Differences in impulsivity and sexual risk behavior among inner-city crack/cocaine users and heroin users
Introduction
Although advances have been made in targeting and preventing behaviors that leave one vulnerable to contracting HIV, more then 700,000 Americans have been diagnosed with AIDS and almost 50,000 more continue to contract HIV infection each year (Centers for Disease Control and Prevention [CDC], 1999). Researchers have identified inner-city drug users as being particularly vulnerable to HIV infection (e.g., Kral et al., 1998). In combination with the risks of intravenous (IV) drug use, inner-city drug users also evidence elevated levels of sexual risk behavior (SRB) including sexual contact with individuals who are at elevated risk for seropositivity (e.g., IV drug users) as well as exchange of sex for drugs/money (Joe and Simpson, 1995, Kral et al., 1998).
Evidence indicates that elevated levels of SRB may be related to level of crack/cocaine use (e.g., DeHovitz et al., 1994, El-Bassel et al., 2000, Hoffman et al., 2000, Ross et al., 2002, Booth et al., 2000, Bux et al., 1995, Camacho et al., 1996, Falck et al., 1997, Grella et al., 1995, Joe and Simpson, 1995, Sanchez et al., 2002). Further, several studies have focused on differences in SRB as a function of a particular drug choice. In most cases, these studies have examined crack/cocaine use among heroin-dependent individuals, with data indicting a positive relationship between level of crack/cocaine use and SRB (Bux et al., 1995, Camacho et al., 1997, Grella et al., 1995, Joe and Simpson, 1995). Despite initial evidence of a unique relationship between SRB and crack/cocaine use, several unanswered questions remain. First, because most studies examining a relationship between SRB and drug choice compare levels of crack/cocaine use among heroin-dependent participants (e.g., Bux et al., 1995, Camacho et al., 1997, Grella et al., 1995, Joe and Simpson, 1995), it is unclear whether elevated SRB is a function of crack/cocaine use specifically, or the additional use of another drug class (i.e., heroin and crack/cocaine use). Indeed, a true test of the role of drug choice in SRB requires more independent groups for interpretation of resulting differences (e.g., primary crack/cocaine users versus primary heroin users).
As a second unanswered question, few studies have examined potential mediators of the relationship between increased levels of SRB and drug choice. One variable that may shed light on this relationship is impulsivity. The focus on this personality variable is supported by indicating that impulsivity is related independently to both SRB (e.g., Hoyle et al., 2000) and overall drug use severity (e.g., Moeller et al., 2002, Howard et al., 1997). Specific to drug choice, past research has indicated that crack/cocaine users to be higher in impulsivity than heroin users (Donovan et al., 1998). Further, studies have compared characteristics of crack/cocaine and heroin users, with a focus on disorders that include reference to impulsivity within their DSM-IV diagnostic criteria (i.e., antisocial, borderline personality disorder). Results of these studies indicated a higher prevalence of personality disorders in crack/cocaine rather then heroin groups (Craig and Olson, 1990, Flynn et al., 1995, Mirin et al., 1988, Raimo et al., 2000). Although it is important not to mistakenly infer causation from these findings, they do argue for further research examining the interrelationship of drug choice, SRB, and impulsivity.
Taken together, the current study attempted to provide further clarification regarding the relationship among drug choice, SRB, and impulsivity. Extending previous research, we focused our examination of drug choice on inner-city drug users in residential treatment who were: (a) primary crack/cocaine users defined as those who reported using crack/cocaine at least 2–3 times per week over the past year prior to treatment and who also reported using heroin less than 2–3 times per week over the past year prior to treatment; (b) primary heroin users, defined as those who reported using heroin at 2–3 times per week over the past year prior to treatment and who also reported using crack/cocaine less than 2–3 times per week over the past year prior to treatment; (c) both primary crack/cocaine and heroin users defined as those who reported using both drugs 2–3 times per week over the past year prior to treatment. Based on the current literature, we hypothesized that primary crack/cocaine users would evidence greater levels of SRB and impulsivity than primary heroin users. In line with literature suggesting greater level of impulsivity and risk taking as a function of polysubstance use (Conway et al., 2003, O’Connor et al., 1995, Ramklint et al., 2001), those using both dugs might be predicted to evidence greater levels of SRB and impulsivity compared to individuals primarily using only one of these drugs. Yet conversely, it might also be predicted that the primary use of heroin combined with the primary use of crack/cocaine might lead to levels of SRB and impulsivity falling somewhere between the two single drug groups. Given these possibilities, no specific prediction was made for the cocaine and heroin group in relation to the two single drug groups. Finally, we hypothesized that if impulsivity is the underlying mechanism in the relationship between drug choice and SRB, then this relationship would be mediated by levels of impulsivity.
Section snippets
Participants
Participants were 123 individuals (M age = 42.52; S.D. = 6.18; 62% male; 90% African American) in a substance use residential treatment facility located in a large urban setting in an East Coast US City. Treatment at this center involves a mix of strategies adopted from Alcoholics and Narcotics Anonymous as well as group sessions focused on relapse prevention and functional analysis. Complete abstinence from drugs and alcohol is required upon entry into the center and through the duration of
Demographic characteristics and other drug classes
As shown in Table 1, drug choice groups (i.e., primary crack/cocaine, primary heroin, and both) were compared on several demographic characteristics and other drug use which was defined as the number of drug classes currently used at least 2–3 times per week across alcohol, marijuana, and hallucinogens including PCP with a total score ranging from 0 to 3. For demographics, drug choice groups differed as a function of gender (P = 0.004), but not age, education, income, or marital status; a lack
Discussion
In a sample of 123 chronic, inner-city drug users, we examined the relationship between SRB (as evidenced by HRBS-SRB score) and drug choice (primary crack/cocaine, primary heroin, and both drugs), and the role of impulsivity as a mediator of this relationship. Results indicated that SRB was significantly higher in the primary crack/cocaine group than in the primary heroin group, with the group using both drugs evidencing intermediate levels of SRB. Beyond differences in SRB, a similar pattern
Acknowledgments
This work was supported by National Institute of Drug Abuse Grant R21 DA14699 awarded to the first author. The authors thank Walter Askew of the Salvation Army Harbor Light Residential Treatment Center of Washington DC, Ernest Russell of the Second Genesis Residential Treatment Center of Washington DC for assistance in subject recruitment, as well as O'Shea Jackson for conceptual guidance.
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