis increased by a factor of 2.1 relative to non-IDUs (95% confidence interval 1.2-3.4, P = 0.0054) Of note, no differences in rates of any anxiety or mood disorder were seen between the groups. IDUs accepting treatment did not differ from treatment refusers on rates of any lifetime psychopathology (Table 2). In particular, those who accepted treatment did not differ from those declining on likelihood of receiving a diagnosis of ASPD (odds ratio 1.2, 95% confidence interval 0.3-3.6, P = NS). Prior work (Tomas et al., 1990; Dinwiddie et al., 1992b) had identified several behaviors with onset before the age of 15 (fighting, initiation of sexual activity, cannabis use, truancy from school, theft, or arrest as a juvenile) which distinguished IDUs from subjects who had significant drug use histories but who reported never injecting. In the ERSA population, however, IDUs did not differ from non-IDUs on rate of reporting onset of these specific behaviors before age 15 years (Table 3), though they did report having engaged in an average of 2.9 f 1.7 of these behaviors, as compared to an average of 2.5 + 1.7 among non-IDUs (T = - 2.3260 with 476 df, P = 0.0204). Similarly, IDUs who accepted treatment were somewhat less likely than IDUs who declined to report a history of fighting before the age of 15. Given multiple comparisons, either (or both) of these findings might not represent a true difference. However, IDUs who did not accept our offer for treatmen.t reported an average of 3.4 ) 1.7 such behaviors before the age of 15, significantly greater than the average of 2.6 f 1.6 such behaviors reported by IDUs who accepted treatment (T = 2.8158 with 156 df, P = 0.006). 3.3. Lifetime substance use and dependence

IDUs as a group reported substantial involvement in drug use, as measured by the number of classes of drug used on a lifetime basis, prevalence of use of specific drug classes, and by lifetime diagnosis of abuse or dependence on specific agents (Table 4). IDUs reported using, on a lifetime basis, an average of 6.3 + 2.6 classes of drugs, compared to 3.2 f 1.7 for non-IDUs (T = - 13.620 with 226.7 df approximatron, P < 0.0001) and met criteria for abuse of or dependence on 3.3 + 1.7 specific substances, versus 2.3 :b 1.2 (T= - 6.555 with 242.7 df approximation, P < 0.0001). By contrast, IDUs who accepted treatment did not differ from IDUs who declined treatment on these measures, reporting lifetime use of

characteristics

Gender Male Female Race African-American Other Ever married Currently employed Education Less than high school High school graduate More than high school Age Any substance abuse treatment in past ERSA treatment Any Methadone Outpatient treatment

Variable

Table 1 Demographic

1.109

8.498

0.706 150.869 14.903

96 (60.8) 78 (49.4) 57 (36.1)

180 (56.3) 9 (2.8) 177 (55.3)

2.289

T= -11.2494 (476 df)

75 (47.5) 39 (24.7) 44 (27.9) 36.5 f 5.7 139 (88.0)

48.543 14.910 13.253

X2

149 (46.7) 97 (30.4) 73 (22.9) 30.1 + 5.9 243 (76.2)

(74.7) (25.3) (58.2) (24.7)

118 40 92 39

308 12 125 135

(96.3) (3.8) (39.1) (42.2)

108 (68.4) 50 (31.7)

IDUs (n=158) n (%)

235 (73.4) 85 (26.6)

Non IDUs (n = 320) n (%)

NS
NS
to.001
NS

P

31 (50.0) 14 (22.6) 17 (27.4) 36.9 + 5.9 48 (77.4)

44 (45.8) 25 (26.0) 27 (28.1) 36.2 f 5.6 91 (94.8)

9.167

T=O.7654 (156 df)

0.237

3.791 4.756 2.066

(68.8) (31.3) (65.6) (29.2)

66 30 63 28

52 10 29 11

(83.9) (16.1) (46.8) (17.7)

4.597

n (%)

In treatment (n = 96)

59 (61.5) 37 (38.5)

(n = 62)

x2

49 (79.0) 13 (21.0)

