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Original article

Drug Use Among Homeless Young People in Los Angelesand Melbourne

Doreen Rosenthal, Ph.D.a,*, Shelley Mallett, Ph.D.a, Norweeta Milburn, Ph.D.b, andMary Jane Rotheram-Borus, Ph.D.b

aKey Center for Women’s Health in Society, The University of Melbourne, Melbourne, AustraliabCenter for Community Health, University of California, Los Angeles, California

Manuscript submitted June 3, 2003; manuscript accepted January 24, 2004

bstract Purpose: To examine the effect of time spent homeless on young people’s substance use and useof drug and alcohol services in two countries with contrasting policy and service environments.Methods: A crossnational survey was conducted of recently homeless and experienced homelessyoung people in Melbourne (N � 674) and Los Angeles (N � 620). Questions were asked aboutalcohol and drug use in the past 3 months, frequency of use, injecting drug use, drug dependency,and perceived need for, and use of, drug and alcohol services. Data were analyzed using logisticregression.Results: Substantial numbers of young people reported use of alcohol and drugs. More Australiansthan Americans and more experienced than newly homeless reported drug use, although there wereno differences in frequency of use in the past 3 months. Polydrug use was common, as were injectingdrugs and responses that signified drug dependency. All were more common among Australians andexperienced homeless young people. A substantial number of young people had “ever” taken partin a drug or alcohol program, but only a minority believed that they needed help from services. Ofthese, only a minority had sought help. This was particularly so among those who were classifiedas drug dependent. Reasons for failure to seek help varied.Conclusion: Substance use is alarmingly high compared to national samples of young people,especially among those who had been homeless for longer periods. Programs to reduce substanceuse must take account of the prevailing drug cultures, as well as different subgroups of thepopulation. © 2008 Society for Adolescent Medicine. All rights reserved.

Journal of Adolescent Health 43 (2008) 296–305

eywords: Youth; Adolescents; Australia; Homeless young people; Substance use; Drug and alcohol services

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Homeless young people are a group widely perceived toe at risk for alcohol and drug use, yet little is known abouthe impact of time spent homeless on their alcohol and drugse [1–7]. Even less is known about homeless young peo-le’s use of drug and alcohol services.

Australia and the United States are similar in some di-ensions (both Western, with large immigrant populations

nd with strong focus on individualistic norms) and with

*Address correspondence to: Doreen Rosenthal, Ph.D., Key Centre foromen’s Health in Society, The University of Melbourne, Parkville,elbourne, Victoria 3070 Australia.

cE-mail address: [email protected]

054-139X/08/$ – see front matter © 2008 Society for Adolescent Medicine. Alloi:10.1016/j.jadohealth.2008.06.002

ome similarities in services (e.g., community-based agen-ies that often have low levels of funding). However inustralia, service providers for homeless young people areore likely to be experienced professionals trained in youthork, social work, or community development. As in allther major urban centers, in Melbourne, the Australian siteor this research, care is organized so that a large number ofelatively small, government-funded community-basedgencies are spread throughout the entire metropolitan area8]. In contrast, services in the Los Angeles, the U.S. site,re more likely to have professional staff working at largehelters that are located within a narrow radius in the inner
ity. Drug-specific services also differ between the two
rights reserved.

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297D. Rosenthal et al. / Journal of Adolescent Health 43 (2008) 296–305

ites. In Melbourne, there are government-funded detoxifi-ation services, drug and alcohol counseling and supportervices, and limited intensive rehabilitation services. Mostmportantly, there are readily accessible needle and syringexchange services throughout Melbourne and dedicated out-each services for substance users. Unlike Melbourne whereouth specific services are widely available, in Los Angelesounty, alcohol and drug treatment services for young peo-le are very limited. Young people have little access toetoxification and drug and alcohol treatment services thatre targeted for adult populations, especially young peoplender the age of 18 years. Needle exchange programs areot widely available or accessible, and are again targeted atdult populations.

