Characteristics of Homeless Youth who Use Cocaine and Methamphetamine

Abstract

This cross-sectional hepatitis health promotion study (N = 156) was designed to identify correlates of cocaine and methamphetamine use, among young, homeless persons living in Los Angeles County. Structured questionnaires were administered at baseline to assess sociodemographic characteristics, drug history and social support. Unadjusted analysis showed that older age, having a history of incarceration, injection drug use (IDU), 10 or more sexual partners and sex for money were associated with both cocaine and methamphetamine use. Logistic regression results showed that injection drug users had over 7 times greater odds of using each stimulant compared with non-users of injection drugs; those reporting at least 10 sexual partners and alcohol use in the past 6 months were more likely to use cocaine than their respective counterparts. African-Americans were also less likely than Whites to report cocaine use. Understanding of these relationships can guide interventions targeting the multiple challenges faced by this population.

Introduction

The estimated prevalence of homelessness in the general adolescent population is between 9% and 15%¹, resulting in almost 2 million homeless and runaway youth². These homeless youths are much more likely than housed youths to engage in injection drug use (IDU), including injection of methamphetamine and other stimulants³. High-risk sexual activity is another prevalent behavior that, coupled with IDU, puts homeless youths at risk for the development of infectious diseases such as Acquired Immunodeficiency Syndrome (AIDS)⁴; and hepatitis⁵.

Correlates of Drug Use among Youth

Several studies have been undertaken to identify correlates of drug use among youths. Age (being over 21), and duration of homelessness (longer than 6 months) have been associated with IDU among homeless youths living in San Francisco³. Results from a systematic review showed that ethnicity (being Caucasian), risky sexual behavior, a history of heroin or other opiate use and a family history of drug use were all associated with methamphetamine use among youths living in North America and Asia⁶. One study of housed young women showed that methamphetamine use was associated with having a methamphetamine-using partner.⁷

Stimulant Use and Young Adults

Cocaine and methamphetamine are two of the stimulants most commonly used by youths⁸. Stimulants elevate mood, increase general feelings of well-being, and enhance energy and alertness⁹, which makes them particularly attractive to homeless persons. Young adults (ranging in age from 18–25 years) have a higher rate of cocaine use than any other age group (National Institute of Drug Abuse [NIDA]⁸. Methamphetamine use is also prevalent among young populations: 4.5% of 12^th graders, 4.1% of 10^th graders, and 3.1% of 8^th graders have reported lifetime use of this drug^8,10.

Adverse health effects of continued cocaine use include cardiovascular disturbances, seizures, and even sudden death¹⁰. Adverse effects associated with continued methamphetamine use include memory loss, aggression, psychotic behavior, heart damage, malnutrition, and severe dental problems¹⁰. Perinatal effects are premature delivery, placental abruption, fetal growth restriction, and heart and brain abnormalities¹¹.

Dangerous Behavior Associated with Stimulant Use among Youth

In addition to having general adverse health effects, stimulants can also produce lowered inhibitions, feelings of invincibility, heightened sexual experiences, hyperactivity⁶ and paranoia¹². These effects can, in turn, increase the likelihood of dangerous behavior. Compared to young men who do not use stimulants, young men who use stimulants report less frequent condom use, a greater number of female partners, and greater exchange of sex for money or drugs. For young women, stimulant use is associated with reports of more sex acts¹³ with a greater number of partners⁷. Use of stimulants can also lead to poor academic performance, stealing, and violence, as well as transmission of infectious diseases¹⁴.

Theoretical Foundation for the Study

The Comprehensive Health Seeking and Coping Paradigm (CHSCP)¹⁵ served as the framework for the proposed study. This model has been successfully applied to investigations focusing on understanding HIV, Hepatitis B and C virus risk and protective behaviors and other health outcomes among drug-abusing, homeless and impoverished adults^16–20 and youth^21,22. The CHSCP provides a foundation in exploring the importance of various cognitive and behavioral domains in relation to the selection of variables in this study; namely, sociodemographic variables, mental health, sexual activity and risky drug and alcohol use; The first of seven components includes a variety of antecedent variables, such as socio-demographic factors, including age, gender, ethnicity, employment status, and foster care and incarceration history. Mediating components include personal (spirituality), social (social support), psychological (depressive symptoms); and behavioral (sexual risk and drug and sexual activity) factors. Outcome variables includes risk behavior (drug and alcohol use).

