Social characteristics of participants in Swiss multicenter opiate trials at time of entry

Preliminary results

Introduction

Switzerland as most other European countries has experienced an aggravation of problems associated with illegal drug use during the late eighties; and an increasing number of drug addicts displays an increasing number of characteristics of social marginality. The traditional therapeutic means seem not to be able to stop this worrying development, because a considerable number of illegal drug users do not appear to be approachable by the present programmes. Especially addicts with social and psychological deficiencies have often difficulties to stay in therapeutic programmes long enough to get rehabilitated. Ongoing illegal activities, contacts with the drug scene and lack of meaningful perspectives regarding the life situation in the future are reported to be main factors of dropping out of therapeutic programmes (Vaillant, 1966a; Vaillant, 1966b; Zahn & Ball, 1972; De Leon & Rosenthal, 1979; Marlatt, 1979; Ball & Ross, 1991; Rosenbaum, 1991; Sickinger, Kindermann W, Kindermann S, Lind-Kramer & Timper-Nittel, 1992; Werkstattbericht des Sozialpsychiatrischen Dienstes, Marz 1992; Caplehorn, McNeil & Kleinbaum, 1993; Reno & Aiken, 1993; Spunt, 1993).

Concerning this situation the Swiss Federal Government started a longitudinal study embedded in a multicentric research design in order to analyse the longterm effects of diversified medical prescription of different narcotics (heroin, morphine and methadone) on long-term drug addicts with signs of social marginaiity (Uchtenhagen, Gutzwiller & Dobler-Mikoia, 1994). The main aims concerning the participants of the multicentric trials are:

Improvement of physical and psychological health

Improvement of social integration and detachment from the drug scene

Reduction of illegal activities

Reduction of drug use (illegal and legal)

In order to be considered for admission participants have to prove that they are heroin dependent at least two years with daily use and that they have failed in at least two therapeutic efforts. They should not be younger than 20 years and deficiencies concerning their social integration and/or psychological well-being and/or health should be present. In additionm, there should be good reasons that no other therapeutic programme is indicated for the participant. The trials are embedded in a scientific design and the participants taking part in the trials have to agree to take part in the scientific interviews and examinations.

The participants are admitted on the basis of a comprehensive assessment procedure including the current social situation, past therapeutic experiencies and a medical examination. The present paper focuses on the social deficiencies and the features of the drug use history according to admission criteria. The corresponding results are based on data from the structured interviews by treatment staff assessing the social deficiencies and features of the drug use history at time of treatment entry. Because the recruitment is still going on and only the first 169 questionnaires are prepared for a statistical analysis, we are able to give here only preliminary results of the degree of social disintegration in the particpants.

Preliminary results

2.1. Sociodemographic characteristics

Looking at the regional distribution of patients who entered trials, we see that the majority is living in the canton of Zurich, most of them in the city of Zurich, because the two trials in the city of Zurich started first. A third of patients live in the canton of Bern and only 10 persons have their residence outside of these two cantons (FIGURE 1). 86% are Swiss citizens and only 14% have a foreign citizenship.

Figure 1: Place of residence of participants at time of entry into trial

Persons who participate in Swiss multicenter opiate trials are in average 30 years old (in all other treatment programms the average age is lower). The youngest is

21 years and the oldest 47 years (FIGURE 2). A third of them are females, two thirds males, which corresponds to similar proportions found in epidemiological studies on drug abuse. The females are in average two years younger than the males.

Figure 2: Age distribution of participants at time of entry into trial

2.2. Social integration

2.2.1 Structural integration

One of the main goals,of the Swiss multicenter opiate trials is to reach drug dependents who show multiple symptoms of social disintegration and who are not yet reached or cannot be maintained by traditional treatment modalities (methadon maintenance, therapeutic communities etc.). The main indicators of social disintegration are bad housing conditions, unemployment and poor financial resources.

Looking at our data we see that a great part of patients in trials are characterized by poor housing conditions: 18% are living on the street (the corresponding figure for patients in methadone maintenance programmes is 9%). 26% have only a single room rented. 9% are still living with their parents and 40% have their own apartment (FIGURE 3). A third of patients have only a temporary housing arrangement.

