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To examine the effect of time spent homeless on young people’s substance use and use of drug and alcohol services in two countries with contrasting policy and service environments.
A cross-national survey was conducted of recently homeless and experienced homeless young people in Melbourne (N=674) and Los Angeles (N=620). Questions were asked about alcohol and drug use in the past three months, frequency of use, injecting drug use, drug dependency and perceived need for, and use of, drug and alcohol services. Data were analyzed using logistic regression.
Substantial numbers of young people reported use of alcohol and drugs. More Australians than Americans and more experienced than newly homeless reported drug use, although there were no differences in frequency of use in the past three months. Polydrug use was common, as were injecting drugs and responses that signified drug dependency. All were more common among Australians and experienced homeless young people. A substantial number of young people had ‘ever’ taken part in a drug or alcohol program but only a minority believed that they needed help from services. Of these, only a minority had sought help. This was particularly so among those who were classified as drug dependent. Reasons for failure to seek help varied.
Substance use is alarmingly high compared to national samples of young people, especially among those who had been homeless for longer periods. Programs to reduce substance use must take account of the prevailing drug cultures, as well as different sub-groups of the population.
Homeless young people are a group widely perceived to be at risk for alcohol and drug use, yet little is known about the impact of time spent homeless on their alcohol and drug use [1–7]. Even less is known about homeless young people’s use of drug and alcohol services.
Australia and the U.S. are similar in some dimensions (both Western, with large immigrant populations and with strong focus on individualistic norms) and with some similarities in services (e.g., community based agencies that often have low levels of funding). However in Australia, service providers for homeless young people are more likely to be experienced professionals trained in youth work, social work or community development. As in all other major urban centers, in Melbourne, the Australian site for this research, care is organized so that a large number of relatively small, government-funded community-based agencies are spread throughout the entire metropolitan area . In contrast, services in the Los Angeles, the US site, are more likely to have professional staff working at large shelters that are located within a narrow radius in the inner city. Drug-specific services also differ between the two sites. In Melbourne there are government-funded detoxification services, drug and alcohol counseling and support services, and limited intensive rehabilitation services. Most importantly, there are readily accessible needle and syringe exchange services throughout Melbourne and dedicated outreach services for substance users. Unlike Melbourne where youth specific services are widely available, in Los Angeles County, alcohol and drug treatment services for young people are very limited. Young people have little access to detoxification and drug and alcohol treatment services that are targeted for adult populations, especially young people under the age of 18 years. Needle exchange programs are not widely available or accessible and are again targeted at adult populations.
In addition to differences in service provision, there are policy differences. Unlike the U.S., Australia has adopted a nation-wide harm-reduction approach to health risk practices, has had multiple national social marketing programs for HIV prevention, and offers universal access to health care. The need for a range of prevention and early intervention services, including mediation, to divert young people from homelessness has been recognized, a financial allowance is available for those homeless young people who are deemed at risk if they return home, and there are dedicated employment schemes for homeless young people. There is an extensive network of needle and syringe exchange services, including street-based outreach via foot patrols and mobile buses, and a variety of dedicated health services and education programs. In recognition of the severity of the problem of substance abuse, Federal and State governments have set up high-level committees to review and develop policy as well as providing on-going advice and funding for innovative drug related programs. In part as a result, there is currently a shift away from punitive deterrents such as jail or juvenile detention for young substance abusers who commit drug-related crimes, to community based programs with an emphasis on rehabilitation. Summarizing the different policy environments, although harm reduction programs exist in the US, there is still an emphasis on a zero tolerance approach to substance use and there have been few, if any, national social marketing programs for substance use or other relevant issues such as HIV. There is an emphasis on disease prevention rather than health promotion and access to government-funded health care and financial support is extremely limited.
