1. 1 SYMPTOMS OF DEPENDENCE AMONG SELF - IDENTIFIED ADULT RECREATIONAL ILLICIT DRUG USERS: A SUB-ANALYSIS OF THE DRUGNET SURVEY A graduate thesis by Shakti Nagarajan, (MPH) Thesis Committee Thomas Nicholson, PhD, David Duncan, DrPH, John B. White, PhD, Lisa L. Lindley, DrPH, Fred Stickle, PhD.

2. 2 INTRODUCTION INTRODUCTION The use and sale of illicit drugs in America continues unabated despite decades of the “War on Drugs” and the “ Zero Tolerance” drug policy. The use and sale of illicit drugs in America continues unabated despite decades of the “War on Drugs” and the “ Zero Tolerance” drug policy. The 2002 National Household Survey on Drug Use and Health (NHSDUH) findings suggest that there has only been a marginal decline in overall drug use. The 2002 National Household Survey on Drug Use and Health (NHSDUH) findings suggest that there has only been a marginal decline in overall drug use.

3. 3 NEGATIVE OUTCOMES OF THE DRUG WAR: Black market for illicit drugs. Black market for illicit drugs. Largest prison system in the world. Largest prison system in the world. Lots of money spent on law-enforcement programs, and media campaigns. Lots of money spent on law-enforcement programs, and media campaigns. Artificial dichotomy of “good” and “bad” drugs-- alcohol and tobacco effects are undermined. Artificial dichotomy of “good” and “bad” drugs-- alcohol and tobacco effects are undermined. Rise in HIV/hepatitis C. Rise in HIV/hepatitis C. Distorted public opinion about “illegal drugs” and users. Distorted public opinion about “illegal drugs” and users. Net result : Millions of Americans break federal laws to use drugs in secrecy.

4. 4 PUBLIC HEALTH APPROACH Aim : Harm reduction and to raise the standard of health of illicit drug users Aim : Harm reduction and to raise the standard of health of illicit drug users Conventional methods of studying this “hidden population” - Medical records, surveys. hidden populationhidden population DRUGNET survey - An online, cross- sectional, survey of nonabusive, recreational adult drug users. onlinesurveynonabusive, recreational adult drug usersonlinesurveynonabusive, recreational adult drug users

5. 5 PURPOSE OF CURRENT STUDY It is imperative to study attributes of drug use at the problematic end of consumption spectrum i.e. Dependence and Abuse It is imperative to study attributes of drug use at the problematic end of consumption spectrum i.e. Dependence and Abuse Was conducted to explore the possibility drug dependence symptoms in a self- identified population of non-abusers Was conducted to explore the possibility drug dependence symptoms in a self- identified population of non-abusers

6. 6 NEED FOR THE STUDY Studies of recreational or occasional non- dependent drug users are rare Studies of recreational or occasional non- dependent drug users are rare Study required to address the health needs of the hidden population of healthy American, recreational drug users Study required to address the health needs of the hidden population of healthy American, recreational drug users Results will provide insights and information about their drug use behaviors that can possibly have a profound impact on conventional drug theories Results will provide insights and information about their drug use behaviors that can possibly have a profound impact on conventional drug theories

7. 7 RESEARCH QUESTIONS 1.Are there any symptoms of drug dependence or abuse, in a self-identified population of non-abusers? 2.If yes, how frequent are they? 3.Is there any pattern to them? DELIMITATIONS U.S. citizens, aged 18 years and older U.S. citizens, aged 18 years and older took the survey on the Internet took the survey on the Internet between December 1997 and June 1998 between December 1997 and June 1998

8. 8 LIMITATIONS AND ASSUMPTIONS LIMITATIONS AND ASSUMPTIONS LIMITATIONS Self-selected subjects - Non-random sampling Self-selected subjects - Non-random sampling Self-reported behaviors. Validity of responses cannot be verified. Self-reported behaviors. Validity of responses cannot be verified.ASSUMPTIONS Individuals answered the questionnaire openly and honestly and to the best of their ability. Individuals answered the questionnaire openly and honestly and to the best of their ability. Individuals were able to understand directions for taking the survey. Individuals were able to understand directions for taking the survey.

