Young Heroin Users in Baltimore: A Qualitative Study

Assignment #5

Assignment 5 will require you to read Young Heroin Users in Baltimore: A Qualitative

Study (2006) by Gandhi, Kavanagh, and Jaffe. The article can be found in the course. While reading the article write an essay based on the three points listed below. Answers should be in complete sentences and demonstrate your ability to understand how the study proceeded. Your writing should be as original as possible (no copy and paste), double spaced, size twelve font, and with 1-inch margins (standard APA format).

The assignment is due Friday, April 16 (11:59pm).

1. Within the introduction section of the article, describe how the author communicates that heroin use by young people was worthy of study.
2. Within the materials and methods section, describe the purpose of the study, assessment instruments utilized, and data analysis techniques.
3. Within the results section, summarize the 7 qualitative characteristics of the study participants. Essentially, what were the qualitative findings of the study?

Young Heroin Users in Baltimore: A Qualitative
Study
Devang H. Gandhi, M.D.,1 Greg J. Kavanagh, M.A.,2 and
Jerome H. Jaffe, M.D.1
1University of Maryland School of Medicine, Baltimore, Maryland, USA
2University of Cincinnati, Cincinnati, USA
Abstract: This study describes the characteristics of 67 young heroin users,
interviewed using a semistructured qualitative questionnaire (QQ) as part of a
larger study of 18- to 25-year-old heroin users seeking detoxification with buprenorphine
at a drug treatment center in Baltimore. This new generation of heroin
users has a different demographic profile compared to older heroin users in this
area. Our data, supported by data from another clinic and from the Maryland
State Alcohol and Drug Abuse Administration, seem to indicate that the younger
heroin users in treatment settings are predominantly White, with a high proportion
of women, often living in the suburbs. Based on responses to the QQ,
all subjects initiated heroin use intranasally, usually in a group setting; 75%
had subsequently gone on to use intravenously. The typical young heroin user
in Baltimore Metropolitan area appears to be a young White man or woman from
a middle=working-class background, with exposure to drug use among close
contacts while growing up, experimenting with gateway drugs with peers before
proceeding first to intranasal, and then intravenous heroin use, engaging in criminal
activities to support the habit, repeatedly seeking help with assistance from
family, but failing to sustain abstinence due to continued exposure to drug using
peers and a poorly implemented plan of aftercare. Further research should focus
on efforts to engage peer groups and families in order to improve treatment
outcomes in young heroin users.
Keywords: Heroin, young adult, qualitative characteristics
The authors wish to thank Dr. Michael Hayes, Ms. Marion Currens, and the
staff at Center for Addiction Medicine, Baltimore, for their generous help in this
project. The project was funded by a grant from The Abell Foundation.
Address correspondence to Devang H. Gandhi, M.D., 701 W. Pratt Street,
Rm 334, Baltimore, MD 21201. E-mail: [email protected]
The American Journal of Drug and Alcohol Abuse, 32: 177–188, 2006
Copyright Q Taylor & Francis Group, LLC
ISSN: 0095-2990 print/1097-9891 online
DOI: 10.1080/00952990500479290
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INTRODUCTION
Heroin use among young people has been a growing cause for concern
since the 1990s. According to the National Household Survey on Drug
Abuse (NHSDA), there was a significant increase in the number of heroin
users during mid-1990s. Among the estimated 101,000 persons who used
heroin for the first time in 1995, 31,000 were under age 18 and another
55,000 were age 18 to 25 (1). Since the mid-1990s, the prevalence of lifetime
heroin use increased for both adolescents and young adults. From
1995 to 2002, the rate among youths aged 12 to 17 increased from 0.1
to 0.4%, and among young adults aged 18 to 25, the rate rose from 0.8
to 1.6% (2).
The annual Monitoring the Future (MTF) survey of eigth, tenth, and
twelfth grade students found that the proportion of eighth graders
reporting lifetime, annual and past 30-day heroin use declined slightly
in 2000. However, among twelfth graders, lifetime, annual and past
30-day heroin use more than doubled to 2.4, 1.5, and 0.7%, respectively,
between 1994 and 2000. The annual rate for heroin use in twelfth graders
was the highest since the MTF survey began (3, 4). In 2001, heroin use
declined at all three grade levels, and has since held steady (5).