When we examine substance use among homeless young people, prevalence estimates vary across studies. This may be because of the definitions of homelessness used, the different settings in which young people are recruited (on the streets, in shelters, clinics), the way substance use and dependence is measured, age of young people, and their geographical location. However, across all studies there has been evidence of relatively high rates of substance use [1–7]. In particular, high rates of injection drug use have been reported in many studies [4,9–11]. The available research indicates that homeless young people use drugs, whether injected or otherwise, more frequently than their home-based peers [12–19].
High levels of substance use/abuse among homeless young people are a concern because of the potential for adverse health outcomes. Considerable attention has been paid to the elevated risk for HIV/AIDS because of these young people’s relatively high rates of injecting and, specifically, unsafe injecting [9,20–22] as well as the association between drug use and unsafe sexual practices [4,17,23,24]. In Australia, where Hepatitis C is a recognized as a significant public health problem, unsafe injecting is by far the most common mode of transmission and homeless young people have elevated rates of infection relative to their home-based peers . Other outcomes associated with high levels of drug use include mental health problems and increased risk of suicide [26–30].
The purpose of this study is to examine the impact of time spent homeless and use of services on young people’s drug use. We report on a cross-national study of young people who are ‘newly’ homeless (left home less than six months ago) and ‘experienced’ homeless (left home more than six months ago). By comparing the substance use of these young people in two countries, Australia and the USA, we are able also to infer the impact of different service provision and drug-related policy.
This study recruited homeless young people in Melbourne, Australia and Los Angeles, United States. Two criteria for participation were used: 1) the young person was between 12 and 20 years; and 2) they had spent the last two consecutive nights away from home (either without their parent’s or guardian’s permission if under 17 years or had been told to leave). Two cohorts of homeless young people were formed: ‘newly’ homeless and ‘experienced’ homeless. Based on information from providers of services to homeless young people about the experiences of their clients, ‘newly homeless young people’ were defined as those who had been living away from a parent or guardian for less than six months and ‘experienced homeless’ were defined as those young people who were living away from a parent or guardian for more than six months.
Recruitment began in October 2000 and ended in August 2002. In Australia, 674 homeless young people (334 males, 340 females; mean age: 17.7 years; SD: 1.6; Range 12–20 years) were recruited from youth or homeless services across metropolitan Melbourne. Most young people (83.7%) were born in Australia and had one or more parents of English-speaking descent (84.8%). The remainder had two parents from culturally and linguistically diverse backgrounds representing a large number of countries, with none containing more than 3% of the sample. (In the Australian context it is not conventional, or appropriate, to use broad race or ethnicity categories as it is in the United States.) In the United States, 620 homeless young people (299 males, 316 females, 3 transgender; mean age: 16.9 years; SD: 2.2; Range 12–20 years) were interviewed from shelters, drop-in centers and street sites. The major ethnic/race groups were Caucasian (26.1%), African-American (21.6%), and Hispanic/Latino (34.4%). Most young people (84.8%) were born in the United States. There were more experienced (N=509) and fewer newly homeless (N = 165) young people in the Australian than the US sample (N = 357 and (N = 261 respectively).
Ethical approval for the project was obtained from institutional ethics committees. Prior to commencing surveys, interviewers conducted comprehensive screening of young people with a 13-item screening instrument. The screening instrument was designed to mask the eligibility criteria, confirm eligibility, and establish whether a young person was a newly or experienced homeless young person. If a young person was eligible, they were invited to participate in the survey. Participants were assured of confidentiality and informed consent was then obtained.
Surveys were conducted by trained interviewers using Questionnaire Delivery System on IBM-compatible laptop computers and lasted between 1 and 1 ½ hours. Questions regarding drug and alcohol use were administered using an Audio-CASI (computer assisted structured interview) where young people used headphones for privacy and entered their answers directly on to the computer. All young people received $20 (local currency) compensation for their participation.
The procedure for recruiting young people into the study differed slightly between research sites because of differences in service systems, policies and congregation patterns of young people. In Australia, young people were recruited through staff working at services. In the United States, interviewers recruited participants from shelters, drop-in centers, and street hang-out sites.
