This study reports baseline data on social conditions and health problems from the first large-scale longitudinal study of treatment-seeking illicit drug users in Finland. Findings from this study highlighted some level of housing instability among treatment-seekers. This lends credence to results from research studies in other countries, which found cases of homelessness and street-dwelling among those who use drugs [28–30]. Galea and Vlahov  argue that homelessness is an important social circumstance that influences the health and well-being of drug users. For example, homeless drug users engage in risky behaviours such as trading sex for drugs and money. IDUs who are homeless may consume drugs in public unhygienic environments, which increase the risk of infection at injection sites and sharing of injecting equipment . In our study, few clients received threats of violence; this differed from the results of a large-scale study conducted in Canada , where a large proportion of illicit drug users reported actual experiences of violence. Therefore, our finding might suggest limited hostility from both drug-using and non-drug using people in Finland.
Unemployment was common. There was a disparity between the number of people who were employed and those who reported salary as their main sources of income; it could be that some clients who were not officially classified as being employed (e.g. students) also earned salary through part-time work. However, collectively, nearly half of the respondents were dependent on government funding in terms of income support and unemployment benefits. Given their low economic capabilities, it is likely that many clients will continue to depend on public funding for sustenance. Therefore, drug-using clients could mount financial pressure on social welfare services.
Some clients reported living within the same household with other legal and illicit drug users. Association with other drug users helps to sustain drug-using habits  and may hamper success in the treatment programme. One hundred and fifty-nine clients (6%) reported having children less than 18 years living in the same household; this might lead to early exposure and transfer of drug-using habits to children. Previous studies have demonstrated that children living in such social environments are predisposed to drug use in their adulthood [35, 36]. Since the likelihood of reporting infectious diseases was 1.40 times higher among those with children less than 18 years, they might have sought treatment out of fear of losing their children or might have been referred by child care and social services.
Treatment-seeking was voluntary (self-referral) for half of the respondents. One possible explanation is that organisation and delivery of drug treatment services in Finland take place at municipality level, so that services are brought closer to drug users. Since self-referral was a significant predictor of reporting social and health problems, these concerns may have necessitated treatment seeking. Referral from the criminal justice system was one percent, which was lower than 37% reported among treatment samples in USA . This might reflect differences in national drug policies, with strong emphasis on criminal justice interventions related to drug use in USA. These findings have implications for treatment outcomes. Health and other concerns provide transient motivation to clients and some may not complete treatment . A British study found high drop out rates among clients coerced into treatment through the criminal justice system . However, a US report  highlighted criminal justice referral as one of the strongest predictors of outpatient treatment completion, probably due to sanctions for non-completion.
A quarter of the respondents (25%) were receiving concurrent treatment elsewhere. This may be related to the fact that the HDI also serves as a treatment needs assessment centre, which receives referrals from other smaller clinics. However, treatment providers should aim to prevent ‘treatment shopping’ among clients. Receiving treatment from multiple centres may interfere with clients’ ability to commit to a specific treatment plan and would result in wastage of public funds. In addition, clients receiving treatment from multiple centres could receive double dose of prescription medication, which might increase the risk of excessive consumption and overdose or sales in illegal street market.
Hepatitis C was the most prevalent infectious disease and may be connected to high use of intravenous drugs in this study population. This finding is consistent with the report of Aceijas and Rhodes , which identified high prevalence of hepatitis C infections among IDUs in most of the 57 countries reviewed. The reported HIV seroprevalence in this study was lower than that reported elsewhere in Europe , possibly due to low prevalence in the general Finnish population which is currently 0.1% . Using opiates as primary drugs of abuse was the strongest factor associated with reporting positive tests for infectious diseases, probably due to sharing of contaminated injecting equipment. This calls for heightened awareness of the needle exchange programmes in Finland.
Depressive symptoms were the most common psychological problems. Our result is consistent with previous research, which suggested that depressive symptoms are common among drug users . Suicidal thoughts and suicide attempts reported by clients may be related to depressive symptoms, which were highly prevalent in this study population. Male clients were 0.65 times less likely to report psychological symptoms, consistent with a previous study , which also reported higher prevalence among female drug users. Therefore, it is important to identify clients who would benefit from a combination of mental health and drug abuse treatment in order to prevent premature deaths from suicide.
Findings from this study have implications for the publicly funded healthcare system in Finland. The existence of drug use with other social and health problems could lead to high healthcare expenditure. Low socioeconomic status, as evidenced by unemployment, low education level, and homelessness, influence risk-taking behaviours and contribute to negative health consequences among those who use drugs . Therefore, there is a need to get drug users into early treatment in order to reduce the financial costs of care. A study conducted among drug users entering treatment in the US found a decline in total medical cost in the post-treatment period . Co-occurring psychological and medical problems should be addressed to prevent relapse and excessive utilisation of health services .
Limitations of the study
Incomplete information for some variables, especially the infectious diseases, suggests that the clinical staff may not have recorded some of the clients’ responses during the initial interview. For example, some clients may have answered no to some of the questions but this was not explicitly recorded. The presence of missing data highlights some of the challenges encountered when using clinical data for research purposes. Improvements in the completeness of medical data will enhance its utility for research purposes. A report from the UK argues that improvements in the standard of medical documentation are essential for planning services and for efficient patient care .
Our study relied on self-reported data, the veracity of which cannot be assured. However, a study by Kokkevi and colleagues  found a high reliability of self-reported information by drug users. Previous research in the UK suggests that drug users are not unwilling to discuss stigmatised behaviours such as sharing of injecting equipment with researchers . We have no reason to assume that clients seeking treatment (largely voluntarily) were not honest in their responses in relation to their social, health and medical status, particularly when public trust in governmental/administrative institutions in Finland is reasonably high. However, it is possible that clients got their test results for HIV and Hepatitis wrong and cross-validation with laboratory investigations would have been useful. That said, the high prevalence of hepatitis C infection in this study was comparable to other European studies among illicit drug users validated with saliva and blood specimens [49–51]. Psychological data were not measured using validated scales, but the clinicians working within the treatment setting had the knowledge and skills required to carry out psychological assessments. Clients seeking treatment may differ in several ways from drug users who are not in contact with the treatment system and this limits the generalisability of our findings to non-treatment seekers.