The European Journal of Public Health Advance Access originally published online on July 21, 2005
The European Journal of Public Health 2005 15(6):580-586; doi:10.1093/eurpub/cki031
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Alcohol and Drugs |
Recreational drug consumers: who seeks treatment?
R. Siliquini1,2, A. Morra1, E. Versino1 and G. Renga1
1 Department of Public Health, University of Torino, Torino, Italy
2 Regional Observatory on Addiction, Regione Piemonte, Italy
Correspondence: Roberta Siliquini, Associate Professor of Public Health, Department of Public Health, University of Torino, Via Santena 5/bis 10126 Torino, Italy, tel: +39 011 6706552, fax: +39 011 6706551, e-mail: roberta.siliquini{at}unito.it
Received March 3, 2004, accepted June 30, 2004
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Abstract |
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Background: Recreational drug consumption represents a complex issue, because of the lack of a shared definition, settings and patterns of consumptions, and poorness of evidence-based treatments. In spite of the great number of users, just few seek specific treatment, probably representing those at major risk of continuing and problematic use. The general objective of this study was to report the characteristics and main consumption patterns of recreational drug consumers treated in Regione Piemonte (Italy), in order to formulate hypotheses suitable for further research aimed at establishing more effective preventive intervention and treatment. Methods: All addiction treatment services in the region were required to fill in, for each user, a questionnaire reporting: contact of the user with the service, socio-demoghaphic data, drugs consumption and interventions/treatments. Results: Among 441 users, 70.3% were new users, 85.5% were males and the average age of consumption onset was 22 years. Psychiatric and traumatics events were present in 13.3% and in 17.9% of cases, respectively. The most frequent primary substances were cocaine (76.9%) and ecstasy (13.8%). Substances taken in association with primary drug are quoted in 75% of cases. Conclusions: The users that get in touch with services are those showing greater problems, representing, therefore, the main target for preventive public health interventions. Some interesting points can be noted: among patients treated, cocaine represents the main issue; females seem to be more sensitive to recreational drug effects; social class (education), settings and use habits are similar for recreational drugs users and heroin users.
Keywords: pattern of consumption, recreational drug consumers, treatment
Health and social problems related to ‘recreational drug’ consumption are a relevant and complex field of research. This complexity can be easily demonstrated by the lack of a shared definition: designer drugs, disco drugs, recreational drugs, psychoactive drugs, synthetic drugs, etc.1–3
What brings all these definitions together is the relatively ‘new’ pattern of consumption4,5 and, on this issue, research presently offers poor and fragmentary evidence.4,6,7
For these reasons, the European Monitoring Centre for Drugs and Drug Addiction (OEDT) set up a project aimed at monitoring typology and doses of market substances (Early Warning System),8,9 and data collected showed, in 2001, a population consumption prevalence varying from 0.5% to 3% for cocaine, from 0.5% to 6% for amphetamine and from 4% to 18% for legal psychoactive drugs sold with medical prescription.6
Recreational drug consumption is a more problematic if we consider the amount of substances used by young.3,10–13 A survey carried out to estimate consumption among 18-year-old users in our region showed a prevalence of 36.6% once-in-life drug consumption. Most of them used multiple drugs in association:7 the average number of substances used was 3.5.
Moreover, even if recreational drug consumption has often been described as not influenced by the risk factors usually associated with addiction, Italian data show a worrying inverse correlation between social class and continuing use of ecstasy, similar to heroin addictives.7
Another limit in recreational drug research is the lack of current informative systems, because consumers very seldom seek help or treatment from the National Health System.
In Italy, <5% of Drug Services patients are treated for other drugs than heroin and alcohol.14
Nevertheless, the few consumers seeking treatment are likely to represent those at major risk for continuing and problematic use and misuse; their description can supply data that will help to formulate hypotheses suitable for further research aimed at establishing more effective preventive interventions and treatments.
The ‘recreational drugs’ working group of the Italian National Institute of Health, Ministry of Health promoted a national survey in order to gather data on recreational drug consumers treated by Drug Services in 2000. The aim of the project was to describe patients' characteristics and the treatments proposed.
In Regione Piemonte, responsibility has been given to the Regional Observatory on Addiction (OED), which performed the survey in collaboration with the Department of Public Health of Torino University.
The general objectives of this paper are: to describe the socio-demographic variables and the reasons that lead patients to seek treatment; and to outline the characteristics and the main consumption patterns of recreational drug consumers treated in Regione Piemonte and the delivered interventions.