Not in treatment n (%)

Among IDUs only

NS NS 0.002

NS 0.029 NS

0.032

P

8 3 g 9

B B 2 a b zB b d 3 3 $

e

g

S.H. Dinwiddie et al. / Drug and Alcohol Llependence 43 (1996) 1-l I

Table 2 DSM-III-R psychiatric diagnoses Diagnoses

Non IDUs (N = 320) n (‘!Io)

IDUs

x2

p

(n = 158) n (54)

Among IDUs only Not in treatment (n = 62) n I,%)

Any mood disorder Major depression Dysthmic disorder Bipolar affective disorder Any other mood disorder Any schizophrenic or schizoaffective disorder Any anxiety disorder Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Simple phobia Agoraphobia Social phobia Posttraumatic stress disorder Antisocial personalitydisorder

x2

P

In treatment (n = 96) n (“h)

24 (7.5) 22 (6.9) 2 (0.6)

17 (10.8) 12 (7.6) 1 (0.6)

1.070 NS 0.012 NS 0.000 NS

4 (6.5)

13 (13.7)

0 (0.0)

1 (1.0)

0.000

NS

35 (11.0)

21 (13.4)

0.377

NS

6 (9.7)

15 (15.8)

0.740

NS

7 (2.2)

8 (5.1)

2.010

NS

4 (6.5)

4 (4.2)

0.072

NS

96 (30.0) 1 (0.3)

54 (34.2) 1 (0.7)

0.674 0.000

NS NS

19 (30.7) 1 (1.7)

35 (36.5) 0 (0.0)

0.337 0.060

NS NS

3 (1.0) 3 (1.0)

2 (1.3) 1 (0.7)

0.000 0.000

NS NS

1 (1.7) 1 (1.7)

1 (1.1) 0 (0.0)

0.000 0.060

NS NS

52 (16.3) 40 (12.6) 46 (14.4) 18 (5.8)

26 (16.6) 22 (14.0) 27 (17.2) 12 (7.9)

0.000 0.085 0.429 0.429

NS NS NS NS

16 (25.8) 9 (14.5) 6 (9.7) 4 (6.9)

28 (29.5) 13 (13.8) 21 (22.1) 8 (8.5)

0.101 0.000 3.243 0.002

NS NS NS NS

97 (30.4)

65 (41.4)

5.185

0.023

31 (50.0)

34 (35.8)

2.564

NS

6.3 + 2.6 classes of drugs compared to 6.2 + 2.6 (T= - 0.195 with 156 df, P = NS) and abuse of or dependence on 2.2 f I. 1 specific substances compared to 2.0 &-0.8 among treatment-declining IDUs (T= 1.387 with 154.9 df approximation, P = NS). IDUs tended to begin use of some classes of drugs earlier than those with no history of injecting, though the magnitude of difference in each case was small. On average, IDUs began substance use (excluding alcohol) approximately 1 year before nonIDUs (Table 5). However, when IDUs who accepted treatment were contrasted with those who declined, only for initiation of cocaine use was a difference found-those who declined treatment reported age at first cocaine use later than those who accepted treatment. No difference in lifetime rate of cocaine dependence was seen, making this apparent difference of dubious consequence. 3.4. HIV risk behaviors

Finally, IDUs were compared to non-IDUs on HIV risk factors and perceived HIV risk at entry into the study. IDUs did not differ from non-IDUs on history of having had a sexually transmitted disease (STD) on a lifetime basis (55.7% of 158 IDUs

