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Crystal methamphetamine initiation among street-involved youth Uhlmann, Sasha; DeBeck, Kora; Simo, Annick; Kerr, Thomas; Montaner, Julio; Wood, Evan Jan 1, 2014

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Crystal methamphetamine initiation among street-involvedyouthSasha Uhlmann, MD, MPH1, Kora DeBeck, PhD1,2, Annick Simo, MSc1, Thomas Kerr,PhD1,3, Julio S. G. Montaner, MD, FRCPC, FCCP1,3, and Evan Wood, MD, PhD, ABIM,FRCPC1,31British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada2School of Public Policy, Simon Fraser University, Vancouver, BC, Canada3Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, BC,CanadaAbstractBackground—Although many settings have recently documented a substantial increase in theuse of methamphetamine-type stimulants, recent reviews have underscored the dearth ofprospective studies that have examined risk factors associated with the initiation of crystalmethamphetamine use.Objectives—Our objectives were to examine rates and risk factors for the initiation of crystalmethamphetamine use in a cohort of street-involved youth.Methods—Street-involved youth in Vancouver, Canada, were enrolled in a prospective cohortknown as the At-Risk Youth Study (ARYS). A total of 205 crystal methamphetamine-naïveparticipants were assessed semi-annually and Cox regression analyses were used to identifyfactors independently associated with the initiation of crystal methamphetamine use.Results—Among 205 youth prospectively followed from 2005 to 2012, the incidence density ofcrystal methamphetamine initiation was 12.2 per 100 person years. In Cox regression analyses,initiation of crystal methamphetamine use was independently associated with previous crackcocaine use (adjusted relative hazard [ARH] = 2.24 [95% CI: 1.20–4.20]) and recent drug dealing(ARH = 1.98 [95% CI: 1.05–3.71]). Those initiating methamphetamine were also more likely toreport a recent nonfatal overdose (ARH = 3.63 [95% CI: 1.65–7.98]) and to be male (ARH = 2.12[95% CI: 1.06–4.25]).Conclusions—We identified high rates of crystal methamphetamine initiation among thispopulation. Males those involved in the drug trade, and those who used crack cocaine were moreSend correspondence to: Dr. Evan Wood, BC Centre for Excellence in HIV/AIDS, 608 - 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada, uhri-ew@cfenet.ubc.ca.Declaration of InterestThe study was supported by the US National Institutes of Health (R01-DA028532) and the Canadian Institutes of Health Research(MOP–102742). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1Canada Research Chair in Inner City Medicine, which supports Dr. Evan Wood. Dr. Kora DeBeck is supported by a MSFHR/St.Paul’s Hospital-Providence Health Care Career Scholar Award. Dr. Julio Montaner has received an Avant-Garde award(DP1DA026182) from the National Institute of Drug Abuse, US National Institutes of Health. Funding sources had no further role instudy design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper forpublication.Dr. Julio Montaner has received grants from, served as an ad hoc advisor to, or spoken at various events sponsored by Abbott, ArgosTherapeutics, Bioject Inc, Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho,Merck Frosst, Pfizer, Schering, Serono Inc., TheraTechnologies, Tibotec, and Trimeris. The authors declare no other competinginterests.NIH Public AccessAuthor ManuscriptAm J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.Published in final edited form as:Am J Drug Alcohol Abuse. 2014 January ; 40(1): 31–36. doi:10.3109/00952990.2013.836531.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptlikely to initiate crystal methamphetamine use. Evidence-based strategies to prevent and treatcrystal methamphetamine use are urgently needed.KeywordsCrystal methamphetamine; social harm; youthIntroductionAmphetamine-type stimulants, including crystal methamphetamine, are the second mostcommonly used illicit drug worldwide, following cannabis (1). As a stimulant, crystalmethamphetamine can affect any organ system in the body (2) and its use has beenassociated with numerous health and social harms. Crystal methamphetamine use isassociated with the spread of infectious diseases, including HIV and hepatitis C (3,4),perhaps because people who use crystal methamphetamine are more likely to engage inrisky sex practices, inject drugs and have a history of incarceration (5–7). A recent study ofHIV-positive men who have sex with men initiating antiretroviral therapy found that crystalmethamphetamine use was strongly associated with unprotected anal intercourse (8). Crystalmethamphetamine is also associated with malnutrition (9) and the negative cardiovasculareffects are well described (2,10).Street-involved youth have high rates of crystal methamphetamine use (6) and thispopulation may be particularly vulnerable to the negative effects of