Research Reports. MERRILL SINGER. HASSAN SALAHEEN. GREG MIRHEJ. CLAUDIA SANTELICE. Bridging the Divide: Drinking among Street. Drug Users.
Research Reports
MERRILL SINGER HASSAN SALAHEEN GREG MIRHEJ CLAUDIA SANTELICE
Bridging the Divide: Drinking among Street Drug Users ABSTRACT In this research report, we present findings on drinking among drug users from a larger multimethod study of the public health consequences of emergent, changing, and understudied drug-related behavioral patterns among street drug users in Hartford, CT. Although drinking and illicit drug use traditionally have been studied in anthropology as separate cultural domains, this conceptual division has hindered examination of the significant level of drinking among street drug users, the motivations for heavy drinking in this population, and the public health consequences of mixing alcohol and other drugs, including drug relapse. [Keywords: drinking, drug use, relapse]
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N A REVIEW of anthropological contributions to the field of substance use and abuse, Linda Bennett and Paul Cook (1996) observe that there is a clear divide in the literature between discussions of alcohol and those that focus on other drugs. Alcohol, which is a powerful psychotropic drug, tends to be studied by one set of researchers, whereas other psychotropics are the domain of a different group of researchers. Exemplifying the divide, the Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures includes a chapter by Dwight Heath and Irene Glasser (2004) on alcohol use and a separate chapter by Bryant Page (2004) on drug use. The Hans Baer et al. (2004) volume on medical anthropology replicates this pattern. Indeed, with reference to substance use in the United States, a reading of the anthropological literature might lead to the conclusion that heavy drinkers do not use illicit drugs and illicit drug users do not drink. As Bennett and Cook (1996:236) note, it would seem as if “it is relatively rare for more than one drug to be encompassed in anthropological studies and publications” (Bennett and Cook 1996:236). There are exceptions to this pattern (e.g., Marshall et al. 2001; Page 2004), of course, but the gulf between these two arenas of anthropological work is both real and consequential. Over time, the split anthropological focus on the use of psychotropics has become particularly problematic in light of the fact that polydrug use has become the norm (Singer 2006). From a public health perspective, the conse-
quences of drug and alcohol mixing are significant. Barry Spunt (1994) and coworkers, for example, examined a sample of 264 individuals imprisoned for homicide to assess the role of marijuana in violence and found that one-third used the drug on the day of the homicide; additionally they found that 80 percent of the latter group was also under the influence of alcohol at the time of the murder. In a study of drug overdose deaths in New York City, Phillip Coffin et al. (2003) found that three drug groups—opiates, cocaine, and alcohol—were involved in 97.6 percent of reported cases, with simultaneous use of two or more of these drug types accounting for 57.8 percent of overdose mortality. Further, many accidental deaths, either from respiratory depression or secondary to accidents, stem from the combined use of alcohol with prescribed or diverted prescription drugs, such as narcotic analgesics or benzodiazepines. Similarly, alcohol mixing with club drugs like GHB (gamma hyroxybutyric acid) has been found to have grave health effects (Gable 2004). Additionally, injection drug users (IDUs) are known to be the population most at risk for hepatitis C viral infection (HCV); at the same time it is known that alcohol use among HCV-infected IDUs both accelerates liver disease and can limit the effectiveness of HCV treatment (Campbell et al. 2006). Of special note relative to a key finding of this report, alcohol is known to function as a “gateway drug” (Kandel and Jessor 2002), a substance that tends to be used first among individuals who later go