9. 9 REVIEW OF LITERATURE Nicholson (1992) - objection to use of phrases such as "drugs of abuse," and "war on drugs" because they shape conceptual thinking and attitudes. Nicholson (1992) - objection to use of phrases such as "drugs of abuse," and "war on drugs" because they shape conceptual thinking and attitudes. Jonas (1994) - no scientific (toxicological, pharmacological, epidemiological or medical) basis whatsoever in segregating the legal drugs from the illicit drugs. Jonas (1994) - no scientific (toxicological, pharmacological, epidemiological or medical) basis whatsoever in segregating the legal drugs from the illicit drugs. Important to clarify nomenclature: use, abuse, and dependence.

10. 10 LITERATURE REVIEW contd. World health organization (WHO) definition of dependence: “ it is a state of psychic or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continuous basis. The characteristics of such a state will vary with the agent involved, and these characteristics must always be made clear by designating the particular type of drug dependence in each specific case; For example, drug dependence of morphine type, of barbiturate type, of amphetamine type, etc”. (WHO, 1965). World health organization (WHO) definition of dependence: “ it is a state of psychic or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continuous basis. The characteristics of such a state will vary with the agent involved, and these characteristics must always be made clear by designating the particular type of drug dependence in each specific case; For example, drug dependence of morphine type, of barbiturate type, of amphetamine type, etc”. (WHO, 1965). To make the term "drug dependence" more precise - a cluster/collection of events that occurred in relation to the dependence pattern in a drug user and called it the “drug dependence syndrome”. (WHO 1981) To make the term "drug dependence" more precise - a cluster/collection of events that occurred in relation to the dependence pattern in a drug user and called it the “drug dependence syndrome”. (WHO 1981) Dependence concept defined in DSM III, DSM III-R, and DSM IV Dependence concept defined in DSM III, DSM III-R, and DSM IV

11. 11 Past Year Any Illicit Drug or Alcohol Substance Dependence or Abuse among Persons Aged 12 or Older: 2002 Note. From “Substance Dependence, Abuse, and Treatment,” by Substance Abuse and Mental Health Services Administration (SAMHSA), 2003, Results from the 2002 National Household Survey on Drug Use and Health (NHSDUH), Chapter 8.

12. 12 METHODS Purpose - to explore the presence of drug dependence symptoms in a non-random sample of recreational drug users from the DRUGNET study. If such symptoms are present, the study will examine their frequency, and patterns Purpose - to explore the presence of drug dependence symptoms in a non-random sample of recreational drug users from the DRUGNET study. If such symptoms are present, the study will examine their frequency, and patterns Results compared to National Household Survey on Drug Use and Health (2002) and the Epidemiologic Catchment Area study (1980-1985) Results compared to National Household Survey on Drug Use and Health (2002) and the Epidemiologic Catchment Area study (1980-1985)

13. 13 RESEARCH QUESTIONS Are there any symptoms of drug dependence? Are there any symptoms of drug dependence? If yes, how frequent are they? If yes, how frequent are they? Is there any pattern to them? Is there any pattern to them? Population - Non-clinical, adult recreational drug users having access to the Internet. Sample Selection - American citizens aged 18 years and older, who completed the DRUGNET survey on the Internet between December, 1997 through June, 1998.

14. 14 PROCEDURES Sub analysis of the DRUGNET survey. Sub analysis of the DRUGNET survey. Respondents were solicited via mailing lists Respondents were solicited via mailing lists Anonymizer link was provided, informed consent taken Anonymizer link was provided, informed consent taken Respondents were allowed to choose between ranges of coded responses. Respondents were allowed to choose between ranges of coded responses.

15. 15 DESIGN - CROSS-SECTIONAL STUDY Sub-analysis of previously collected DRUGNET survey data (March, 1997 - June, 1998). Sub-analysis of previously collected DRUGNET survey data (March, 1997 - June, 1998). Questions pertaining to drug dependence based on the DSM-III-R drug dependence criteria were formulated and incorporated into the survey in December 1997. Questions pertaining to drug dependence based on the DSM-III-R drug dependence criteria were formulated and incorporated into the survey in December 1997. 541 respondents 541 respondents

16. 16 INSTRUMENTATION Four major subdivisions : Demography and lifestyle indices Demography and lifestyle indices Experiences with drugs Experiences with drugs Past legal history and attitudes regarding drug use And, Past legal history and attitudes regarding drug use And, The general well –being schedule (GWBS) The general well –being schedule (GWBS) Focus of this study - items 26 through 33 (based on DSM III-R), - demographics subdivision. A subject who responded positively to three or more of the drug dependence questions would qualify as a potential “drug-dependent individual.”