crystalmethamphetamine given their street entrenchment and other health and social challenges,(11). Recent cross-sectional studies from Canada have shown that over 70% of street-involved youth who use drugs use crystal methamphetamine (6). High rates of crystalmethamphetamine use among street-involved youth may be the result of cheap cost and easyaccess (12,13). Crystal methamphetamine is made from readily available substances, such aspseudoephedrine, and can be produced in local “meth labs,” which are usually smalloperations in residential locations (2). In a cohort of Canadian street-involved youth, almost65% of study participants could obtain crystal methamphetamine within 10 minutes (13).Other reasons for crystal methamphetamine initiation may include curiosity andentrenchment in local drug scenes (14).Several health and social factors have previously been associated with crystalmethamphetamine use in street-involved youth. A study of homeless youth showed thatthose with a history of foster care placement were more likely to use crystalmethamphetamine than those without (15). Other factors previously associated with crystalmethamphetamine use include a history of incarceration, older age, trading sex for moneyand injection drug use (6,16). A 2008 meta-analysis found that crystal methamphetamineuse was associated with several harmful behaviours, including risky sexual practices andalcohol and cigarette consumption (12). However, all studies included in the meta-analysiswere either cross-sectional or retrospective and many of the risk factors analyzed came fromone study with a small sample size (12). The study authors concluded that future researchshould utilize prospective study designs so that temporal relationships between risk factorsand crystal methamphetamine use can be established (12).Although there is a lack of research on factors affecting initiation of crystalmethamphetamine among street youth, there is a diverse literature in other populations. Forinstance, gender differences in methamphetamine use patterns are well described (17,18)and seem to vary based on the population studied. A Chinese study of adults with substanceabuse found that men were more likely to use methamphetamine than women (19).Similarly, in a cohort of adult injection drug users from Canada, female gender was found toUhlmann et al. Page 2Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptbe protective against methamphetamine initiation (20). In contrast, a study of injection drugusers in Tijuana, Mexico, found that females were more likely to use methamphetamine, afinding possibly explained by an increased prevalence of methamphetamine use among sex-trade workers (21). However, a common finding is that females tend to initiatemethamphetamine use at a younger age (17).Ethnic differences in methamphetamine use have also been studied (22–24). This literaturegenerally suggests that methamphetamine use is more common among individuals ofCaucasian ethnicity (23,24), especially male blue-collar workers (2).Mental health disorders have also been associated with methamphetamine use. A recentsystematic review found that methamphetamine use was associated with psychosis anddepression in young people (25). Of the few prospective studies included in the analysis, onefound that methamphetamine users were more likely to have depression, dysthymia andpost-traumatic stress disorder (PTSD) (26), although a separate study found that earlydepression and anxiety were not predictive of future methamphetamine use in adulthood(27). Despite these findings, most of the studies included in the systematic review werecross-sectional. Therefore, conclusions regarding possible links between pre- existingmental health disorders and subsequent methamphetamine initiation could not be made.Despite the recognition of increasing crystal methamphetamine use among high-risk youngpeople, few prospective studies have examined socio-demographic and drug use- related riskfactors for initiation of use. Therefore, the present study was conducted on a prospectivecohort of street-involved youth to examine rates of initiation and risk factors for initiationinto crystal methamphetamine use.MethodsThe At-Risk Youth Study (ARYS) is a prospective cohort study of Vancouver street-involved youth that has been described in detail previously (28). In brief, extensive streetand agency-based outreach recruitment methods, with snowball sampling (wherebyparticipants recruit their friends), were utilized. Eligibility for the ARYS study included age14–26 years at baseline and use of illicit drugs other than marijuana in the past 30 days. Atbaseline and every 6 months thereafter, participants completed an interviewer- administeredquestionnaire pertaining to socio-demographic information and sex- and drug-related riskbehaviors, including specific drugs used and modes of use. Pre- and post- test counseling, aswell as