In addition to differences in service provision, there areolicy differences. Unlike the United States, Australia hasdopted a nation-wide harm-reduction approach to healthisk practices, has had multiple national social marketingrograms for HIV prevention, and offers universal access toealth care. The need for a range of prevention and earlyntervention services, including mediation, to divert youngeople from homelessness has been recognized, a financialllowance is available for those homeless young people whore deemed at risk if they return home, and there are dedi-ated employment schemes for homeless young people.here is an extensive network of needle and syringe ex-hange services, including street-based outreach via footatrols and mobile buses, and a variety of dedicated healthervices and education programs. In recognition of the se-erity of the problem of substance abuse, Federal and Stateovernments have set up high-level committees to reviewnd develop policy as well as providing on-going advicend funding for innovative drug-related programs. In part, asresult, there is currently a shift away from punitive deterrents

uch as jail or juvenile detention for young substance abusersho commit drug-related crimes to community-based pro-rams with an emphasis on rehabilitation. Summarizing theifferent policy environments, although harm reduction pro-rams exist in the United States, there is still an emphasis onzero tolerance approach to substance use and there have

een few, if any, national social marketing programs forubstance use or other relevant issues such as HIV. There isn emphasis on disease prevention rather than health pro-otion, and access to government-funded health care andnancial support is extremely limited.

When we examine substance use among homeless youngeople, prevalence estimates vary across studies. This maye because of the definitions of homelessness used, theifferent settings in which young people are recruited (onhe streets, in shelters, clinics), the way substance use andependence is measured, age of young people, and theireographical location. However, across all studies there haseen evidence of relatively high rates of substance use1–7]. In particular, high rates of injection drug use have
een reported in many studies [4,9–11]. The available re- w
earch indicates that homeless young people use drugs,hether injected or otherwise, more frequently than theirome-based peers [12–19].

High levels of substance use/abuse among homelessoung people are a concern because of the potential fordverse health outcomes. Considerable attention has beenaid to the elevated risk for HIV/AIDS because of theseoung people’s relatively high rates of injecting and, spe-ifically, unsafe injecting [9,20–22], as well as the associ-tion between drug use and unsafe sexual practices4,17,23,24]. In Australia, where Hepatitis C is a recognizeds a significant public health problem, unsafe injecting is byar the most common mode of transmission, and homelessoung people have elevated rates of infection relative toheir home-based peers [25]. Other outcomes associatedith high levels of drug use include mental health problems

nd increased risk of suicide [26–30].Although the problems associated with substance use

mong homeless young people have been well documented,ignificant gaps exist in the research literature. These in-lude the impact on young people’s substance use of lengthf time spent homeless and their use of services. Withespect to the former, Kipke et al [27] found a significantssociation between time spent homeless and substance use,lthough Baron [31] found this association only for hardrugs. In terms of use of drug and alcohol services, oneustralian review of drug and alcohol services for youngeople reported that those who use illicit drugs rarely usedpecific drug services [32]. Another reported that youngeople have very low awareness of specialist drug servicesnd rarely access these services [33], and a substantialumber reported bad experiences, mainly related to disap-roval and lack of support, while using services [12].

The purpose of this study is to examine the impact ofime spent homeless and use of services on young people’srug use. We report on a crossnational study of youngeople who are “newly” homeless (left home less than 6onths ago) and “experienced” homeless (left home more

han 6 months ago). By comparing the substance use ofhese young people in two countries, Australia and thenited States, we are able also to infer the impact of dif-

erent service provision and drug-related policy.

ethods

ample

This study recruited homeless young people in Mel-ourne, Australia, and Los Angeles, California. Two criteriaor participation were used: (1) the young person was be-ween 12 and 20 years, and (2) they had spent the last 2onsecutive nights away from home (either without theirarent’s or guardian’s permission if under 17 years or hadeen told to leave). Two cohorts of homeless young people
ere formed: “newly” homeless and “experienced” home-

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298 D. Rosenthal et al. / Journal of Adolescent Health 43 (2008) 296–305

ess. Based on information from providers of services toomeless young people about the experiences of their cli-nts, “newly homeless young people” were defined as thoseho had been living away from a parent or guardian for less

han 6 months, and “experienced homeless” were defined ashose young people who were living away from a parent oruardian for more than 6 months.

