Blackwell Science, LtdOxford, UKADDAddiction1360-0443 2003 Society for the Study of Addiction to Alcohol and Other Drugs98Original ArticleHeroin

administration routes during HIV epidemicMara J. Bravo

et al.

RESEARCH REPORT

Reasons for selecting an initial route of heroin administration and for subsequent transitions during a severe HIV epidemic
Mara J. Bravo1, Gregorio Barrio2, Luis de la Fuente1,3, Luis Royuela2, Laura Domingo3 & Teresa Silva3
Secretara del Plan Nacional sobre el Sida, Madrid,1 Centro Universitario de Salud Pblica (CUSP), Madrid,2 Proyecto Itnere, Centro Nacional de Epidemiologa, Instituto de Salud Carlos III, Madrid, Spain3

Correspondence to: Luis de la Fuente Centro Nacional de Epidemiologa Instituto de Salud Carlos III Calle Sinesio Delgado 6 28029 Madrid Spain Tel: +34 91 387 75 08 E-mail: lfuente@isciii.es Submitted 8 August 2002; initial review completed 25 October 2002; nal version accepted 3 February 2003

ABSTRACT Aim To identify the most important reasons for selecting a particular route of heroin administration and for subsequent transitions during a period of epidemic HIV transmission. To study temporal trends in these reasons. Design Cross-sectional survey. Participants Nine hundred heroin users in three Spanish cities: 305 in Seville, 297 in Madrid and 298 in Barcelona. Measurements A separate analysis was made of the reasons for ve types of behaviour: (a) selecting injection as the initial usual route of heroin administration (URHA); (b) changing the URHA to injection; (c) never having injected drugs; (d) selecting the smoked or sniffed route as the initial URHA; and (e) changing the URHA to a non-injected route. Subjects were invited to evaluate the importance of each reason included in a closed list. Spontaneously selfperceived reasons were also explored in an open-ended question for each of the ve types of behaviour studied. Findings The primary reason selected for each type of behaviour was: (a) pressure of the social environment; (b) belief that injection is a more efcient route than smoking or snifng heroin; (c) concern about health consequences (especially fears of HIV and overdose), and fear of blood or of sticking a needle into ones veins; (d), pressure of the social environment and (e) concern about health consequences and vein problems. For women, having a sexual partner who injected heroin played a decisive role in initiating or changing to injection. Few people spontaneously mentioned market conditions for purchasing heroin as an important reason for any behaviour, nor did many mention risk of overdose as reasons for (c) or (d). Conclusions These ndings should be considered when designing interventions aimed at preventing initiation of injecting or facilitating the transition to non-injected routes. KEYWORDS transitions. Administration route, heroin, injecting, smoking, snifng,

RESEARCH REPORT

INTRODUCTION The three most frequent routes of heroin administration are injection, smoking and snifng. The use of a particu 2003 Society for the Study of Addiction to Alcohol and Other Drugs

lar route has important implications for a users health and social life. The injected route generates by far the most severe health problems, primarily infections and overdose [13]. These problems, particularly infections
Addiction, 98, 749760

750

Mara J. Bravo et al.

such as HIV/AIDS, HCV and HBV, which are associated with sharing contaminated injection material, are major threats to public health in many countries. Consequently, preventing the use of the injected route and facilitating the change to other routes of administration are important public health objectives [4]. These are feasible objectives as previous studies have shown that the usual route of heroin administration (URHA) can change during a drug users career, that the proportion of heroin users whose URHA is injection varies greatly by geographical area, and that this proportion has decreased in recent years in some countries [58]. Despite this evidence, few interventions have been developed to prevent initiation of injecting or to facilitate the change to other routes, except for methadone maintenance programmes [911]. Studies have found that the main reasons for adopting or maintaining the injected route are its superior efciency compared to the smoked or sniffed routes[1217], the fact of having used the injected route in the past [12,17,18], and the inuence or pressure of primary social relationships (sexual partner, friends, family) [5,14,19,20]. Among the reasons observed to explain the adoption and maintenance of the smoked or sniffed routes are the inuence or pressure of the social environment (including fear of the social stigma of injection) [6], concern about the negative health consequences of injection [12], particularly fear of HIV infection [17,21] and the market availability of high purity heroin for smoking (in base form) [22] or snifng (in salt form) at competitive prices [20,21,23]. Most of these factors have been detected in epidemiological studies of association (individual or ecological), without asking users directly about the reasons for initiating, maintaining or giving up a particular route of administration. Studies of association have made it possible to identify important factors that users may not perceive, and to describe some of the social and demographic characteristics of users adopting or changing to a given route. Nevertheless, it is necessary to complete this view with studies that directly explore the drug users opinions and perceptions. An in-depth exploration of drug transition routes in Spain is of particular interest because the AIDS epidemic related with injecting drug use (mainly heroin) has been one of the most severe of all the developed countries [24]. Furthermore, the spread of injected heroin use in Spain occurred during a time of rapid transformation from an authoritarian political regime to a democratic system, with additional socio-economic problems, a situation which may present many similarities to that of some eastern European countries today. This study aims to identify the main reasons for selecting or changing to a specic route of heroin administra 2003 Society for the Study of Addiction to Alcohol and Other Drugs

tion, and to explore their temporal trends. Its results could be useful in guiding decisions on harm reduction policy in countries that have undergone an experience similar to that of Spain.