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Singer et al. • Drinking among Street Drug Users on to the use of illicit drugs. The dual use of alcohol with a range of other mind- or mood-altering drugs, in sum, appears to be an important source of drug-related morbidity and mortality, the examination of which, especially from an anthropological perspective, is limited. The purpose of this research report is to disseminate findings on drinking patterns in a group of urban drug users. One of the pitfalls of the current divide between drug and alcohol studies highlighted by our findings is that until we began to look closely at drinking among our participants, we had previously failed to identify the significant role it played in relapse (as what might be called a “gateway-back drug”) among individuals who had achieved a period of drug-use abstinence. METHODS The findings reported here are from the Centers for Disease Control and Prevention–funded study entitled “Community Responses to Risks of Emergent Drug Use in Hartford, CT.” The study includes the following components: (1) the use of ethnographic and epidemiological methods to assess drug-use patterns, to identify and track the diffusion of emergent and changing drug-use patterns— including new drugs and drug combinations, consumption methods, drug-using populations, and drug-use contexts—and to determine associated HIV and related health risks; (2) identification and assessment of local geotemporal epicenters of drug-user HIV and related health risks; (3) tracking and analysis of emergent drug use and risk trends across key sociodemographic characteristics of the drug-using population; and (4) utilization of a researcher–provider–community partnership model to develop and implement a Rapid Response Team, composed of researchers, drug treatment providers, health care providers, HIV prevention workers, community members, and public health officials to assess and implement rapid public health initiatives in response to project findings on emergent drug use and risk trends. [Singer et al. 2005; Singer et al. in press; Vivian et al. 2005]
Data collection involved six-month cycles of ethnographic discovery and exploration of new behaviors and trends, and simultaneous surveys among approximately 250 street outreach-recruited drug users (individuals were 18 years of age or older, reported current drug use besides marijuana or alcohol, and had not been in drug treatment for the last 30 days). In each survey cycle, supplemental questions were added to expand the information collected about items of interest identified during the previous wave of data collection. The third survey— conducted between January and July, 2005, for which 241 drug users were interviewed—included a set of questions about drinking patterns. Findings from each survey were reported to a Rapid Response Team, following the participatory action research model. The ultimate goal of the project was to test a participatory action research and practice model for drug-related public health programming.
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FINDINGS Participants in the study ranged in age between 18 and 60 years, with a mean age of 34.7 years among males and 34 years among females. Approximately 30 percent of male and 38 percent of female participants were African American, 50 percent of male and 40 percent of female participants were Latino, and 17 percent of male and 19 percent of female participants were white, based on self-report. About 40 percent of participants reported that they were homeless and 60 percent reported no employment. Of the 241 participants in the third wave of data collection, 57.7 percent reported current use of crack cocaine, 56.5 percent reported powder cocaine use, 57.7 percent reported marijuana use, and 33 percent reported heroin injection, among a range of other illicit or illicitly acquired pharmaceutical drugs including sedatives, pain killers, and methamphetamine. Additionally, almost all (97.5 percent) participants reported that they had used alcohol at some point in their lives, with a mean age at first use of alcohol of 14.58 years. As this was at a younger age than they began using illicit drugs on average, it appears that alcohol served as a gateway drug among participants. As one participant, a 44-year-old white male, noted during his in-depth interview, drinking and various antisocial behaviors began for him even before his teen years: I was starting drinking, gettin’ high with weed, and ‘um, we had that little gang. . . . But we’d go around, breakin’ in cars, go into school, fightin’ with the other kids. . . . My mother couldn’t handle it . . . she was workin’ two jobs. . . . So I would be out all night, ten, twelve years old. Goin’ around the projects, knockin’ on doors, spray painting doors, you know, little kid stuff. And then fightin’, breakin’ windows in cars, stealin’ radios. . . . That’s how we started. [interview, June 22, 2002]