Recruitment began in October 2000, and ended in Au-ust 2002. In Australia, 674 homeless young people (334ales, 340 females; mean age � 17.7 years; SD � 1.6,

ange � 12–20 years) were recruited from youth or home-ess services across metropolitan Melbourne. Most youngeople (83.7%) were born in Australia and had one or morearents of English-speaking descent (84.8%). The remain-er had two parents from culturally and linguistically di-erse backgrounds representing a large number of countries,ith none containing more than 3% of the sample. (In theustralian context it is not conventional, or appropriate, tose broad race or ethnicity categories as it is in the Unitedtates.) In the United States, 620 homeless young people299 males, 316 females, 3 transgender; mean age � 16.9ears; SD � 2.2, range � 12–20 years) were interviewedrom shelters, drop-in centers, and street sites. The majorthnic/race groups were Caucasian (26.1%), African Amer-can (21.6%), and Hispanic/Latino (34.4%). Most youngeople (84.8%) were born in the United States. There wereore experienced (N � 509) and fewer newly homeless (N �

65) young people in the Australian than the U.S. sample (N �57 and N � 261, respectively).

rocedure

Ethical approval for the project was obtained from insti-utional ethics committees. Prior to commencing surveys,nterviewers conducted comprehensive screening of youngeople with a 13-item screening instrument. The screeningnstrument was designed to mask the eligibility criteria,onfirm eligibility, and establish whether a young personas a newly or experienced homeless young person. If aoung person was eligible, they were invited to participaten the survey. Participants were assured of confidentialitynd informed consent was then obtained.

Surveys were conducted by trained interviewers using auestionnaire Delivery System on IBM-compatible laptop

omputers, and lasted between 1 and 1.5 hours. Questionsegarding drug and alcohol use were administered using anudio-CASI (computer-assisted structured interview)here young people used headphones for privacy and en-

ered their answers directly on to the computer. All youngeople received $20 (local currency) compensation for theirarticipation.

The procedure for recruiting young people into the studyiffered slightly between research sites because of differ-nces in service systems, policies, and congregation patterns
f young people. In Australia, young people were recruited a
hrough staff working at services. In the United States,nterviewers recruited participants from shelters, drop-inenters, and street hang-out sites.

easures

The research reported here is part of a longitudinal andross-sectional study. Only those measures relevant to theresent paper are presented. In all cases, a “yes” responseas scored 1; a “no” response was scored 0.

rug and alcohol use

A modified version of the National Household Survey onrug Abuse [34] was used to assess alcohol and drug useehaviors over young people’s lifetime and in the past 3onths. The survey measures the use of alcohol, marijuana,

rack/cocaine, heroin, barbiturates, over-the-counter (i.e.,egal nonprescription) drugs, amphetamines, inhalants, hal-ucinogens, and prescription drugs. Questions were asked ineference to the past 3 months only. For each substance wessessed whether or not the substance was used (“yes”/no”), the frequency of use (number of days used in the pastmonths), and whether the drug was injected (“yes”/“no”).igns of dependency were assessed by four questions (an-wered “yes” or “no”): “Have you ever tried to cut downour drug use?”; “Have you ever needed larger amounts toet some effect?”; “Have you ever felt that you needed orere dependent on drugs?”; and “Have you ever had with-rawal symptoms?” In addition, a mean dependency scorefrom 0 to 4) was calculated.

ervice use

Young people were asked if they had “wanted to enter anlcohol or drug treatment program, if they had “actuallyntered an alcohol or drug treatment program,” or hadparticipated in detox.” Responses (“yes”/“no”) were ob-ained for two time periods: “ever” and the “past 3 months.”articipants were also asked three further questions aboutervice utilization: “In the last 3 months, did you feel youeeded help for alcohol or drug use” (“yes”/“no”)? “Didou go for help” (“yes”/“no”)? “Overall, how satisfied wereou with the service you received” (1 � very dissatisfied to� very satisfied)? Young people who indicated they did

eed help but did not seek it from a service were asked tondicate (“yes”/ “no”), from a list of 13 reasons (e.g., did notnow where to go, afraid they would contact my family),hy they had not sought help.