This study examines characteristics of young homeless cocaine and methamphetamine users in an effort to identify correlates of stimulant use. Findings can help health care providers better identify persons at risk for the development of stimulant use behaviors and conditions and inform the development of substance abuse prevention programs for at-risk homeless youths⁶.

Methods

This cross-sectional study uses baseline information from a pilot longitudinal intervention study on hepatitis A and B vaccination among homeless youths. Baseline data were collected between February 2009 and July of 2009. The study was approved by the UCLA Human Subjects Protection Committee and has been described in detail elsewhere²³.

Participants and Setting

Eligibility criteria for the longitudinal study included: a) being homeless; b) aged 15–25 years; and c) actively engaged in drug use for the last six months. A convenience sample of 156 homeless youths was recruited from a drop-in site in Santa Monica, California, that served homeless youth.

Procedure

Homeless youths were informed of the study by flyers posted at the site. Following written screening consent, research staff conducted a brief eligibility assessment to obtain information about basic demographic characteristics, Texas Christian University (TCU) drug screening items²⁴, homeless status, and hepatitis B vaccine-related factors. Research staff then obtained a second written informed consent from eligible homeless youths, administered a baseline questionnaire, paid participants $10 for completion of the screener and baseline questionnaire, and randomized participants into intervention and control groups.

Measures

Socio-demographic variables collected at baseline by a structured questionnaire included age, ethnicity, gender, education, and histories of sexual partners, and foster care. Based on preliminary analyses, age was dichotomized at 20 or older, education was dichotomized at high school or equivalent and number of sexual partners was dichotomized at its median of 10. Dangerous sexual encounters were assessed by an item asking about trading sex for money.

Drug and alcohol use were measured by a modified TCU Drug History form²⁴. This questionnaire has been tested with drug-using homeless adults and youth²⁵; it records the lifetime and current (within the last six months) use of 16 drugs used by injection, intradermally and orally. Drugs assessed included the outcome measures of cocaine and methamphetamine, as well as heroin, inhalants, hallucinogens, and alcohol. An item assessing use of nicotine was added to the questionnaire.

Social Support was measured by an item that inquired whether social support came primarily from drug or alcohol users, non-substance users, or equally from substance and non-substance users or whether there was no social support. For regression analyses, social support was dichotomized as any versus none.

The CES-D Depression Scale (CES-D)²⁶ assessed mental health. This 20-item scale measures depressive symptoms on a 4-point continuum ranging from 0 to 3. The CES-D has well-established reliability and validity and has been used in a wide variety of populations. In this study, reliability for the CES-D was .91. The 20 individual item scores were summed to construct the CES-D scale.

All instruments and items have been previously tested, modified and validated using homeless populations.

Data Analysis

Unadjusted associations of cocaine use and methamphetamine use with sociodemographic, physical health and behavioral measures were examined with chi-square tests. Variable selection was guided by the CHSCP¹⁵.

Because of the relatively large number of correlates, stepwise backward logistic regression modeling was used to assess independent associations between each of the stimulants and sociodemographic, health, and behavioral measures. The initial model for each stimulant contained variables that were related to that stimulant at the .15 level in unadjusted analyses. The .10 level was used for retention. Variables in the final models were assessed for multicollinearity and model goodness of fit was checked with Hosmer-Lemeshow test. Analyses were conducted using SAS, version 9.1.3.

Results

Almost three-fourths (74%) of participants were male and between 20 and 25 years of age. The sample was also primarily white (55%), educated through high school (60%), acquainted with the juvenile or adult justice system (68%), and depressed (53%). Over one-fourth (28%) reported injection drug use and over half (53%) reported 10 or more lifetime sex partners. Over half the sample used each of the stimulants (Table 1).

Table 1.