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Methods |
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Regione Piemonte is an area in north-western Italy (
5 million inhabitants). All 63 addiction treatment services in the region were required to fill in a card/questionnaire for each recreational drug user. Every subject treated whose primary substance of consumption was not opiates, cannabis or alcohol was defined as a ‘recreational drug user’.
The questionnaire was structured in four main sections, referring to (a) details of the contact of the user with the addiction service, (b) socio-demographic data, (c) drug consumption and (d) interventions and treatments.
Section (a) was directed towards identifying the user as a ‘new user (for the service)’ or as an ‘already known user’, and towards understanding how and why a subject comes into contact with an addiction service (person or institution that referred the user to the service, subject's requests at the first contact with the service, eventual other services—different from addiction services—of first contact). Furthermore, it also considered the presence of traumatic or psychiatric post-consumption events (eventually reporting a specific diagnosis).
Section (b) evaluated users socio-demographic characteristics (gender, age, working condition, marital status, education).
Section (c) aimed to describe substances and habits of consumption. It also required the indication of: consumption onset age; favourite consumption setting; and the most frequent use habits (alone, together with friends or partner, etc.). Moreover, substances taken in association with the primary drug were surveyed.
Section (d) refered to interventions: place, duration, intervention typology and outcomes.
Among the 650 cards sent to the services to be filled in (related to cases known on the basis of ministerial cards), 441 were sent back to the OED of Region Piemonte (67.8% of cards returned). Cards were returned from 70% of the regional services.
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Results |
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Socio-demographic characteristics
Among all recreational drug users (n = 441), the majority of subjects (70.3%) were new users (for the service); 85.5% were males [average age 27.8 years; standard deviation (SD) 7.36], 14.5% were females (average age 25.8 years old, SD 8.21). The average age of consumption onset for the primary drug was 22 years, and no significative differences are seen between for genders (figure 1). It should be pointed out that the consumption onset age was rather homogeneous for different drugs, except ecstasy and hallucinogens, for which the onset occured
4 years earlier compared with the average age.
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In all 51.5% of subjects had a regular job, 41.7% an occasional job or unemployed, 5.2% were students and 1.1% were committed to prison (table 1). Some significant differences can be seen between genders: females were more often students or occasional workers. The prevailing level of education was secondary school (69.5%); 9.9% of subjects had a primary school qualification, 18.6% a high or professional school qualification and 0.5% a degree (table 1).
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Referring to what led users to seek treatment, 50.4% of subjects went autonomously to the service or were sent by affected persons (relatives or friends), 40.4% were sent by ‘institutions’ (public authorities, police forces) and 9.2% by social or health professionals (hospital, private psychologist or physician, departments of mental health, social support services, etc.) (data not shown). Subject's requests at the first contact with the service were consistent with this data; in fact, half of the subjects expressed requests regarding relatives or in the affective sphere and
47% expresses requests ‘forced’ by the law sanction system (table 2).
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Psychiatric events were reported on 13.3% of cards; among these, in 46.6% a specific diagnosis was quoted. The most frequent event was personality disorder (29.6%), followed by depression (18.5%), drug dependence delirium (14.7%), panic disorders (11.1%) and psychotic disorders (11.1%) (table 3).
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Traumatic events were present in 17.9% of cards: road accidents in 27.1%, followed by sudden illness (26.1%), attempt at suicide (18.5%), brawls (18.5%) and falls (6.5%) (table 3).
Patterns of consumption
The most frequent primary substance (the substance that led the subject to the service) was cocaine (76.9%), followed by ecstasy (13.8%), and considerably lower percentages for amphetamine, hallucinogens, LSD, benzodiazepines and poppers. Table 4 shows the significant differences between genders in primary substance consumption: cocaine was prevailing substance in males (79.3%), while females were characterized by a higher ecstasy (20.3%), amphetamines and benzodiazepines consumption (15.6% in total).
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Among 441 users treated at the addiction services, the presence of substances taken in association to primary drug was quoted on 75% of the cards; among these, in 27% the were two or three associated substances, while in 1% there were four or five drugs besides the primary one. The average number of substances consumed was 1.99 for males and 1.89 for females.
Cocaine was taken as the only substance in 27.1% of cases; the most frequent substances taken in association were opiates (46.2%), cannabis (42.5%) and alcohol (28.7%). Ecstasy was taken in association with cocaine in 8.1% of cases.