Data from the Community Epidemiology Work Group at the
National Institute on Drug Abuse (6, 7) also suggest that indicators for
heroin use continued to remain high but stable inmany areas while declining
in some in recent years, and that the abuse of heroin has been spreading to
suburban communities and among younger population. In the Baltimore
area, it accounted for over 60% of drug-related treatment admissions (7).
While most heroin users were living in metropolitan areas, the new
generation of heroin users seems to be less concentrated in the inner cities
and involves more suburban youth (8). There also has been a change in
the ways these young people use heroin. Among recent initiates found
by the 1995 and 1996 NHSDA, 95% were under age 26 and 77% had
never injected heroin. In contrast, the 1991 and 1992 NHSDA showed
61% of the heroin users were younger than 26 and only 46% had never
injected. One reason for this pattern may be the high levels of heroin
purity—as high as 94% in Baltimore (9)—allowing easier initiation by
intranasal route by young people. However, a more recent report from
New Jersey indicates that this trend may be changing, with an increase
in the proportion of heroin injectors between 1995 and 1999 (10). The
present generation of young heroin users appears to differ substantially
from the older heroin users (11). It, therefore, is important to test the
assumption that the characteristics and solutions derived from the previous
epidemic of heroin use apply to the new generation, and study
the new cohort of heroin users.
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Our knowledge of the new generation of heroin users is limited (12).
One review of literature on adolescent heroin use (13) found only 5 studies
describing clinical characteristics of young heroin users, most of
which took place in 1970s. A few recent ethnographic studies (11, 14, 15)
are available. Some more information recently has become available from
Substance Abuse and Mental Health Services Administration
(SAMHSA)–Center for Substance Abuse Treatment (CSAT) Adolescent
Treatment Models (ATM) initiative (16, 17). These studies include subjects
in the 13–21 years age group, in residential treatment, reporting lifetime
heroin use. The present study focuses on 18- to 25-year-old subjects
reporting heavy, almost daily, heroin use, seeking a brief outpatient
detoxification. The study examines some characteristics of young heroin
users in the Baltimore Metropolitan area by asking questions such as:
What are their sociodemographic and family characteristics? What, in
their perception, started them using heroin? What keeps them using?
How do they view the risks associated with their heroin use? How do they
access treatment?
MATERIALS AND METHOD
The aim of this study was to define the characteristics of treatmentseeking
young (18- to 25-year-old) heroin users, based on their responses
to a qualitative questionnaire. The study was conducted as part of a larger
project examining short and medium term outcomes after a very brief
(3–4 days) detoxification using buprenorphine in 18- to 25-year-old
heroin users (18). It also uses data obtained from the State of Maryland,
Alcohol and Drug Abuse Administration (ADAA), for comparison.The
study protocol was approved by the Institutional Review Board at the
University of Maryland, School of Medicine and informed consent was
obtained from all participants. A Federal Certificate of Confidentiality
also was obtained to protect sensitive information. This report includes
a subsample of 67, out of a total sample of 119 subjects recruited into
the larger study, who consented to a detailed interview. The main reasons
for nonparticipation were inability to go through an extensive interview
due to withdrawal discomfort and time restriction imposed by dependence
on someone else for transportation. There were no significant
differences in the demographics (age, gender, race, place of residencecity=
suburban) and duration of heroin use between the total sample in
the overall study, and those who participated in the qualitative study.
Subject recruitment was carried out between April and November
2000, at a large outpatient drug treatment clinic located in downtown
Baltimore City. The clinic provides outpatient detoxification services to
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over 3,000 patients each year. About 25% are in the 18- to 25-year-old
age group, a majority of whom use heroin as their primary drug of abuse.
Assessment Instruments: The subjects received an initial assessment,
which included a clinical evaluation, the Addiction Severity Index (19),
the Readiness to Change Questionnaire (20), a respondent locator form
and a qualitative questionnaire (QQ). The QQ was adapted from an ethnographic
instrument being used in a study with heroin users in the same
age group in San Francisco (Murphy, 2000, personal communication).
It covers seven domains of inquiry: 1) Early life history, 2) First heroin
use, 3) Family and social support, 4) Current drug use, 5) Drug treatment,
6) Illegal activities, and, 7) Health.
Interview Process: The interview was loosely structured and was conducted
by a Masters level psychologist (GJK). The process involved asking
probe questions and following up with additional questions as needed.
The answers were transcribed at the end of the interview, based on interview
notes. Subjects were free to choose not to answer specific questions.
