Drug network characteristics as a predictor of cessation of drug use among adult injection drug users: a prospective study.

Few studies have examined recovery from opiate and cocaine dependence without treatment, referred to as "natural recovery," "spontaneous recovery," and "spontaneous remission." The present study examined the relationship between network characteristics and cessation of heroin, cocaine, and crack use in a sample of underclass inner-city injection drug users in Baltimore, Maryland. Participants were enrolled in an experimental human immunodeficiency virus (HIV) preventive intervention. Between the baseline and follow-up interviews, which averaged 5.2 months, 24 (7%) of 335 participants reported ceasing to use heroin, cocaine, and crack. Individuals who had reported cessation of drug use at follow-up had reported at baseline a smaller proportion of their network members with whom they used drugs (p < .02). Using multiple logistic regression analyses and adjusting for baseline drug use, enrollment in drug treatment, and demographic and background variables, cessation of drug use was associated with a lower proportion of personal network members in one's drug network (odds ratio [OR] = 25.4, p < .05). The data from this study suggest that network members have potential for social influence on the cessation of drug use.

Depressive symptoms, drug network, and their synergistic effect on needle-sharing behavior among street injection drug users.

In this study, we examined the relationship between depressive symptoms and needle-sharing behavior in a community sample of intravenous drug users (N = 499) in Baltimore, Maryland. Based on the polytomous logistic regression, higher depressive symptoms were positively associated both with needle sharing after cleaning with bleach and with needle sharing without first cleaning with bleach at the bivariate analyses. This relationship remained significant (OR = 1.66) even after adjusting for demographic characteristics, life events, drug use patterns, and social and drug networks. A significant synergistic effect of depressive symptoms and drug network on needle sharing after cleaning with bleach and needle sharing without cleaning was observed. More depressed intravenous drug users who also had a larger drug network were found to be at higher risk of needle sharing after cleaning with bleach, as well as needle sharing without cleaning (OR = 2.59). Depression status is discussed as a predisposing factor and drug network size as a precipitating factor for needle-sharing behavior. Implications for preventing needle-sharing behavior by reducing depressive symptoms are discussed.

Gender differences in injection-related behaviors among injection drug users in Baltimore, Maryland.

Baseline data from 640 injection drug users in the Stop AIDS for Everyone study, an HIV preventive intervention were used to examine gender differences in self-reports of injection behaviors. In both the bivariate and multivariate analyses men reported injecting alone, in semipublic areas, and at their mother's residence more often than women. In the bivariate analyses, women reported denser personal networks, and in the multivariate analyses, women reported significantly greater overlap between their drug and sex networks. These data suggest that this overlap of sex and drug networks may reduce women drug injectors' ability to adopt and maintain HIV protective behaviors. The data also suggest that interventions need to address gender differences in the social context of risk behaviors.

Social network characteristics and injecting HIV-risk behaviors among street injection drug users.

As an alternative approach to individually-focused understanding of HIV risk behavior, this study explored the relationship between social network characteristics and HIV-risk injecting behaviors. Subjects were 499 inner-city injection drug users (IDUs) recruited from the streets of Baltimore, Maryland. Analysis of structural and functional network data indicates that a substantial proportion of drug sharing network members also provided social support, often because of family and sexual partner relationships. IDUs with larger drug networks which also provided social support were more likely to share needles, while IDUs with larger drug networks which did not provide social support were more likely to inject in commercial settings. The findings suggest that social support from drug network members has differential effects on injecting HIV-risk behaviors among IDUs. HIV prevention efforts should be expanded to reach drug-sharing networks and should take into account their social support relationships.

The relationship between risk networks' patterns of crack cocaine and alcohol consumption and HIV-related sexual behaviors among adult injection drug users: a prospective study.

Social context may be an important determinant of drug and alcohol consumption and HIV-related behaviors. To assess the influence of peers on drug users' risk behaviors this study examined the association between individual level and group level behaviors. This analysis reports on the prospective association between baseline self-reported drug and alcohol use of the network members of injection drug users, and self-reported sexual behaviors and alcohol use at 5-month follow-up. Participants were a nontreatment sample of inner-city injection drug users who volunteered for a network-oriented HIV preventive intervention. They were predominantly unemployed, African American males. Of the 71 index participants who completed both the baseline and follow-up interviews, 227 of their drug network members were enrolled in the study. At baseline indexes' sexual risk behaviors were significantly associated with their drug network members' level of crack cocaine use. At follow-up higher levels of alcohol and crack use among drug network members were associated with indexes' reports of multiple sex partners and increased alcohol consumption. Higher levels of crack use among the drug network members were associated with the indexes' reporting casual sex partners at follow-up. These results highlight the importance of studying the role of peer group influence and the social context of risk behaviors.

People and places: behavioral settings and personal network characteristics as correlates of needle sharing.

