Addiction Research and Theory October, 2005, 13(5): 477487

Heroin use and barriers to treatment in street-involved youth

BRUNA BRANDS1,2, KAREN LESLIE2,3, LAURA CATZ-BIRO1, & SELINA LI1
1 3

Centre for Addiction and Mental Health, Toronto, Ontario, 2University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada

(Received 2 February 2005; in final form 4 April 2005)

Abstract High rates of drug use and risk behaviours have been reported among street involved youth. The present study examined the drug use and risk behaviours in adolescent heroin users, assessed motivation for treatment, and identified barriers to accessing treatment. Forty-nine heroin-using adolescents from four youth community agencies in Toronto were interviewed. Participants reported having used, on average, four different substances in the previous month. Seventy-nine percent had engaged in injection drug use and of these, 58% had shared their injecting equipment. Significant gender differences were found in the prevalence of psychiatric and family problems, the type of drug programs used, and perceived barriers to treatment. Although more than half of the sample had sought treatment for their substance use problems and were knowledgeable about the treatment options available, many believed factors such as lack of housing, finances, and contact with drug-using acquaintances would hamper their rehabilitation. Treatment programs for these youth should include the assessment and treatment of comorbid psychiatric disorders, and the provision of comprehensive services including safe housing, vocational guidance and financial supports.

Keywords: Adolescent, heroin use, substance abuse treatment, youth

Introduction Although heroin use has not been increasing among high school students, opioid dependence remains a growing problem among street youth. Compared to school students, Toronto street youth show rates of heroin use at least 10 times higher for most drugs, and multiple drug use is the norm (Adlaf, Zdanowicz & Smart, 1996; Smart & Adlaf, 1991).

Correspondence: Dr Bruna Brands, Clinical Research, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario, ON M5S 2S1, Canada. E-mail: Bruna_Brands@camh.net ISSN 1606-6359 print: ISSN 1476-7392 online 2005 Taylor & Francis DOI: 10.1080/16066350500150624

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A comparison of data from four national surveys in the United States also found much higher rates of heroin use among street youth (13.6%) and shelter youth (4.4%) than youth living at home (0.5%) (Greene, Ennett & Ringwalt, 1997). In two Canadian studies, street youth were found to be at a particularly high risk of contracting HIV through injection drug use (DeMatteo et al., 1999; Roy et al., 2000). Martinez et al. (1998) also reported extremely high rates of alcohol and drug use, injection drug use, and needle sharing among a sample of homeless, runaway, and street youth in three Northern California cities. In addition, being recently homeless is an important predictor for initiating injection drug use (Fuller et al., 2002; Roy et al., 2003). Heroin-using adolescents have the highest rate of injection drug use when compared to youths who use other substances (Hopfer, Mikulich & Crowley, 2000). Street youth using heroin, cocaine or methamphetamine exhibited more HIV risk behaviour in their sexual activities than youths not using these drugs (Gleghorn, Marx, Vittinghoff & Katz, 1998). Comorbidity of substance use and other psychiatric disorders is an important issue in the treatment of adolescents (Hopfer, Khuri, Crowley & Hooks, 2002; Pugatch et al., 2001). Gender may also play a role in how the expression of a comorbid psychiatric disorder impacts an adolescents ability to access and stay in a treatment program (Blood & Cornwall, 1994; Dakof, 2000; Rivers, Greenbaum & Goldberg, 2001). Little empirical evidence focusing on treatment outcomes for heroin-using adolescents has been reported. Hopfer et al. (2002), in a recent review of the literature, found only nine studies that addressed treatment of heroin-using youths. The treatments included various forms of methadone treatment: short-term detoxification, long-term detoxification, low-dose methadone, and methadone maintenance for heroin-dependent youths. The results showed that retention was highest for treatment with methadone maintenance, and time in treatment was the best predictor of reduced opioid use. Although the effectiveness of methadone in the treatment of opioid dependence in adults has been well documented (Ball & Ross, 1991; NIH Consensus Conference, 1998), it is infrequently a treatment option for adolescent heroin users. A long-term treatment outcome study reported that adolescents were not experiencing the same positive results from treatment as adults did. This was attributed to their overall resistance to treatment and lack of appropriate treatment programs (Manisses Communications Group, 1998). In the United States, federal regulations require that adolescents have two documented failures of drug-free detoxification before they may be considered for methadone maintenance. In Canada, guidelines for the use of methadone in those under 18 years do not exist. As well, there is a lack of appropriately tailored treatment programs for adolescent heroin users. In Ontario, treatment options for youths with heroin use are limited. The two main treatment options available for these young people are: acute detoxification (not assisted by long-acting opioids and not specifically designed for adolescents) and outpatient management (i.e. individual/family/group counselling). Other treatment programs available for adolescents with substance abuse problems include day treatment programs and residential programs. There are few safe houses where adolescents can reside while accessing treatment. The outcome data associated with most of these services are sparse. The problem in engaging and retaining adolescent drug users in treatment has been widely recognized. Attrition is a problem that pervades the field of substance abuse treatment (Craig, 1985; Hartnoll, 1992; Jankowski & Drun, 1977; Stark, 1992), but is especially noted among youth (Blood & Cornwall, 1994; Kaminer, Tarter, Bukstein & Kabene, 1992), particularly in outpatient settings (Baekeland & Lundwall, 1975; Hubbard, 1989).