1.352 NS

versus 56.3% of 320 non-IDUs, x2 = 0.000 with 1 df) but were actually less likely than non-IDUs to report having had an STD within the 6 months prior to entry into the study (1.9% versus 7.8%, x2 = 5.678 with 1 df, P = 0.017). Although IDUs and non-IDUs did not differ on mean number of sex partners in the 6 months prior to beginning the study (2.3 + 6.0 among non-IDUs as compared to 5.1 + 19.0, T= 1.8067 with 172.4 df approximation, P = 0.07), it was clear that variance was much greater among IDUs. In addition, IDUs were more likely to report having engaged in risky sex practices (e.g. anal intercourse, failure to use condoms, etc.) in the prior 6 months and were more likely to have had sex in the last 6 months with a partner who had injected drugs. Although IDUs were more likely to report a history of prostitution, they were no more likely than non-IDUs to report exchanging drugs for sex (Table 6). Overall, IDU was associated with increase in odds of 2.6 (95% confidence interval 1.4-4.7, P = 0.0021) of reporting two or more high-risk behaviors. IDUs accepting treatment tended to be less likely to report having had an STD on a lifetime basis (49.0% of 96 of those accepting treatment versus 66.1% of 62 declining, x2 = 3.832 with 1 df, P = 0.05)

S.H. Dinwiddie et al. /Drug

6

and Alcohol Dependence 43 (1996) 1 -I 1

Table 3 Behavior problems Variables

Cannabis ~15 years old Sex < 15 years old Truant < 15 years old Theft < 15 years old Fighting < 15 years old Juvenile arrest Mean number of problems

Non IDUs (n = 320) n (“/)

IDUs (n=158) n (%)

Among IDUs only

P

x2

P

X2 Not in treatment (n = 62) n (“XI)

In treatment (n = 96) n (%)

89 (27.8)

48 (30.4)

0.339

NS

22 (35.5)

26 (27.1)

0.891

NS

169 (53.0)

94 (59.9)

1.754

NS

43 (69.4)

51 (53.7)

3.210

NS

220 (69.0)

118 (75.2)

1.671

NS

47 (75.8)

71 (74.7)

0.000

NS

139 (43.6)

79 (50.3)

1.666

NS

37 (59.7)

42 (44.2)

2.998

NS

88 (27.6) 2 (0.6) 2.5 k 1.7

51 (32.5) 2 (1.3) 2.9 + 1.7

0.995 0.036 T= -2.3260 (475 df)

NS NS 0.0204

27 (43.6) 1 (1.6) 3.4 5 1.7

24 (25.7) 1 (1.0) 2.6 f 1.6

4.916 0.000 T= 2.8158 (156 df)

0.027 NS 0.006

but did not differ on having had an STD in the last 6 months (2.1% versus 1.6%, x2 = 0.000 with 1 df, P = 1.00 by Fisher’s exact test). No difference between groups was seen on number of partners in the prior 6 months (4.4 + 9.9 among those out of treatment versus 5.6 f 23.1 among those in treatment, T = 0.4636 with 139.3 df approximation), likelihood of having sex in the prior 6 months with a partner who had injected drugs, or history of prostitution. No differences by treatment were noted in sharing injecting equipment. Overall, IDUs declining treatment did not differ from those accepting treatment in odds of reporting two or more high-risk behaviors (odds ratio 1.4, 95% confidence interval 0.3-5.8, P= NS).

Interestingly, IDUs did not differ from non-IDUs on perceived HIV risk: Of the 158 IDUs, only 13.9%, versus 10.6% of 320 non-IDUs, perceived their HIV risk to be high, while an additional 59.5% (versus 55.9% of non-IDUs) felt there was ‘some chance’ of HIV, with the remainder believing they were at no risk (x2 = 2.812 with 2 df, P= NS). IDUs tended to do better than non-IDUs on a test of knowledge of HIV knowledge, with 50.3% scoring 20 or better out of a possible 22 as compared to non-IDUs, only 36.5% of whom did as well; conversely, only 10.2% of the IDUs scored below 17, versus 12.9% of the non-IDUs (x2 = 8.322 with 2 df, P = 0.016). Comparison of IDUs who accepted treatment to those who declined showed no comparable differences: of 95 who accepted treatment, 54.7% scored 20 or better, and only 6.3% answered fewer than 17 questions correctly, versus 43.6% and 16.1% of 62

who declined treatment (x2 = 4.496 with 2 df, P = NS). Moreover, the groups were comparable in their perception of HIV risk, with 16.7% of those accepting treatment believing they were at high risk and another 60.4% who believed they had ‘some chance’ of contracting the virus, compared to 9.7% and 58.1% respectively of those who declined treatment (x2 = 2.593 with 2 df, P = NS).