Figure 3. Housing conditions of participants at time of entry into trial

Regarding job-performance, the majority of patients have not been working during the past 12 months and only 16% have a job currently (the corresponding figure for patients in methadone maintenance programmes is 37 %) (FIGURE 4).

Figure 4: Working situation of participants at time of entry into trial

Accordingly, most of them supported themselves by social welfare and illegal activities in the last month before entering the trial (FIGURE 5).

Figure 5: Sources of income of participants at time of entry into trial

Analysing the financial situation in more details we see that the participants needed a high monthly amount of money for their drug consumption while their living expenses are mostly extremely low. Regarding the high costs of illegal drug consumption, the high extent of illegal sources of income is not surprising (FIGURE 6).

Figure 6: Association between monthly expenses for drug consumption and illegal sources of income at time of entry into trial

2.2.2. Social networks

Drug addicts which dropped out from social structures have usually their social contacts within the drug scene. The relationships with parents and friends outside the drug scene are often strained. Regarding our sample we were interested to see if the drug addicts entering the trials show deficiencies also in their social contacts.

It is striking how often the patients in our sample report having no good friends (25%). Regarding the percentage of social contacts we see that only 34% have their friends and colleagues mainly outside the drug scene, while the majority spend their time with people inside the drug scene (FIGURE7).

Figure 7: Association between social contacts outside the drug scene and having a confident at time of entry into trial Looking At current partnerships we see that 60 % have no intimate partner

2.3. Social disintegration

2.3.1. Delinquency

Looking at past experiencies with court and prison we see that most drug addicts entering trials have been sentenced by court at least once in their life (FIGURE 8): 44% show such experiences before the onset of consumption of hard drugs and only 13% report no convictions during their drug career. Another third has been sentenced more than three times during this period. Also one third faces currently a court trial.

Figure 8: Experiences with court and prison at time of entry into trial

Also experiencies with prison are common: 21% had been arrested and detained already before starting consumption of hard drugs, and the corresponding percentage during the drug career runs up to 67%. 12% had at least one imprisonment before their drug career, while only 31% report not having been imprisoned during their drug career (FIGURE 8).

Especially female drug addicts often support themselves by prostitution. Looking at this aspect in our sample we see an overall percentage of 36% who made experiencies with prostitution in their life. The corresponding percentage of patients who engaged in prostitution during the last 6 months runs up to 19%. Regarding females only, these figures are higher: 64% have prostitued themselves during certain periods in their life and 43% did so in the last six months.

2.3.2. Drug consumption

The trials are intended for patients who have been heroin dependent for at least two years. Regarding this criterion we were interested to analyse the typical drugconsumption-patterns in our sample.

Looking at the biography of patients who entered trials, we see that the majority of them already had experience with several drugs. Especially alcohol, tranquilizers and cannabis have been used, usually before starting with heroin and/or cocaine.

The first contact with heroin occurred at an average age of 18 years; the first phase of daily consumption followed at an average age of 19 years (FIGURE 9).

Figure 9: Age at the onset of daily heroin and cocaine use.

The average length of the heroin career was 10 years at entry.

Most of patients consumed, in addition to daily heroin, cocaine and/or other drugs, especially cannabis, alcohol and/or benzodiazepines during the last four weeks before entry (FIGURE10).

Figure 10: Use of additional drugs to heroin at time of entry into trial

2.3.3. Earlier treatments

Participation in the trials should not be the first treatment of heroln addicts. Accordingly the patients in our sample show multiple earlier treatments in their history (FIGURE 11):

Figure 11: Earlier treatments for drug

Regarding the type of earlier treatments we see that the patients mostly have experiencies with different treatment modalities Only 7% never tried a detoxification and 27% have undertaken more than 5 such efforts. 58% entered a residential treatment at least once in their life and 95% stayed at least once in methadone maintenance (FIGURE 12).

Figure 12: Type of earlier treatment

Patients coming directly from methadone maintenance programmes show equal characteristics of social disintegration as other participants in the trials. Regardless of their current treatment they continued illegal drug use: 94% of them reported daily use of heroin in the last four weeks before entry into trial; the corresponding percentage for cocaine is 50%. 48% used both heroin and cocaine daily. More than half of them were part of the drug scene and two thirds supported themselves by illegal means. Accordingly they showed a poor job-performance: 58% were jobless since more than 12 months.

