Social network correlates of self-reported non-fatal overdose
Introduction
In Baltimore and many other metropolitan areas in the United States, rates of heroin overdose have increased dramatically in the prior decade (Substance Abuse and Mental Health Administration, 2002). Given the high mortality and health sequelae associated with drug overdoses, identifying individuals who are at risk of overdose may assist us in developing appropriate methods of treatment and prevention. The majority of heroin overdose studies have focused on pharmacological effects of heroin alone and with interactions with other drugs. Drug purity and poor physical health are risk factors for heroin overdose as are factors that may lead to decreased drug tolerance such as drug detoxification, hospitalization, arrest, and imprisonment (Darke et al., 1996a, Gossop et al., 1996, Warner-Smith et al., 2001). Yet, a study of recent non-fatal drug overdose among injection drug users in California (Seal et al., 2001) found an association between reporting an overdose in the prior 2 years and an index of social marginalization, as measured by homeless; incarcerated for 5 or more years; self-identifying as lesbian, gay, bisexual, or transgender; and exchanging sex for money or drugs. One potential explanation for this association is that individuals who are homeless or trade sex for drugs have less control of when, where, and with whom they inject. Consequently, it is difficult for them to control their dosing.
Although few studies have examined social and contextual factors associated with drug overdose, it is evident that drug overdose is caused by more than amount of drug ingested. Several investigators have documented that individuals who die from heroin overdoses often have similar or lower opiate blood levels to individuals who do not overdose (Darke et al., 2002, Darke et al., 1997). Context of drug administration can have a profound effect of overdose risk. Galea et al. (2003) presented findings that in New York City odds of death due to overdose are positively associated with unequal neighborhood income distribution, as measured by the percent of total income earned by the lowest earning 70% of households and the Gini Coefficient. Laboratory studies have also found that environment is associated with risk of overdose death. An administration of heroin to laboratory animals in a new setting increased the likelihood of overdose death (Gutierrez-Cebollada et al., 1994).
Most heroin overdose occur in the presence of other people (Darke et al., 1996b, Powis et al., 1999). Yet, there is little information on how others may influence drug overdoses or the factors that lead to overdose. The present study examined the relationship between history of drug overdoses and social contextual factors as assessed by social networks and roles in the drug economy among cocaine and opiate users. A social network is typically defined as a set of individuals that are linked together by one or more specific types of relations between them (Wasserman and Faust, 1994). An egocentric or personal network is an individual and all of their ties for specific types of relationships (e.g., a sex network is those individuals with whom the ego has sex with). Network factors are associated with drug users’ HIV serostatus (Friedman et al., 2000). Several studies have found that network factors influence drug behaviors. Individuals with larger drug networks tend to use more drugs and are more likely to report sharing needles and cookers (Latkin et al., 1994). Needle sharing may result from unexpected injection episodes during interactions with drug using network members. Networks that have more injectors may also have social norms that promote risk behaviors of needle sharing. These same large networks may also promote the use of greater amounts of drugs.
There are several reasons to expect that social network factors influence overdose. Social factors may influence the frequency, regularity, and quantity of drug use. Having more network members who are active users may increase availability of drugs and impede controlling use. In addition to drug network members promoting use, network members’ drug use may trigger physiological and psychological cues to use drugs. In the current study, we were also interested in examining the characteristics of relationships that may protect against the risk of drug overdose. Specifically, social support may help to regulate drug use, whereas conflictual ties and drug users in the network would mitigate against regulating drug use.
Section snippets
Sample
The data used in this study were collected as part of the Self-Help in Eliminating Life Threatening Diseases (SHIELD) project, an experimental HIV prevention intervention. Participants were recruited through targeted outreach in areas of high drug activity in Baltimore as assessed through ethnographic observations, focus groups, and geocoding of all drug-related arrests in the city over a 3-year period. Potential index participants were provided a written description of the study and a
Results
The study sample comprised of 742 SHIELD participants who reported a lifetime history of snorting heroin, injecting drugs, or smoking crack. The demographics, health status, and drug use characteristics are presented in Table 1 by recency of last overdose (never, past, recent). Almost all (96%) were African American, 42% were female and 28% currently employed. The average age was 43 years and over half (56%) had completed more than 11 years of school. Two-thirds of the whole sample (62%) rated
Discussion
The data from the current study suggests that even after adjusting individual level frequency of drug use and demographic factors, social network factors are associated with history of recent overdose. Specifically, the number of injectors in the network and the number of networks that the index had conflict with was associated with overdose recency. Social network factors have been found to be associated with other health conditions among drug users such as HIV and STIs (Friedman et al., 1997,
Acknowledgements
This work was supported in part by a grant from the National Institute on Drug Abuse (R01 DA13142) and the Open Society Institute-Baltimore Drug Addiction Treatment Program (20007265).
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