The research reported here is part of a longitudinal and cross-sectional study. Only those measures relevant to the present paper are presented. In all cases, a ‘yes’ response was scored 1; a ‘no’ response was scored 0.
A modified version of the National Household Survey on Drug Abuse  was used to assess alcohol and drug use behaviors over young people’s lifetime and in the past three months. The survey measures the use of alcohol, marijuana, crack/cocaine, heroin, barbiturates, over-the-counter (i.e. legal non-prescription) drugs, amphetamines, inhalants, hallucinogens, and prescription drugs. Questions were asked in reference to the past three months only. For each substance we assessed whether or not the substance was used (‘yes’/‘no’), the frequency of use (number of days used in the past three months), and whether the drug was injected (‘yes’/‘no’). Signs of dependency were assessed by four questions (answered ‘yes’ or ‘no’): ‘Have you ever tried to cut down your drug use?’; ‘Have you ever needed larger amounts to get some effect?’; ‘Have you ever felt that you needed or were dependent on drugs?’; and ‘Have you ever had withdrawal symptoms?’. In addition, a mean dependency score (from 0 to 4) was calculated.
Young people were asked if they had ‘wanted to enter an alcohol or drug treatment program’, if they had ‘actually entered an alcohol or drug treatment program’, or had ‘participated in detox’. Responses (‘yes’/‘no’) were obtained for two time periods: ‘ever’ and the ‘past three months’. Participants were also asked three further questions about service utilization: ‘In the last 3 months, did you feel you needed help for alcohol or drug use’ (‘yes’/‘no’)? Did you go for help’ (‘yes’/‘no’)? ‘Overall, how satisfied were you with the service you received’ (1= very dissatisfied to 4= very satisfied)? Young people who indicated they did need help but did not seek it from a service were asked to indicate (yes/no), from a list of 13 reasons (e.g. did not know where to go, afraid they would contact my family), why they had not sought help.
In all the analyses there was only one significant effect of gender. This occurred for use of marijuana, used by fewer young women than men in the past three months. Consequently, all further analyses examined only the effects of site and type and the interaction of these using logistic regression. In all analyses, young people from Australia and the experienced homeless were the reference groups for site and type respectively.
Descriptive data and effects of gender, site and type (experienced or newly homeless) are presented for: (i) use/non use of alcohol and drugs, (ii) frequency of use, (iii) polydrug use, (iv) experience of injecting drugs, (v) drug dependency, and (vi) experience with alcohol and drug services. Given the large number of tests, α was set to p<.01 to avoid Type 1 errors.
As Table 1 shows there was, overall, considerable use of alcohol or drugs in the past three months by these young people. Use of alcohol and marijuana was high across both sites although the former was significantly higher for Australians (OR =.529) and the latter for experienced homeless young people (OR=.571). Of particular concern was the number of young people who used heroin, amphetamines, LSD/acid (more than one-quarter of the experienced homeless), and crack/cocaine (over one-fifth of the experienced homeless). Relatively few used methadone. In general, significantly more Australians used drugs than did Americans (Amphetamines: OR=.634; Heroin: OR=.467; Sedatives/tranquilizers: OR=.494; Methadone: OR=.416).
Use of drugs was far more prevalent among experienced homeless young people than among those who were newly homeless. In addition to marijuana, there were significant effects for amphetamines (OR=.442), LSD/acid (OR=.478), crack/cocaine (OR=.454), heroin (OR=.241), sedatives/tranquilizers (OR=.492), analgesics/pain killers (OR=.319), and ecstasy (OR=.429). There were no significant site by type interactions.