17. 17 DATA ANALYSIS Input Variables: 1)Problems in life from drug use 2)Using drugs dangerously 3)Problems with legal system 4)Argument with family and friends about use of drugs 5)Withdrawal symptoms 6)Problems stopping use 7)Obtaining drugs consumes a lot of time 8)Been in treatment for dependence Coding of responses: Responses coded as follows: Yes - 1 Yes - 1 No – 0 No – 0 Data analyzed using SPSS.

18. 18 DATA ANALYSIS contd. DATA ANALYSIS contd. First two research questions –First two research questions – Answered by examining responses of items 26-33 Utilizes the Frequencies subprogram of SPSS. Reported using regular frequency and cumulative frequency tables. Third research question –Third research question – Utilizes the Principal Components Analysis (PCA) subprogram of SPSS. Initial tests of assumptions Initial tests of assumptions Kaier-Meyer-Okin Measures of Sampling Adequacy Kaier-Meyer-Okin Measures of Sampling Adequacy Bartlett ‘s Test of Sphericity Bartlett ‘s Test of Sphericity

19. 19 PCA is a statistical technique that can be applied to a single set of variables to discover “which variables in the set form coherent subsets that are relatively independent of each other” (Tabachnik and Fidell, 1989).is a statistical technique that can be applied to a single set of variables to discover “which variables in the set form coherent subsets that are relatively independent of each other” (Tabachnik and Fidell, 1989). summarizes patterns of correlation among observed variables and reduce it to a small number of components to provide an operational definition (in terms of Eigen values) of underlying processes and test theories that will explain the underlying processes.summarizes patterns of correlation among observed variables and reduce it to a small number of components to provide an operational definition (in terms of Eigen values) of underlying processes and test theories that will explain the underlying processes.

20. 20 Scree plots will be graphed to determine the components that will account for meaningful amounts of shared variance in the sample. Scree plots will be graphed to determine the components that will account for meaningful amounts of shared variance in the sample. Further analysis of patterns will be done using Rotated Component Matrix technique to redefine factors of importance by enhancing the variance produced by the weighted factors. Further analysis of patterns will be done using Rotated Component Matrix technique to redefine factors of importance by enhancing the variance produced by the weighted factors. The results will then be interpreted and discussed accordingly. The results will then be interpreted and discussed accordingly.

21. 21 RESULTS - SUMMARY Sample Selection - 541 United States citizens, aged 18 years or older who responded to the DRUGNET survey, between December 1997 and June 1998.

22. 22 Demographics of Study Sample: 88.9% - White88.9% - White Average age 31.8 yrs.Average age 31.8 yrs. Men outnumbered women 3:1.Men outnumbered women 3:1. Ninety-four percent employed.Ninety-four percent employed. Approximately one-third of the subjects were married, and 43.9% had never been married.Approximately one-third of the subjects were married, and 43.9% had never been married. More than 9 out of 10 individuals were happy with their marital status.More than 9 out of 10 individuals were happy with their marital status. The majority of the survey participants had a college education and one-fourths of them were currently attending college.The majority of the survey participants had a college education and one-fourths of them were currently attending college. Average GPA 3.4Average GPA 3.4 Median income of $50,000 - $69,999Median income of $50,000 - $69,999

23. 23 LIFESTYLE AND BEHAVIORAL INDICES 88.6% of the survey respondents did not attend religious services regularly.88.6% of the survey respondents did not attend religious services regularly. Almost half of the subjects reported strong feelings of spirituality.Almost half of the subjects reported strong feelings of spirituality. 39.6% respondents reported that they participated in community activities.39.6% respondents reported that they participated in community activities. 72.8%, (n = 394) voted regularly in the general elections.72.8%, (n = 394) voted regularly in the general elections. More than 9 out of 10 respondents felt that they were in good health.More than 9 out of 10 respondents felt that they were in good health. 97.2% engaged in non-drug related recreation.97.2% engaged in non-drug related recreation. One-third had regular parental childcare responsibilities,One-third had regular parental childcare responsibilities, 4 out of 10 individuals reported that their children knew about their use of illicit drugs.4 out of 10 individuals reported that their children knew about their use of illicit drugs.