Some questions that did not apply to the individual’s circumstances were
omitted, and ambiguous or unreliable responses were excluded from the
analysis, resulting in a variable number of responses to each content area.
Comparison Data: We obtained some demographic data from two
additional sources (a local drug treatment clinic providing similar services
and the Maryland State ADAA) for comparison in order to establish
whether the unusual demographic characteristics of our study sample
were consistent with the characteristics of similar patients from other treatment
settings locally and within the entire Baltimore Metropolitan area.
Data Analysis: Common theme statements within each of the 7 areas
of the QQ were established by examining the content of each area, for
example, under Early Life History, subjects’ responses were compiled
and determined as supporting or refuting the statement: ‘‘The subject
had a satisfactory family life and relationships up to high school.’’ Each
item was scored based on the subject’s responses, as supporting, refuting,
or neither supporting nor refuting (including refusal to respond, ambiguous
response, or not applicable to subject’s situation) the common theme
statement. The proportion of patients supporting, refuting or doing
neither was then calculated.
RESULTS
Demographics
Sixty-seven subjects were interviewed. The mean age was 21.3 years
(range 18 to 25 years). There was a roughly equal proportion of men
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and women (52 and 48%, respectively). The mean duration of heroin use
was 4.3 years (
2.3). Sixty percent lived in Baltimore City, while the
others came from the surrounding counties. Eighty-two percent had no
health insurance.
The overwhelming majority of 18- to 25-year-old heroin users seeking
detoxification in the clinic, and among our study group (94% White,
6%African American), wasWhite. This is in sharp contrast to the overall
clinic patient population, which has a preponderance of African
Americans. To investigate whether this was a phenomenon unique to this
clinic, or a reflection of a more widespread trend, we examined the
demographics of heroin users at another inner city clinic providing similar
services. We also obtained geographically matched data from the
Maryland State Alcohol and Drug Abuse Administration which tracks
admissions to all licensed drug treatment programs in the state. Both
showed a great preponderance of whites (68.5 and 78.7%, respectively)
among 18- to 25-year-old heroin users seeking treatment.
Qualitative Characteristics
The analysis of responses to QQ yielded the following salient findings:
Early Life History: The vast majority of the patients, 89.4% (59=66),
had exposure to a drug and=or alcohol problem among family members
or friends while growing up, prior to their own first use. Among these
close associates were 20 fathers, 13 mothers, 11 brothers, 5 sisters, 16
second degree relatives, and 30 ‘‘friends.’’ Thirty-four (57.6%) had at
least one parent or sibling with a drug and=or alcohol problem prior to
the onset of drug use. Almost half of the patients, 47.0% (31=66),
reported truancy and=or poor academic performance, and had dropped
out of high school. Few patients (12=67, 17.9%) reported having any college
education and none had received a college degree. About half of the
patients reported receiving some drug and alcohol education at school,
but only 18.8% (6=32) stated it was adequate. Patients reported that
the main problem with the education was that it focused almost entirely
on what they considered ‘‘soft drugs’’ (e.g. alcohol, cannabis, and nicotine)
and did not address the consequences of addiction such as tolerance,
withdrawal and dependency associated with heroin, cocaine, and
benzodiazepines.
First Heroin Use: All patients had used other drugs, such as alcohol
and marijuana, before trying heroin for the first time. When patients did
try heroin for the first time, all of them reported intranasal administration.
Almost all respondents, 98.3% (58=59), were introduced to drug
use by friends or a family member. First time users were more likely to
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have had heroin given to them free (23=37, 62.2%). A few could not recall
the situation in which they first used heroin (12=67). The most common
locations cited for first use were at congregations of young people—at a
party, 29.1% (16=55), or in a small group, 69.1% (38=55). Only one subject
reported first use while alone. About half of the respondents felt sick
(vomiting or nausea) after their first use, (26=54, 48.1%), and one-third
did not use again until weeks or months after their first administration
of heroin.
Current Heroin Use: A majority, 57.6% (38=66), spent an average of
between $50.00 and $100.00 daily on heroin use, while the rest reported
spending less than $50 daily. Almost 75% (50=67) were using through
intravenous injection at the time of this study, although all had started
out using intranasally. The mean duration of heroin use for intravenous
users was 4.4þ= 2.4 years, while the duration for nonintravenous users
was 3.8þ= 1.9 years. Over 95.0% (61=63) of the patients reported buying
their drugs in Baltimore City, usually with their friends (68.3%),
although 40.3% (27=67) lived in the surrounding counties.