Participants who used each drug reported the mean number of days that the drug was used in the past three months. Two-way ANOVA (site by type) for each drug yielded significant main effects of type for alcohol and marijuana only and no significant main effects of site or interaction effects. Experienced homeless young people used alcohol and marijuana more frequently than did their newly homeless peers [F(1,940) = 25.62, p<.001 and F(1,851) = 19.64, p<.001 respectively]. Marijuana was used most frequently (on average about 45–50 days by experienced homeless young people and 35 days by newly homeless), followed by prescribed antidepressants (on average 30 days) and prescribed antipsychotic/mood regulating medications (on average 25 days). Although heroin was used more frequently by Australians and experienced homeless young people(Australian experienced homeless: 37 days; Australian newly homeless: 13 days; US experienced homeless: 24 days; US Australian newly homeless: 3 days), these (and other) differences were not significant because of wide variability among young people in frequency of drug use.
Table 2 shows the number of drugs used by young people in the past three months. A disturbingly high number had used multiple drugs, with one-quarter to one-third using three to five drugs and more than one-quarter of the experienced homeless using six or more drugs. Mean number of drugs varied across site and type of homelessness with Australian young people and experienced homeless reporting significantly more polydrug use than their American and newly homeless counterparts [F(1,1285)=15.23, p<.001 and F(1,1285)=57.68, p<.001 respectively]. There was no significant site by type interaction.
Of the total sample, over one-quarter of the experienced homeless had injected at least one drug type during the preceding three months but considerably fewer of their newly homeless peers had done so (10.9% of Australians and 4.7% of Americans). The drugs most frequently injected were amphetamines and heroin. These were injected by about one-fifth of the experienced homeless and a small percentage of newly homeless − 7.5% for both drugs among the Australian sample and 1.6% and 3.1% respectively among the Americans.
Table 3 shows the percentage of young people, of those who used a drug, who injected that drug within the previous three months. Not surprisingly, heroin was the most commonly injected drug, with a substantial majority of users choosing this mode of ingestion. Amphetamines and crack/cocaine were injected by nearly half the Australians and, overall, there was a considerable amount of injecting for all drugs especially for the Australian sample. However, there were only two effects of site: significantly more Australians than Americans injected amphetamines (OR=.551) and crack/cocaine (OR=.336). Only one significant effect of homeless type was found: experienced homeless were more likely to inject amphetamines than new homeless young people (OR=.128). There were no significant interactions of site by type. Australians and experienced homeless were significantly more likely than Americans and new homeless to have injected any drug (OR=.446 and OR=.203 respectively).
As Table 4 shows, a majority of Australians and a substantial minority, up to half, of the Americans answered ‘yes’ to at least one of the four questions measuring dependency, a pattern that is repeated for experienced homeless compared to their newly homeless peers. There were significant effects of site and type for all four questions. More Australians and experienced homeless than Americans and new homeless responded ‘yes’ to each of the questions: ‘Have you ever tried to cut down?’ (OR=.581 and .429 respectively); ‘Have you ever needed large amounts to get some effect? (OR= .477 and .401 respectively); Have you felt that needed drugs or were dependent (OR= .385 and .346 respectively); and ‘Have you ever had withdrawal symptoms (OR=.384 and .361 respectively). There were no significant site by type interactions.
A two-way ANOVA (site by type) on mean total scores for the four questions yielded significant site and type effects with Australians and experienced homeless young people reporting greater signs of dependency [F(1,1283) = 51.48, p<.001 and F(1,1283) = 79.50, p<.001 respectively].
Table 5 shows that a substantial number of homeless young people had ‘ever’ taken part in a drug or alcohol program although, not surprisingly, more experienced than new homeless reported doing so. This was confirmed by the logistic regressions, with significant type effects for all three questions (OR=.295, .386, and .293 respectively). Significantly more Americans than Australians had actually entered an alcohol or drug treatment program (OR=1.858). More experienced homeless had wanted to enter an alcohol or drug treatment program in the past three months (OR=.396), but this was largely owing to the difference in the Australian experienced and new homeless samples.
Responses to the questions about service utilization in the past three months are also shown in Table 5. Two young people who said they needed help for drug and/or alcohol issues in the last three months but who had not used drugs in the last three months were excluded from this analysis. Responses revealed that about one-fifth to one-third of homeless young people believed that they had needed help. For this question, there was a significant effect of site (OR=.526), type (OR=.375) and an interaction between these such that the groups reporting the greatest and the least need for help were the Australian experienced and newly homeless young people respectively, with both groups of US young people occupying a middle position. Of those who needed help, one-third to one-half had sought help, with no site or type effects. Satisfaction with services used was relatively high and was similar across all groups.