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This problem is even more critical among homeless youths. Even though these youths present with higher rates of health and psychological problems, they are difficult to engage and maintain in treatment (Slesnick, Meyers, Meade & Segelken, 2000; Smart & Ogborne, 1994). Barriers impeding successful intervention with this population include: lack of insurance or knowledge of how to use insurance (U.S. data), lack of transportation, few available services, confidentiality issues, and unrealistic stereotypes of these youth held by service providers (Cronquist, Edwards, Galea, Latka & Vlahov, 2001; De Rosa et al., 1999; Slesnick et al., 2000). Service utilization by homeless youth has not been well studied. In one study, De Rosa and his group (1999) interviewed a group of homeless youths in Los Angeles to identify barriers to services and ways to overcome them. Barriers reported by these youths included restrictive rules, concerns about confidentiality, and age limitations. Suggested improvements included more targeted services, more long-term services, revised age restrictions, and better vocational training. In their study of runaway youths, Slesnick, Meade and Tonigan (2001) described the relationship between service utilization and alcohol and drug use, but did not report any information about barriers to services or expectations about treatment. These two studies, although targeting homeless youths, only examined use of social and medical services in general, and failed to focus on use of substance abuse treatment in particular. In a subsequent study, Slesnick (National Institute on Drug Abuse, 2002) reported that among runaways, barriers to treatment included denial of a problem, fear of treatment, and negative experiences with treatment providers. Among street youth, barriers included no home address or telephone, serious mental illness and drug addiction, and being unable to provide housing to minors. The present study was conducted to determine the patterns of drug use in a street involved group of adolescent heroin users, identify barriers to accessing treatment, assess motivation with respect to treatment, and identify other relevant issues in these young peoples lives which may impact on the success or lack of success of a treatment program. Methods The sample consisted of 49 street involved youth, recruited through ads and handouts at four youth serving agencies in Toronto. All the agencies have a drop-in component and provide food in addition to other services which include (but are not present at all agencies) health services, laundry, counselling, and vocational/educational assistance. The eligibility criteria for recruitment were: males and females 1219 years of age; use of heroin in the past 12 months, any route; and self-described as involved in street life. Structured interviews were conducted from October 2000 to April 2002. The structured interview was created using a variety of resources (Smart & Adlaf, 1991; Smart, Adlaf, Walsh & Zdanowicz, 1992; Truong, Williams & Timoshenko, 1998). Sociodemographic information, specific drug use patterns, characteristics of heroin use including symptoms of opioid dependence, tolerance and withdrawal, risk factors for infections associated with heroin use, and efforts to quit or cut down was collected. In the remainder of the interview, the interviewees were asked open-ended questions to obtain information about their experiences of the impact of substance use on their lives, their treatment experiences, and their perceptions/ideas/biases about treatment in general and methadone in particular. Prior to starting the study, the questionnaire was piloted with five heroin-using youths. The interviews were conducted by clinicians experienced in interviewing substance-using youth, and who were trained to use this particular questionnaire. The interviews were