Three-quarters of the participants in the survey (75.1 percent) reported that they currently drink alcoholic beverages. Among these drinkers, drinking occurred on average 14 days of the previous one-month period, with alcohol consumption occurring on average twice during the last 48 hours. Over 80 percent of drinking participants (83.1 percent) reported that the last alcohol they consumed was in a bar. Participant responses to the supplemental drinking questions are reported in Table 1. Notably, 80.7 percent of participants who were drinkers reported mixing alcohol with other drugs, while 79 percent indicated that they are more likely to use drugs when under the influence of alcohol. Almost all participants (84 percent) reported devoting more of their resources to acquiring drugs rather than alcohol. Participants reported that they drink alcohol for a number of reasons. For almost half (45.4 percent), drinking helps them feel comfortable with other people, whereas about a fourth of participants (23.5 percent) reported that alcohol helped them to have sex—two drinking motivations that are common in the general population as well. With reference to other drug consumption, the majority of
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TABLE 1. Participant drinking patterns and effects
TABLE 2. Negative effects of drinking
• Do you usually use alcohol alone or with other drugs? Alone Other drugs • Do you ever drink to “take the edge off” or “come down” from drugs? • Reasons to drink: Feel more comfortable approaching/talking other people Have sex • Ever use alcohol if drugs are not available? • Ever use alcohol if you can’t afford drugs? • Are there specific drugs that you like to combine with alcohol? Yes No • Which drugs do you like to combine with alcohol: Powder Cocaine Crack Marijuana Heroin Speedball (heroin and cocaine mixture) Pills • When you are under the influence of alcohol, are you more likely to use drugs? Yes No • Do you spend more money on alcohol (including bars and clubs) than on drugs? Yes No
• Which do you believe has caused more problems in the lives of people around you? Alcohol Drugs • Are there specific drugs which have caused problems for you when combined with alcohol? Yes No • Which drugs have caused problems for you when combined with alcohol? Heroin Powder cocaine Crack Pills Speedball (heroin and cocaine) • Do you believe that alcohol is addictive? • Please tell me if using of alcohol causes you to do any of the following: Fight Cause damage to property Have a car accident Argue with husband/wife, boy/girlfriend Feel physically sick Feel depressed Get arrested • Ever felt that you should cut down on your drinking? • People annoyed you by criticizing your drinking? • Ever felt bad or guilty about your drinking? • Ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
35 (19.3%) 146 (80.7%) 106 (58.9%) 83 (45.4%) 43 (23.5%) 131 (72.0%) 127 (70.2%) 132 (72.9%) 45 (24.9%) 44 (32.8%) 21 (15.9%) 19 (14.4%) 12 (9.1%) 8 (6.1%) 3 (2.3%) 139 (79.0%) 37 (21.0%) 25 (13.8%) 152 (84.0%)
participants who drink (58.9 percent) indicated that they use alcohol to “take the edge off” or to “come down” from the effects of other drugs (58.9 percent). As one participant, a 52-year-old African American woman, commented: “Cuz the high, yea it cuts the edge off of it too, but it makes you feel better, yea it makes it better, it does” (interview, September 6, 2005). One purpose drinking served among drug users, in other words, was to modulate the experience of being under the influence of other drugs. Cocaine, either in powder form or as crack, was the drug participants told us that they are most likely to mix with alcohol use. One participant, a 37year-old African American man, explained during in-depth interview, “When you smoking crack, it [alcohol] calms you down. You know what I’m sayin’, it will calm you down so it’s like two combined together just like mellow it out” (interview, June 3, 2005). In this instance, in that cocaine is a central nervous system stimulant and alcohol a depressant, drinking is being used to control aspects of the cocaine high that participants find unpleasant or to “come down” at the point that they want to lessen the effects of cocaine. In qualitative interviews, participants mentioned using alcohol to get to sleep after a “cocaine binge” of several days duration or to help them stay calm when using cocaine. Participants also stated that cocaine use, in turn, allowed them to continue drinking and stay awake for a longer period. Another purpose of drinking is as a “back-up high” when other drugs are not available (72 percent) or are unaffordable (70.2 percent). As one participant, the 52-year-old African American
64 (35.6%) 107 (59.4%) 59 (32.8%) 121 (67.2%) 15 (25.4%) 11 (18.6%) 6 (10.2%) 6 (10.2%) 4 (6.8%) 166 (91.7%) 92 (50.3%) 47 (25.8%) 38 (21.0%) 64 (35.4%) 37 (20.4%) 26 (14.2%) 27 (14.8%) 127 (69.4%) 90 (49.5%) 110 (60.1%) 74 (40.4%)