It is of interest that, among those who responded ‘yes’ to one or more of three drug dependence questions, only 38.2% reported that they needed help and, of these, only 43.1% had sought help. There were no significant effects of site or type nor were there any significant interactions for either needing or seeking help. However those who reported drug dependence were more likely to report needing help than those who did not [χ2(1)=217.94, p<.001]., but not more likely to actually have sought help. Of the non drug dependent who needed help (3.2%), 50% had sought help.
Relatively few young people who needed help had not sought that help from services. The reasons given for failure to seek help varied (Table 6). Most commonly, failure to seek help was due to feelings of embarrassment, lack of knowledge or money or concerns about the service itself (e.g., unable to help, scared that the service would contact the young person’s family). In general, it appeared that more Americans than Australians failed to seek help because of concerns about the services, and this was particularly so for the newly homeless US sample. However, statistical tests were not carried out to detect differences between the sites and types of homeless young people because in most cases cell frequencies were very low and results would not be sufficiently robust to be reliable.
As might be expected, there was a high amount of drug use among these young people in the past three months but this tended to vary according to site and time spent homeless. Most were using alcohol and marijuana and a disturbing number were using ‘harder’ illicit drugs such as heroin, amphetamines, crack/cocaine and LSD/acid. The party drug, ecstasy, was also used by many young people. Alcohol, heroin, amphetamines, sedatives and methadone were used more Australians than Americans and those who had been homeless for a longer period were more likely to have used most of the drugs than their more recently homeless peers. A substantial number of young people had engaged in poly-drug use in the past three months and the number of drugs used in the three-month period was greater for Australians and more experienced homeless young people. Overall, injecting drugs was more common among the Australians than the US young people and among the experienced homeless compared to their newly homeless peers. Similar differences were obtained in response to questions about drug dependency.
These rates of substance use are dramatically higher than those reported in two Australian national surveys examining drug use in the past 12 months. Among home-based 14–24-year-old Australians in 1998 , marihuana, the most commonly used drug, was used by only half the number of respondents compared with these homeless young people. Use of heroin was more than 20 times more common and amphetamines were five times more common among our homeless sample. In another national survey  in the previous year, one-third of young people had used marihuana, 15% had used acid and/or speed, 5% had used cocaine and 2.5% had used heroin. In the U.S., similarly high rates of substance use relative to the general population of young people were reported. A national survey of lifetime use of illicit drugs among young people in high school  showed that use of illicit drugs was substantially less than that reported in a three-month period by our US homeless sample. For example, 42% reported lifetime marijuana use, 3.1% reported lifetime heroin use, 9.4% reported lifetime cocaine use and 9.8% reported lifetime methamphetamine use. Very few students (2.3%) reported lifetime injecting drug use.
Comparison with earlier studies of homeless young people is difficult because of differences in sampling strategies, time frames used to estimate drug use, and reporting of specific drugs. It appears, however, that there have been shifts in the extent to which young people have used specific drugs. Data from American studies indicate that while use of alcohol and marijuana has remained relatively stable, use of heroin, crack/cocaine and amphetamines was substantially higher among our Los Angeles sample [4,5,23,26,27). In comparison with the one study found in which ecstasy use was reported , there was a substantial increase in use among our sample. We have found no comparable data for Australian homeless young people, however Hillier et al. reported high levels of drug and alcohol use among a sample homeless adolescents .