Sample Characteristics (N = 156)

Characteristics	N	Percent
Gender:
Male	115	73.7
Female	41	26.3
Age:
15–19	41	26.3
20–25	115	73.7
Race/Ethnicity:
African-American	21	13.5
White	86	55.1
Hispanic	19	12.2
Mixed	17	10.9
Other	13	8.3
Education:
High School/GED	93	59.6
< 12 years	63	40.4
Working Full-Time or Part-Time
Yes	20	12.8
No	136	87.2
Person of Faith:
Yes	85	54.8
No	70	45.2
Foster Care:
Yes	44	28.2
No	112	71.8
Primary Social Support Source:
Drug/Alc Users	60	38.5
Non-Users	21	13.5
Both Equally	64	41.0
No Help	11	7.1
Juvenile Hall/Jail/Prison:
Yes	106	68.4
No	49	31.6
Depresseda:
Yes	82	52.6
No	74	47.4
> 10 Lifetime Partners
Yes	83	53.2
No	73	46.8
Ever Traded Sex for Money:
Yes	21	13.6
No	134	86.4
Injection Drug Use, Ever:
Yes	43	27.6
No	113	72.4
Recentb Alcohol Use:
Yes	136	87.2
No	20	12.8
Ever Used Cocaine:
Yes	92	59.0
No	64	41.0
Ever Used Methamphetamine:
Yes	84	53.9
No	72	46.2

^aCES-D score ≥ 16

^bPast 6 months

As shown in Table 2, a number of factors, including older age, a juvenile hall/jail/prison history, IDU, having at least 10 partners and having traded sex for money, were associated with both cocaine and methamphetamine use in unadjusted analyses. Having a high school education or equivalent, social support and recent alcohol use were associated with cocaine use, but not with use of methamphetamine. Not reporting faith and having been in foster care were associated with methamphetamine use only. Although race/ethnicity was not associated with stimulant use in overall analyses, subanalyses indicated that African Americans were less likely to use cocaine than Whites (p < .05).

Table 2.

Associations of Cocaine and Methamphetamine Use with Socio-Demographic, Health and Behavioral Characteristics

Characteristics	% Ever Use Cocaine	P-Valuea	% Ever Use Methamphetamine	P-Valuea
Gender:		.663		.262
Male	60.0		56.5
Female	56.1		46.3
Age:		.022		.001
15–19	43.9		26.8
20–25	64.4		63.5
Race/Ethnicity:		.181		.809
African-American	38.1		47.6
White	65.1		58.1
Hispanic	57.9		47.4
Mixed	64.7		47.1
Other	46.2		53.9
Education:		.041		.725
High School/GED	65.6		52.7
< 12 years	49.2		55.6
Working Full-Time or Part-Time:		.283		.284
Yes	70	12.8	65.0
No	57.4	87.2	52.2
Person of Faith		.533		.035
Yes	56.5		45.9
No	61.4		62.9
Foster Care History:		.458		.001
Yes	63.6		75.0
No	57.1		45.5
Primary Support:
Drug/Alc Users	71.7	.011	60.0	.434
Non-Users	66.7		57.1
Both Equally	50.0		50.0
No Support	27.3		36.4
Juvenile Hall/Jail/Prison:		.018		.001
Yes	65.1		67.0
No	44.9		24.5
Depressedb:		.389		.553
Yes	62.2		56.1
No	55.4		51.4
≥ 10 Lifetime Partners		.001	.	.003
Yes	72.3		65.1
No	43.8		41.1
Ever Traded Sex for Money		.030		.001
Yes	81.0		90.5
No	56.0		48.5
Injection Drug Use:		.001		.001
Yes	86.1		83.7
No	48.7		42.5
Recentc Alcohol Use:		.005		.070
Yes	63.2		56.6
No	30.0		35.0

^aChi-square test

^bCES-D ≥ 16

^cPast 6 months

In logistic regression analyses (Table 3), IDU was the only common correlate of use of each stimulant, with injection drug users having over 7 times greater odds of using stimulants compared to non-users of injection drugs. Other positive correlates of cocaine use were reporting 10 or more sex partners and use of alcohol in the past 6 months. African Americans were less likely to report cocaine use than Whites. Youths lacking social support also had lower odds of reporting cocaine use than those with more support. Youths with a history of foster care and those who had been in juvenile hall/jail/prison had over 3 times greater odds of methamphetamine use than their counterparts without these histories. Older age and trading sex for money were also associated with methamphetamine use controlling for potential confounders.