MATERIALS AND METHODS Design and participants A cross-sectional survey in three Spanish cities was carried out between March and December 1995. The three cities were selected based on the prevalence of the different routes of administration of heroin [25]: in Barcelona the injected route had predominated for some time; in Madrid the smoked route had recently become the primary one; and in Seville the smoked route had predominated for a number of years. The initial sample consisted of 909 users. All were both regular (life-time use of heroin 15 times) and recent users (heroin used during past 30 days), and all had used heroin at least weekly at some point in their lives. Three hundred and ve participants lived in Seville, 304 in Madrid and 300 in Barcelona. In each city, approximately half the users were recruited in drug treatment centres and the rest were recruited in the street. All participants in the drug treatment sample had begun treatment in 1995, and none of the heroin users recruited outside the centres had been treated for heroin addiction in the previous year. In selecting the treatmentusers all drug addiction treatment centres reporting to the State Information System of Drug Abuse (SEIT in Spanish) during 1994 were included in the sample, except for prison programmes. The total included 25 centres. In each city the sample in each centre was assigned proportionally to the number of treatments reported to the SEIT in the second quarter of 1994. Users out of treatment were selected through targeted sampling [26] and snowball sampling techniques [27]. Some 65.4% (299) were recruited directly by the interviewers in areas where it was assumed there would be a relatively high probability of nding them; 19.3% were introduced or named by key informants and 15.3% were named by other people interviewed (snowball sampling). The target areas for recruitment were meeting places for users (68.9%), areas where drugs are sold (22.7%) and others (8.4%). Services and settings which could have led to a selection bias in terms of route of administration (needle exchange programmes, pharmacies and others) were not included. Key informants who named or introduced users were friends or acquaintances of interviewers (42.0%), friends of the people interviewed (3.4%), workers in treatment services (15.9%) and other people who worked with drug users (38.6%). Snowball sampling was used in an attempt to make the sample more repreAddiction, 98, 749760

Heroin administration routes during HIV epidemic

751

sentative by including people who might not be found in traditional target areas (those more integrated into mainstream society) as well as hidden networks of users. For this purpose, each person interviewed who was selected by targeted sampling or named by key informants was asked to name up to four heroin users who met the inclusion criteria and who, if possible, were not present in the same target area where the person interviewed was recruited. This technique was not as efcient as expected, however, as most users did not name anyone (only 182 people were named); when they did, the people named were often present in the same place, or it was difcult to interview them because they could not be located, or they did not keep their appointments. The 28 interviewers were people who had privileged access to the target areas and the centres where they worked because of their personal and professional contacts. Verbal informed consent was obtained from all study participants. The sampling methodology has already been described in detail elsewhere [8]. Information was obtained by personal interview. A structured questionnaire was used, including pre-coded questions for the following variables: socio-demographic prole, current use of drugs, history of heroin use, evolution of usual route of heroin administration (URHA), history of injection of any drug, and HIV serological status. The reasons for ve behaviours related with the route of administration were investigated separately) adopting injection as the main (most frequent) route when usual (weekly) heroin use started (rst URHA); (b) changing URHA to injection (to consider a change as URHA transition, it had to be maintained for at least 30 days); (c) never having injected drugs; (d) adopting the smoked or sniffed route as rst URHA; and (e) changing URHA to a non-injecting route. To investigate reasons for adopting the rst URHA, a closed list of factors or circumstances that might have inuenced the adoption of the initial URHA (injecting, snifng or smoking) was presented to each subject. For each factor, the interviewee was asked to indicate whether or not it had been present when the initial URHA was adopted and, if so, what importance he/she gave to that factor (very important, rather important, not very important, not at all important). Two more lists of suggested factors were presented, one for those whose rst URHA was injection and one for those whose rst URHA was either snifng or smoking. Reasons for never having injected any drug and for changing the URHA were explored in a way similar to that described above. In the latter case, if various changes had taken place, only the most recent one was taken into account. Additional questions were asked about whether the change in URHA had been reached after a period of abstinence (and, if so, how this period of abstinence had been attained), and
2003 Society for the Study of Addiction to Alcohol and Other Drugs

how the transition affected the amount of heroin used. The interviewer offered a different set of factors depending on whether the change was to injection or to a noninjecting route. The lists were developed based on a previous exploratory study. Nevertheless, to avoid excluding any factors that may not have been included in the closed list and to determine the importance given spontaneously to certain reasons, subjects were asked in an open-ended question to mention the three most important reasons for adopting each of the ve behaviours. This approximation to the free-listing technique [28] as a method of preliminary exploration of the free and spontaneous discourse of the person interviewed was carried out before presenting the closed lists to avoid suggesting any particular reason to the study subjects.

Data analysis The analysis included 900 of the 909 subjects initially recruited (305 in Seville, 298 in Barcelona and 297 in Madrid). Nine people were eliminated because of major inconsistencies in their replies about changes in the route of administration. The proportion of users who said that a specic factor or circumstance had been present when adopting a rst URHA or changing URHA was calculated. We then calculated the percentage of people who considered that factor rather or very important in adopting the behaviour investigated. The highest non-response rate for any behaviour investigated through a closed list was 3.0%. The c2 test or c2 for trend was used to compare proportions. The null hypothesis was rejected when P < 0.05. The reasons stated in the open-ended questions were recorded and transcribed literally. Two investigators read and classied these reasons and discrepancies independently were resolved by consensus. The response rate for each category identied were calculated. The proportion of users who did not state spontaneously any reasons varied between 2.0% and 4.4%. The statistical analysis was performed with SPSS/ PC6.0 for Windows [29].

RESULTS General characteristics of the sample A detailed description of the sample has been published elsewhere [8,30]. Most participants were male (81.8%), aged 2535 (68.1%), single (72,6%), had fewer than 9 years of school education (77.7%) and did not have a regular job (79.2%). Some 26.1% received most of their income from illegal activities and another 23.3% from marginal occupations. Almost half (46.2%) had been in
Addiction, 98, 749760

752

Mara J. Bravo et al.