ata analysis

In all the analyses there was only one significant effect ofender. This occurred for use of marijuana, used by feweroung women than men in the past 3 months. Consequently,ll further analyses examined only the effects of site andype and the interaction of these using logistic regression. In
ll analyses, young people from Australia and the experi-

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nced homeless were the reference groups for site and type,espectively.

esults

Descriptive data and effects of gender, site, and typeexperienced or newly homeless) are presented for: (1)se/nonuse of alcohol and drugs, (2) frequency of use, (3)olydrug use, (4) experience of injecting drugs, (5) drugependency, and (6) experience with alcohol and drug ser-ices. Given the large number of tests, � was set to p � .01o avoid type 1 errors.

se/nonuse of alcohol and/or drugs in the past 3 months

As Table 1 shows there was, overall, considerable use oflcohol or drugs in the past 3 months by these young people.se of alcohol and marijuana was high across both sites,

lthough the former was significantly higher for Australiansodds ratio [OR] � .529) and the latter for experiencedomeless young people (OR � .571). Of particular concernas the number of young people who used heroin, amphet-

mines, LSD/acid (more than one-quarter of the experi-nced homeless), and crack/cocaine (over one-fifth of thexperienced homeless). Relatively few used methadone. Ineneral, significantly more Australians used drugs than didmericans (amphetamines: OR � .634; heroin: OR � .467;

edatives/tranquilizers: OR � .494; methadone: OR �416).

Use of drugs was far more prevalent among experiencedomeless young people than among those who were newlyomeless. In addition to marijuana, there were significantffects for amphetamines (OR � .442), LSD/acid (OR �

Table 1Percentage of young people who used each drug in

Drug Mel

Exp(N �

Alcohola,d 81.2Marijuanab,c 72.7LSD/acidb,c 26.3Antidepressants 23.1Inhalants 13.0Amphetaminesa,b,c 46.6Antipsychotic/mood regulating medication 12.3Crack/cocaineb,c 21.3Heroina,b,d 26.3Sedative/tranquilizersa,b,c,d 30.2Analgesics/pain killersb,d 22.5Methadonea,c 7.7Ecstasyb,d 33.2

a Significant main effect of site.b Significant main effect of type.c p � .01.d p � .001.

478), crack/cocaine (OR � .454), heroin (OR � .241), d

edatives/tranquilizers (OR � .492), analgesics/pain killersOR � .319), and ecstasy (OR � .429). There were noignificant site � type interactions.

requency of use

Participants who used each drug reported the mean num-er of days that the drug was used in the past 3 months.wo-way analysis of variance (ANOVA) (site � type) forach drug yielded significant main effects of type for alco-ol and marijuana only and no significant main effects ofite or interaction effects. Experienced homeless young peo-le used alcohol and marijuana more frequently than didheir newly homeless peers, F (1, 940) � 25.62, p � .001,nd F (1, 851) � 19.64, p � .001, respectively. Marijuanaas used most frequently (on average about 45–50 days by

xperienced homeless young people and 35 days by newlyomeless), followed by prescribed antidepressants (on av-rage 30 days) and prescribed antipsychotic/mood regulat-ng medications (on average 25 days). Although heroin wassed more frequently by Australians and experienced home-ess young people (Australian experienced homeless: 37ays; Australian newly homeless: 13 days; U.S. experiencedomeless: 24 days; U.S. newly homeless: 3 days), theseand other) differences were not significant because of wideariability among young people in frequency of drug use.

olydrug use

Table 2 shows the number of drugs used by youngeople in the past 3 months. A disturbingly high number hadsed multiple drugs, with one-quarter to one-third usinghree to five drugs and more than one-quarter of the expe-ienced homeless using six or more drugs. Mean number of

onths by site and type

Los Angeles

d New(N � 165)