Ecstasy was taken as the only substance less frequently than cocaine (19.7%), and was mainly associated with cannabis (59.2%), alcohol (26.5%) and cocaine (22.5%). Opiate drugs were associated with ecstasy in just 18.3% of cases.
Amphetamines were almost always used in association with other drugs (as an only substance in just 7.7%), mostly cocaine (33.3%), hallucinogens and LSD (33.3%), alcohol (25.0%) and cannabis (25.0%).
The favourite consumption settings were, for all substances, private domiciles (30.4%), discos (25.3%), other public places such as pubs, bars, etc. (21.8%), and open air places such as streets or parks (20.7%). Schools and stadiums were indicated as favourite consumption settings in <1%. With regard to consumption habits, it was frequently declared that consumption takes place together with friends (58.7%); 34.7% declared using the substance alone and 6.6% together with the partner (data not shown).
Interventions
In 92.7% of cases interventions were completely developed within the addiction service; in the remaining 7.3%, treatments occurred outside of addiction treatment services, mostly in prison (data not shown).
The interventions carried out and their frequencies are shown in table 5. Urinary controls represented the most frequent intervention (53.3%), followed by psychological colloquies (46.3%), socio-educational help (44.7%) and medical intervention (39.9%); 26.1% of subjects were treated pharmacologically. In just 6.1% of cases the subject was sent to a specific treatment centre; the least frequent intervention was represented by group treatment (3.4%). Usually (30%) two combined interventions were received; in general, 80.5% of users received one to three kinds of treatments.
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Referring to treatment outcomes, 22.7% gave up the treatment and 1.2% of subjects died (data not shown).
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Discussion |
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The discrepancy between the clear perception of a phenomenon of great social relevance, such as that of recreational drug consumption, and the difficulty in getting an accurate description of it is becoming more and more evident; the elements of complexity have been mentioned above. Therefore, it is extremely difficult to cope with health needs deriving from recreational drug use, not only because in most cases the needs are not expressed, but, above all, because users often reject interventions and supports provided by social and health-care systems.
The aim of this study was to describe a very limited aspect of the problem (among recreational drugs users, only a small minority comes into contact with addiction treatment services), analysing crucial aspects, such as users' typology and consumption patterns. It is most probable that the recreational drug users that do get in touch with services are those showing greater post-consumption health problems, therefore representing the main target for preventive public health interventions.
The degree of representativeness of the data collected in this region can be considered good, because of the percentage of described cases and by reason of a further analysis of the cases for which the services did not provide data: missing data were not due to systematic errors, but to a failure of compliance of some services, the patients from which are not different from the rest of the region.15
Furthermore, the results presented in this study can be regarded as representative also at a national level, not only because Regione Piemonte patients represent 25% of the population covered by national research, but also because results do not differ from Italian ones.16
Recreational drug users represent, in Regione Piemonte, 5% of total addiction services patients (7.3% in Italy),16 notwithstanding the large diffusion of consumption shown by other scientific studies carried out on the same population.7 This limited use of services is an element that should be taken into account, with reference to its possible causes; in fact, even though it is probably true that recreational drug users seldom express their own treatment needs (40% of subjects are sent to an addicition service by public authorities or police forces), it should be pointed out that most addiction treatment services were set up to provide support to another user typology (primarily heroin users).
The gender distribution of recreational drug users is similar to that of heroin users;15 however, the age distribution is different. Recreational drug users are younger than heroin users by 10 years. However, it should be stressed that the average age at the first contact with addiction services in recreational drug users, although lower than that for heroin users, is >19 years, the age at which people usually achieve a secondary school degree. These data, together with the fact that 80% of the subjects do not have a secondary school degree and that 30% are unemployed, confirm that, as stated in previous publications,7 the problematic consumption does not involve all social classes, but is more frequent in lower socio-economic classes, in accordance with the known model for heroin users.
Regarding the age of first consumption, it should be pointed out that ecstasy and hallucinogen consumption are among the earliest (average age 18 years), in particular among females, while psychoactive legal drug use is considerably later for females, although the average age is low for both genders. It therefore emerges that, among the subjects which, for behavioural or health reasons, get in touch with the services, illegal synthetic substances are used earliest (41% of the users between 12 and 16 years old), while psychoactive legal drugs and cocaine are often used for the first time in post-teenage age groups. These data confirm a preference among teenagers for the drugs that are easiest to find on the market and the most suitable to be taken in social contexts; this information should be taken into account by services since, obviously, the planning of preventive or treatment interventions should not overlook the age classes they are addressing.
