The relationship between alcohol use and injecting drug use: Impacts on health, crime and wellbeing
Introduction
People who inject drugs (PWID) are at risk of a variety of adverse health and criminogenic outcomes, such as overdose and arrest (Dietze et al., 2005, Kerr et al., 2005, Kinner et al., 2009, Stoove et al., 2009, Teesson et al., 2008). Age- and sex-standardised rates of mortality from overdose or other drug related causes are high (Degenhardt et al., 2011), and involvement with the legal system is frequently noted among samples of PWID (Kinner et al., 2009). They also report significantly lower levels of overall life satisfaction than the general community (Dietze et al., 2010). It is therefore not surprising that studies have also found that PWID are frequent users of health services (Darke et al., 2007, Kerr et al., 2005). For example, 60% of participants in a cohort of PWID in Vancouver accessed an Emergency Department and 78% accessed primary care services over a two-year period (Kerr et al., 2005).
A large body of research has examined exposures associated with these adverse outcomes among PWID. For example, the use of central nervous system depressants such as benzodiazepines and alcohol has been shown to be a risk factor for non-fatal overdose (Dietze et al., 2005) and drug (i.e., frequent crystal methamphetamine injection) and chronic disease-related (i.e., HIV) exposures have been shown to be significant predictors of service utilisation (Kerr et al., 2005). However, few researchers have examined alcohol consumption as a key explanatory variable for adverse outcomes in PWID (other than overdose). For example, most studies of service utilisation in PWID (e.g., Darke et al., 2007, Kerr et al., 2005) did not include alcohol consumption as an explanatory variable in analysis. Similarly, past studies of overall personal wellbeing of PWID failed to consider the potential impact of alcohol consumption (Dietze et al., 2010). The omission of alcohol consumption exposures in these studies is somewhat surprising given the well-established link between problematic alcohol consumption patterns and acute and chronic health harms in general populations (Babor et al., 2010), and given that alcohol use is known to increase risk for adverse outcomes among PWID.
Various studies have shown associations between alcohol consumption and the perpetration of aggressive and violent behaviour in the general population (Chermack and Blow, 2002, Graham and Homel, 2008, Graham and Wells, 2001, Marshall et al., 2008). Possibly as a result of the disinhibitory effects of alcohol, alcohol is seen as having a causative role in violent or aggressive behaviour (Parker and Auerhahn, 1998, Room and Rossow, 2001). This proposition is supported by evidence that increasing alcohol consumption is associated with increased severity of aggression (Graham and Wells, 2001). In the literature on injecting drug use, the role of alcohol consumption in violent behaviour has been demonstrated in numerous studies (e.g., Marshall et al., 2008, Torok et al., 2008); however, the measurement of alcohol consumption in these studies is not consistent. For example, Torok et al. (2008) use the Alcohol Use Disorders Identification Test (AUDIT) scores to measure consumption in their sample, treating them as a continuous measure of alcohol consumption, in spite of the fact the AUDIT is a screening measure of alcohol disorders, comprising measures of consumption and harm, not consumption alone. In contrast, Marshall et al. (2008) developed a binary measure of alcohol consumption in which a ‘yes’ indicated that the participant consumed at least four (Canadian standard) drinks per day in the previous six months, allowing for only a restricted measurement of alcohol consumption. Nevertheless, with these measurement caveats in mind, alcohol has been consistently associated with violent victimisation and perpetration in studies of PWID.
In summary, previous research suggests a causative role for alcohol in aggressive incidents and that this would be expected to be manifested in PWID. However, in relation to other life domains such as health and wellbeing, alcohol is rarely included as an explanatory variable in analyses involving PWID. Heavy drinking does not always impact on these life domains for the wider population (e.g., alcohol dependence per se is not associated with increased visits to general practitioners; Proudfoot and Teesson, 2009), but it is unknown whether alcohol consumption or heavy drinking would impact on these domains for PWID after adjusting for potential confounders, in particular intensity of illicit drug use. If alcohol consumption or heavy drinking is linked to a kind of generalised deviance and poorer health among PWID, then particular drinking patterns would be independently associated with decreases in measures across all these life domains. If, on the other hand, alcohol use is associated with violent behaviours alone, then one would expect that alcohol consumption or heavy drinking would only impact on measures these behaviours alone.
In order to examine these issues this study has been specifically designed to explore the effects of alcohol consumption, and heavy drinking in particular, on health, criminogenic and life satisfaction outcomes for PWID.
Section snippets
Sample and interviews
A sample of 688 PWID was recruited and interviewed as part of the Melbourne Injecting Drug User Cohort Study (MIX). MIX involves interviewing eligible participants (18–40 years of age, injecting in the month prior to interview) annually using a structured questionnaire that canvasses participant demographics, patterns of lifetime and recent (past month) alcohol and other drug acquisition and use, and the health and social consequences of drug use. Interviews take place in different locations
Results
The distribution of drinking scores across the sample is shown in Table 1 along with a selection of other drug use and demographic characteristics. The sample was comprised largely of unemployed males who reported frequent heroin use in the past week. Just over a third of the sample reported no drinking in the month prior to interview, with 44% classified as having moderate drinking status and 20% as high-risk. Overall, the sample characteristics were similar to samples of PWID recruited in
Discussion
In this study, we examined how moderate and heavy drinking patterns and recent abstinence related to various health, criminogenic and quality of life outcomes in a sample of PWID. Our results showed that PWID whose past month drinking pattern was defined as moderate (between 1 and 7 on our version of the AUDIT-C) did not differ markedly in health outcomes from those who reported abstinence in the previous month. However, a significant effect for moderate drinking was found for measures of
Role of funding source
Nothing declared.
Contributors
Authors PD, MS, CA, DJ, MH and TK designed the study. PD and RJ managed the manuscript preparation and the statistical analysis. All authors contributed to and have approved the final manuscript.
Conflict of interest
PD and RJ are joint recipients of an untied educational grant from Reckitt-Benckiser.
Acknowledgements
The MIX study is funded by the National Health and Medical Research Council (545891 and 1001144) and the Colonial Foundation Trust. PD is supported by an Australian Research Council Future Fellowship. TK is funded by the Canadian Institutes for Health Research and the Michael Smith Foundation for Health Research. The authors also gratefully acknowledge the contribution to this work of the Victorian Operational Infrastructure Support Program.
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