referral to health services, was provided at each interview. At every visit,participants also provided blood samples in order to ascertain HIV and hepatitis C (HCV)infection status and received $20 CAD as remuneration. The study has received ethicsapproval by the Research Ethics Board of the University of British Columbia. For thepresent analyses, individuals recruited between September 2005 and May 2012, reportingnever having used crystal methamphetamine at baseline and who had at least one follow- upvisit (to assess for initiation into crystal methamphetamine use) were eligible.Given this study’s objective to identify socio-demographic characteristics potentiallyassociated with crystal methamphetamine initiation (27), and given past analyses showingthe potential role of a range of sociodemographic characteristics on methamphetamine useand related harms (6,12,15–19,21,23–27), we selected the following covariates a prioribased on their known or hypothesized relationship with the primary outcome: age atinterview; age of first illicit (hard) drug use; gender (female versus male); ethnicity(Caucasian versus other); high school drop-out (yes versus no); living in Vancouver’s druguse epicenter, known as the “Downtown Eastside” (14) (yes versus no); homelessness (yesversus no); injection drug use (yes versus no); daily marijuana use (yes versus no); cocaineUhlmann et al. Page 3Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptuse (yes versus no); crack cocaine smoking (yes versus no); heroin use (yes versus no);nonfatal overdose (yes versus no); borrowing or sharing syringes (yes versus no); anyinjection of drugs in public (yes versus no); hepatitis C positivity (yes versus no); HIVpositivity (yes versus no); unsafe sex, defined as vaginal or anal penetration without acondom (yes versus no); diagnosis of a mental illness (yes versus no); victim of violence(yes versus no); police encounter, defined as having been stopped, searched or detained bypolice (yes versus no); history of sexual abuse (yes versus no); history of physical abuse (yesversus no); involvement in sex work, defined as exchanging sex for money, gifts, food,shelter, clothes, drugs or other (yes versus no); and drug dealing (yes versus no). Unlessotherwise noted, all behavioral variables refer to the 6-month period prior to the interview.All variable definitions have been used extensively and were identical to earlier publications(29,30).Descriptive statistics were used to describe the sample at baseline. Categorical explanatoryvariables were analyzed using Pearson’s chi-square test and continuous variables wereanalyzed using the Wilcoxon rank sum test. We then used Cox regression analysis toidentify risk factors for initiation into crystal methamphetamine use. As a first step, bivariateCox regression analyses were used. In order to adjust for potential confounding, we fit amultivariate model where all variables that were p ≤ 0.20 in Cox regression bivariateanalyses were considered in a full model. Variable selection for the final model was doneusing Akaike Information Criterion (AIC) statistic with a backward model selectionprocedure (31). All statistical analyses were performed using SAS software version 8.0(SAS, Cary, NC, USA). All p values are two sided.ResultsBetween September 2005 and May 2012, 1019 street youth were recruited into the ARYScohort, among whom 704 (69.0%) reported any prior crystal methamphetamine use atbaseline. Overall, 205 (20.1%) reported never having used crystal methamphetamine atbaseline interview and had at least one follow-up visit and were therefore included in theanalysis. There were no significant differences in age, gender or ethnicity between theseparticipants and the 110 (10.8%) individuals who were ineligible for the present studybecause they did not complete a study follow-up visit (all p > 0.05).Of the 205 participants, 46 (22.4%) reported crystal methamphetamine use at some pointduring follow-up for an incidence density 12.2 per 100 person-years. Among this sample,the median age was 21 (interquartile range [IQR]: 19–24), 135 (65.8%) were male, and 116(56.6%) were Caucasian. The median follow-up duration was 19.9 months (IQR = 11.7–29.0).Table 1 displays the baseline characteristics of the study sample. Almost two-thirds ofparticipants (65.4%) were homeless in the 6 months prior to baseline interview and a highprevalence of illicit drug use was present, including marijuana (48.8%), cocaine (48.8%),crack cocaine (45.4) and heroin (18.0%). Injection drug use was also common with 12.7%of participants reporting injection drug use in the 6 months prior to baseline interview. Therewas also a high prevalence of unsafe sex (48.3%), mental illness (39.5%), victims ofviolence (42.4%) and drug dealing (52.2%).Table 2 shows the unadjusted and adjusted relative hazards of crystal methamphetamineinitiation. As shown, in the multivariate Cox regression