Subjects contact services for affective reasons (50.2%), or are sent by institutions, public authorities and police forces (46.6%). So, it is clear how, while a considerable percentage show an expressed need (be it of physical, psychic or social health), the other 50% come into contact with services only in order to avoid administrative sanctions.
Seldom (4.1%) are patients referred to services by other health-care services (hospitals, emergency departments, mental health services or general practitioner): this could suggest that recreational drugs represent a hidden medical issue. Relevant psychiatric or traumatic post-consumption events are recorded in anamnesis, and a large percentage of subjects undergo a medical/psychiatric intervention (47%) and/or a pharmacological treatment (26%). These data illustrate how the recreational drug phenomenon, besides being ‘underground’ in relation to the consciousness of its spreading, needs to be analysed in depth, with a focus on its effects.5
It should be also underlined that cocaine consumption is the most problematic among non-opiate drugs, for both frequency and trend, characterized by a continuous increase in its use,15,16 while meta-amphetaminic synthetic substances interest a low percentage of subjects.
Moreover, although literature17 displays a male:female ratio of 2–3:1 for ecstasy consumption, females receiving treatment for amphetamine and meta-amphetamine consumption in our region as in Italy, represent >50% of patients; even though the total number is very low, this could mean that females are more sensitive to the issue (and consequently more open to the treatment), or more exposed to problematic use.
Recreational drug use is characterized by a high frequency of polyconsumption: just 25% of subjects use only one substance, but when cocaine is excluded, this percentage drops to 16%. Polyconsumption seems to be much higher in subjects who come into contact with services because of problematic use of amphetamines, meta-amphetamines and legal psychoactive drugs (probably used not only as curative self-prescription but also as substance abuse).
On this basis, it is necessary to identify related health outcomes and to set survey activities based on hospital admissions and mortality able to quote all substances taken by the subject.
Private domiciles and open air places represent >50% of use settings; these data, which are quite similar to the national ones,16 should bring attention to use habits, which seem to no longer be limited to traditional social transgression settings, like discos and raves, and to have turned from group consumption to private or alone consumption. This evidence, in particular if pointed out in higher risk groups (such as persons treated at addiction services), introduce alarming new elements in relation to the low possibility of controlling use when it occurs in private settings,18 and the practice of taking substances alone or in small groups, very well-known among heroin users, introduces new risk factors such as users' marginalization from their contemporaries.
As regards interventions, we are dealing with a certain homogeneity: while urinary tests constitute a law obligation for subjects sent to the services by public authorities and police forces, psycho-social/educational and medical/pharmacological interventions occur with the same frequency.
The variability in treatment could derive from both the different training and professional role of workers and, above all, from a still poor application of evidence-based health care principles in daily practice. However, it is true that, regarding recreational drugs, the literature on the effectiveness of treatments is still lacking methodologically rigorous studies: activities are more frequently experience-based than evidence-based.19
In summary, it can be underlined that:
- in spite of the great number of users,7 just a few come into contact with services; it needs to be determined whether these individuals are healthy, or whether the addiction services are not attractive;
- among addiction services, patients treated for non-opiate substances, cocaine represents the main issue, in Piemonte as in Italy, and it is therefore necessary and fundamental to invest in research about effective treatments;
- females seem to be more sensitive to recreational drugs' effects even though they represent a low proportion of the people searching treatment;
- the age of use onset is, in average, lower for ecstasy and hallucinogens, in comparison with other investigated substances;
- social class (defined by education), settings and use habits are similar for recreational drugs users and heroin users; and
- there are no evidence-based treatments for the problematic consumption of recreational drugs.
The synthesis of the different variables can give useful cues and ideas for the evaluation of a ‘gateway effect’,20–23 the definition of primary prevention programmes directed at populations at higher risk for a problematic use24 and the future research about treatments.
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Acknowledgments |
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We thank Valeria Siliquini for data collection and Mara Volpe for the translation of the paper. R.S. was responsible for the design and conduct of the study, for substantial contribution to data discussion and for revising the paper. A.M. conducted the data analysis and was responsible for drafting the paper. E.V. participated in writing the paper. G.R. was responsible for revising the paper. This work was funded by internal funds of Osservatorio Epidemiologico delle Dipendenze-Regione Piemonte. The study was made possible thanks to the cooperation of Regione Piemonte Drug Addiction Services.
Key points
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