woman quoted above, explained, if drugs are not readily available she drinks instead, more so than she would have if she had not really wanted drugs: “I would drink more. . . . I would drink more. . . . Cuz, its worth more, but I don’t need it as much. I was with the liquor when I don’t have no crack. I got to get me where I want to go” (interview, September 6, 2005). As displayed in Table 2, almost all participants (91.7 percent) believed that alcohol is addictive, while two-fifths (40.4 percent) reported a pattern of drinking (i.e., drinking in the morning to stave off a hangover) suggestive of abusive levels of drinking. Moreover, participants reported experiencing a range of negative effects associated with their drinking. The most widely reported problem among participants associated with drinking is getting into fights, followed by causing property damage, getting into arguments with romantic partners, automobile accidents, getting arrested, feeling depressed, and getting physically sick. Most (80.7 percent) felt the people they knew had suffered greater problems associated with their drug use than because of drinking. Still, about a third (32.8 percent) reported that they had problems when they mixed alcohol with certain drugs, especially with heroin, which, like alcohol, is a central nervous system depressant. Additionally, most of the participants (69.4 percent) were concerned about their drinking and felt that they needed to reduce their levels of consumption. Indeed, most (60.1 percent)
Singer et al. • Drinking among Street Drug Users TABLE 3. Gateway-back drugs Did you ever stop using drugs for a period of at least six months and then begin re-using them? Yes 186 (77.1%) What was the very first drug or alcohol you picked up when you started using again Alcohol 54 (29.0%) Marijuana 33 (17.7%) Crack 23 (12.4%) Cocaine 11 (5.9%) Heroin 54 (29.0%) Xanax,/Ativan/Valium 1 (0.5%) Oxycontin 1 (0.5%) Oxycodone (percodan) 1 (0.5%) Speed ball (heroin and cocaine) 1 (0.5%) N = 179 (96.0%)
felt guilty about how much they drank. Nonetheless, about half (49.5 percent) reported getting annoyed when other people urged them to cut back on their drinking. Notably, the majority of our participants (77.1 percent) had been able to stop drug use for a period of six or more months since becoming a regular drug user. All of them, subsequently, had relapsed and were using illicit drugs at the time of their recruitment into the study. As reported in Table 3, the two most common drugs they took up first were heroin and alcohol, followed by marijuana, and powder or crack cocaine. In other words, for about a third of our participants (29 percent), alcohol had played a role in their life as a “gateway-back” into illicit drug use after a period of abstinence. One participant, a 32-year-old Puerto Rican man, noted: “People think that marijuana is like a gate, a gate opens for drugs. No. No, I think alcohol is the open gate for drugs, any type of drug” (interview, November 2, 2004). Additionally, during their in-depth interviews, several participants noted that a period of intensified drinking marked a loss of their ability to control their level of drug use. In such cases, drinking did not usher in a relapse to drug use but to higher and less-controlled levels of drug use.
CONCLUSION The anthropology of psychotropic substance use, in both its alcohol and drug-use literatures, has tended to emphasize the ways in which consumption fits into a larger cultural pattern. As Heath and Glasser comment with reference to drinking: “The use of alcohol is part of the social fabric of many cultures in the world and has been so since ancient times” (2004:293). Similarly, Page observes: “Anthropologists, using their holistic perspective in examining how herbal remedies and mind altering drugs fit into the lives of the people who use them, have provided especially useful information and perspective on human variability related to drug use” (2004:374). In other words, anthropologists have tended to bring a contextual lens to human interactions with psychotropic consumption. Unfortunately, this holistic approach often has not included both alcohol and other drug use within a single view of behavior, and as a consequence some important interactions between drink-
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ing and drug use may be left out of the picture. The findings reported here affirm significant levels of alcohol consumption among street drug users, while examining the motivations drug users have for mixing alcohol and other drugs as well as viewing some of the consequences they suffer as a result of this polydrug-use pattern. Moreover, we have found that drinking may be a slippery slope that leads abstinent drug users back into a life of illicit drug use, a signpost for drug treatment providers to note in the messages they convey to drug users. Drug users in recovery may not identify drinking as a significant risk for illicit drug-use relapse, making drinking a particularly dangerous substance for this population.