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conducted in a private setting and lasted for approximately 1 hour. Rewards for participation in the interview were food vouchers and cinema passes. This study was approved by the Ethics Boards of the Centre for Addiction and Mental Health and The Hospital for Sick Children. Informed consent was obtained prior to administering the questionnaire. Data analyses Open-ended questions on reasons for seeking help, perceived barriers to accessing treatment, opinions about existing treatment programs, and expectations about treatment were coded by two research team members. The responses were first organized into general themes and categories and then coded independently by the two coders. The average rate of agreement was 92%. Discrepancies were discussed and reconciled between the coders. The quantitative data and coded qualitative items were analyzed using mainly descriptive statistics. Gender differences were examined, as previous studies have found gender differences in drug use, self-reported dependence, perceived need for treatment, and psychiatric comorbidity among adolescents with substance use disorders (Dakof, 2000; Kim & Fendrich, 2002; Latimer, Stone, Voight, Winters & August, 2002; Martin, 2003; Rivers et al., 2001). Chi-squares and t-tests were used to test for gender differences in the analyses. Results The sample consisted of 25 males and 24 females. Their demographic characteristics are listed in Table I. These youth were predominantly white, left home at about 13 years of age and, had approximately a Grade 10 education. More males stayed at shelters or on the street than females, while more females lived in group homes, rooming houses, houses or apartments. Males tended to start using heroin at an older age (X 15.4 years) compared to the females (X 14.5 years). Table II presents information on drug use and risk behaviours. Seventy-two percent of the sample had used heroin more than 20 times in the past year. More than three-quarters of the sample had injected heroin and about 58% of these had shared injection equipment

Table I. Demographics. Male (n 25) Age (years SD) Education level (grade) Age of first heroin use (years)* Age left home (years) Ethnicity: White Chinese Aboriginal Other Residence*: Streets/shelter House/apartment Rooming/group home Other *p < 0.05. 18.0 1.0 10.1 1.2 15.4 1.3 13.3 3.9 58% 8% 4% 29% 84% 16% Female (n 24) 17.6 1.0 10.0 1.8 14.5 1.4 13.1 2.8 71% 8% 4% 16% 46% 29% 21% 4%

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Table II. Drug use and risk behaviours. Total (n 49) Frequency of heroin use (12 months) 05 times 619 times 2040 times Withdrawal symptoms None 13 symptoms 4 symptoms Injected heroin Ever shared injection equipmenta Overdoses on opiates (accidental or intentional) Average number of overdoses Received medical treatment for overdose Use of new needles in past 12 monthsb Never/rarely Sometimes/often Almost always/always Use of condomsc Never/rarely Sometimes/often Almost always/always 16% (8) 12% (6) 72% (35) 12% (6) 8% (4) 80% (39) 79% (38) 58% (22) 52% (25) 3.2 3.1 43% (21) 3% (1) 16% (6) 81% (30) 15% (7) 41% (19) 44% (20)

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a Only 38 subjects (18 male and 20 female) responded to this item, which was not applicable to those who did not inject. b One subject did not respond to this question. c One subject never had sex and two subjects did not respond to this question.