Conclusions and final remarks

Different studies show that the risk of dropping out from traditional treatment settings is especially high for drug addicts who display multiple characteristics of social marginality at time of entry into treatment facility (Vaillant, 1966a; Vaillant, 1966b; Zahn et al., 1972; De Leon et al., 1979; Marlatt, 1979; Ball et al., 1991; Rosenbaum, 1991; Sickinger et al., 1992; Werkstatt Bericht des Sozialpsychiatrischen Dienstes, Mfirz 1992; Caplehorn etr al., 1993; Reno et al., 1993; Spunt, 1993). In order to reach these addicts by an additional treatment modality the Swiss Federal Government has started the scientifical trials. The main aim of the trials is to analyse the long-term effects of a diversified medical prescription of narcotics (heroin, morphine and methadone) to long-term drug addicts with signs of social marginalization with whom other therapeutic efforts have failed so far (Uchtenhagen et al., 1994).

The present paper focuses on the degree of social marginalization in the population entering trials in the first phase of recruitment. The main interest is to analyse to what extent the participants correspond to the theoretically formulated admission criteria, in other words, to what extent the trials successfully reached the intended target population. 8ecause the recruitment phase is still going on and only part of the data is currently available, the results presented are preliminary. In spite of this limitation, however, the following conclusions can be made:

Drug addicts often show poor social integration and multiple corresponding deficiencies (Zimmer Hofler, Uchtenhagen & Christen, 1983; Uchtenhagen &

Zimmer Hofler, 1985a; Uchtenhagen & Zimmer Hofler, 1985b; Zimmer Hofler, Christen, Uchtenhagen & Meyer-Fehr, 1985; Des Jarlais, 1989; Hornung, Fuchs, Alvo, Pfister, Bossy & Grob, 1991; Dobler-Mikola & Zimmer Hofler,1993).

Such deficiences are overrepresented in participants at time of entry into trial. They are - even more often than the participants of methadon maintenance programmes - characterized by poor housing conditions and a low degree of job performance. Accordingly they dispose only of poor economical resources inside of ordinary social frameworks or have an illegal income, and a large part of them is dependent from social welfare.

Criminalization of drug addicts is often observed to be an important obstacle to successfull reintegration (Hunt, Lipton & Spunt, 1984;.Uchtenhagen, 1988). The participants of trials are usually involved in illegal activities in several respects. They often support their drug use as dealers or by other illegal activities and they had repeated contacts with court and prison. Females are often additionally involved in prostitution.

Drug consumption is generally associated with breakdown of social relationships (Reno & Aiken, 1993). The participants of trials seem to be especially socially isolated. Many of them have no social confidents and the majority has their main contacts within the drug scene. The majority of participants has experienced a long drug use history with multiple drug use. They are also older than participants in other treatment facilities. In addition most of them have undertaken several efforts to start a treatment.

The participants coming from methadone maintenance-programmes also show multiple characteristics of social disintegration. Considering their ongoing use of illegal heroin during the maintenance they would hardly have been successful in this modality (Spunt, 1993) . Thus the analysed data indicate that participants in the Swiss opiate trials are especially disintegrated, heavily addicted drug users for whom other treatment efforts have failed. Taking into account the formulated admission criteria, we therefore can conclude that until now the trials have reached in a satisfactory way the target population.

4. Literatur

Ball JC, Ross A (1991) The effectiveness of methadone maintenance treatment: Patients, programs, services, and outcomes. New York: Springer Verlag.

Caplehorn JRM, McNeil DR & Kleinbaum DG (1993) Clinic policy and retention in methadone maintenance. Int J Addict 28 (1): 73-89.

De Leon G & Rosenthal MS (1979) Therapeutic communities. in: A Dupont, J Godstein, J O'Donnel (eds) Handbook on drug abuse. Washington: US Government Printing Office: 39-49.

Des Jarlais, DC (1989) AIDS prevention programs for intravenous drug users: diversity and evolution. Int Rev Psychiatry 1: 101-108.