24. 24 Frequency of Drug Dependence Symptoms Drug Dependence Symptom YesNo Missing Data n%n%n Problems in life from use of illicit drugs 15829.238370.8-- Using illicit drugs under dangerous circumstances 35866.717933.34 Problems with legal system due to use of illicit drugs 10118.843781.23 Argument with family and friends over use of illicit drugs 16831.336968.74 Withdrawal symptoms on stopping the use of an illicit drug 7814.545985.54 Problems stopping use of illicit drugs 6712.547187.53 Procuring and using illicit drug takes a lot of time in the life of the respondent 366.749993.36 Has ever been in treatment for drug abuse or dependence 305.650794.44

25. 25 Total Problem Score (showing reported number of drug dependent symptoms). Number of drug dependent symptoms FrequencyValid %Cumulative Percent None11922 One1683153 Two10619.672.6 Three6612.284.8 Four427.892.6 Five224.196.7 Six11298.7 Seven50.999.6 Eight20.4100 Total541100

26. 26 Using the frequency of these symptoms, it was ascertained that 27.4% (n = 148) of the respondents (i.e. roughly every one in four respondents) were potentially “drug dependent” individuals.

27. 27 The following criterion tests were applied: (a) The Kaiser-Meyer-Olkin Measure of Sampling Adequacy – Our study sample achieved a value of 0.763 (b) Bartlett’s Test of Sphericity – An approximate Chi-Square value of 454.525 with a 28 degree of freedom, and a significance value of 0.000 was achieved

28. 28 Total Variance Explained in Principal Component Analysis Initial EigenvaluesRotation Sums of Squared Loadings ComponentTotal% of Variance Cumulative % Total% of Variance Cumulative % 12.42230.275 1.95124.391 21.03912.98343.2581.50918.86743.258 30.9712.12855.387 40.8911.12866.515 50.82410.30276.817 60.6898.60785.425 70.617.62693.051 80.5566.949100

29. 29 SCREE PLOT First two components were extracted.

30. 30 Rotated Component Matrix 1 for Principal Component Analysis Input Variables12 Problems in life from use of illicit drugs0.4910.509 Using illicit drugs under dangerous circumstances0.30.254 Problems with legal system due to use of illicit drugs-0.0390.841 Argument with family and friends over use of illicit drugs0.5440.134 Withdrawal symptoms on stopping the use of an illicit drug0.7310.047 Problems stopping use of illicit drugs0.7320.115 Procuring and using illicit drug takes a lot of time in the life of the respondent 0.4640.092 Has ever been in treatment for drug abuse or dependence0.1930.661 1 Rotation Method: Varimax with Kaiser Normalization

31. 31 NET RESULT The first two components account for approximately 43% of the total variance. The first two components account for approximately 43% of the total variance. The Varimax rotation helped ascertain that physical symptoms of drug dependence like withdrawal illness, and difficulty stopping use loaded high on the first component, while problems with the legal system and having been in treatment loaded high on the second component. The Varimax rotation helped ascertain that physical symptoms of drug dependence like withdrawal illness, and difficulty stopping use loaded high on the first component, while problems with the legal system and having been in treatment loaded high on the second component. This meant that the first component comprised of a pattern of individuals suffering from physical symptoms of withdrawal illness. These individuals constitute a potential target population for treatment and rehabilitation interventions. On the other hand, the second component reflects a pattern of individuals who have had legal problems due to the use of illicit drugs and have received treatment although they report less physical symptoms. This meant that the first component comprised of a pattern of individuals suffering from physical symptoms of withdrawal illness. These individuals constitute a potential target population for treatment and rehabilitation interventions. On the other hand, the second component reflects a pattern of individuals who have had legal problems due to the use of illicit drugs and have received treatment although they report less physical symptoms.