4. Discussion There is now considerable evidence from both treatment and nontreatment samples that rates of ASPD among IDUs are markedly elevated: In this study, 41% of IDUs received this diagnosis, a figure very closely in accord with other reports (Brooner et al., 1992; Dinwiddie et al., 1992~). This diagnosis, in fact, was the only one which was found significantly more frequently among IDUs as compared to nonIDUs with a substantial drug use history, even though the sample was quite homogeneous, with non-IDUs also reporting quite high rates of substance exposure, substance dependence and associated impairment in functioning in major life roles such as employment and educational attainment. This homogeneity and the overall severity of substance-related difficulties allowed us to study individuals who clearly would qualify for drug abuse treatment-and who because of social disadvantage typically have found access to treatment much more difficult-and to compare them to a comparably-ill but treated population. Moreover, the systematic diagnosis andstructured interviews allowed for more flexibility in

S.H. Dinwiddie et al. 1 Drug and Alcohol Dependence 43 (1996) I-1 I Table 4 Lifetime drug use and DSM-III-R

psychoactive

substance dependence diagnoses

Non IDUs (n = 320) n (‘XI)

IDUs (n = 158) n (%I)

Cannabis Stimulants Cocaine Sedative-hypnotics Heroin Other opiates Phencyclidine Hallucinogens Inhalants

278 114 290 65 58 84 97 42 4

(87.2) (35.7) (90.9) (20.4) (18.2) (26.3) (30.4) (13.2) (1.3)

133 91 146 107 148 150 40 62 12

(84.2) (57.6) (92.4) (67.7) (93.7) (94.9) (25.3) (39.2) (7.6)

0.533 19.718 0.141 100.686 242.346 196.262 1.101 40.620 11.223

Alcohol abuse/dependence Cannabis dependence Amphetamine dependence Sedative-hypnotic dependence Cocaine dependence Opiate dependence Phencyclidine dependence Hallucinogen dependence Inhalant dependence Any abuse/dependence diagnosis

189 216 53 12 268 35 76 27 2 304

(59.1) (67.5) (16.6) (3.8) (83.8) (10.9) (23.8) (8.4) (0.6) (95.0)

113 97 56 44 123 124 29 36 5 157

(71.5) (61.4) (35.7) (28.2) (77.9) (78.5) (18.4) (22.8) (3.2) (99.4)

6.53 1.486 20.739 58.088 2.094 214.345 1.495 17.795 3.131 4.677

Drug

IDUs only (n = 62) n (“/o)

(n = 96) n (n/o)

NS
53 37 59 42 55 57 21 25 8

(85.5) (59.7) (95.2) (67.7) (88.7) (91.9) (33.9) (40.3) (12.9)

80 54 87 65 93 93 19 37 4

(83.3) (56.3) (90.6) (67.7) (96.9) (96.9) (19.8) (38.5) (4.2)

0.019 0.068 0.533 0.000 2.971 1.023 3.240 0.003 2.947

NS NS NS NS NS NS NS NS NS

0.011 NS < 0.001 < 0.001 NS < Cl.001 NS
56 40 24 16 51 42 14 11 3 62

(80.7) (64.5) (38.7) (25.8) (82.3) (67.7) (22.6) (17.7) (4.8) (100.0)

63 57 32 28 72 82 15 25 2 95

(65.6) (59.4) (33.7) (29.8) (75.0) (85.4) (15.6) (26.0) (2.1) (99.0)