prison. The mean duration of heroin use was 10.2 years. Ninety per cent used heroin on a daily or nearly daily basis, 70.1% had used cocaine during the past 12 months and 48.5% had used it during the past 30 days. With regard to the URHA, 51.7% were smokers, 41.7% were injectors and 6.6% were sniffers. Smokers predominated in Seville (76.1%) and Madrid (70.7%), and injectors predominated in Barcelona (77.3%), with an increasing trend in the use of non-injecting routes in all three cities. Forty-ve per cent changed the URHA during their drug use career, usually just once (32.3%). With respect to the most recent change of URHA, 50.1% changed to injection, 41.2% changed from injection to smoking or snifng and 8.7% changed between noninjecting routes (from snifng to smoking or vice versa). Seventy-one per cent had injected drugs at least once, with major variations among cities. Most subjects, when injecting for the rst time, used heroin (86.6%) and were injected by someone else (55.3% by a close friend, 8.2% by a casual acquaintance, 3.3% by a family member and 2.4% by others). The proportion of those injected by someone else was higher before 1987 (79%) than afterwards. Women had been injected for the rst time by their sexual partner in a much larger proportion than men (29.8% versus 1.3%, P < 0.00001), although the total proportion of those injected by another person was not signicantly different from that of men (81.6% and 74%, P = 0.13). Reasons for choosing injection as rst URHA Of all the participants, 301 chose injection as the rst URHA. The most important reason was the inuence of the social environment; that is, the fact that either most of their friends or their sexual partner also used this route (Table 1). The importance of having an injector as a sexual partner was much stronger among women: 50.0% of women considered that this was a rather or very important reason to adopt the injected route versus 10.2% of men (P < 0.00001). These differences are due mainly to the fact that when women started injecting they were much more likely than men to have had a sexual partner who injected (52.2% versus 15.3%, P < 0.00001). Among those whose sexual partner injected, 95.8% of women and 66.7% of men (P = 0.02) considered that it was an important reason for adopting the injected route. The second reason was the belief that injected heroin has a greater or better effect than smoking or snifng (Table 1). When temporal variations were analysed, a decreasing but non-signicant trend in the importance of the inuence of the social environment was observed in more recent years. An increasing belief in injection as more
2003 Society for the Study of Addiction to Alcohol and Other Drugs

efcient than smoking or snifng was also observed (Table 1). Reasons related to the market (unavailability of heroin suitable for smoking or snifng, or availability of low purity heroin) were considered rather or very important by 28.3% of subjects in the closed list (Table 1), but hardly anyone mentioned this factor spontaneously in the previous open-ended question. In fact, only 1.4% mentioned the availability of good heroin for injection as an important reason.

Reasons for transitions from usually smoking or snifng heroin to injecting Of all those interviewed, 202 changed from usually smoking (104) or snifng (98) to injecting in the most recent URHA transition. Of these, 14.3% changed after a period of abstinence lasting at least 1 month, achieved in most cases without the assistance of treatment. After the change of route, 62.4% of participants started using a smaller quantity of heroin, 29.2% continued using the same amount and 8.4% started using more. The two main reasons for changing the URHA were the superior effectiveness (better or greater effect) and efciency (same effect for less money) of injection compared to other routes. Another relatively important reason for the transition was the inuence or pressure of the social environment (Table 1). Having a partner who injected was a more important reason for changing to the injected route in women: 38.9% of women considered it was a rather or very important reason versus only 7.2% of men (P < 0.00001). These differences are due mainly to the fact that when women changed to injection they much more frequently had a sexual partner who injected than did men (50.0% versus 8.4%, P < 0.00001). Among those who had an injecting sexual partner, 77.8% of the women and 85.7% of the men considered that this fact was important in explaining the change to injection, a difference that was not statistically signicant. There were important differences in the reasons given by those who changed from smoking and those who changed from snifng to injection. Smokers more said frequently that the availability of better heroin for injecting was an important reason for the transition (30.6% versus 13.5%, P = 0.005), and more often referred to the belief that injecting was a more efcient route (62.2% versus 45.6%, P = 0.03), whereas they were less inuenced by the social environment (31.6% versus 57.7%, P = 0.0003). In looking at temporal variations, it was found that the inuence of the social environment decreased significantly. It also appears that the importance of difculties in smoking or snifng heroin due to intolerance or disease, the availability of better heroin for injecting than for
Addiction, 98, 749760

Heroin administration routes during HIV epidemic

753

Table 1 Importance given to reasons for adopting injection as rst usual route of heroin administration (URHA) and for changing from smoking or snifng to injecting heroin. % who considered this reason as rather or very important in changing from smoking or snifng to injectingb

% who considered this reason as rather or very important in adopting injecting as rst URHAa Year of initiation of usual use of heroin/year of most recent change of main route of administration Inuence of social environment The majority of his/her friends who were using heroin injected His/her sexual partner used heroin by the injected route Belief that injected heroin had better effect Availability of better heroin for injecting than for smoking or snifng Unavailability of good heroin for smoking/snifng Heroin purity was low or had decreased Belief that injecting was more efcient than smoking/snifng Limited money to buy heroin t for smoking/snifng Large increase in the price of heroin Desire to use smaller quantities of heroin Difculties in smoking or snifng because of disease Possibility of obtaining syringes through various services Being in prison Having recently been released from prison

Total 71.1 66.8 16.3

<1982 70.7 66.7 19.2

198287 74.4 72.2 14.0

198895 65.2 56.1 16.7

Total 45.3 40.6 12.8

<1992 55.2 53.2 12.8

199295 28.6*** 20.8*** 11.7

51.3 28.3 24.7 10.0 23.0 23.0 3.7 1.7 1.7 1.3

46.9 27.3 23.2 6.1 23.0 17.2 2.0 1.0 3.0 1.0

51.5 32.6 29.6 11.8 25.7 25.7 5.1 0.7 1.5 0.7

57.6 21.2 16.7 12.1 26.2 26.2 3.0 4.5 0.0 3.0

71.8 21.7 12.3 14.3 63.4 51.5 7.9 40.9 3.4 3.0 3.9 2.0

72.8 17.6 11.2 12.0 58.1 45.2 9.6 39.2 0.8 2.4 4.0 1.6

71.1 28.6* 14.3 18.2 71.4 61.0* 5.2 44.2 7.8* 3.9 3.9 2.6

a The total number of subjects analysed (n) varied between 298 and 301, depending on the reason considered. bThe total number of subjects analysed (n) varied between 202 and 203, depending on the reason considered. Statistical signicance of linear trend or of differences between periods: *P 0.05, **P 0.01,***P 0.001.

smoking or snifng, and the belief in the superior efciency of injected heroin all increased signicantly over time (Table 1). Market reasons (unavailability of good quality heroin to smoke or sniff, decreased purity) were considered important in explaining the change to injection for 21.7% of users (Table 1), but these reasons were not expressed in the previous open-ended question.

who had never injected chose reasons related to the inuence of the social environment or of having enough money to buy heroin suitable for smoking or snifng (Table 2). Few people expressed concern about a higher risk of overdose from injection in the previous open-ended question. In fact, only 4.2% of those who had never injected mentioned this reason.