Experienced(N � 357)

New(N � 261)

83.0 69.6 57.160.4 67.8 56.714.5 28.0 15.317.0 16.9 8.814.5 16.0 11.527.9 35.7 14.6

9.1 12.0 6.211.0 24.4 19.27.9 14.3 1.9

17.6 17.6 5.48.5 23.2 9.63.0 3.4 0.8

17.6 26.3 14.9

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rugs varied across site and type of homelessness with

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ustralian young people and experienced homeless report-ng significantly more polydrug use than their American andewly homeless counterparts, F (1, 1285) � 15.23, p �001, and F (1, 1285) � 57.68, p � .001, respectively. Thereas no significant site � type interaction.

njecting drugs

Of the total sample, over one-quarter of the experiencedomeless had injected at least one drug type during thereceding 3 months but considerably fewer of their newlyomeless peers had done so (10.9% of Australians, 4.7% ofmericans). The drugs most frequently injected were am-hetamines and heroin. These were injected by about one-fth of the experienced homeless and a small percentage ofewly homeless –7.5% for both drugs among the Australianample and 1.6% and 3.1%, respectively, among the Amer-cans.

Table 3 shows the percentage of young people, of thoseho used a drug, who injected that drug within the previousmonths. Not surprisingly, heroin was the most commonly

njected drug, with a substantial majority of users choosing

Table 2Number of drugs used in past 3 months by site and

Number of drugs used Melbourne

Experienced

No drugs 7.31–2 drugs 27.93–5 drugs 34.26� drugs 30.6Mean # of drugs (SD)a,b,c 4.17 (2.93)

a Significant main effect of site.b Significant main effect of type.c p � .001.

Table 3Percentage of young people (of those who used theand type

Drug N

Amphetaminesb,c,d,e 44Antipsychotic/mood regulating medication 13Crack/cocaineb,d 26Heroin 20Sedative/tranquilizers 25Analgesics/pain killers 23Methadone 5Ecstasy 33Injecting drug usera,b,c,e 128

a Had injected any one drug.b Significant main effect of site.c Significant main effect of type.d p � .01.
e p � .001.
his mode of ingestion. Amphetamines and crack/cocaineere injected by nearly half the Australians and, overall,

here was a considerable amount of injecting for all drugsspecially for the Australian sample. However, there werenly two effects of site: significantly more Australians thanmericans injected amphetamines (OR � .551) and crack/

ocaine (OR � .336). Only one significant effect of home-ess type was found: experienced homeless were more likelyo inject amphetamines than new homeless young peopleOR � .128). There were no significant interactions ofite � type. Australians and experienced homeless wereignificantly more likely than Americans and new homelesso have injected any drug (OR � .446 and OR � .203,espectively).

rug dependency

As Table 4 shows, a majority of Australians and a sub-tantial minority, up to half, of the Americans answeredyes” to at least one of the four questions measuring depen-ency, a pattern that is repeated for experienced homelessompared to their newly homeless peers. There were sig-

(%, mean)

Los Angeles

Experienced New

16.5 27.232.5 37.524.9 24.926.1 10.3

2 (2.51) 3.54 (3.11) 2.22 (2.18)

ho injected each drug in last three months by site

Melbourne Los Angeles

Experienced New Experienced New

48.7 10.9 34.4 5.317.7 6.7 4.7 0.045.4 22.2 21.8 2.083.5 76.9 84.3 60.024.8 10.3 9.5 0.021.1 7.1 8.4 0.015.4 16.7 0.0 0.014.9 3.4 12.8 0.031.6 8.6 17.1 2.3

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ificant effects of site and type for all four questions. Moreustralians and experienced homeless than Americans andew homeless responded “yes” to each of the questions:Have you ever tried to cut down?” (OR � .581 and .429,espectively); “Have you ever needed large amounts to getome effect?” (OR � .477 and .401, respectively); “Haveou felt that needed drugs or were dependent” (OR � .385nd .346, respectively); and “Have you ever had withdrawalymptoms” (OR � .384 and .361, respectively). There wereo significant site � type interactions.