32. 32 COMPARISON OF RESULTS WITH THE ECA AND THE NHSDUH 2002 FINDINGS A direct comparison of the results of the DRUGNET survey to the results of the ECA or NHSDUS cannot be done because the samples surveyed are different. A direct comparison of the results of the DRUGNET survey to the results of the ECA or NHSDUS cannot be done because the samples surveyed are different. The ECA found that in the total sampled population of 3,925 individuals, 6.2% had a history of abuse/dependence syndrome (Anthony & Helzer, 1991). The ECA found that in the total sampled population of 3,925 individuals, 6.2% had a history of abuse/dependence syndrome (Anthony & Helzer, 1991). According to the NHSDUH, among those who had ever used illicit drugs, 4.3% were classified as being substance dependent in the past year. According to the NHSDUH, among those who had ever used illicit drugs, 4.3% were classified as being substance dependent in the past year. Our study ascertained that 27.4% (n = 148) of the respondents (i.e. roughly every one in four respondents) were potentially “drug dependent” individuals. Our study ascertained that 27.4% (n = 148) of the respondents (i.e. roughly every one in four respondents) were potentially “drug dependent” individuals.

33. 33 DISCUSSION Study provided an adequate demographic and behavioral profile of the survey participants. Study provided an adequate demographic and behavioral profile of the survey participants.

34. 34 DISCUSSION Do 1 in 4 respondents really suffer from drug dependence? Further clinical evaluation would give the right picture. Do 1 in 4 respondents really suffer from drug dependence? Further clinical evaluation would give the right picture. Our survey had close-ended questions – hence no qualitative assessment of responses. Instrument bias possible. Our survey had close-ended questions – hence no qualitative assessment of responses. Instrument bias possible. Lack of a specific time frame for the persistence of drug dependence symptoms in the survey instrument. Study projects lifetime prevalence of drug dependence in the sample. Lack of a specific time frame for the persistence of drug dependence symptoms in the survey instrument. Study projects lifetime prevalence of drug dependence in the sample.

35. 35 IMPLICATION OF VARIMAX ROTATION OF PCA RESULTS Encounters with law enforcement were driving treatment among the study sample. Encounters with law enforcement were driving treatment among the study sample. This also indicates that scarce treatment resources are being wasted on the wrong subset of the population This also indicates that scarce treatment resources are being wasted on the wrong subset of the population Alternatively, non-abusive drug users may not need treatment for dependence but may be engaging in risky behaviors that can be addressed through harm reduction interventions. Alternatively, non-abusive drug users may not need treatment for dependence but may be engaging in risky behaviors that can be addressed through harm reduction interventions.

36. 36 THE RESULTS Validates the existence of a hidden population of recreational drug users. Validates the existence of a hidden population of recreational drug users. Demonstrates value of an on-line computer based tool in accessing such populations. Demonstrates value of an on-line computer based tool in accessing such populations. Provided a broad profile of recreational drug users. Provided a broad profile of recreational drug users. Validates the arguments put forth by opponents of the “drug war.” Validates the arguments put forth by opponents of the “drug war.” That is, although prevention of drug dependence is a much talked about issue in this country, it is still the legal system that drives the clinical system to implement treatment and rehabilitative measures on those individuals that it feels right for such measures. The majority of individuals who actually report symptoms of dependence have been left to fend for themselves.

37. 37 RECOMMENDATIONS Drug policy makers need to consider the ramifications of studies like the DRUGNET survey and other such community studies that differ from conventional concepts. Drug policy makers need to consider the ramifications of studies like the DRUGNET survey and other such community studies that differ from conventional concepts. More tolerant and more practical drug policy. More tolerant and more practical drug policy. Further research that explores patterns of drug dependence in non-biased, non-clinical populations should be encouraged Further research that explores patterns of drug dependence in non-biased, non-clinical populations should be encouraged Essay questions should be used in the questionnaire format of studies like DRUGNET, this will allow for qualitative research. Essay questions should be used in the questionnaire format of studies like DRUGNET, this will allow for qualitative research. Studies like the DRUGNET survey need to be put back on line to access populations with sensitive issues. Studies like the DRUGNET survey need to be put back on line to access populations with sensitive issues.

38. 38 For copies of survey instrument, references and resources used in this study address all correspondence to shaktinagarajan@yahoo.com shaktinagarajan@yahoo.com or Thomas.Nicholson@wku.edu. Thomas.Nicholson@wku.edu Thank you