Reasons for never having injected drugs Of the total sample, 262 subjects had never injected drugs. The two major reasons for most people were concern about negative health consequences (especially fear of HIV and other infections, and fear of overdose) and fear of blood or of the physical act of inserting a needle in ones veins. More than half those interviewed
2003 Society for the Study of Addiction to Alcohol and Other Drugs

Reasons for choosing smoking or snifng as rst URHA Of the total sample, 599 users adopted a non-injecting route (384 smoking and 215 snifng) as the rst URHA. Most of those interviewed considered that concern about negative health consequences (infections, overdose or dependence) was the main reason for choosing the smoked or sniffed route. The second most frequently choAddiction, 98, 749760

754

Mara J. Bravo et al.

Table 2 Reasons given as rather or very important for never having injected (n = 262).

Fear of health consequences of injection Fear of infection by HIV or other agents Belief that injecting implies higher risk of overdose Belief that injecting implies much higher risk of dependence Fear of blood or of inserting a needle in ones veins Inuence of social environment Fear of losing sexual partner Fear of losing the majority of ones friends Fear of being discovered and of losing ones job Having enough money to buy heroin suitable for smoking or snifng Always having good heroin available for smoking or snifng

95.8 87.4 76.7 58.0 89.3 59.5 37.4 29.7 24.8 54.1 20.2

Table 3 Importance given to reasons for adopting snifng or smoking as rst URHA, and for switching from injecting to smoking or snifng heroin. % who considered this reason as rather or very important in switching from injecting to smoking/snifngb

% who considered thisreason as rather or very important in adopting snifng or smoking as rst URHAa Year of initiation of usual use of heroin/year of most recent change of main route of administration Fear of health consequences of injecting Belief that smoking or snifng implies lower risk of overdose Fear of infection by HIV/having an HIV testc Belief that smoking/snifng implies lower risk of dependence Inuence of social environment The majority of his/her friends who used heroin sniffed or smoked His/her sexual partner smoked or sniffed heroin Availability of good heroin suitable for smoking/snifng Heroin purity was high or had increased considerably Availability of heroin suitable for smoking, but not for injecting Belief that smoked/sniffed heroin had better effect Increased capacity to buy heroin More money available to buy heroin for smoking/snifng Considerable decrease in the price of heroin Difculties to inject because of vein problems Being in prison Having recently been released from prison

Total 70.6 45.3 44.0 38.5 64.6 59.9 16.1 25.0 19.3 11.2 19.1 4.9 1.2 0.3

<1982 56.8 38.3 29.6 28.4 65.4 61.7 11.1 44.4 40.7 18.5 22.2 2.5 0.0 1.2

198291 69.6 45.6 42.5 38.7 64.3 60.7 14.3 23.9 17.9 10.4 18.5 5.1 1.2 0.2

199295 86.1*** 49.5 62.0*** 45.5* 65.3 55.4 27.7*** 14.0*** 8.0*** 8.9* 17.8 5.9 2.0 1.0

Total 77.1 56.7 61.4 40.4 31.5 16.3 25.3 6.0 23.5 35.5 24.8 19.4 43.0 10.2 6.6

<1992 79.2 60.0 57.4 38.6 31.0 16.8 22.8 5.0 21.8 36.6 27.7 17.8 51.0 11.9 4.0

199295 73.8 51.6 67.7 43.1 32.3 15.4 29.2 7.7 26.2 33.8 20.3 21.9 30.8* 7.7 10.8

a The number of subjects analysed (n) varied between 594 and 596, depending on the reason considered. bThe number of subjects analysed (n) varied between 165 and 166, depending on the reason considered. cIn the case of reasons for initiating usual heroin use by smoking or snifng, this refers to Fear of infection by HIV or other agents. Statistical signicance of linear trend or of differences between periods: *P = 0.05, **P = 0.01,***P = 0.001.

sen reason was social inuence or pressure, mainly by friends or the sexual partner (Table 3). Similar to the case of injection, the importance in absolute terms of having a sexual partner who did not inject when selecting smoking or snifng as the initial route of administration was much greater for women. Indeed, 47.0% of women considered
2003 Society for the Study of Addiction to Alcohol and Other Drugs

it was a rather or very important reason versus 8.6% of men (P < 0.00001). These differences were due mainly to the fact that when they adopted the smoked or sniffed route, women were more likely than men to have a sexual partner who used heroin by these routes (51.3% versus 10.9%, respectively, P < 0.00001). Among those who
Addiction, 98, 749760

Heroin administration routes during HIV epidemic

755

had a sexual partner using the same non-injecting route, 91.7% of women and 78.8% of men (P = 0.10) considered that this was important in the adoption of the smoked or sniffed route. There were some differences between those whose rst URHA was the smoked route and those who sniffed. Smokers more often feared HIV and other infections (51.8% for smokers and 30.0% for sniffers, P < 0.0001), believed that heroin used by the selected route was more effective than injecting (23.5% versus 11.3%, P = 0.0004) and believed that the risk of overdose was lower (50.1% versus 36.5%, P = 0.002). When analysing temporal trends, it was seen that the importance of health reasons increased, in particular the fear of HIV or other infections (Table 3). This phenomenon was most notable among sniffers, among whom the proportion of those who considered health reasons as important increased from 43.8% before 1982 to 88.0% in 199295 (signicant linear trend, P = 0.0002), while the proportion of those who feared infection rose from 16.7% to 60.0% (P = 0.0003). The importance of having a sexual partner who used the same route also increased. The importance of market availability of good heroin suitable for smoking/snifng decreased, in particular the availability of high purity heroin (Table 3). Another signicant trend was seen among sniffers: the proportion of those who said their belief that sniffed heroin has a better effect than injected heroin was important in their choice of rst URHA dropped from 18.8% before 1982 to 0.0% in 199295 (P = 0.02). In the open-ended question the belief that smoking or snifng implies a lower risk of overdose was rarely cited (1.9%).