analysis, factors that wereindependently associated with crystal methamphetamine initiation included being male(adjusted relative hazard [ARH] = 2.12 [95% CI: 1.06–4.25]), crack cocaine smoking (ARH= 2.24 [95% CI: 1.20–4.20]), nonfatal overdose (ARH = 3.63 [95%CI: 1.65–7.98]) and drugUhlmann et al. Page 4Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptdealing (ARH = 1.98 [95% CI: 1.05–3.71]). Several factors were also significantlyassociated with crystal methamphetamine use in the unadjusted model (injection drug use,cocaine use and police encounters), but were no longer significant in the adjusted model.DiscussionIn the present study, we found high rates of crystal methamphetamine initiation amongstreet-involved youth and found that being male, smoking crack cocaine and engaging indrug dealing were all independently associated with crystal methamphetamine initiation.Those reporting crystal methamphetamine initiation were also more likely to report a recentnonfatal overdose.To our knowledge, this is the first study to show prospectively that crystalmethamphetamine initiation is associated with crack cocaine smoking among street-involved youth. Those participants who smoked crack cocaine had over two times the risk ofinitiating crystal methamphetamine use. Our findings are consistent with studies of otherhigh-risk populations, which show a link between crystal methamphetamine and crackcocaine use (32,33). This reflects the possibility that crack cocaine use predisposes to otherstimulant use, such as crystal methamphetamine, and visa versa. Street youth who usestimulants may be part of social networks where other stimulant use is readily available (34).As well, entrenchment in drug culture likely precipitates use of other drugs (14). Anotherpossibility is that street youth who use crack cocaine may switch to crystalmethamphetamine, as it is easy to access (13). Furthermore, first use of harder drugs oftenoccurs between the ages of 18–22, a similar age range to our population (35). Given thatstimulant users often engage in polysubstance use, and that crack cocaine has beenassociated with HIV and HCV risk behavior (36–39), the possible combination of crackcocaine use with crystal methamphetamine use is especially concerning from a public healthperspective.This study is also unique in that it shows, prospectively, that drug dealing is a risk factor forcrystal methamphetamine use. This is supported by a prior study that found an associationbetween more frequent crystal methamphetamine use and crystal methamphetamineinjection with drug dealing in a cohort of methamphetamine users (40). The associationbetween dealing drugs and initiation of crystal methamphetamine may represent severalfactors. First, drug dealers may be more likely to use the drugs they are selling, especially asmany drug users sell drugs to support their own drug use (40,41). Secondly, drug dealingoften occurs in a hostile, violent environment and crystal methamphetamine use may helpdealers cope in this environment. Conversely, people who have hostile personalities may bemore likely to deal drugs and use drugs such as crystal methamphetamine (40). Interestingly,a 2011 study by Werb et al. showed that drug dealers who recently used crystalmethamphetamine were less willing to cease dealing than those that recently used otherdrugs (42). Thirdly, as drug dealers are targets for law enforcement, they are less likely toaccess harm reduction or drug prevention or treatment programs (43). Nevertheless, theconnection between drug dealing and subsequent initiation of crystal methamphetamine useis unknown and is an area for further research.Our study showed that men were significantly more likely to initiate crystalmethamphetamine use, a finding seen in other studies (40,44). The cause of this genderdifference is unknown, but it may relate to drug market influences, including potentiallymen having more opportunity to buy drugs (45,46). It also may relate to the popularity ofcrystal methamphetamine in the men-who-have-sex-with-men population, though this groupis overall not well represented in our sample (47). However, these findings may also be theUhlmann et al. Page 5Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptresult of regional differences, as a 2012 study of 156 street youth in Los Angeles found nogender differences among crystal methamphetamine users (16).There are several limitations to this study. As there are no voters’ lists or other registriesfrom which to draw a random sample, caution is required when interpreting our results toother populations of street youth. However, it is noteworthy that the cohort demographicsare similar to other local and international studies of street-involved youth (16,48,49).Second, there is a concern of socially desirable responding in studies of marginalizedpopulations (50). With respect to this concern, we know of no reason why risk