(including both cleaned or uncleaned with bleach before using). More than half had overdosed on opioids and the average number of overdoses was 3.2 3.1. The reasons for overdoses include drug quality (54%), took too much to get high (17%), suicide (17%), and multiple drug use (12%). Figure 1 shows the drug use pattern of this sample. The majority of the sample comprised of multiple drug users. They reported having used, on average, 4 (SD 2.2) different substances other than alcohol and tobacco in the past month and 8.5 (SD 2.7) substances in their lifetime. There is no gender difference in the reported number of substances used in the past month. However, in terms of lifetime use, females reported to having used a significantly greater number of substances than males (9.3 3.0 vs. 7.8 2.1, p < 0.05). More than 90% had used tobacco, alcohol and cannabis in their lifetime and more than 80% had used these drugs in the past 30 days. Due to the selection criteria, the entire sample had used heroin in their lifetime. About 60% had used heroin in the past 30 days. The youths were asked if their use of heroin had caused any problems in their home life, social life, school/employment, as well as for their physical and mental health. Figure 2 shows the reported life domains affected by heroin use. More than 60% had reported problems in physical health, family, school/employment, finance, and other relationship. About half reported housing problems and slightly less than half reported emotional problems. Gender differences were found in two areas: more females reported family disruption and emotional problems than male subjects. To assess the prevalence of comorbidity among this group, respondents were asked to report any mental health problems that they had experienced. Significantly more females (83%) than males (44%) reported to having mental health problems ( p < 0.01). The rate of attempted suicide was also significantly higher among females (63%) than

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Tobacco Cannabis Alcohol Heroin Methadone Rx Opioids Benzodiazepines Cocaine Crack Amphetamines Hallucinogens Ecstasy Glue/Inhalants OTC Codeine Preparations Barbiturates 0 Past 30 days 10 20 30 40 50 60 70 80 90 100

Percentage (n = 49) Lifetime

Figure 1. Drug use.

Other activities disrupted Legal problems Emotional problems* Housing problems Other relationships School/Employment Financial problems Family disruption* Physical problems 0 Male Female 10 20 30 40 50 60 70 80
* p<0.05 * p<0.05

Percentage (n = 49)

Figure 2. Life domains impacted by heroin use.

males (30%) ( p < 0.05). Approximately 47% of the group had received prescribed medications and 37% had been hospitalized for mental illness. The youths were asked if they had tried to cut down or quit using heroin. Seventy-nine percent had tried to quit using heroin; 70% had tried to quit by themselves and 52% had tried going to a clinic or drug program to get help in quitting. Significantly more females than males had tried to quit using heroin (92% vs. 67%, p < 0.05), and more females than males had tried going to a clinic or drug program to get help in quitting (67% vs. 38%, p < 0.05). A number of reasons for wanting to quit were given, including being worried about negative effects of the drug, wanting a normal life, family, friends, time, and money. Of those who tried to stop on their own, 63% had done it cold turkey; 20% reported that they had used other street drugs and 10% had used methadone off the street.

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The most frequently used drug treatment modalities were individual counseling (27%) and detoxification (27%). Other treatment programs included methadone maintenance (16%), residential treatment (14%), self-help groups (12%), day treatment (10%), group therapy (8%), doctor prescribed home detox kits (8%), and institutional treatment (4%). It must be noted that detoxification programs used by these youth were not geared specifically for youth. Many pointed out the need for youth detox. Most of the residential treatment programs were also not youth specific. Only one participant reported attending a youth residential treatment program. There were significant gender differences with respect to the type of drug programs used. Virtually none of the males reported having used residential treatment ( p < 0.01) or group therapy ( p < 0.05), in contrast to the females (29 and 17% respectively). Significantly more females reported having used methadone maintenance (29% females vs. 4% males, p < 0.05) and detoxification (46% females vs. 8% males, p < 0.01). On the other hand, none of the females reported to have used self-help groups (attended by 24% of the males, p < 0.05). Many of those who tried to stop using heroin reported physical problems, withdrawal symptoms, emotional distress, mood changes, and difficulty sleeping. The majority (82%) had started using again. The reasons given for starting to use heroin again included positive effects of the drug (24%), peer influence (15%), coping strategy (12%), availability and craving (12%), withdrawal (9%) and stopped only to reduce tolerance (9%). When asked if they had support from family or friends to quit drugs or to remain in treatment, most (78%) reported to have some support from friends, partners, or families. When asked what kind of supports would be needed to help quit using, almost half of the sample identified housing as a needed support. Other supports included employment or school, counsellor, doctor, medical treatment, financial help, family, friends, drug-free environment, emotional support, recreation, and information about available treatment. About 34% of the sample reported to have sought help for their drug use but did not receive it. Respondents were asked what had prevented or made it difficult for them to get help. Figure 3 presents the perceived barriers to seeking treatment. Program restrictions and influences of friends were most frequently mentioned, followed by stigma and fear of stereotyping, lack of knowledge of where to go, poverty, housing, and fear of withdrawal symptoms. Significant gender differences were found in some of the perceived barriers to treatment. More females than males reported program restrictions (38% vs. 0%, p < 0.01) and stigma (25% vs. 4%, p < 0.05), while more males than females (32% vs. 4%, p < 0.05) considered influences of friends as barriers.