Reasons for transition from usually injecting heroin to smoking or snifng Regarding their most recent change of URHA, 166 users shifted from injecting to smoking (148) or snifng (18). Of these, 45.5% changed after a period of abstinence lasting at least 1 month, achieved in many cases without help from any treatment centre. After the transition, 52.7% of participants began using larger quantities of heroin, 21.0% continued using the same amount and 26.3% began using less. The most important group of reasons for giving up injecting were related with negative health consequences. Fear of becoming infected or of nding out the result of an HIV test was considered an important reason for 61.4% (Table 3). The two next most frequently chosen reasons were the difculty of injecting because of poor vein conditions and the inuence of the social environment. The importance of difculties in injecting was higher among women than among men: 70.0% of
2003 Society for the Study of Addiction to Alcohol and Other Drugs

women considered this reason as important in changing to a non-injecting route versus 37.0% of men (P = 0.002). With regard to the inuence of the social environment, the importance of having a sexual partner who smokes or sniffs heroin was greater among women: 30.0% of women considered that this was rather or very important versus 13.2% of men (P = 0.05). These differences are due mainly to the fact that women more often had a sexual partner who smoked or sniffed heroin when they changed to that route (30.0% of women versus 16.2% of men, P = 0.13). Among those who had a sexual partner who sniffed or smoked, 81.8% of men and 100% of women considered that this fact was important when changing to smoking or snifng. An increased capacity to buy heroin (because of higher income or lower priced heroin) and the availability of good quality and high purity heroin suitable for smoking or snifng were also important reasons (Table 3). Being in prison at the time of the transition to smoking or snifng was selected as an important reason by 10.2% of those who adopted one of those routes. The importance of having veins in poor condition as a reason for changing to a non-injected route decreased signicantly over time. The importance of the belief that smoking/snifng implies a lower risk of overdose than injecting also decreased, but this was not statistically signicant. Conversely, there was an increase over time in the importance of social pressure, as well as the fear of HIV infection or the knowledge of an HIV test result, although these differences did not reach statistical significance (Table 3). The availability of heroin suitable for smoking or sniffing was rarely mentioned spontaneously in the openended questions (1.8%). Similarly, the belief that the risk of overdose is lower from smoking or snifng than from injection was mentioned by only 4.8% of those interviewed.

DISCUSSION Factors inuencing initiation of injecting or transition to this route The reasons for adopting injection initially as the URHA were different from those chosen to explain the transition to this route. The inuence of the social environment was most important in the choice of injection as the initial route, whereas the transition to injection was more inuenced by the conviction that injecting heroin is more effective or efcient than smoking or snifng it. Our data suggest that during the rst years of the heroin epidemic in Spain (before 1987), the inuence of peers (friends, neighbours, school companions) or sexual partners was the most important factor affecting the
Addiction, 98, 749760

756

Mara J. Bravo et al.

adoption of injection as the initial route of heroin administration. In fact, 74.4% of those who chose injection as the URHA between 1982-1987 considered that social inuence had been important in selecting this route; in 79% of cases they were injected for the rst time by another person, generally a close friend. From 1987 onwards, the spread of the smoked route resulted in a decreasing proportion of heroin users who injected; thus the weight of the social factor in the initiation of injecting also decreased, although it remained important. Our study and others [5,8,12,16] have found that having an injector as a sexual partner can be decisive in initiating or shifting to the injected route. Our study also suggests that the effect of this factor is much stronger for women than for men, mainly because the proportion of women who have an injecting sexual partner is much higher, and also because women give more importance to this factor. The belief that injection is more efcient or effective than other routes was the most important reason for the transition to injecting. Other studies have found similar results [13,14,19]. The importance that drug users attribute to this reason reveals the unstable situation of many smokers and sniffers with a high level of dependence. In fact, this group may well act as a time-bomb that could produce a ood of new injectors when the appropriate conditions arise, such as restrictions in the supply of heroin suitable for smoking, a rise in the price/ purity rate, etc. Although injecting is not necessarily an inevitable consequence of heroin use [8,20], it has been observed recently that the high frequency of smoking or snifng is an important determinant of the transition to injecting [12]. One factor not considered as important either in adopting injection as the rst URHA or in changing to this route was the availability of free sterile syringes through various programmes. These results are consistent with evidence obtained by other methods [5,16,31]. Several factors related to the choice of injection as the initial route of heroin administration or the transition to this route were not perceived spontaneously as relevant by most users. One was the market factor, especially the characteristics of heroin supplied on the market (unavailability of heroin suitable for smoking or snifng, availability of low purity heroin). The reason why the heroin supply is not perceived spontaneously as an important inuence on the route of administration is not clear, but a similar phenomenon probably occurs in the daily life of people in the general population when they choose what products to buy. Few people think of the inuence of supply on their patterns of consumption and those who do tend to overrate their freedom of choice. In any case, although there is probably a strong association between
2003 Society for the Study of Addiction to Alcohol and Other Drugs

the supply and route of heroin administration, little evidence exists about its direction or temporal sequence. Were users forced to begin smoking because base heroin replaced white heroin in the drug market, or did this change occur because users demanded a product with less risk? Probably both things happened, to some extent. In any case, if characteristics of the heroin supply can inuence the route of administration, this implies that changes in policies to control the drug supply may modify the proportion of heroin users who inject. Similarly, stronger control of drug trafcking could provoke an increase in the price : purity ratio, and thus an increase in the proportion of injectors. An ethnographic study carried out in New York shows, however, that restrictions on the heroin supply do not automatically or immediately produce transitions to injection, and that users may have multiple responses, such as starting a drug dependence treatment, using other drugs, reducing or even eliminating use [23]. This phenomenon would in any case have to be conrmed in other areas.

