Differences in Characteristics of Heroin Inhalers and Injectors at Admission to Treatment

J. C. Maxwell, R. T. Spence, & T. M. Bohman UT Center for Social Work Research

Introduction Purpose: to understand why heroin inhalers (snorters) in Texas enter treatment sooner than injectors. This study extends earlier findings by comparing the characteristics of heroin injectors versus inhalers at their first admission to publicly-funded treatment using CODAP/TEDS data. This study will build on earlier studies, but looks at differences in patterns of heroin use in a much larger sample characterized both by its race/ethnic diversity and by the use of black tar heroin, a type of heroin primarily seen only in the western United States and Mexico. This project has three phases: 1) analysis of CODAP/TEDS data on clients who had a primary problem with heroin; 2) in-depth interviews with heroin users in public and private programs; and 3) interviews and focus groups with heroin inhalers and injectors who are not in treatment. This poster reports on the first phase only. Sample 9,732 unduplicated adults who were first admissions to TCADA-funded residential, outpatient drug-free, or outpatient methadone treatment programs between January 1, 1997 and December 31, 2001. Clients had a primary problem with either inhaled or injected heroin which they had used in the month prior to admission. While they were first admissions to TCADA programs, 64% had been treated previously in non-TCADA-funded programs. 92.5% were injectors and 7.5% were inhalers. Mean age at admission was 35.8 years (SD 10.6). Age of first use of heroin was 22.9 years (SD 8.0). The mean lag between first use and admission to TCADA-funded treatment was 13.5 years (SD 10.8). 69% were male; 49% were Hispanic, 40% were Anglo, and 12% were African American. Average annual legal income was $5,522; 17% were employed and education level was 11.1 years. 75% lived with their families, 28% were married or co-habiting with a partner, 11% were homeless, and 30% were involved with the criminal justice or legal system. 33% reported a secondary problem with powder cocaine, 12% with alcohol, 7% with marijuana, and 4% with crack cocaine; 38% reported no problems with other drugs.

Results

Discussion

Comparisons of Heroin Injectors and Inhalers on Demographic, Criminal Justice Status, Treatment, Drug Use, and Substance Abuse Impairment Characteristics
Demographics Age at Admission Age of First Use LagFirst Use to Entry to Treatment (Years) Injectors 36.0 22.8 13.8 S.E. 0.482 0.188 0.463 Inhalers S.E. 31.0 0.614 23.5 0.347 8.1 Odds Ratio* .81 .43 1.15 2.82 1.23 .61 1.72 1.61 1.14 1.23 1.23 0.604 Pr> |t] <.0001 <.0001 <.0001 Confidence Limits 0.70-0.94 0.31-0.61 0.94-1.40 1.83-4.33 1.01-1.51 0.50-0.73 1.09-2.72 1.31-1.98 0.87-1.49 1.03-1.47 0.99-1.53

Multivariate Prediction of Heroin Inhaler versus Injector Status from Demographic, Criminal Justice Status, Treatment, Drug Use, Second Drug Problems and Substance Abuse Impairment Characteristics
Logistic Regression Model Estimate Pr> |Z| Demographics Male versus Female -0.10 0.43 0.91 African American versus Anglo 2.51 0.00 12.32 Hispanic versus Anglo 0.55 0.00 1.74 Age at Admission -0.10 0.00 0.91 Age of First Use 0.06 0.00 1.06 Live with Family -0.09 0.64 0.91 Homeless -0.26 0.18 0.77 Pregnant 0.13 0.67 1.14 Minor Children in Home 0.31 0.02 1.36 Years of Education 0.05 0.52 1.05 Employed at Admission 0.20 0.10 1.22 Yearly Income 0.11 0.02 1.11 Criminal Justice Status Criminal Justice/Legal Involvement 0.00 0.99 1.00 On Probation -0.26 0.62 0.77 On Parole -0.82 0.09 0.44 Treatment First TCADA Treatment 0.39 0.00 1.47 Admitted to Methadone 0.23 0.57 1.26 Second Drug Problem None 0.17 0.42 1.18 Alcohol 0.37 0.20 1.45 Powder Cocaine -0.51 0.13 0.60 Crack Cocaine 0.65 0.01 1.91 Marijuana 0.59 0.08 1.80 Substance Abuse Impairment (% with 0 Days of Problems in Last Month) Sickness/Health Problems -0.19 0.06 0.83 Employment Problems -0.01 0.85 0.99 Family/Marital Problems 0.06 0.56 1.06 Peer/Social Problems in -0.07 0.58 0.93 Psychological Problems 0.00 0.95 1.00 Drug/Alcohol Problems -0.04 0.64 0.96 Odds Ratio