3.468 0.231 0.223 0.129 0.768 5.961 0.796 1.041 0.251 0.000

NS NS NS NS NS 0.015 NS NS NS NS

-

determining lifetime substance-related problems and psychopathology than use of cross-sectional rating scales of either addiction or psychopathology. In contrast to the finding of a difference in the rate of ASPD, no difference in lifetime rates of depression was seen, either comparing IDUs to nonIDUs, or in comparing those who accepted treatment to those who declined it. Thus, our data do not support a strong role for depressive illness as a motivating factor for entering treatment, although we could not rule out the possibility that low mood or a mood disorder active at the time of treatment entry might have distinguished the groups. However, these findings are consistent with other data showing surprisingly low levels of psychological distress among IDUs, even those recently informed of HIV seropositivity (Davis et al., 1995) and low rates of active depression among cocaine addicts presenting for treatment (Ziedonis et al., 1994). This study also adds further support to the observation that IDUs as a group are more likely to have had a number of behavioral problems in childhood and early adolescence (Tomas et al., 1990; Dinwiddie et al., 1992b). However, in this sample the magnitude of difference between IDUs and non-IDUs on this measure was quite small, suggesting that using presence of these behaviors as a means of identifying those at high risk for later injecting would be inefficient. Nonetheless, the finding that IDUs have a

greater number of behavioral problems even than individuals with substantial drug use who choose not to inject suggests that IDU is best seen as another manifestation of a long-standing pattern of behavior consisting of disregard for social norms and increa;sed willingness to take risks rather than being primarily an index of severity of drug use. This interpretation is further strengthened by the finding that IDUs accepting treatment tended to have had fewer such behavior problems than those declining treatment-one of the few differences seen between those groups. Indeed, IDUs accepting treatment showed few differences from those who declined it in rates of use of specific psychoactive substances, rates of dependence on specific substances, or age at onset of use, though they were more likely to have received substance abuse treatment in the past. Given the multiple comparisons on these measures, the few differences found are likely to represent Type I error. The possibility that IDUs as a group tend to be less concerned about consequences of their behaviors is given some support as well by the finding that, despite engaging in a practice known to be associated with HIV infection, only 14% felt themselves to be at high risk, even though two-thirds in addition to injecting drugs had engaged in more than one high-risk sexual activity and a quarter had engaged in sex with a partner known to be a drug injector.

n

278 114 290 65 58 84 93 42 4 319

Substance

Cannabis Stimulants Cocaine Sedative-hypnotics Heroin Other opiates Phencyclidine Hallucinogens Inhalants Age first drug used Age first injection

Table 5 Age at onset

15.8 _+3.4 18.1 54.1 24.9 _+5.5 22.0 + 6.5 22.0 _+5.1 21.8 f 5.1 21.5 k 4.4 19.4 f 3.1 14.5 _+3.9 16.8 + 4.7

Non IDUs

133 91 146 107 148 150 40 62 12 158

n 15.4 _+3.3 17.0 * 3.4 23.8 _+6.3 19.4 f 5.2 20.2 _+4.8 19.8 + 4.7 22.2 f 5.4 17.6 f 3.9 17.3 k4.1 15.9 + 4.0

IDUs 1.188 2.033 1.824 2.772 2.301 3.169 -0.782 2.324 -1.177 2.177

T 409 203 434 113.4 204 232 135 102 14 365.8

df NS NS NS 0.0065 NS 0.0017 NS 0.0221 NS 0.0301

P 53 37 59 42 55 57 21 25 8 62 56

?I 15.1 _+3.3 17.1 +_4.0 25.4 f 6.7 19.4 & 5.2 19.7 _+3.7 19.6 f 3.6 22.4 k 5.7 17.7 +4.1 17.3 f 4.5 15.3 * 3.3 21.1 f 5.2

Not in treatment 80 54 87 65 93 93 19 37 4 96 93

n

15.6 _+ 3.3 16.9 + 2.9 22.7 _+ 5.8 19.4 + 5.2 20.5 _+ 5.3 19.9 k 5.2 21.9 k 5.3 17.6 f 3.8 17.3 _+ 3.8 16.3 f 4.3 21.9 _+ 5.7

In treatment

-0.869 0.298 2.5491 (144) -0.086 - 1.093 -0.365 0.307 0.150 0.000 - 1.591 - 0.834

