Social and behavioral factors associated with injection drug use among Iranian men living in Kermanshah city
Iran is among the countries with the highest rates of opioid and heroin consumption in the world. Smoking opium among the Iranian population has historical and traditional roots; however the rising rate of injection drug use is a relatively new phenomenon. This project was designed as a retrospective case-comparison study, aiming to identify the social and behavioral factors that are associated with initiating injection drug use among a population of 948 male drug users, who sought addiction treatment at a methadone clinic in western Iran between February 1, 2004 and August 31, 2005. Logistic regression was employed to assess the statistically significant social and behavioral risk factors for injection drug use initiation. The study population included 177 injecting drug users, constituting 18.67% of the total participants, and 771 non-injecting drug users. The initial crude analysis of the data indicated that drug users who were younger, more educated, unemployed, addicted at a younger age, lived in an urban area, were not married and had no children, initiated smoking before the age of 20, had one addicted blood-relative, used drugs four times or more per day, ceased drug use while in prison or began with or used other drugs like buprenorphine, heroin, or marijuana were more likely to turn to injection drug use. However, after adjustment for confounding effects through logistic regression analysis only younger age, buprenorphine use, high daily frequency of drug use, and history of drug use cessation in prison camps, remained associated with initiating injection. Interestingly, the impact of the associated risk factors was considerably different between the participants who indicated their onset date of drug use as after versus prior to the year 2000, coinciding with the ban on poppy production in neighboring Afghanistan, which is the primary source of opiate import into Iran. Most notably, the subjects who initiated injection after 2000 were more likely to be highly educated, receiving at least a high school diploma or higher, whereas the group that initiated drug use prior to the year 2000 were shown to have a significantly higher rate of imprisonment and attempts at quitting in law-enforced rehabilitation facilities. It was also demonstrated that the population who began drug use after the year 2000 had an increased shift towards using buprenorphine, which is highly associated with increasing the drive towards injection, and increasing the prevalence of the associated infections such as human immunodeficiency virus (HIV), Hepatitis C Virus (HCV), and other injection-associated adverse health outcomes. This analysis elucidated that changes in policy and governmental control measures could indirectly influence the choices and behaviors of drug users, demonstrating the interplay between social and behavioral factors. Therefore, in order to minimize detrimental effects of policy changes, harm reduction interventions must be dynamic and cater to the needs of target populations who are at risk of opting for drug use behaviors that could be more harmful to their long-term health. Factors such as date of addiction initiation may indirectly affect the risk of injection initiation, and information on these factors can guide us to identify and assess other contextual factors that may have an impact on the significance of risk factors that could lead to injection initiation. This observation is especially significant in the context of addiction in a country such as Iran, with a constantly changing economy. Caution must therefore be applied to not group drug using populations in a single category when designing public policy, health interventions, or treatment measures. Therefore, identifying the risk factors for injection initiation in the context of environmental and societal changes is of utmost importance in order to provide appropriate harm reduction solutions for those who have yet to inject and are at highest risk for injecting.