A two-way ANOVA (site � type) on mean total scoresor the four questions yielded significant site and type ef-ects with Australians and experienced homeless youngeople reporting greater signs of dependency, F (1, 1283) �1.48, p � .001 and F (1, 1283) � 79.50, p � .001,espectively.

Table 4Percentage of young people who had experienced sand status

Dependency questions

Ever tried to cut down?a,b,c

Ever needed larger amounts to get some effect?a,b,c

Felt you needed or were dependent?a,b,c

Ever had withdrawal symptoms?a,b,c

Mean score (0–4)a,b,c

a Significant main effect of site.b Significant main effect of type.c p � .001.

Table 5Service utilization by site and age (of those who us

Service utilization

Wanted to enter a alcohol or drug treatment programEverd,g

Last 3 monthsd,e,f,g

Actually entered a alcohol or drug treatment prograEverc,d,g

Last 3 monthsParticipated in detox

Everd,g

Last 3 monthsService utilization for alcohol or drug use

Needed helpc,d,e,f,g

Sought helpa

Mean satisfactionb

a As percentage of those who needed help.b Satisfaction levels: 1 � very dissatisfied; 4 � vc Significant site main effect.d Significant type main effect.e Significant interaction.f p � .01.
g p � .001.
ervice utilization

Table 5 shows that a substantial number of homelessoung people had “ever” taken part in a drug or alcoholrogram, although, not surprisingly, more experienced thanew homeless reported doing so. This was confirmed by theogistic regressions, with significant type effects for all threeuestions (OR � .295, .386, and .293, respectively). Sig-ificantly more Americans than Australians had actuallyntered an alcohol or drug treatment program (OR �.858). More experienced homeless had wanted to enter anlcohol or drug treatment program in the past 3 monthsOR � .396), but this was largely owing to the difference inhe Australian experienced and new homeless samples.

Responses to the questions about service utilization inhe past 3 months are also shown in Table 5. Two young

drug dependence in the past three months by site

elbourne Los Angeles

perienced New Experienced New

.2 47.9 55.5 45.2

.5 40.0 44.3 22.3

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43.7 18.6 35.9 23.728.8 13.8 21.1 20.6

24.3 11.0 37.4 12.610.4 6.9 11.4 7.4

18.6 6.3 17.8 3.77.3 4.2 5.0 1.6

34.8 16.7 21.9 21.648.1 33.3 38.5 39.03.25 3.22 2.55 3.28

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eople who said they needed help for drug and/or alcoholssues in the last 3 months but who had not used drugs in theast 3 months were excluded from this analysis. Responsesevealed that about one-fifth to one-third of homeless youngeople believed that they had needed help. For this question,here was a significant effect of site (OR � .526), typeOR � .375) and an interaction between these such that theroups reporting the greatest and the least need for helpere the Australian experienced and newly homeless youngeople, respectively, with both groups of U.S. young peopleccupying a middle position. Of those who needed help,ne-third to one-half had sought help, with no site or typeffects. Satisfaction with services used was relatively highnd was similar across all groups.

It is of interest that, among those who responded “yes”o one or more of three drug dependence questions, only8.2% reported that they needed help and, of these, only3.1% had sought help. There were no significant effectsf site or type nor were there any significant interactionsor either needing or seeking help. However those whoeported drug dependence were more likely to reporteeding help than those who did not, �2 (1) � 217.94,� .001, but not more likely to actually have sought

elp. Of the nondrug dependent who needed help (3.2%),0% had sought help.