Factors inuencing initiation of smoking/snifng heroin and transition to these routes Contrary to what others have found [15,32], heroin users in Spain state that the fear of health consequences (infections, overdose, dependence) are the most important reason why they have never injected heroin or why they have changed to a non-injecting route. Between 1982 and 1995 health reasons were most important with regard to the adoption of smoking or snifng as rst URHA, although this did not occur during the early years of the heroin epidemic. The most important health reason, particularly in the last period studied, was fear of HIV or other infections, or of having an HIV test. Some authors suggest that the inuence of the AIDS epidemic and of prevention programmes might have induced safer drug use behaviour, including changes to non-injecting routes [21,33,34]. This inuence should have been especially strong in Spain, where the prevalence of HIV infection among injectors reached 40% to 75% [3,35] during the 1980s. Nevertheless, neither the intensity of the AIDS epidemic in the various Spanish regions nor the activities carried out to ght it can explain satisfactorily the temporal and geographical trends in the different routes of heroin administration. In fact, the transition to smoking began before there was a public awareness that HIV was transmitted by contaminated syringes, and the regions with the highest prevalence of HIV among injectors have always been (and still are) those with the highest proportion of injectors among heroin users [36]. Other health reasons for adopting a non-injecting URHA were the belief that injecting heroin implies a
Addiction, 98, 749760

Heroin administration routes during HIV epidemic

757

higher risk of overdose than smoking or snifng and that it also implies a greater risk of dependency. The higher risk of dependency when injecting appears rather doubtful in the light of some studies [12,37], particularly when compared with smoking. The deeprooted belief that injecting is a riskier route for dependency may be explained by the results of several other studies [38,39] and by the strong negative perception of injecting compared to other routes of administration. This belief may help to slow down the transition towards injection, but may also make smoking and snifng appear of little consequence. The second most important factor in switching from injecting to smoking/snifng was the difculty of injecting due to vein problems. Injecting in many different sites of the body, as well as the emergence of vein problems, seem to be more frequent among women than among men [40], which is consistent with our studys nding that women more often perceive difculties in injecting because of vein problems as important in the transition to a non-injected route. The inuence or pressure of the social environment was also an important reason for stopping injection. Norms and group attitudes against injectors may exist nowadays, because they are perceived as losers in very poor health [5]. This factor may have become increasingly important in recent years, which is logical considering that the proportion of heroin users who adopt noninjecting routes has been continuously on the rise. An aversion to needles or to injections was a very important reason for never having injected drugs. This factor has been pointed out by other authors [7], and it probably varies by social or ethnic group. Some injectors have even mentioned that they felt this aversion before they started injecting drugs and that they were only able to overcome it when another person injected them while they were looking the other way [41]. Finally, contrary to what might be expected, being in prison seems to have been more important in the case of the transition to noninjecting routes than the other way around. Some factors were not perceived spontaneously as important by most users with regard to the choice of smoking or snifng as the rst URHA. Most striking among these was market conditions (availability of heroin suitable for smoking or snifng, availability of high purity heroin, low price of heroin). The inuence of this factor in the case of smoking seems obvious, since it is practically impossible to smoke heroin if one cannot obtain base heroin. In New York, the decrease in the price : purity ratio of heroin seems to have coincided with an increase in its use by snifng [42]. Moreover, the availability of high purity heroin suitable for smoking has probably favoured the fact that a large proportion of heroin sniffers in the United States have not shifted to injec 2003 Society for the Study of Addiction to Alcohol and Other Drugs

tion [17,43]. Similarly, the belief that the smoked or sniffed route involves a lower risk of overdose was rarely cited spontaneously by any of those interviewed. The open-ended questions did not reveal any important reasons that were not already included in the categories of the closed lists for each of the ve types of behaviour studied.

Implications for intervention and research Acting on the factors that inuence injection is a high priority to avoid or reduce the principal health problems associated with heroin use. Given the high risk of dependence related with non-injecting use, it is also important to limit the spread of heroin snifng and smoking. This study suggests that multiple reasons often exist for adopting a given route of heroin administration, which result from the interaction of individual, social and market factors. Although some factors are unlikely to be modied by social or health-related actions, innovative interventions should be designed to prevent drug users from injecting [10]. For instance, recognition of the inuence of peers and sexual partners means that initiating or shifting to injection may be partly avoided by acting on and through the peer group and its leaders. One immediate idea is to act directly on sniffers and smokers with a high risk of transition by making them more conscious of the risks of injection, helping them to develop skills to confront offers of injection, and helping them to avoid or reduce contacts with injector networks. Peers and sexual partners may have a decisive inuence on the adoption of injection, and are often the people from whom injectors receive their rst heroin injection. Thus, it is also necessary to focus on those who are already injecting, who are more visible and accessible than non-injectors, to prevent them from injecting or promoting injection among their non-injecting sexual partners and friends [10]. There is evidence that these interventions are feasible, acceptable and effective [9]. In any case, given the strong inuence of sexual partners on the choice of the route of administration, a high priority would be to act on sexual partners with an injecting and a non-injecting member. The perception of health risks related to injecting seems to have acted as a strong determinant in choosing the smoking or snifng route, and in the transition to non-injecting. In this regard, it is also necessary to make heroin users more conscious of the risk of hepatitis C infection and of overdose. The fact that many users may change to injection because of its greater efciency and effectiveness means that smokers and sniffers with a high level of dependence are exposed to an important risk of injecting, albeit sporadically. Consequently, they should be a target group for prevention and treatment programmes (with adequate
Addiction, 98, 749760

758

Mara J. Bravo et al.

doses of oral opioids), and should be particularly aware that the risk of HCV and HBV infection at the beginning of an injection career are very high [11,17,44], as is the risk of overdose for sporadic injectors [4547]. Other factors, such as the characteristics and price of heroin available on the market, are difcult to control, and little effort has been made to design and implement such interventions. We believe it is possible to choose market control options that may minimize the risk of injecting. It has been proposed recently that control efforts should be concentrated on countries and black market sectors that produce and distribute salt heroin [10].

ACKNOWLEDGEMENTS The eldwork for this study was nanced through FIS project 94/1527, and the data analysis through FIPSE project 3035/99. We would like to thank Aurelio Daz and Mila Barruti for their co-operation in the questionnaire design; Valentn Mrquez and Juan Gamella (Madrid) for their collaboration in the denition of settings and the selection of interviewers. We also wish to thank the City and Regional Plans on Drugs that facilitated access to drug treatment centres (Lluis Torralba, Josep Mara Suelves, Carlos Mateo, Emiliano Martn and Fernando Arenas), as well as all drug treatment centre co-ordinators. The views expressed in this work are solely the responsibility of the authors and are not necessarily shared by the institutions in which they work.