Family and Social Support: Most (56=58, 96.6%) of the patients
reported that their families knew about their drug problem. The revelation,
while upsetting to their families, only infrequently resulted in
threats or loss of family support, and most patients reported continuing
help from their families to make treatment possible. Fewer than a quarter
(12=52, 23.1%) of respondents associated with or knew heroin using
peers who had been able to maintain abstinence for six months or longer.
Many patients stated that they avoided contact with recovering friends
because they did not want to jeopardize their recovery.
Drug Treatment: Most patients (88.7%; 55=62) did not report having
difficulty getting into a treatment program, though not all patients were
able to find their preferred treatment modality which may have been
inpatient detoxification and rehabilitation or methadone maintenance.
While 61.2% (41=67) had identified a rehabilitation program they might
attend after the detoxification, over one-half (24=41) of these patients
reported having no other plan of action following detoxification to support
abstinence. Some (18=67, 26.9%) did not identify any rehabilitation
plans and 11.9% (8=67) said they would only attend Narcotics Anonymous
meetings. The majority of the patients, 78.1%(50=64), had multiple
prior treatment attempts which mostly involved outpatient detoxification
treatments. Out of these patients, 70% (35=50) had achieved some period
of abstinence, followed by a relapse, but the rest had never stopped using
heroin. Feeling sick (8.6%, 3=35) and cravings=being around other users
(91.4%, 32=35) were the two primary reasons for relapse. Attempts to
quit ‘‘cold turkey’’ were often reported, but only 10.6% (7=66) of the
patients had ever done so successfully for a month or longer.
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Illegal Activities: Seventy percent (34=50) of those who responded
reported involvement in illegal activities. Common illegal activities were
stealing goods=money, 44.1% (15=34); selling drugs, 26.5%, (9=34) and
buying drugs for others, 17.6% (6=34). A few patients (4=34, 11.8%),
refused to reveal the nature of their illegal activities, while admitting to
having performed such activities.
Health: Despite the obvious risks, 64.2% (34=53) of the respondents,
73.5% of whom were intravenous drug users, reported not being concerned
about health problems. A majority of the patients, 68.3%
(43=63), believed that clean needle use or snorting drugs adequately protected
them from disease. Although 52.2% (35=67) did not report any
psychiatric disorders and major physical problems, 47.8% (32=67) had
been diagnosed in the past with at least one physical or mental disorder,
most commonly depression (93.8%) or a chronic physical illness (18.8%).
The majority of patients, 76.1% (51=67) had tested negative for HIV at
least once in the past. One patient was HIV positive and another had
never followed-up on his results.
DISCUSSION
This study serves to raise a number of intriguing questions that merit
further investigation. The demographics of the sample as well as the data
obtained from State of Maryland ADAA are very striking. The relative
absence of African Americans and the overwhelming preponderance of
Caucasians in the data from all geographic areas suggest 2 possibilities:
1) few African Americans in this age group use heroin, and=or, 2) they
are unable or unwilling to seek treatment during this stage of their drug
use. An epidemiological study looking at the prevalence of heroin use in
young African Americans may help to clarify this issue.
The family background and upbringing of these individuals seem
particularly remarkable for the high rate of prior exposure to drug use
in the family or someone else close to them. Most subjects considered this
an important factor in their initiating drug use. This is comparable to an
80% prevalence of substance use by a family member reported by
Pugatch et al. (21). This also is consistent with the observation by Li
et al. (22) that substance use by parents and friends was associated with
a greater risk of adolescent substance use, and may mark a group at a
high risk to proceed to serious drug problems, and an important target
for prevention efforts.
Predictably, all began by first using some substance other than heroin.
Although the initial use of heroin in this group was always intranasal,
there was a very high rate of progression to intravenous use.
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This suggests that increasing tolerance to heroin makes it difficult for
many users to sustain their intranasal use beyond a limited period of
time, despite the high purity of heroin available on the street. The high
rates of intravenous use in this sample also may be because heroin users
who inject are more likely to seek treatment.
Hartnoll (23) suggested that ability to use a substance intranasally
may lead to the emergence of new groups of users by circumventing the
negative image of intravenous use. The ease and perception of ‘‘safety’’
of initiating heroin use via intranasal route also may explain, at least in
part, the serious lack of concern about health risks among these subjects.