Relatively few young people who needed help had notought that help from services. The reasons given for failureo seek help varied (Table 6). Most commonly, failure toeek help was because of feelings of embarrassment, lack ofnowledge or money or concerns about the service itselfe.g., unable to help, scared that the service would contacthe young person’s family). In general, it appeared thatore Americans than Australians failed to seek help be-

ause of concerns about the services, and this was particu-arly so for the newly homeless U.S. sample. However,

able 6easons why young people did not get help by site and type (N � 165)a

eason N

idn’t know where to go or what service to use 48he service cost too much 21he service was too far away 14ad experience with staff last time 10hought the service couldn’t help me 30ad no money to get there 33ad to wait a long time for an appointment 21cared they’d contact my social worker or the police 18cared they’d contact my family 29ervice was closed when needed 14idn’t fit eligibility criteria 11oo nervous or embarrassed to talk about the problem 43anted to/did fix problem myself 12

ouldn’t be bothered getting help or didn’t have time 29ther 22

a Multiple responses were possible.

tatistical tests were not carried out to detect differencesetween the sites and types of homeless young peopleecause in most cases cell frequencies were very low andesults would not be sufficiently robust to be reliable.

iscussion

As might be expected, there was a high amount of drugse among these young people in the past 3 months, but thisended to vary according to site and time spent homeless.

ost were using alcohol and marijuana and a disturbingumber were using “harder” illicit drugs such as heroin,mphetamines, crack/cocaine, and LSD/acid. The partyrug, ecstasy, was also used by many young people. Alco-ol, heroin, amphetamines, sedatives, and methadone weresed more Australians than Americans and those who hadeen homeless for a longer period were more likely to havesed most of the drugs than their more recently homelesseers. A substantial number of young people had engaged inolydrug use in the past 3 months and the number of drugssed in the 3-month period was greater for Australians andore experienced homeless young people. Overall, inject-

ng drugs was more common among the Australians thanhe U.S. young people and among the experienced homelessompared to their newly homeless peers. Similar differ-nces were obtained in response to questions about drugependency.

These rates of substance use are dramatically higher thanhose reported in two Australian national surveys examiningrug use in the past 12 months. Among home-based 14 to4-year-old Australians in 1998 [16], marihuana, the mostommonly used drug, was used by only half the number ofespondents compared with these homeless young people.se of heroin was more than 20 times more common and

mphetamines were five times more common among our



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omeless sample. In another national survey [35] in therevious year, one-third of young people had used mari-uana, 15% had used acid and/or speed, 5% had usedocaine, and 2.5% had used heroin. In the U.S., similarlyigh rates of substance use relative to the general populationf young people were reported. A national survey of life-ime use of illicit drugs among young people in high school36] showed that use of illicit drugs was substantially lesshan that reported in a 3-month period by our U.S. homelessample. For example, 42% reported lifetime marijuana use,.1% reported lifetime heroin use, 9.4% reported lifetimeocaine use, and 9.8% reported lifetime methamphetaminese. Very few students (2.3%) reported lifetime injectingrug use.

Comparison with earlier studies of homeless young peo-le is difficult because of differences in sampling strategies,ime frames used to estimate drug use, and reporting ofpecific drugs. It appears, however, that there have beenhifts in the extent to which young people have used specificrugs. Data from American studies indicate that althoughse of alcohol and marijuana has remained relativelytable, use of heroin, crack/cocaine, and amphetaminesas substantially higher among our Los Angeles sample

4,5,23,26,27]. In comparison with the one study found inhich ecstasy use was reported [9], there was a substantial

ncrease in use among our sample. We have found noomparable data for Australian homeless young people,owever Hillier et al [37] reported high levels of drug andlcohol use among a sample homeless adolescents.

Although some young people do leave home because ofheir drug use, there are many for whom this is not anmportant precipitating factor. Only one-third of our sampleeported personal drug or alcohol use as an important orery important reason for leaving home, and over one-halfeported drug and alcohol use as not important [38]. Ourata do suggest that the time young people are homeless hasn impact on the likelihood of using and injecting drugs.iven the evidence that drug use increases with age among

dolescents [35], it is not surprising that our older experi-nced group follows this pattern. As Baron [31] suggests,omelessness exposes young people to environments whererugs are readily available and used. Two interpretations ofhese data are possible. On the one hand, the longer thexposure to these environments, the more likely it is thatrugs will be used, at least in part to alleviate the cumulativetress of being homeless. Alternatively, young people whore using drugs are more likely to remain homeless. Ourollow-up study, now in progress, will enable us to assesshese alternative explanations.

