Coexisting social conditions and health problems among clients seeking treatment for illicit drug use in Finland: The HUUTI study

Background Illicit drug use is an important public health problem. Identifying conditions that coexist with illicit drug use is necessary for planning health services. This study described the prevalence and factors associated with social and health problems among clients seeking treatment for illicit drug use. Methods We carried out cross-sectional analyses of baseline data of 2526 clients who sought treatment for illicit drug use at Helsinki Deaconess Institute between 2001 and 2008. At the clients’ first visit, trained clinicians conducted face-to-face interviews using a structured questionnaire. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors associated with social and health problems. Results The mean age of the clients was 25 years, 21% (n = 519) were homeless, 54% (n = 1363) were unemployed and 7% (n = 183) had experienced threats of violence. Half of the clients (50%, n = 1258) were self-referred and 31% (n = 788) used opiates as their primary drugs of abuse. Hepatitis C (25%, n = 630) was more prevalent than other infectious diseases and depressive symptoms (59%, n = 1490) were the most prevalent psychological problems. Clients who were self-referred to treatment were most likely than others to report social problems (AOR = 1.86; 95% CI = 1.50–2.30) and psychological problems (AOR = 1.51; 95% CI = 1.23–1.85). Using opiates as primary drugs of abuse was the strongest factor associated with infectious diseases (AOR = 3.89; 95% CI = 1.32–11.46) and for reporting a combination of social and health problems (AOR = 3.24; 95% CI = 1.58–6.65). Conclusion The existence of illicit drug use with other social and health problems could lead to increased utilisation and cost of healthcare services. Coexisting social and health problems may interfere with clients’ treatment response. Our findings support the call for integration of relevant social, medical and mental health support services within drug treatment programmes.


Background
Illicit drug use has become a major concern in Europe, with high estimates of past year use of cannabis (23 million), cocaine (4 million), MDMA ('ecstasy' , 2.6 million) and amphetamines (2 million) among 15 -64 years olds [1]. Among the same age group in Nordic countries, lifetime prevalence of cannabis use is 36.5% in Denmark, 16.2% in Norway, 14.3% in Finland, and 12.5% in Sweden [2]. In response, many countries have initiated drug treatment programmes to counter negative health and social consequences of illicit drug use. In Finland, those seeking treatment for drug use have access to both specialised and generic services. Specialised services are provided through outpatient clinics, short-term inpatient care, rehabilitation units and support services. Treatment services are also available through primary, social and health care services [3].
Use of illicit drugs is associated with emotional and behavioural changes which make drug-taking assume precedence over other areas such as school, work, family and other relationships [4]. An American longitudinal education survey, initiated prior to high school entry, indicate that drug users have fewer years of schooling [5]; this might impact negatively on their career prospects and predispose them to social disadvantage due to difficulties in finding and maintaining jobs [6]. Due to poor financial situation, their living conditions deteriorate, stable housing becomes unaffordable and some may end up living on the streets [7,8]. Family responsibilities are also affected: for those who live with children, the risk of neglect/child abuse increases due to drug-related poor parenting skills [9].
Illicit drug use has also been implicated in the spread of blood-borne infectious diseases such as HIV and Hepatitis C due to sharing of non-sterile injecting equipment by injecting drug users (IDU) [10][11][12]. However, the risk of infectious diseases is not limited to IDUs. Transmission among non-injecting drug users has been reported to occur when a person infected with a bloodborne virus shares straw/tubing to snort drugs with an uninfected person, where they share other items which could convey blood such as toothbrushes, and through a sexual relationship with a sero-negative partner [13]. Through these routes, the risk of becoming infected is low compared to sharing infected needles/syringes. Irrespective of route of drug administration, the risk of blood-borne viruses being transmitted between drug users, and indeed between drug users and non-drug users through social and sexual interactions, should be considered an important public health issue. Other infections and health problems reported among drug users include abscesses, cellulitis, bacterial endorcarditis, necrotizing fasciitis, osteomyelitis, candidosis, thrombophlebitis, and ulcers [14].
The prevalence of psychological disorders is known to be high among those who use illicit drugs [15]. Such disorders may precede drug use [16] and they may also occur as a result of it [17]. Co-occurring psychological disorders have been found to lower clients' readiness to change their addictive behaviours [18], resulting in poor treatment outcomes. Clients experiencing both drug addiction and psychological disorders tend to use more services, have higher relapse and re-admission rates thereby increasing the cost of treatment [19].
Identifying conditions that coexist with drug use is necessary for planning and provision of additional services based on identified needs. The epidemiological part of the "huumehoito tietokanta" (HUUTI, translated as drug treatment database) consortium research project is the first large-scale longitudinal study of illicit drug users seeking treatment in Finland. The aim of this paper is to describe the prevalence and factors associated with social and health problems that coexist with drug use based upon information provided by clients at their first visit to Helsinki Deaconess Institute (HDI).