Withdrawal Poverty/Housing Don't know where to look Stigma/Fear* Friends* Program restrictions** Has not looked for treatment 0 male female 5 10 15 20 25 30 35
* p<0.05 * p<0.05 ** p<0.01

Percentage (n = 49)

Figure 3. Perceived barriers to seeking treatment.

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Depression/Stress Withdrawal symptoms Easy access to heroin Restrictions from treatment* Treatment option inadequate Wouldn't know where to start* Lack of motivation Lack of housing/money** Lack of family/friends* Pressure from friends 0 male female 5 10 15 20 25 30 35
** p<0.01 * p<0.05 * p<0.05 * p<0.05

Percentage (n = 49)

Figure 4. Factors impeding successful treatment.

Respondents were also asked what kinds of things might get in the way with getting successful treatment. Their responses were summarized in Figure 4. Pressure from friends was reported as the number one factor impeding successful treatment. Other factors included lack of family and friends, lack of housing and money, lack of motivation, lack of knowledge of where to start, inadequate treatment options, restrictive program rules, easy access to heroin, withdrawal symptoms, and depression and stress. There were, again, significant gender differences in the perception of factors that impeded successful treatment. None of the males reported lack of housing or money (reported by 25% of the females, p < 0.01) or restrictions from treatment (reported by 17% of the females, p < 0.05). Also, more females (29%) than males (4%) reported lack of family or friends ( p < 0.05). On the other hand, none of the females, as compared to 20% of the males, considered not knowing where to start as an impeding factor ( p < 0.05). When asked where the ideal place for treatment would be, many of the respondents preferred a street clinic, residential, and or less structured treatment settings. Some of the suggestions included: not a hospital, preferably with other youth, relaxed friendly setting, dont want to feel like a patient, far away place, staff who know what they are doing, and somewhere you can sleep in. With regard to methadone, the majority (91%) had heard about it, but many (48%) expressed concern about its addictive effect. About half thought that methadone or another medication could help them quit heroin. Many of these respondents were ambivalent about methadone treatment. Some of their responses included: It is good . . . will try it someday . . . have to be careful not to get addicted. Methadone may work but need to be seen in clinic and pharmacy . . . May as well use heroin. It is also an opiate. Some concerns about methadone were expressed, e.g. Methadone is more addictive than heroin; methadone is harder to get off. Methadone gets in your bones; worse withdrawal than heroin. Made of heroin, addictive, super high. Its hard to quit, increase weight, daily pickup, cant go away. Dangerous, too much control with doctors, hard to kick. Discussion Heroin use in street involved youth is associated with significant comorbidity including mental health issues, and physical health risks. The youth in this study reported polysubstance use and high-risk behaviours such as sharing of injecting equipment and