T

131 62 144 105 141.6 145.3 38 60 10 151.7 147

df

NS NS 0.0118 NS NS NS NS NS NS NS NS

P

11 (7.0) 43 (27.2) 104 (65.8) 73 (46.2) 14 (8.9) 27 (16.5) 38 (24.1)

n (%)

n (“h)

33 (10.3) 146 (45.6) 141 (44.1) 94 (29.4) 31 (9.7) 64 (20.0) 12 (3.8)

IDUs (n=158)

Non IDUs (n = 320)

a Defined as receiving either money or drugs in exchange for sex.

High-risk sexual activities in the last 6 months 0 1 2 or more Prostitution (ever) Receiving drugs for sex Giving drugs for sex Sex with IUU m the last 6 months Shared needle (ever) Shared equipment in the last 6 months

Behavior

Table 6 Selected HIV risk behaviors

20.128 12.447 0.016 0.653 44.399

x2

to.001
P

1 (1.6) 22 (35.5) 39 (62.9) 25 (40.3) 5 (8.1) 13 (2.0) 13 (21.0) 45 (73.8) 13 (21.0)

Not in treatment (n = 62) n (%)

IDUs only

10 (10.4) 21 (21.9) 65 (67.7) 48 (50.0) 9 (9.4) 13 (13.5) 25 (26.0) 78 (82.1) 28 (29.2)

In treatment (n = 96) n (“Al)

6.889 1.057 0.000 1.019 0.289 1.088 0.926

x2

0.032 N.S. N.S. N.S. N.S. N.S. N.S.

P

10

S.H. Dinwiddie et al. 1 Drug and Alcohol Depmdmce 43 (1996) I -- 1 I

Moreover, among IDUs, fear of HIV infection did not appear to be a significant motivation for seeking treatment, as measured both by perceived risk and by reported high-risk behaviors such as sharing works or engaging in high-risk sexual activity. Consistent with this observation, IDUs accepting treatment differed little from those declining on reporting high-risk behaviors; if anything, those in treatment reported more, rather than fewer, high-risk behaviors, though likelihood of reporting commercial transactions for sex, needle-sharing, or having sex with an IDU partner did not differ between the groups. These results differ slightly from those reported by Watkins et al. (1992), who found that IDUs not in treatment tended to report higher rates of exchanging sex for money or drugs and had more sexual partners; however, our data are generally consistent with Watkins et al. in that, whether in or out of treatment, IDUs appear to continue to be at risk for HIV infection because of their sexual behavior. Although street-outreach programs have been shown to reduce levels of drug use and encourage treatment-seeking, substantial numbers of IDUs still do not avail themselves of drug treatment (Dinwiddie et al., 1992d; Brown and Needle, 1994; Siegal et al., 1995). Perhaps the most intriguing finding in this regard was the overall lack of difference between IDUs compared on acceptance of treatment, based on lifetime psychopathology, substance use, perceived HIV risk, HIV knowledge, and participation in high-risk behaviors. Our results also confirm prior work (Dinwiddie et al., 1992~) suggesting that IDUs as a group-defined as reporting any drug injecting on a lifetime basis, rather than current IDU-comprise a relatively homogeneous group characterized by very high rates of ASPD and multiple drug dependence. Any lifetime IDU is indicative of very substantial lifetime involvement in psychoactive substance use, with associated problems, and our results suggest that, for these characteristics at least, this observation is true whether or not subjects are recruited through treatment. Thus, results of studies carried out on treatment-derived samples may be reasonably generalizable to the larger pool of IDUs. Finally, this study is further indication that, given the high rate of ASPD and multiple substance-related problems among IDUs, innovative methods are necessary to attract patients to treatment programs and to retain them once enrolled. While further efforts at education regarding risk of HIV infection among drug users are needed, our data suggest that for many IDUs this concern is not necessarily a motivation to seek treatment.

Acknowledgements

This work was supported DA00209 and DA061 63.

by

NIDA

Grants

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