The evidence of differences between the Australian andmerican participants in our study is more difficult to in-

erpret. The fact that the Australians are older and morexperienced accounts, at least in part, for these differences.his explanation is consistent with evidence that indicates
oung people experiment with a greater range of drugs as p
hey get older, peaking in late adolescence and declining inhe mid to late 20s [39]. Other factors may also be relevant.ne is the fluctuating availability and cost of drugs in the

wo cities. For example, during the recruitment period,ustralia was experiencing the end of a glut of high-grade

nd inexpensive heroin and the beginning of a heroinrought [40]. As a consequence of this drought, youngeople switched to other more freely available and lessostly drugs, notably amphetamines. These shifts in therug market are reflected in our data.

Another possibility arises from the different policy en-ironments in the two countries. In Australia, the policy ofarm minimization is nationally accepted and implemented.his is best exemplified by the existence of needle andyringes exchange programs nationwide. In contrast, al-hough there is variability in drug-related policy and prac-ice in the United States, the emphasis is on a zero tolerancepproach to illicit drug use, enforced by tough legal sanc-ions. Clearly, the social, cultural, and political environ-ents in the two countries impact on young people’s use of

rugs, and may lead to greater experimentation if not long-erm use among Australian young people. There is someupport for this argument in the finding of considerableariability among the Australians in their frequency of drugse, suggesting that many of these young people may berialing drugs. To understand these crossnational differencese need a more focused examination of the reasons thatoung people use drugs and the related cultural and policynvironments in which these behaviours are enacted.

Of those young people who used drugs, only a minorityad availed themselves of treatment programs. It is of in-erest that most of the drug users in our sample did notelieve that they needed help for their alcohol or drug use,ncluding two-thirds of those who might be classified asrug dependent. Of those who needed help, only aboutne-third to one-half and fewer than half of the dependentroup actually sought help.

More Australians than Americans believed that theyeeded help, although this difference did not apply to actu-lly seeking help. The reasons for the former may includehe greater number of Australians who were using drugsnd/or the larger number of freely available services that areocated in each of the metropolitan regions in comparisonith those in Los Angeles. Nevertheless, on the whole, there

s a large number of young people who clearly do noterceive themselves to be in need of drug and alcoholervices despite drug use that could be defined as dependent.his suggests that for many of these young people there isdissonance between researchers’ measures of “depen-

ence” and the meanings and value that drug practices haveor the young person him/herself.

There are some limitations to the study. Recruitment ofoung people largely through services meant that those whoo not access services were underrepresented. This was
articularly the case among the Australians, where street-

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ased youth were not part of the sample. Further research iseeded to examine more closely the quality, availability,nd uptake of treatment services. Finally, our data do notddress the debate about causal pathways. A longitudinaltudy is needed to establish whether problematic drug usereceded or postdates homelessness.

onclusions

It is clear from these data that drug use is alarmingly highn both populations sampled in this study, especially amonghose who had been homeless for longer periods. Despite theseimilarities, there are differences in the drug use culturesmong young people in each city. Any attempts to developrograms that aim to reduce drug use must take account of therevailing drug cultures that exist at the time and the locationt which these programs will be delivered as well as differentubgroups of the population. By this, we do not only refer tohe length of time that young people have been exposed to aomeless environment. We need also to consider the meaningshat drug use has for young people and the effects of drugs onhem. Effective drug prevention and support programs foromeless young people must not only consider their drug useulture, they must also take account of the chaotic and unstableature of their lives.

cknowledgments

The authors wish to thank Paul Myers, Judith Edwards,ndrea Witkin, and a team of interviewers for their contri-utions to this research. The research reported in this paperas funded by the National Institute of Mental Health

NIMH), Grant number: MH61185.

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The impact of substance use on adolescents