Study limitations This study explores the subjective reasons chosen from a series of lists provided by study investigators of reasons for initiating or changing routes of heroin administration. These reasons may not coincide completely with the objective determinants of such behaviours. In addition it is evident that, even though we made a previous exploratory study to ensure inclusion of the reasons given in the usual discourse of drug users, the formulation of closed replies is always a reductionist approximation of reality. The inclusion in the interview of an open-ended question, posed neutrally to avoid biasing the response in any way, palliates this limitation to some degree and has enriched the results. Both methods offer similar and complementary information, and no strong inconsistencies were seen. As in many studies of illegal drug use, questions could be raised about how representative our sample was based on two main factors: the non-probabilistic nature of the subsample of street-users and ignorance of the proportion of treatment-users in the whole population of heroin users. To minimize the problems derived from the rst factor we worked with a large sample, seeking to include as diverse a selection of users as possible. The second factor is unlikely to introduce major bias because the differences between the general characteristics of treatment-users and street-users were small. The results of this study may also be limited by recall bias, or may reect the dominant perception regarding the phenomenon under consideration more than the subjects true reasons at the time. Moreover, most of the questions about the reasons for different types of behaviour focused on the usual route of heroin administration, which did not allow us to explore, for instance, the reasons for occasional injection perceived by those who usually smoked or sniffed. Finally, this study focused on heroin users (which in Spain include the great majority of injectors); therefore, we do not know to what extent these results may apply to other drugs such as cocaine.
2003 Society for the Study of Addiction to Alcohol and Other Drugs

REFERENCES
1. Sporer, K. A. (1999) Acute heroin overdose. Annals of Internal Medicine, 130, 584590. 2. Gossop, M., Grifths, P., Powis, B., Williamson, S. & Strang, J. (1996) Frequency of non-fatal heroin overdose: survey of heroin users recruited in non-clinical settings. British Medical Journal, 313, 402. 3. Bravo, M. J. & De la Fuente, L. (1991) Epidemiologa de la infeccin por VIH en los usuarios de drogas por va parenteral [Epidemiology of HIV infection among IVDUs]. Publicacin Ocial de Sociedad Espaola Interdisciplinaria de SIDA, 2, 335342. 4. Stimson, G. V. (1996) Drug injecting: the public health response in the next decade. Addiction, 91, 10981099. 5. Van Ameijden, E. J. & Coutinho, R. A. (2001) Large decline in injecting drug use in Amsterdam, 19861998: explanatory mechanisms and determinants of injecting transitions. Journal of Epidemiology and Community Health, 55, 356363. 6. Swift, W., Maher, L. & Sunjic, S. (1999) Transitions between routes of heroin administration: a study of Caucasian and Indochinese heroin users in south-western Sidney, Australia. Addiction, 94, 7182. 7. Strang, J., Grifths, P. & Gossop, M. (1996) Heroin smoking by chasing the dragon: origins and history. Addiction, 91, 673683. 8. De la Fuente, L., Barrio, G., Royuela, L., Bravo, M. J. & The Spanish Group for the Study of the Route of Heroin Administration (1997) The transition from injecting to heroin smoking in three Spanish cities. Addiction, 92, 17331744. 9. Hunt, N., Stillwell, G., Taylor, C. & Grifths, P. (1998) Evaluation of a brief intervention to prevent initiation into injecting. Drugs: Education, Prevention and Policy, 5, 185 194. 10. Hunt, N., Grifths, P., Southwell, M., Stillwell, G. & Strang, J. (1999) Preventing and curtailing injecting drug use: a review of opportunities for developing and delivering route transition interventions. Drug and Alcohol Review, 18, 441 451. 11. Van Ameijden, E. J. C. & Coutinho, R. A. (1998) Maximum
Addiction, 98, 749760

Heroin administration routes during HIV epidemic

759

12.

13.

14.

15.

16.

17. 18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

impact of HIV prevention measures targeted at injecting drug users. AIDS, 12, 625633. Van Ameijden, E. J. C., Van den Hoek, J. A. R., Hartgers, C. & Coutinho, R. A. (1994) Risk factors for the transition from noninjection drug use and accompanying AIDS risk behavior in a cohort of drug users. American Journal of Epidemiology, 139, 11531163. Crofts, N., Louie, R., Rosenthal, D. & Jolley, D. (1996) The rst hit: circumstances surrounding initiation to injecting. Addiction, 91, 11871196. Gamella, J. (1994) The spread of intravenous drug use and AIDS in a neighbourhood in Spain. Medical Anthropology Quarterly, 8, 131160. Casriel, C., Des Jarlais, D. C., Rodrguez, R., Friedman, S. R., Stepherson, B. & Khuri, E. (1990) Working with heroin sniffers: clinical issues in preventing drug injection. Journal of Substance Abuse Treatment, 7, 110. Des Jarlais, D. C., Casriel, C., Friedman, S. R. & Rosenblum, A. (1992) AIDS and the transition to illicit drug injection results of a randomised trial prevention programme. British Journal of Addiction, 87, 493498. Mathias, R. (1999) Heroin snorters risk transition to injection drug use and infectious disease. NIDA Notes, 14, 111. Neaigus, A., Miller, M., Friedman, S. R., Hagen, D. L., Sifaneck, S. J., Ildefonso, G. & Des Jarlais, D. C. (2001) Potential risk factors for the transition to injecting among noninjecting heroin users: a comparison of former injectors and never injectors. Addiction, 96, 847860. Casriel, C., Rockwell, R. & Stepherson, B. (1988) Heroin sniffers: between two worlds. Journal of Psychoactive Drugs, 20, 437440. Sotheran, J. L., Goldsmith, D. S., Blasco, M. & Friedman, S. R. (1999) Heroin snifng as self-regulation among injecting and non-injecting heroin users. Journal of Drug Issues, 29, 401422. Hamid, A., Curtis, R., McCoy, K., McGuire, J., Conde, A., Bushell, W., Lindenmayer, R., Brimberg, K., Maia, S., Abdur-Rashid, S. & Settembrino, J. (1997) The heroin epidemic in New York City: current status and prognoses. Journal of Psychoactive Drugs, 29, 375391. De la Fuente, L., Saavedra, P., Barrio, G. Royuela, L. & Vicente, J. (1996) Temporal and geographic variations in the characteristics of heroin seized in Spain and their relation with the route of administration. Drug and Alcohol Dependence, 40, 185194. Andrade, X., Sifaneck, S. J. & Neaigus, A. (1999) Dope sniffers in New York City: an ethnography of heroin markets and patterns of use. Journal of Drug Issues, 29, 271298. European Centre for the Epidemiological monitoring of AIDS (EuroHIV) (2001) HIV/AIDS Surveillance in Europe. End-year report 2000, no. 64. Saint Maurice, France: EuroHIV. Delegacin del Gobierno para el Plan Nacional sobre Drogas (DGPNSD) (1994) Sistema Estatal de Informacin sobre Toxicomanas (SEIT), Informe 1993 [State Information System on Drug Abuse, Report 1993]. Madrid: Ministerio de Justicia e Interior. Watters, J. K. & Biernacki, P. (1989) Targeted sampling: options for the study of hidden populations. Social Problems, 36, 416430. Hartnoll, R., Grifths, P., Taylor, C., Hendrick, V., Blanken, P. & Nolimal, D. (1997) Handbook on Snowball Sampling. Strasbourg: Pompidou Group, Council of Europe. Ort, A. (1990) La apertura y el enfoque cualitativo o