Sharing of contaminated needles constitutes one of the primary modes of HIV transmission in the U.S. This study examined social and environmental factors as possible correlates of needle sharing in a sample of inner-city drug users in Baltimore, Maryland. Drug users' social context was assessed through an analysis of personal networks, and the environmental context of drug use was assessed through a delineation of injection settings. The 330 respondents participating in an HIV prevention study were administered two surveys an average of 5.2 months apart. An examination of the association of network characteristics at baseline and needle sharing at followup revealed that the factors of higher total network density, larger drug network size, and injecting at friends' residences were positively associated with reports of sharing needles that had been cleaned with bleach. Sharing of needles that had not been disinfected with bleach was positively associated with reports of injecting in semipublic areas (streets, rooftops, parks, cars, public bathrooms, and abandoned buildings). These data support ecological and resource models of needle sharing and suggest the potential utility of network-oriented strategies for reducing needle sharing among injecting drug users.

The long-term outcome of a personal network-oriented HIV prevention intervention for injection drug users: the SAFE Study.

Social influence processes have been found to affect numerous drug and health-related behaviors. We postulated that by using a network-oriented intervention it may be possible to capitalize on social influence processes to reduce human immunodeficiency virus (HIV) risk behaviors. The present study used an experimental study design for delivering a psychoeducational acquired immunodeficiency syndrome (AIDS) preventive intervention to injection drug sharing networks. Participants were recruited from the ALIVE study, an epidemiological study in Baltimore. In the present paper we examine the self-reported behavioral outcomes of 117 injection drug users 18 months after the baseline interview. HIV seronegative experimental participants reported significantly less frequent needle sharing and less injecting of heroin and cocaine than controls. In multiple logistic regression models of HIV seronegative participants, there was a significant negative association between assignment to the experimental group and the HIV-related behaviors of needle sharing and sharing of cookers in the prior 6 months; controls were 2.8 times more likely than experimentals to report needle sharing and were 2.7 times more likely to report sharing cookers. The results of this 18-month follow-up suggest that among injection drug users network-oriented interventions may be a promising approach to HIV prevention.

Using social network analysis to study patterns of drug use among urban drug users at high risk for HIV/AIDS.

Few studies have examined the current social relationships of injecting drug users. This paper examines the structural and relationship characteristics of the social networks of injecting drug users, and the relation of social network characteristics to the HIV infection risk behavior of frequency of injecting heroin and cocaine. The study sample was comprised of 293 inner city injecting drug users in Baltimore, Maryland. Most participants (89%) reported at least one family member in their social network, and 44% listed their mother or step-mother in their network. Presence of family members in personal social networks was not related to patterns of drug use examined here; however, those who reported a partner in their personal social network injected significantly less often than those who did not report a partner. Network density and size of drug subnetworks were positively associated with frequency of drug injection. The results of this study suggest that social network analysis may be a useful tool for understanding the social context of HIV/AIDS risk behaviors.

My place, your place, and no place: behavior settings as a risk factor for HIV-related injection practices of drug users in Baltimore, Maryland.

Information is sparse on the social context of illicit drug injection behaviors and their relationship to HIV infection. This study examined relationships between injection settings, injecting with others, and HIV risk behaviors of sharing needles and not cleaning contaminated needles in a sample of 630 inner-city injecting drug users in Baltimore, MD. Through open-ended interviews, five primary settings of injection behavior were identified. These settings included one's own, friends' and mother's residence, shooting galleries, and semipublic areas. Most participants reported injecting in their own residence (92%) and friends' residence (86%) in the prior 6 months. In a multiple regression analysis, injecting at friends' residence, in shooting galleries, and in semipublic areas and frequency of injecting with others were significantly associated with frequency of sharing uncleaned needles, "slipping" (i.e., failure to disinfect shared needles), and not always cleaning used needles before injecting. Results suggest that interventions may benefit from targeting settings as well as behaviors to reduce the spread of HIV.

Correlates of needle sharing among injection drug users.

OBJECTIVES: The sharing of contaminated injection equipment is the primary mode of human immunodeficiency virus (HIV) transmission for injection drug users. This study examined demographic factors, life events, and drug use practices that are potential risk factors for sharing injection equipment. METHODS: Between February 1988 and March 1989, 2921 active injection drug users were interviewed and questioned about their backgrounds, life-styles, and patterns of injection drug use. RESULTS: Of 2524 participants who reported injecting drugs within the 6 months prior to study enrollment, 70.4% reported recent needle sharing. A multivariate analysis found needle sharing to be more frequent among those with a history of arrest and lower socioeconomic status, even after accounting for other demographic and drug use variables. In addition, recent needle sharing was higher in male homosexual or bisexual men than in their heterosexual counterparts. CONCLUSIONS: These data suggest that injection drug users have an economic motive to share needles and that the availability of free and legal needles may reduce levels of needle sharing.

The relationships between sexual behavior, alcohol use, and personal network characteristics among injecting drug users in Baltimore, Maryland.