% Male .0068 % Anglo <.0001 % Hispanic .1716 % African American <.0001 % Live with Family .0430 % Homeless <.0001 % Pregnant .0206 %Minor Children in Home <.0001 Years of Education .3586 %Employed at Admission .0253 Yearly Income .0610 Criminal Justice Status % Involved Criminal Justice 30.7 25.6 .69 <.0001 0.59-0.80 Legal System % on Probation 10.8 11.1 .95 .7498 0.69-1.31 % on Parole 13.5 6.3 .36 <.0001 0.26-0.49 Treatment %First TCADA Treatment 35.2 49.3 1.91 <.0001 1.68-2.18 %Admitted to Methadone 29.0 37.7 0.94 .3342 0.84-1.06 Secondary Drug Problem %None 38.2 29.9 1.24 .0886 0.97-1.58 %Alcohol 12. 2 10.4 1.04 .6838 0.86-1.25 %Powder Cocaine 33.3 31.5 .51 <.0001 0.36-0.71 %Crack Cocaine 4.0 8.7 2.19 <.0001 1.82-2.63 %Marijuana 6.1 14.3 2.21 <.0001 1.73-2.82 Substance Abuse Impairment (% with 0 Days of Problems in Last Month) Sickness/Health Problems 62.8 70.6 .68 .0598 0.46-1.02 Employment Problems 35.7 45.3 .66 .0257 0.46-0.95 Family/Marital Problems 43.3 46.7 .81 .2110 0.59-1.12 Peer/Social Problems 61.3 63.1 .88 .5198 0.60-1.29 Psychological Problems 41.8 45.2 .84 .2741 0.61-1.15 Drug/Alcohol Problems 14.0 14.8 .87 .5878 0.52-1.45
*Odds ratios greater than 1 indicate inhalers are more likely to have this characteristic present while odds ratios less than 1 indicate inhalers are less likely to have this characteristic present

Percent Percent Injectors Inhalers 70.0 61.7 40.7 29.2 49.6 34.5 9.7 36.2 74.9 80.6 11.4 5.0 1.58 2.18 32.1 43.3 11.0 11.3 16.9 23.3 $5,426 $6,694

Pr> |Z|

Consistent with other studies, we found that there are significant differences between injectors and inhalers at admission to treatment. Inhalers are younger, more likely to have used heroin for fewer years, to be first admissions to treatment, to have children in the home, and to have higher annual incomes. Texas injectors and inhalers reported no difference in number of days that heroin was used in the month prior to admission. We would speculate that some of the inhalers had reached a level of dependence where their habits could no longer be maintained through daily inhaling and that faced with the need to shift to injecting, they had, instead, chosen to enter treatment. Our study found that there were very large differences by race/ethnicity, with African Americans in the sample being much more likely to be inhalers than injectors. This finding is not well understood and will be the focus of additional study. While the bivariate analysis showed that injectors were more likely to have problems with the legal system and to be on parole, which would be a reflection of their longer crime careers, these patterns were not significant in the multivariate prediction model, which controlled for age. Having minor children in the household was a significant predictor of being an inhaler. Only higher income was a significant economic predictor of inhaling when age, gender, and race/ethnicity were controlled. However, findings about the economic status may be confounded because TCADA programs give priority to povertylevel clients. Limitations/Further Study The findings from this first phase of the study are limited by the variables collected in CODAP/TEDS and they cannot be generalized to all heroin users in treatment in Texas since only 9 of the 69 methadone programs in the state report CODAP/TEDS data. Collecting comparable data on clients in private programs is part of Phase 2 of this research study. Phase 2 will be in-depth face-to-face interviews with heroin users to determine reasons for shifting or not shifting to needles. Data will be collected on patterns of use of other drugs, attitudes towards needle use (fear of needles or needle fixation), prior sexual and physical abuse, mental and physical status, childhood and family history, criminal history, and reasons for remaining an inhaler or for shifting to injection. Phase 3 will be interviews and focus groups with heroin users who have never been in treatment.

Analysis
40

Demographics of Injectors & Inhalers at Admission to Treatment

Injectors
35 30 25 20 15 10

80%

Demographics of Injectors & Inhalers at Admission to Treatment

Demographics of Injectors & Inhalers at Admission to Treatment

90% 80% 70% 60% Injectors Inhalers

Statistical models included a generalized linear model with the outcome modeled as a binomial and multinomial distribution and a hierarchical linear model for continuous outcomes. The Generalized Estimating Equation (GEE) model was used to account for the variation in heroin user characteristics due to treatment program. All analyses were conducted using SAS v8.

Inhalers

70% Injectors 60% Inhalers

50%

40%

50%
30%

40% 30% 20%

20%

Acknowledgements
5
10%

10%

Funding from NIDA (R21 DA014744) Cooperating treatment providers and study participants Accepted for publication in Substance Use and Misuse. Contact Jane Maxwell 512 232-0610 jcmaxwell@mail.utexas.edu

0 Admission Age*
*p <0.05

0%

0%
Male* Anglo* Hispanic Black*

Age 1st Use*

Lag*

# Days Used

*p <0.05

Live with Family*

*p <0.05

Homeless*

Pregnant*

Kids at Home*

Employed*