Table 3.

a: Logistic Regression Results for Cocaine Use (N = 156)
Characteristic	OR	95% CI	P value
Ethnicity (vs White)
African-American	0.28	(0.09. 0.90)	.033
Hispanic	0.73	(0.24, 2.21)	.578
Mixed	0.82	(0.24, 2.85)	.752
Other	0.61	(0.16, 2.38)	.472
No Social Support	0.17	(0.03, 0.84)	.030
>= 10 Partners	3.10	(1.44, 6.70)	.004
Recent Alcohol Use	5.39	(1.50, 19.36)	.010
Injection Drug Use	8.13	(2.61, 25.31)	.001

b: Logistic Regression Results for Methamphetamine Use (N = 156)
Characteristic	OR	95% CI	P value
Age ≥ 20	3.38	(1.22, 9.35)	0.019
Person of Faith	0.30	(0.13, 0.70)	.006
Foster Care	3.14	(1.19, 8.33)	.021
Juvenile Hall/Jail/Prison	3.52	(1.39, 8.93)	.008
Trade Sex for Money	5.89	(1.18, 29.47)	.031
Injection Drug Use	7.39	(2.49, 21.92)	.001

Discussion

Our study results show that there are several factors which correlate with cocaine and methamphetamine use among homeless youth in unadjusted analyses. In particular, we found that IDU, having had at least 10 sexual partners, and having traded sex for money were associated with both cocaine and methamphetamine use. These findings are consistent with findings from other recent studies. For example, injection drug using youth has been associated with being under 18 years of age, having had an episode of homelessness in the last six months, and the use of heroin or cocaine³. About one-third to one half of all homeless youth exchange sex for money, drugs, food, or a place to stay²⁷, while drug use among homeless men has been associated with having multiple sexual partners²⁸. However, our findings are unique in quantifying the extent of sexual partners with whom youth engaged sexually. German et al.⁷ found that among young Thai women, having multiple sexual partners was associated with methamphetamine use.

Our study also showed that recent alcohol use is associated with lifetime cocaine use. Poly-substance use, including the use of alcohol, is very common among homeless youths^29,30 and methamphetamine abuse has been linked to alcohol abuse among non-homeless youths,³¹ however we didn’t find a link between methamphetamine and alcohol.

We also examined the role of social support and its effect on stimulant use among our participants. Youths lacking social support had lower odds of reporting cocaine use compared with those who had more support. The literature contains contrasting reports on the relationship of social support with drug use among young populations. Greater levels of social support have been found to be deterrents to drug use among homeless youth living in San Diego²⁹. Alternatively, among homeless groups, Padgette et al.³² were not able to show that social support was associated with positive drug use reduction. However, programs that focus on building social support systems for homeless youth have been positively associated with drug abuse reduction³³. Thus, we have added additional findings to the literature in this regard. Moreover, our findings of the negative relationship between spirituality and methamphetamine use is novel information that can be further considered as a positive factor which can be incorporated into successful intervention programs for homeless drug-using youth.

Regarding the effect of ethnicity on stimulant use, we found that African-American homeless youth were less likely to report cocaine use compared to their White counterparts. This is consistent with findings from Russell and colleagues⁶ showing that Caucasian youth are more likely to use methamphetamines compared with African American youth⁶. The cocaine finding is also consistent with findings from an earlier study showing that African-American homeless youth in San Diego were less likely to engage in substance abuse behaviors compared with their non-African-American counterparts²⁹.

In addition to ethnicity, we found that older age was associated with methamphetamine use among our participants. This finding adds new knowledge to the literature on associations of age and methamphetamine use. Being younger than 18 years has been identified as a predictor of IDU among homeless youths living in Montreal³⁴. In a more recent study of homeless youths living in the U.S., younger age (the mean age of drug abuse onset being 19 years) has also been associated with substance use³⁰.