behaviorswould be differentially reported between crystal methamphetamine users and nonusers.Nevertheless, although confidentiality is assured as part of the interview and interviewersare trained to build trust and rapport with the participants, it is possible we underestimatedsome behaviors in the present study.In summary, the present study found high rates of crystal methamphetamine initiationamong street-involved youth and that this behavior was associated with being male, crackcocaine smoking and drug dealing. These findings identify a specific population that maybenefit from more targeted intervention strategies. In an environment where public healthinitiatives are continuously hindered by a lack of funding, targeting the highest risk groupswith evidence-based interventions may be the most efficient way of decreasing rates ofinitiation of crystal methamphetamine use and decreasing the subsequent spread ofinfections diseases and other harms. However, our findings also underscore the urgent needfor novel evidence-based prevention and addiction treatment initiatives for crystalmethamphetamine users.AcknowledgmentsThe authors thank the ARYS study participants for their contribution to the research, as well as current and pastresearchers and staff. We would specifically like to thank Cody Callon, Jennifer Matthews, Deborah Graham, PeterVann, Steve Kain, Tricia Collingham, and Carmen Rock for their research and administrative assistance.References1. UNODC. United Nations Office on Drugs and Crime: Recent Statistics and Trend Analysis of IllicitDrug Markets. 2012.2. 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Factors associated with early adolescent initiationinto injection drug use: implications for intervention programs. J Adolesc Health. 2006; 38:462–464.49. Corsi KF, Kwiatkowski CF, Booth RE. Predictors of methamphetamine injection in out-of-treatment IDUs. Subst Use Misuse. 2009; 44:332–342.Uhlmann et al. Page 8Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript50. Des Jarlais DC, Paone D, Milliken J, Turner CF, Miller H, Gribble J, Shi Q, et al. Audio- computerinterviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomisedtrial. Lancet. 1999; 353:1657–1661.Uhlmann et al. Page 9Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptUhlmann et al. Page 10Table 1Characteristics of 205 street-involved youth reporting never having used crystal methamphetamine at baseline.Characteristic Total (%) (n = 205)Age at interview (median [IQRa]) 21.4 (19.1–23.5)Age of first hard drug use (median [IQR]) 16.0 (14.0–18.0)Male 135 (65.8)Caucasian 116 (56.6)High school drop-out 140 (68.3)Living in the DTESb,c 49 (23.9)Homelessness 134 (65.4)Injection drug use 26 (12.7)Daily marijuana use 100 (48.8)Cocaine used 100 (48.8)Crack cocaine smoking 93 (45.4)Heroin use 37 (18.0)Frequent alcohol use 24 (11.7)Nonfatal overdose 14 (6.9)Syringe sharing 3 (1.4)Public injection 16 (7.8)Hepatitis C positive 7 (3.4)HIV positive 2 (1.0)Unsafe sex 99 (48.3)Mental illness diagnosis 81 (39.5)Victim of violence 87 (42.4)Police encounter 57 (27.8)History of sexual abuse 46 (22.4)History of physical abuse 74 (36.1)Sex work 10 (4.9)Drug dealing 107 (52.2)aIQR, interquartile range.bDTES, downtown eastside.cRecent = all behavioral variables refer to the past 6 months.dPowder by any route.Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptUhlmann et al. Page 11Table 2Bivariate and multivariate Cox regression analysis of factors associated with crystal methamphetamineinitiation in street-involved youth.Unadjusted AdjustedCharacteristic Relative hazard (95% CI) p Value Relative hazard (95% CI) p ValueAge at interview (yes versus no) 0.93 (0.84–1.03) 0.157Male (yes versus no) 1.70 (0.86–3.34) 0.126 2.12 (1.06–4.25) 0.035Caucasian (yes versus no) 1.08 (0.60–1.93) 0.809Homelessnessa (yes versus no) 1.69 (0.93–3.07) 0.084Injection drug use (yes versus no) 2.15 (1.09–4.27) 0.028Daily marijuana use (yes versus no) 1.18 (0.65–2.15) 0.584Cocaine useb (yes versus no) 1.86 (1.02–3.38) 0.043Crack cocaine smoking (yes versus no) 3.35 (1.72–6.53) <0.001 2.24 (1.20–4.20) 0.012Heroin use (yes versus no) 1.63 (0.82–3.23) 0.162Alcohol use (yes versus no) 1.23 (0.55–2.76) 0.610Nonfatal overdose (yes versus no) 4.34 (2.08–9.09) <0.001 3.63 (1.65–7.98) 0.001Unsafe sex (yes versus no) 1.06 (0.59–1.89) 0.847Mental illness diagnosis (yes versus no) 1.62 (0.90–2.88) 0.104Police encounter (yes versus no) 2.04 (1.10–3.77) 0.023 1.66 (0.88–3.14) 0.118History of sexual abuse (yes versus no) 0.74 (0.35–1.54) 0.414History of physical abuse (yes versus no) 1.49 (0.81–2.73) 0.197Sex work (yes versus no) 1.67 (0.59–4.71) 0.334Drug dealing (yes versus no) 3.05 (1.70–5.46) <0.001 1.98 (1.05–3.71) 0.034aAll behavioral variables refer to the past 6 months.bPowder by any route.Am J Drug Alcohol Abuse. Author manuscript; available in PMC 2015 January 01.

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