Access to drug and alcohol treatment among a cohort of street-involved youth

Abstract

Background

A number of options for treatment are available to young drug users, but little is known about the youth who actually attempt to access such services. Here we identify characteristics of a cohort of street-involved youth and highlight commonly encountered barriers.

Methods

From September 2005 to July 2007, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of 529 drug users aged 14–26 living in Vancouver, Canada. Participants who attempted to access any addiction services in the 6 months prior to enrollment were compared in univariate analyses and multiple logistic regression modeling of socio-demographic and drug-related factors.

Results

Factors positively associated with attempting to access services included Aboriginal ethnicity (adjusted odds ratio [AOR] = 1.66 [1.05–2.62]), high school education (AOR = 1.66 [1.09–2.55]), mental illness (AOR = 2.25 [1.50–3.38]), non-injection crack use (AOR = 2.93 [1.76–4.89]), and spending >$50 on drugs per day (AOR = 2.13 [1.41–3.22]). Among those who experienced difficulty-accessing services, the most commonly identified barrier was excessively long waiting lists. In a subgroup analysis comparing those who tried to access services but were unsuccessful to those who were successful, risk factors positively associated with failure included drug bingeing (odds ratio [OR] = 2.86 [1.22–6.76]) and homelessness (OR = 3.86 [1.11–13.4]).

Conclusions

In light of accumulating evidence that drug use among street youth is associated with risky health-related behaviors, improving access to treatment and other addiction services should remain an important public health priority.

Introduction

Because illicit substance use has detrimental effects on individual users, communities, and justice and health care systems, the high prevalence of drug and alcohol use among youth remains a critical public health concern (American Society of Addiction Medicine, 1994; United Nations Office on Drugs and Crime, 2000). Particularly vulnerable to the harms of substance use are ‘street youth’, a term applied to adolescents and young adults living part time or full time on the street (Mallett et al., 2005). This population is generally characterized by perilous living conditions that include high rates of poverty, homelessness, and drug use (Canadian Centre on Substance Abuse, 2007, Roy et al., 2004). The factors causing youth to live on the street are complex; prior personal drug use is occasionally a primary reason for leaving home, but more commonly, family conflict or family breakdown occurs prior to youth leaving home (Mallett et al., 2005). Since many street youth do not receive parental support, it is not surprising that once on the street, youth often self-aggregate into peer networks to survive. These networks may additionally serve as the basis for social use of alcohol and narcotics and other risk-related behavior (Kissin et al., 2007).

Surveillance data from seven urban centers across Canada revealed a lifetime prevalence of illicit drug use of 95.3% among street youth (Public Health Agency of Canada, 2006). Additionally, 22.3% of street youth had injected drugs at some time in their life. Similarly, in a sample of US street youth, 20.6% had recently injected drugs and 78.7% of these users had recently shared a syringe (Gleghorn et al., 1998), a practice associated with high risk of transmission of numerous infectious diseases, including human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Alarmingly, one recent cross-sectional study of street youth in Russia revealed an HIV prevalence of 78.6% among injection drug users and of 86.4% among those who shared needles (Kissin et al., 2007).

Readily accessible addiction treatment services are a crucial component of efforts to curb the ill effects of substance use (Cartwright, 1988, Johnson et al., 2000, Rydell et al., 1996, Wood et al., 2003). A variety of modalities exist, including residential treatment programs, professional counseling services, peer-support programs (e.g., Alcoholics’ Anonymous, AA and Narcotics’ Anonymous, NA), substitution therapies for heroin addiction (e.g., methadone maintenance therapy), and detoxification programs, to name some common examples, but ultimately, effective treatment may employ several of these and must be comprehensive and multidimensional (Leshner, 1999). In most Western settings, the demand for such services typically exceeds their availability, and an array of other barriers may further limit the ability of users to access the addiction services they seek (American Society of Addiction Medicine, 1994; Neale et al., 2007, Rydell et al., 1996, Wenger and Rosenbaum, 1994, Wood et al., 2005).

The majority of research to date examining treatment seeking and its associated barriers has focused on adults rather than youth (Battjes et al., 2003, Simpson, 2001). In general, the process of obtaining addiction treatment is understood as progressing in stages, beginning with outreach and proceeding to induction, followed by early therapeutic engagement, and finally, treatment and follow-up care (Simpson, 2001). In this model, a variety of background personal experiences and environmental characteristics are believed to predict treatment readiness. In the adult literature, it is well established that a variety of client-level and program-level factors influence whether a substance-abusing individual will access treatment (Neale et al., 2007). Users more likely to seek help may include those who are female (Fletcher et al., 2003, Zule and Desmond, 2000), are older (Wu and Ringwalt, 2004), do not belong to an ethnic minority (Wood et al., 2005), are involved in the sex trade (Zule and Desmond, 2000), have patterns of addiction marked by a high degree of abuse and/or dependence (Handelsman et al., 2005), and have health problems including HIV (Handelsman et al., 2005, Zule and Desmond, 2000).

Conceivably, a similar array of characteristics may influence whether youth seek treatment, although to date, these factors have been poorly studied in younger drug-using populations. In extending the above findings from adult users to young users, it is possible, for example, that youth experiencing more severe drug use-related consequences (such as having a high degree of abuse or dependence, contracting a blood-borne disease such as HIV or HCV, or offering sex for drugs) may be more likely to seek treatment. In this vein, other negative consequences of drug use could also cause youth to seek addiction services, such as transitioning to injection drug use, spending large amounts of money on drugs, or experiencing non-fatal overdose. Other, non-drug-related factors may lead to differential rates of treatment seeking among youth as among adults. Such factors might include, for example, age, gender, ethnicity, education level, and history of mental illness, all of which merit further study in young drug-using populations.

There is also evidence that among adult drug users who seek treatment, certain subsets of users are more likely to encounter barriers along the way. Particularly vulnerable groups among adult drug users may include women (Swift and Copeland, 1996), ethnic minorities such as those of Aboriginal ethnicity (Wood et al., 2005), rural-dwellers (Staton et al., 2001), the homeless (Deck and Carlson, 2004), and prisoners (Deck and Carlson, 2004, Staton et al., 2001). While there is a possibility that these findings would be similar among young drug users who experience difficulty accessing treatment, there is also reason to believe they might not be. When compared to adults, youth may have very different routes by which they access the treatment system (Leslie, 2008). For example, youth, when compared to adults, may be the targets of vastly different outreach programming or may have less knowledge of how to navigate health care and social service systems. Risk factors for encountering barriers to treatment among young drug users therefore deserve more attention.

A better understanding of which youth access addiction services, what their drug use patterns are, and what barriers they encounter can help inform policy to refine programs and engage young users early in the development of substance dependence. Among street youth in particular, concerns about accessing addiction services may include perceptions that program rules are too strict or that confidentiality will not be maintained (De Rosa et al., 1999). The present study attempts to identify the socio-demographic and drug-related characteristics of street youth who attempt to access addiction services, their perceived barriers, and the rates of success and failure of these attempts.

In following from the above findings that certain subgroups of adult drug users are more likely than others to seek treatment, we hypothesize that among a range of non-drug-related factors such as gender, age, ethnicity, housing status, education level, and mental health status, characteristics can be identified that are associated with street youth being more likely to seek treatment. Additionally, we expect that some aspects of drug use patterns, such as type of drug used and route of administration will be associated with treatment seeking. We also hypothesize that the negative consequences of drug use, including having a recent history of non-fatal overdose and spending large amounts of money on drugs per day, will be related to attempts to access addiction services. Moreover, we aim to identify barriers encountered as street youth attempt to access these services and identify factors associated with encountering these difficulties.