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inconsistent condom use. They also reported a high rate of psychiatric disorders, in particular, depression and bipolar disorder. Females reported significantly higher rates of depression/bipolar disorder and suicide attempts than males. The majority of youth had attempted to quit using heroin. Approximately half of these had accessed some kind of treatment program. Females reported accessing detox, residential and group type programs while males were more likely to access self-help type programs (e.g. Narcotics Anonymous). Some of the youth described being fearful in these programs, which were in adult settings, because no youth specific withdrawal management programs were available. It appears that gender may play a role in both self-identification of comorbid issues, and in ability to access treatment. Females identify themselves as having more concurrent disorder than males, and use treatment options that involve the assistance of others as opposed to self-help type modalities. This is congruent with some of the existing literature that has identified gender differences in self-identified psychiatric comorbidity and in treatment readiness/retention (Dakof, 2000; Blood & Cornwall, 1994; Kim & Fendrich, 2002; Latimer et al., 2002; Martin, 2003; Rivers et al., 2001). In addition to the need for withdrawal management and ongoing treatment for opioid dependence, the participants in this study identified numerous other areas requiring assistance. These include housing, employment, schooling, and emotional support. The lack of these resources is seen as a barrier to both accessing and being successful in treatment. Studies have shown that the lack of secure housing increases the tendency towards risky drug use behaviours as well as impedes their chance to recovery (Rowe, 2005). Housing provision is an important first step to help these youths address their drug use problems. This study confirms some of the existing literature in the area of adolescent substance abuse, and adds specific information about the patterns of use and treatment needs of heroin using youth. Limitations of this study include the retrospective nature of data collection, which introduces recall bias on the part of the study participants. The sample size was relatively small; however, statistically significant results were generated. Moreover, the youth in this study may be a select group of heroin users who are accessing community agencies; however, there may be another subset of heroin using youth who are not accessing such agencies. If such a group could be captured, it may well be that those individuals display even more high risk activity, are less motivated to seek treatment, and have additional barriers to accessing treatment than the participants in the present study. Information on factors that motivate and impede access to treatment is crucial in planning and developing successful treatment programs for this group. Treatment planning for adolescents with heroin dependence should acknowledge factors such as comorbid mental health problems, fear of withdrawal symptoms, and other anticipated stresses associated with treatment. Clearly, the need for assessment and appropriate treatment of coexisting psychiatric problems is important. The role for pharmacologic agents as components of treatment needs further exploration. Approximately one half of the participants felt that they might benefit from some kind of pharmacologic therapy such as methadone or a similar type of drug. It is not clear where these youth obtained their information about methadone and other pharmacologic therapies. Some reported their experiences with methadone obtained on the street as opposed to being provided by a licensed prescriber. Provision of accurate information about methadone and other medications could address some of the concerns reported by the subjects in our study. Peer based education, or interventions provided in settings that these youth identify as being safe and trustworthy, would

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likely be most successful. These educational components of treatment are important areas for further development and evaluation. As an effort to increase the range of treatment options available to heroin-dependent adolescents, a treatment program that includes the use of long acting opioids (e.g. methadone/buprenorphine) is proposed. Such programs for adults have proven effective in decreasing/eliminating illicit drug use, reducing transmission of HIV, hepatitis C and sexually transmitted diseases, reducing criminal activities, increasing employment, and improving interpersonal relationships (NIH Consensus Conference, 1998). In the current study, many youth were interested in receiving assistance in quitting. We believe that what is currently known about the successful treatment of opioiddependent adults along with the issues identified in this study, can be used to design an effective, age-appropriate program for heroin abusing adolescents. It is almost self-evident to state that substance abusing youth require developmentally congruent treatment settings, staffed by professionals who have sufficient experience working with this highly vulnerable population. Presently, very few treatment programs meeting the needs of this young population are available and there is a lack of systematic research on the relative efficacy of these programs. Consequently, a randomized, control study within a youth-friendly environment, comparing pharmacologic versus non-pharmacologic/conventional treatment conditions could be the next logical step to develop and evaluate efficacious interventions for these youth. Acknowledgements Supported by Research in Psychiatry Grants Program, Centre for Addiction and Mental Health. The authors would like to thank Dr Stephen Rivers for his critical review and editorial assistance with the manuscript. The authors are also indebted to Evelyn Neilas, MSW and Megan McCormick, MSW for conducting some of the interviews. References
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