Study design
The original sample consisted of a non-random sample of 4817 clients who sought treatment at HDI between 31 January 1997 and 31 August 2008. However, to minimize the amount of missing data for some variables of interest, this analysis was restricted to a subset of clients who attended the HDI between 2001 and 2008. There were no selection criteria: all consecutive clients who sought treatment at HDI during the study period were included in the study. This paper is based upon information provided by each of the clients during their first visit (i.e. their first face-to-face interview) at HDI, which serves as the baseline for subsequent longitudinal analyses.

Subjects
A total of 2526 clients (1702 males and 824 females) sought treatment at the HDI between 2001 and 2008. The HDI is a large drug treatment provider in Helsinki and clients came from the Greater Helsinki area including some surrounding semi-rural communities. Treatmentseeking at HDI was based on client self-referral, referral from doctors or other treatment centres, and other sources. Following initial assessment during the first visit, treatment plans were drawn up and clients were assigned to various drug treatment modalities for subsequent visits. Ethical approvals were obtained from the Research Ethics Committee of the Hospital District of North-Savo and the Ethics Committee of HDI. Permissions were obtained from the Ministry of Social Affairs and Health of Finland and from appropriate municipal authorities of all Greater Helsinki area communities where clients resided.

Instrument
Items on the questionnaire were adapted from the European Addiction Severity Index (EuropASI), the Treatment Demand Indicator Protocol (TDI) and other questions, which were relevant for evaluation of treatment needs and clinical monitoring of clients. The EuropASI is the European version of Addiction Severity Index (ASI) [20,21] which contains questions on drug use, employment/support, family/social history, psychiatric disorders, medical and legal issues. Researches have demonstrated the reliability and validity of the EuropASI [22,23]. The TDI, developed by the Pompidou Group of the Council of Europe [24][25][26], contains questions on treatment contact, sociodemographic information and drug use. The reliability of self-reported data using TDI was estimated to be 90% [24].

Data collection
At first visit, trained clinicians interviewed clients using a structured questionnaire to obtain self-reported information on: drug use history, accommodation, employment and social history and medical and psychiatric histories. Clients provided information about their main reason for seeking treatment, referral to treatment, previous contact with any drug treatment centre, and whether they were receiving concurrent treatment elsewhere. To assess their social situations and demographics, clients responded to questions about their level of education; marital status; employment; and main source of income at the time of interview. They also responded to questions about their children under 18 years and other drug users living in the same household. Homelessness was defined as the presence or absence of postal code/address. Questions were asked about threats of violence from anybody (i.e. external sources). Infectious disease status was based on selfreports from clients based upon their perception of previous laboratory investigations. Clients were asked if they had been screened for infectious diseases (HIV, Hepatitis A, Hepatitis B and Hepatitis C) in the past and for the results of the tests. Data on depressive symptoms were based on self-reports. The clinicians (nurses and physicians who specialised in psychiatry and addiction medicine) asked further questions to assess other mental health conditions including psychosis and suicidal thoughts and/ or attempts.

Data analysis
Variables were expressed as a proportion of the denominator (2526). Factors associated with social problems and heath problems (infectious diseases and psychological problems) were initially assessed in univariate logistic regression models. Thereafter, multivariate logistic regression analyses (forced entry method) were utilised to assess the independent effect of variables that were statistically significant in the univariate analyses. Those coded as zero were the reference categories. The four dependent variables (recorded as yes = 1, no = 0) were social problems (homelessness or unemployment or threats of violence); infectious diseases (HIV or Hepatitis A or Hepatitis B or Hepatitis C); psychological problems (depressive symptoms or psychotic symptoms or suicidal thoughts or suicide attempt); and a combination of social and health problems (i.e. combinations of social problems, infectious diseases and psychological problems). Independent variables considered included age (in years), gender (male = 1, female = 0); marital status (married = 1, unmarried = 0); education (≥ high school = 1, < high school = 0); children under 18 years (yes = 1, no = 0); referral to treatment (selfreferral = 1, other referrals = 0); use of alcohol as primary drugs (yes =1, no = 0); use of cannabis as primary drugs (yes = 1, no = 0); use of prescription medicines as primary drugs (yes = 1, no = 0); use of opiates as primary drugs (yes = 1, no = 0); use of stimulants as primary drugs (yes =1, no = 0); use of other drugs as primary drugs (yes = 1, no = 0). Other primary drugs refer to hallucinogens, solvents/inhalants, gamma-hydroxybutyric acid and anabolic steroids. Results were expressed as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). All analyses were carried out using SPSS version 17 for windows (SPSS Inc., Chicago IL).