29. 30.

31.

32.

33. 34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

estructural: la entrevista abierta semidirectiva y la discusin en grupo [The qualitative or structural focus: the semi-directed interview and group discussion]. In: Alianza Editorial, ed. El anlisis de la realidad social. Metodos y tcnicas de investigacin [The Analysis of Social Reality: Research Methods and Techniques], pp. 171203. Madrid. Norussis M. J. (1993) SPSS for Windows: Advanced Statistics, Release 6.0. Chicago: SPSS Inc. Barrio, G., De la Fuente, L., Royuela, L., Daz, A., RodrguezArtalejo, F. & The Spanish Group for the Study of the Route of Drug Administration (1998) Cocaine use among heroin users in Spain: the diffusion of crack and cocaine smoking. Journal of Epidemiology and Community Health, 52, 172 180. Vlahow, D. & Junge, B. (1998) The role of needle exchange programs in HIV prevention. Public Health Reports, Supplement 1, 7580. Sibthorpe, B. & Lear, B. (1994) Circumstances surrounding needle use transitions among injection drug users: implications for HIV intervention. International Journal of the Addictions, 29, 12451257. French, J. F. & Safford, J. (1989) AIDS and intranasal heroin. Lancet, i, 1082. Des Jarlais, D. C., Friedman, S. R. & Ward, T.P. (1993) Harm reduction: a public health response to the AIDS epidemic among injecting drug users. Annual Review of Public Health, 14, 413450. Hernndez-Aguado, I., Avino, M. J., Prez-Hoyos, S., Gonzlez-Aracil, J., Riz-Prez, I., Torrella, A., Garca de la Hera, M., Belda, M., Fernndez, E., Santos, C., Trullen, J. & Fenosa, A. (1999) Human immunodeciency virus (HIV) infection in parenteral drug users: evolution of the epidemic over 10 years. International Journal of Epidemiology, 28, 335340. De la Fuente, L., Lardelli, P., Barrio, G., Vicente, J. & Luna, J. D. (1997) Declining prevalence of injecting as main route of administration among heroin users treated in Spain, 1991 1993. European Journal of Public Health, 7, 421426. Barrio, G., De la Fuente, L., Lew, C., Royuela, L., Bravo, M. J. & Torrens, M. (2001) Differences in severity of heroin dependence by route of administration: the importance of length of heroin use. Drug and Alcohol Dependence, 63, 169 177. Gossop, M., Grifths, P., Powis, B. & Strang, J. (1992) Severity of dependence and route of administration of heroin, cocaine and amphetamines. British Journal of Addiction, 87, 15271536. Smolka, M. M. & Schmidt, L. G. (1999) The inuence of heroin dose and route of administration on the severity of the opiate withdrawal syndrome. Addiction, 94, 11911198. Darke, S., Ross, J. & Kaye, S. (2001) Physical sites among injecting drug users in Sydney, Australia. Drug and Alcohol Dependence, 62, 7782. McBride, A., Pates, R. M., Arnold, C. & Ball, N. (2001) Needle xation, the drug users perspective: a qualitative study. Addiction, 96, 10491058. Strang, J., Des Jarlais, D. C., Grifths, P. & Gossop, M. (1992) The study of transitions in the route of drug use: the route from one route to another. British Journal of Addiction, 87, 473483. National Institute on Drug Abuse (NIDA) (2000) Epidemiological Trends in Drug Abuse, vol. I. Proceedings of the Community Epidemiological Work Group, June 2000, pp. 3250. Bethesda, MD: NIDA.
Addiction, 98, 749760

2003 Society for the Study of Addiction to Alcohol and Other Drugs

760

Mara J. Bravo et al.

44. Garfein, R. S., Vlahov, D., Galai, N., Doherthy, M. C. & Nelson, K. E. (1996) Viral infections in short-term injection users: the prevalence of the hepatitis C, hepatitis B, human immunodeciency, and human T-lymphotropic viruses. American Journal of Public Health, 86, 655661. 45. Brugal, M. T., Barrio, G., De la Fuente, L., Regidor, E., Royuela, L. & Suelves, J. M. (2002) Factors associated with non-fatal heroin overdose: assessing the effect of frequency and route of heroin administration. Addiction, 97, 319327.

46. Van Haastrecht, H. J. A., Van Ameijden, E. J. C., Van Den Hoek, J. A. R., Mientjes, G.H.C., Bax, J. S. & Coutinho, R. A. (1996) Predictors of mortality in an Amsterdam cohort of human immunodeciency virus (HIV) positive and HIV negative drug users. American Journal of Epidemiology, 143, 380391. 47. Tagliaro, F., De Battisti, Z., Smith, F.P., & Marigo, M. (1998) Death from heroin overdose: ndings from hair analysis. Lancet, 351, 19231925.

2003 Society for the Study of Addiction to Alcohol and Other Drugs

Addiction, 98, 749760