BACKGROUND AND OBJECTIVES: Studies on the relationship between alcohol consumption and HIV-related risk behaviors report inconclusive and contradictory results. GOAL OF THIS STUDY: This study sought to examine the relationship between drug and alcohol use, personal network characteristics, and sexual risk behaviors. STUDY DESIGN: A sample of 290 injecting drug users in Baltimore, Maryland, were interviewed. RESULTS: More than half the males and 28% of the females reported multiple partners within the prior 6 months, and 33% of the males reported exchanging money or drugs for sex. For males, heavy drinking was significantly associated with multiple partners, exchanging money or drugs for sex, and casual sex. The personal network characteristics of size and density, as measured by the percentage of network members who knew each other, were associated with sexual risk behaviors. CONCLUSION: These results indicate that among injecting drug users in Baltimore, heavy drinkers, and those with larger, lower density personal networks have increased levels of sexual risk behaviors.

An approach to the impaired physician.

The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention.

Parental drinking and gender factors in the prediction of early adolescent alcohol use.

This study examines the relationship between children's reports of their parents' drinking patterns, and the child's alcohol misuse and heavy alcohol use in early adolescence. Subjects were 2,213 fifth and sixth grade students. Data on the child's alcohol use and misuse, and parent alcohol use, were derived from classroom-administered questionnaires. Increased reported level of drinking by mother or by father was significantly associated with increased odds of alcohol misuse and heavy alcohol use among the children; these results held for both boys and girls when examined separately. Examination for possible confounding effects of assortative mating by parental drinking suggests that reports of heavy drinking in either parent increases the risk of alcohol misuse and heavy alcohol use in children. Implications for prevention efforts are discussed.

Depression as an antecedent of frequency of intravenous drug use in an urban, nontreatment sample.

The present study examined the relationship between depressive symptoms and frequency of drug use in 91 low income nontreatment intravenous drug users in Baltimore, Maryland. The majority of participants were injecting both heroin and cocaine. Scores on the depression scale at both waves were correlated with frequency of injection at wave two. Depression at wave one had a higher correlation with frequency of injections at wave two than did concurrent depression at wave two. Even after accounting for several confounds between depression and frequency of injection, depression at wave one remained highly correlated with frequency of injection at wave two.

Alcoholism and occupations: a review and analysis of 104 occupations.

A review of the many attempts to establish an association between occupations and alcoholism reveals that most do not deal with data about clinically defined alcoholism but instead use data about cirrhosis mortality, self-reported alcohol problems, and frequent and heavy drinking. The present study establishes an association between occupations and diagnoses of Alcohol Dependence Disorder and Alcohol Abuse Disorder, using data from a large population-based household interview study. Statistical adjustment using logistic methods reveals that apparent associations between occupations and alcohol-related disorders previously reported in the literature are due to characteristics of those employed in various occupations. The prevalence of alcohol dependence and abuse in two high risk industries, construction and transportation, is confirmed. More than one in four construction laborers and one in five skilled construction trades workers received a DIS/DSM-III diagnosis related to alcohol abuse. In the transportation industry one in six heavy truck drivers and material movers received an alcohol diagnosis. Analyses of the data from individuals currently employed and not employed in their occupation reveals reduction in risk for those who leave some occupations and increased risk for those who leave other occupations. Evidence is presented that employment in some occupations may be protective for Alcohol Dependence. The findings support the view that occupation may be associated with Alcohol Dependence and Alcohol Abuse independent of demographic variations. Previously proposed explanatory models for associations between occupations and alcohol problems are called into question because they do not take into account the demographic characteristics and employment status of workers.

Sometimes we're our own worst enemies.

There is a sense of frustration among physicians involved in the decision and policy making processes within health care institutions. Because the endpoint is reached at glacial speed, too much time, money, and opportunity is lost. The decision making process can be repetitious and tedious because of unnecessary steps. By eliminating certain tactics and strategies employed by upper-level management in many health care institutions, the decision making process becomes more effective. This article focuses on the medical staff's role in the decision making process; explains why tactics to involve the medical staff are ineffective and why eliminating the medical staff from certain aspects of the process does not jeopardize the institution; and concludes that the hospital board and its delegates should be autonomous in the decision making process.

Needle-cleaning practices among intravenous drug users who share injection equipment in Baltimore, Maryland.

In Baltimore, Maryland, between 1988 and 1989, 2,921 intravenous drug users were recruited into a study of drug injection practices and human immunodeficiency virus (HIV) infection. Sixty-three percent reported both current use and sharing of needles; almost all these (N = 1,757) reported using injection equipment immediately after it was used by another intravenous drug user. Of the 1,757, 62% said that they "typically" cleaned the used equipment with bleach or alcohol before injecting. These data suggest that information about disinfecting needles has disseminated into this population and identifies several groups to target for interventions.

A physician's exposure to defamation.

The article defines defamation, discusses how to avoid a defamation action, and suggests defenses against a defamation action. Several examples are given that demonstrate common situations where liability exists and how a physician should respond. The article explains that at times we have a duty to speak and differentiates between our legal, moral, and ethical duty. Defamation should not be a concern for those involved in the peer review process, as long as they are truthful or act in a good faith belief that what they are saying is true. The article should enhance peer review by encouraging physicians to participate without fear of a retaliatory law suit.