Finally, we found that persons with a history of incarceration (i.e. having been in juvenile hall, jail, or prison) and those who had previously been in foster care were three times more likely to use methamphetamine than counterparts without such a background. The incarceration findings provide added support to the evidence to date: Incarceration has been associated with both cocaine and methamphetamine use among general populations³⁵; this study provides more specific knowledge about homeless youth in particular. In a recent study of homeless youths, methamphetamine use was correlated with incarceration³⁶. The association of methamphetamine use with foster care is also consistent with findings in a report published by the Public Health Agency in Canada. In that report, having ever lived in a group or foster home was associated with drug abuse among homeless youth populations³⁷.

Study Limitations

We used a convenience sample of participants recruited from Santa Monica, California. Given the lack of random sampling, our results may not be widely generalizable to other groups of homeless youths living elsewhere across the United States or even in other parts of Los Angeles. However, representative samples of homeless adults are very difficult and expensive to construct and much less is known about homeless youth. This pilot study used data from a site homeless youth chose to frequent, and thus may reflect characteristics of homeless youth who are willing to use informal services. The fact that many of the findings are consistent with previous studies of homeless youth suggests that the sample was not atypical. Another study limitation is the fact that we used questionnaires based on self-report to collect information from our participants. This procedure may threaten the study validity due to social response bias. However, in a previous study of homeless women, we found good agreement between self-reported cocaine use and objective data based on hair analysis³⁸.

Despite the limitations addressed above, our study has important strengths. We were able to collect information on a wide variety of variables and identify a number of characteristics of homeless youth who use cocaine and methamphetamine. While other studies have examined variables associated with drug use among homeless youth, our study is unique in that we were able to show that there are a number of factors which can coexist and, at the same time, have a potential impact on stimulant use among homeless youth. It is not a surprise that having no social support, recent alcohol use, injection drug use and having multiple sex partners were associated with cocaine use; however, we need to further explore findings that being a person of faith and having a history of foster care placement were associated with methamphetamine use. We are unaware of studies that identify these relationships.

Conclusion

Findings from this study have important implications with respect to how our society deals with substance abuse among young, homeless persons. We have shown that stimulant use is a problem that often coexists with other difficulties (i.e., alcohol use, having been incarcerated, and sexual promiscuity). Stimulant use among ex-offenders is associated with increased HIV risk behaviors³⁹. Stimulant use also is associated with behavior necessary to support addiction, i.e., sex trade involvement, theft, and other criminal activities that result in incarceration³⁶. In light of our findings, drug abuse reduction interventions should be designed to address the multiple challenges that confront young, homeless people. Our findings also suggest that the effect of social support among young drug users needs clarification. We believe that future studies of the effect of social support will help healthcare providers ascertain how to best provide for the psychosocial needs of this very challenging population.

Our findings indicate almost one third of the homeless youth reported a history of foster care placement. Research identifies the link between foster care history and homelessness^40,41. The National Alliance to End Homelessness⁴² reports over 26,000 youth age out of the child welfare system annually and never reconnect permanently with their biological family. Youth who emancipate from foster care are at risk for negative outcomes, such as homelessness, poverty, incarceration, mental illness and substance abuse⁴².

Scant evidence exists in the literature related to stimulant use among homeless youth and young adults with a history of foster care placement. It is known, however, that children with a history of abuse and multiple, unstable foster care placements have serious mental health disorders, such as depression, anxiety, aggression, attention-deficit/hyperactivity disorder, conduct disorder, or post-traumatic stress disorder⁴³. Pharmacotherapy is the mainstay of treatment for childhood mental disorders, with constant clinical observation⁴⁴. Homeless youth and young adults with a history of foster care placement will not have access to beneficial psychotropic medications; they might seek stimulants to decrease symptoms. More research is needed with this specific population of homeless individuals. Treatment interventions might be different compared with those for homeless youth/young adults without this history.