Dobler-Mikola A & Zimmer Hofler D (1993) K'ientinnen drogentherapeutischer Gemeinschaften in der Schweiz zwischen 1978/79 und 1990/91. Drogalkohol 2: 69-82.

Hornung R, Fuchs W, Alvo K, Pfister L, Bossy C & Grob P (1991) Das Zurcher Interventions-Pilotprojekt gegen Aids fur Drogengefahrdete und Drogenabhangige (Zipp-Aids): zwei Jahre Aids-Pravention am Zurcher Platzspitz (1989-1990). Institut fur Sozial- und Praventivmedizin Zurich.

Hunt DE, Lipton DS & Spunt B (1984) Patterns of criminal activity among methadone clients and current narcotics users not in treatment. J Drug Issues 14: 687-702.

Marlatt GA (1979) Alcohol Use and Problem Drinking: a Cognitive-Behavioral Analysis. New York: Academic Press.

Rosenbaum M (1991) Staying off methadone maintenance. J Psychoactive Drugs 23 (3): 251-260.

Reno RR & Aiken LS (1993) Life activities and life quality of heroin addicts in and out of methadone treatment. Int J Addict 28 (3): 211-232.

Sickinger R, Kindermann W, Kindermann S, Lind-Kramer R & Timper-Nittel A (1992) Wege aus der Drogenabhangigkeit. Gelungene und gescheiterte Ausstiegsversuche. Freiburg im Breisgau: Lambertus Verlag.

Spunt BJ (1993) The link between identity and crime for the heroin addict in methadone treatment. Int J Addict 28 (9): 813-825.

Uchtenhagen A (1988) Zum Deliquenzverlauf bei Drogenabhangigen. In: Jugend und Delinquenz. Schweizerische Arbeitsgruppe fur Kriminologie, Reihe Kriminologie Band 3: 337-369.

Uchtenhagen A & Zimmer Hofler D (1985a) Heroinabhangige und ihre "normalen" Altersgenossen. Bern: Haupt Verlag.

Uchtenhagen A & Zimmer Hofler D (1985b) Psychosocial Development Following Therapeutical and Legal Interventions in Opiate Dependence. A Swiss National Study. Eur J Psychol Educa, Vol. ll, 4: 443-458.

Uchtenhagen A & Dobler-Mikola A (1994) Methadone maintenance treatments in Canton Zurich. Zurich: Unpublished manuscript.

Uchtenhagen A, Gutzwiller F & Dobler-Mikola A (1994) Versuche fur eine firztliche Verschreibung von Betfiubungsmitteln: Studienprotokoll der Begleitevaluation (1. Aufl.). Unveroffentlichte Dokumentation. Zurich.

Vaillant GEA (1966a) A tweive-year follow-up of New York narcotic addicts: I. The relation of treatment to outcome. Amer J Psychiat 122: 727-737.

Vaillant GEA (1966b) A twelve-year follow-up of New York narcotic addicts: III. Some social and psychiatric characteristics. Arch Gen Psychiat 15: 599609.

Werkstattbericht des Sozialpsychiatrischen Dienstes (Mfirz 1992) Forschungsverbund therapeutischer Einrichtungen: Klienten und Klientinnen therapeutischer Gemeinschaften im Brennpunkt von Praxis und Forschung. Forschungsinformation aus dem Sozialpsychiatrischen Dienst Serie V. (5).

Zahn MA & Ball JC (1972) Factors related to cure of opiate addiction among Puerto Rican addicts. Int J Addict 7: 237-245.

Zimmer Hofler D, Uchtenhagen A, Christen St (1983) The family situation of addicts and nonaddicts. Proceedings of the 7th World Conference on Therapeutic Communities in Chicago. May 8-13.

Zimmer Hofler D, Christen St, Uchtenhagen A, Meyer-Fehr P (1985) "Normal" oder Opiatabhfingig im Zweijahres-Verlauf. In: A Uchtenhagen, D Zimmer Hofler (Hg) Heroinabhfingige und ihre "normalen" Altersgenossen. Bern: Haupt Verlag: 168-284.