Drug use patterns
Details of drug use patterns among all the clients have been described elsewhere [27] but a brief description is provided here. Lifetime prevalence was highest for cannabis (78%). Almost 40% were using five drugs at the time of interview, signifying polydrug use. Opiates were the most frequently reported primary drug of abuse (30%). Forty-five percent administered their primary drugs intravenously and 44% used their primary drugs daily during the past month. Cannabis was the most common secondary drug (34%). The secondary drugs were mostly smoked (39%) and were mostly consumed once per week or less frequently (33%) during the past month.

Health problems reported at first visit Infectious diseases
HIV was the least reported infectious disease and the prevalence of positive screening tests was 2% (n = 48; Table 2). The prevalence of positive tests for other infectious diseases included 3% (n = 70) for Hepatitis A, 3% (n = 84) for Hepatitis B and 25% (n = 630) for Hepatitis C. Based on the route of administration of the primary drugs, reports of a positive screening test for HIV (71%), Hepatitis A (79%), Hepatitis B (74%) and for Hepatitis C (74%) were higher among intravenous drug users than the others. As shown in Table 4, factors associated with reporting positive screening test for infectious diseases included using opiates as primary drugs of abuse (AOR = 3.89; 95% CI = 1.32-11.46); having children under 18 years (AOR = 1.40; 95% CI = 1.06-1.84); being self-referred to treatment (AOR = 1.31; 95% CI = 1.03-1.67); and being older (AOR = 1.08; 95% CI = 1.06-1.10).
Further analyses were carried out on those clients who reported a combination of social and health problems. Multivariate analysis (Table 4) showed that factors associated with reporting both social and health problems included using opiates (AOR = 3.24; 95% CI = 1.58-6.65) and using stimulants (AOR = 2.28; 95% CI = 1.10-4.72) as primary drugs of abuse; being self-referred to treatment Missing data 171 (7) Children under 18 years, n (%) Yes c 599 (24) No 1713 (68) Missing data 214 (8) Referral to treatment, n (%) Self-referral 1258 (50) Other referrals d 1184 (47) Missing data 84 (3) Primary drugs of abuse, n (%) Use of alcohol as primary drugs 659 (26) Use of cannabis as primary drugs 382 (15) Use of prescription medicines as primary drugs 55 (2) Use of opiates as primary drugs 788 (31) Use of stimulants as primary drugs 599 (24) Use of Other drugs as primary drugs e 43 (2) Missing data -

Discussion
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 streetdwelling among those who use drugs [28][29][30]. Galea and Vlahov [31] argue that homelessness is an important social circumstance that influences the health and wellbeing 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 [32]. In our study, few clients received threats of violence; this differed from the results of a large-scale study conducted in Canada [33], 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 nondrug 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 [34] 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 [37]. 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 [38]. A British study found high drop out rates among clients coerced into treatment through the criminal justice system [39]. However, a US report [40] 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 [41], 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 [42], possibly due to low prevalence in the general Finnish population which is currently 0.1% [43]. 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 [44]. 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 [45], 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 [31]. 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 posttreatment period [46]. Co-occurring psychological and medical problems should be addressed to prevent relapse and excessive utilisation of health services [19].

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 [47].
Our study relied on self-reported data, the veracity of which cannot be assured. However, a study by Kokkevi and colleagues [24] 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 [48]. 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 crossvalidation 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][50][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.

Conclusion
This study highlighted the coexistence of illicit drug use with other social and health problems. Drug use problems do not exist in isolation. It is essential to address adverse social situations and health problems that may interfere with clients' ability to stay focused and comply with therapy. Our findings support the call for integration of relevant social, medical and mental health support services with drug treatment programmes. Diverse opinions exist regarding the increase in the overall cost of treatment due to additional expenses on support services. However, provision of such services could be more cost-effective, at least in the long run, in reducing morbidity, boosting retention rates and facilitating the recovery process.

Competing interests
The authors declare that they have no competing interests.