M ERRILL S INGER Hispanic Health Council, Hartford, CT 06106 H ASSAN S ALAHEEN Hispanic Health Council, Hartford, CT 06106 G REG M IRHEJ Hispanic Health Council, Hartford, CT 06106 C LAUDIA S ANTELICE Hispanic Health Council, Hartford, CT 06106 REFERENCES CITED Baer, Hans, Merrill Singer, and Ida Susser 2004 Medical Anthropology and the World System. 2nd ed. Westport, CT: Greenwood Publishing. Bennett, Linda, and Paul Cook 1996 Alcohol and Drug Studies. In Medical Anthropology. C. Sargent and T. Johnson, eds. Pp. 235–251. Westport, CT: Praeger. Campbell, Jennifer, Holly Hagen, Mary Latkin, Richard Garfen, Elizabeth Golub, Micaelea Coady, David Thomas, Steffanie Strathdee, and The Strive Project 2006 High Prevalence of Alcohol Use among Hepatitis C Virus Antibody Positive Injection Drug Users in Three U.S. Cities. Drug and Alcohol Dependence 81(3):259–265. Coffin, Phillip, Sandro Galea, Jennifer Ahern, A. Leon, David Vlahov, and K. Tardiff 2003 Opiates, Cocaine and Alcohol Combinations in Accidental Drug Overdose Deaths in New York City, 1990–98. Addiction 98(6):739–747. Gable, Robert 2004 Acute Toxic Effects of Club Drugs. Journal of Psychoactive Drugs 36(3):303–313. Heath, Dwight, and Irene Glasser 2004 Alcohol Use. In Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures. Carol Ember and Melvin Ember, eds. Pp. 293–300. New York: Kluwer Academic/ Plenum Publishers. Kandel, Denise, and Richard Jessor 2002 The Gateway Hypothesis Revisited. In Stages and Pathways of Drug Involvement. Denise Kandel, ed. Pp. 365–372. Cambridge: Cambridge University Press. Marshall, Mac, Genevieve Ames, and Linda Bennett, eds. 2001 Anthropological Perspectives on Alcohol and Drugs at the Turn of the New Millenium. Special Issue, Social Science and Medicine 53(2):153–262. Page, J. Bryant 2004 Drug Use. In Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures. Carol Ember and Melvin Ember, eds. Pp. 374–382. New York: Kluwer Academic/ Plenum Publishers. Singer, Merrill 2006 Something Dangerous: Emergent and Changing Illicit Drug Use and Community Health. Prospect Heights, IL: Waveland Press.
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Singer, Merrill, Greg Mirhej, Claudia Santelice, Erika Hastings, Juhem Navarro, and Jim Vivian In press Tomorrow Is Already Here, Or Is It? Steps in Preventing a Local Methamphetamine Outbreak. Human Organization. Singer, Merrill, Greg Mirhej, Susan Shaw, Hassan Salaheen, Jim Vivian, Erika Hastings, Lucy Rohena, DeShawn Jennings, Juhem Narvarro, Alan H. B. Wu, Andrew Smith, and Alberto Perez 2005 When the Drug of Choice Is a Drug of Confusion: Embalm-
ing Fluid Use in Inner City Hartford, CT. Journal of Ethnicity and Substance Abuse 4(2):71–96. Spunt, Barry 1994 The Role of Marijuana in Homicide. The International Journal of the Addictions 29(2):195–213. Vivian, Jim, Hassan Saleheen, Merrill Singer, Juhem Navarro, and Greg Mirhej 2005 Under the Counter: The Diffusion of Narcotic Analgesics to the Inner City Street. Journal of Ethnicity and Substance Abuse 4(2):97–114.