While some young people do leave home because of their drug use, there are many for whom this is not an important precipitating factor. Only one-third of our sample reported personal drug or alcohol use as an important or very important reason for leaving home and over one-half reported drug and alcohol use as not important . Our data do suggest that the time young people are homeless has an impact on the likelihood of using and injecting drugs. Given the evidence that drug use increases with age among adolescents , it is not surprising that our older experienced group follows this pattern. As Baron  suggests, homelessness exposes young people to environments where drugs are readily available and used. Two interpretations of these data are possible. On the one hand, the longer the exposure to these environments, the more likely it is that drugs will be used, at least in part to alleviate the cumulative stress of being homeless. Alternatively, young people who are using drugs are more likely to remain homeless. Our follow-up study, now in progress, will enable us to assess these alternative explanations.
The evidence of differences between the Australian and American participants in our study is more difficult to interpret. The fact that the Australians are older and more experienced accounts, at least in part, for these differences. This explanation is consistent with evidence that indicates young people experiment with a greater range of drugs as they get older, peaking in late adolescence and declining in the mid to late 20s . Other factors may also be relevant. One is the fluctuating availability and cost of drugs in the two cities. For example, during the recruitment period, Australia was experiencing the end of a glut of high grade and inexpensive heroin and the beginning of a heroin drought . As a consequence of this drought, young people switched to other more freely available and less costly drugs, notably amphetamines. These shifts in the drug market are reflected in our data.
Another possibility arises from the different policy environments in the two countries. In Australia the policy of harm minimisation is nationally accepted and implemented. This is best exemplified by the existence of needle and syringes exchange programs nation-wide. In contrast, while there is variability in drug-related policy and practice in the United States, the emphasis is on a zero tolerance approach to illicit drug use, enforced by tough legal sanctions. Clearly the social, cultural and political environments in the two countries impact on young people’s use of drugs and may lead to greater experimentation if not long-term use among Australian young people. There is some support for this argument in the finding of considerable variability among the Australians in their frequency of drug use, suggesting that many of these young people may be trialing drugs. To understand these cross-national differences we need a more focused examination of the reasons that young people use drugs and the related cultural and policy environments in which these behaviours are enacted.
Of those young people who used drugs, only a minority had availed themselves of treatment programs. It is of interest that most of the drug users in our sample did not believe that they needed help for their alcohol or drug use, including two-thirds of those who might be classified as drug dependent. Of those who needed help, only about one-third to one-half and fewer than half of the dependent group actually sought help. More Australians than Americans believed that they needed help although this difference did not apply to actually seeking help. The reasons for the former may include the greater number of Australians who were using drugs and/or the larger number of freely available services that are located in each of the metropolitan regions in comparison with those in Los Angeles. Nevertheless, on the whole there is a large number of young people who clearly do not perceive themselves to be in need of drug and alcohol services in spite of drug use that could be defined as dependent. This suggests that for many of these young people there is a dissonance between researchers’ measures of ‘dependence’ and the meanings and value that drug practices have for the young person him/herself.
There are some limitations to the study. Recruitment of young people largely through services meant that those who do not access services were underrepresented. This was particularly the case among the Australians, where street-based youth were not part of the sample. Further research is needed to examine more closely the quality, availability, and uptake of treatment services. Finally, our data do not address the debate about causal pathways. A longitudinal study is needed to establish whether problematic drug use preceded or postdates homelessness.
It is clear from these data that drug use is alarmingly high in both populations sampled in this study, especially among those who had been homeless for longer periods. In spite of these similarities, there are differences in the drug use cultures among young people in each city. Any attempts to develop programs that aim to reduce drug use must take account of the prevailing drug cultures that exist at the time and the location at which these programs will be delivered as well as different sub-groups of the population. By this, we do not only refer to the length of time that young people have been exposed to a homeless environment. We need also to consider the meanings that drug use has for young people and the effects of drugs on them. Effective drug prevention and support programs for homeless young people must not only consider their drug use culture; they must also take account of the chaotic and unstable nature of their lives.
The authors wish to thank Paul Myers, Judith Edwards, Andrea Witkin, and a team of interviewers for their contributions to this research.
Funding Source: The research reported in this paper was funded by the National Institute of Mental Health (NIMH), grant number: MH61185.
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