The relatively low rates of testing for HIV are a cause for concern and
may result from denial of health risks, a reluctance to be tested, or lack
of access to testing. As expected, drug use in this age group seems to be
initiated and sustained as a social activity involving peers or sexual partners.
This underscores the importance of involving peer groups in prevention
and treatment strategies aimed at young drug users. A recent study of
female adolescents from this geographic area (24) also stressed the importance
of opposite gender peer influence in the initiation of heroin use.
The significant proportion of patients who reported selling drugs
and=or buying drugs for others may be directly related to the spread of
heroin use in the suburban and rural areas surrounding Baltimore. Furst
et al. (25) recently reported that heroin users in the rural areas surrounding
New York City typically start by getting drugs from their friends,
then buying drugs locally. When they become dependent, to finance their
drug use, some find ways to purchase drugs in larger quantities in New
York City, reselling them to others in their home areas at a significant
mark-up in price. Such resellers often initiate others into heroin use in
order to increase the pool of potential customers.
Most reported that the failure of their previous attempts to quit using
was a result of their association with their still-using peers. Young heroin
users differ from older users in having relatively intact family support systems,
stressing the importance of involving families in the treatment
efforts for this population.
Based on these data, a profile of the average young heroin user in
Baltimore Metropolitan area appears to emerge: A young white man
or woman from a middle=working class background, with exposure to
drug use among close contacts while growing up, goes on to experiment
with gateway drugs with peers, resulting in academic problems, proceeds
to intranasal heroin use, becomes involved in criminal activities to support
the habit, seeks help repeatedly with assistance from an alarmed
but supportive family, but relapses quickly due to continued exposure
to drug using peers and a poorly implemented plan of aftercare, culminating
in intravenous heroin use, usually in conjunction with a variety
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of other substances, and with increasing health and psychosocial
problems.
Substance users in this age group are particularly important in
targeting harm reduction and secondary prevention efforts. Our qualitative
data indicate some cause for optimism, along with some reasons for
serious concern. The retention of links to and support from families,
repeated efforts to seek treatment and relative ease in finding it, are positive.
On the other hand, the high rate of and the rapid progression to
intravenous drug use, poor recognition and understanding of associated
health risks, a high degree of denial of vulnerability to health risks, lack
of sustained efforts to maintain abstinence after detoxification, high
frequency of criminal involvement, are all causes for serious concern.
On balance, it seems that treatment encounters such as a brief detoxification,
though of limited effectiveness (18), may present crucial opportunities
for interventions directed at health education, morbidity
reduction, long-term engagement in treatment, outreach efforts to engage
drug-using peers in treatment, and physical and mental health screening
and treatment.
Our findings are preliminary and some limitations apply to this
study:
1) The study population was recruited from a single clinic; therefore, the
findings may not necessarily generalize to other settings or geographic
areas. However, the sample was well distributed over the entire metropolitan
area and closely matches the distribution of heroin users of
this age enrolled in drug treatment, as reported to Maryland State
Alcohol and Drug Abuse Administration.
2) These findings may not apply to young African American heroin users
given their small number in our sample. The precise reasons for the
overwhelming excess of whites in this sample remain unclear. The
phenomenon seems to be consistent with trends in other treatment settings
in the area, and older African Americans are well represented in
the clinic patient population. It, therefore, seems unlikely that the preponderance
of whites among young heroin users is specific to this
clinic. A similar trend has also been reported from New York (11),
Pennsylvania (26), and the San Francisco area (27).
3) The data collection method involved semistructured interviews, which
were not tape-recorded. The same interviewer conducted the interviews.
While this provides the advantage of consistency in procedure,
it also may raise the issue of interviewer bias, which was not systematically
addressed. The post-interview transcription method used to
record the data, while promoting rapport with the subject, may have
resulted in some data recall bias.
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4) The subjects were able to refuse to answer specific questions. This may
have resulted in selective or limited revelation of sensitive information.
As the interviews were conducted during the first three days
of detoxification, some subjects had significant withdrawal discomfort
during this time, which may have had an adverse impact on their ability
to participate.
Despite these limitations, this study serves to define some characteristics
of the younger generation of heroin users in Baltimore metropolitan
area, and provides a basis to formulate hypotheses for future research
involving this patient population.
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