Publications II

The following unpublished brief ethnographic notes may help explain some of the difficulties of street-work:

Outreach interventions with inhalant abusing central city street girls.

Timothy Ross

“Even among other drug users solvent users stand out as deviant” (Oetting 1998)

In street outreach harm reduction interventions in Bogotá with multi-problem young people in prostitution the most severe dependence and associated problems have been found in inhalant abusers, for whom there are no specialist attention services.

Meetings over several weeks with members of a group of glue ‘huffers’ have been condensed from field diaries.

The author has known four of the eight core members of the group for over two years and as their glue consumption has intensified from occasional to constant use, has observed social, physical and psychological deterioration and increased resistance to entering treatment.

In recent contacts attempts at engagement were renewed.

The location is the area around a small run-down hotel in Santa Fe, a central Bogotá prostitution, gang and drug zone with the city’s highest rate of HIV infection (SDS 2008).

Visit 1: D was alone in the doorway huffing from a bag of glue. Initially confused, with the rapid passing of toluene intoxication she became animated and receptive. She has a history of severe neglect, abuse and abandonment, sub-clinical depressive symptoms, 4th grade schooling, no known family member or other social support, and uses glue throughout the day. Now 18, she is no longer eligible for child protection services and has little opportunity for change. On initiating a motivational intervention she expressed hope and (unformed) plans for exiting prostitution, entering a recovery programme and returning to education. She asked for help, requested my phone number and said she would telephone to be taken to a day center.

She did not call.

Visit 2: D was not there. Two other core members, K and S, very high, denied knowing her. K said her social worker will help her go back to primary school. She is 16, has prostituted and consumed glue, marijuana, cocaine, benzodiazepines and alcohol since 12. Brought up into prostitution by her mother, by age 13 she had assumed the persona of the “baby-pro” (Inciardi 1984). She was in a shiny silver-white sateen jacket with nylon fur collar, tight jeans and bare midriff, and has a manipulative, aggressive and acquisitive style that suggests elements of personality disorder.

S claimed to be in tenth grade. Her flat affect, dissociation and weak grasp on reality have worsened with her glue consumption over the past year.

Condoms and lubricants were distributed.

Visit 3. K and S were very high, alternately arguing violently and warmly sharing glue in typical huffer ‘bizarre comradeship’ (McSherry, 1988, p. 114). On initiating a motivational intervention with S. she abruptly threw aside her glue and talked about going to University to study languages.  K ran to pick up the discarded glue bag.

Visit 4. K, S, D, I, C and 3 older girls were very high and quarrelsome, one animatedly acting out an incident in which another girl suffered a serious knife wound.

K, I and S were too high to talk lucidly, although eagerly accepted condoms and lubricants. D rapidly sobered, equitably shared out a box of biscuits and returned to the previous conversation about going back to school and exiting prostitution and glue. She insisted she was using less. I could see a bottle of glue half hidden in her bra. We made a new arrangement to take her to start a recovery programme. She asked for my phone number again as she had lost my card.

Visit 5. K, glue in hand, S and D not present. Su came out of the hotel, extremely thin, 16, wearing the pastel blues and pinks of the current “baby-pro” style, a bag of glue visible in her pocket. Asked what she wants to do in the coming year, she replied: “Study”. She completed 6th grade two years ago before she entered full time street prostitution. I took her through a confrontational exercise of calculating how many men have paid her for penetrative sex -- over 2,000  -- and the concomitant disease risk. A psychologist who previously worked with her considers Su too sociopathic to merit further intervention.

These meetings confirm some of the difficulties of working with solvent abusers: lability, hostility and cognitive difficulties whilst intoxicated; inconstancy and a chaotic life-style; deviance, social isolation and low educational level; dysfunctional upbringing and psychiatric issues; use of multiple other substances; risk of major health problems and violence; lack of positive social networks and difficulty accessing treatment; and poor outcome prognosis.

Their vulnerability, need for care, lack of opportunities and sporadic expressions of willingness and attempts to find ways out, demand a commitment to finding adequate ways of working with them, of achieving access to existing services and creating support networks, despite frustration and disappointment over their difficulties in maintaining contact and keeping appointments, and the absence of official interest and services.

After each contact impressions and hypotheses were shared amongst outreach partners and plans for future action were drawn up. We concluded that there is a sufficiently empathic relation with D to begin drawing on her remaining strengths and engage her in day center activities. Once one member of the group commits it may become more feasible to bring a second (S) into a programme. There is a “peer cluster” effect (Oetting & Beauvais 1986, 1987) in entry to substance use: similarly there may be clustering in exits. Whilst disappointed that constant intoxication and personality problems leave so few amenable to motivational interventions, minimal goals were being achieved. On the next visit we need to aim at separating D spatially for at least a short time, and if possible S, from the others, to be able to work with them without pressure to consume and participate in the primary group, and to set specific targets for each intervention.

Attitudes are generally extremely negative towards glue huffers, with beliefs that they are “brain damaged” beyond hope (Jumper-Thurman et al 1995). “There is no point in trying, they are a lost cause” (Psychologist, Bogotá adolescent attention programme) Other substance users look down on solvent abusers (DH 2005) and there is reluctance to accept them in services, negative expectation of treatment outcomes and little interest among substance misuse researchers leading to a “relative paucity of information” about inhalant use (Neumark et al 1998).

Definitions and diagnosis of coexisting disorders are scarce for the Bogotá glue-consuming prostitution community. Resistance to engagement in treatment means few have had full psychiatric or psychological evaluation and mental health status can only be assessed by clinical observation, knowledge of family and personal histories and the existing literature. Day center staff previously noted that S displayed psychotic traits prior to her present heavy inhalant use; that D had depressive characteristics related to early maternal abandonment; and that K and Su had manipulative and exploitative sociopathic traits. Whilst not meeting DSM-IV criteria for full-blown disorders, these sub-clinical conditions preceding but now coexisting with and exacerbated by problematic substance use, appear to fit two mechanisms of interaction of mental health and substance misuse problems and justify definitions of  ‘Dual Diagnosis’ (Department of Health 2002, p 7). P, 20, from a related glue/prostitution group, last year had a florid psychotic episode and in late December presented again with prodromal symptoms to request referral on for therapy.

Prevalence data for inhalant abuse are limited. According to Sharp & Brehm (1977) US household surveys in the 1970’s found inhalant use roughly equal to LSD and cocaine with up to 17.1% in some high school student populations reporting life-time use. In the U.K. the Department of Health (2005) lists inhalants as causing more deaths than illegal drugs, with 6% of 11-15 year olds reporting last year use. In Colombia Duque et al (1992) list inhalants as the fourth most prevalent substance after alcohol, tobacco and marijuana, with 6.6% of 12-17 year olds reporting life time use and 3.2% last month use. (Inherent sampling bias of household surveys may leave out significant numbers of inaccessible street glue huffers).

Risk is exceptional for STIs/HIV, violence (as victims and authors), criminal justice issues, unwanted pregnancy, accidental injury, malnutrition, organ damage and other major physical, neurological and mental health problems, reduced life expectancy and QUALY. Sudden death is frequent in inhalant abusers (Johns 1991). The author has observed progressive and life-threatening deterioration in this group and has recorded extremely high mortality from AIDS and murder in this and connected groups.

Outcomes are poor. Levels of deviance and personality disorders higher than in users of other substances (Oetting and Webb 1992), resistance to intervention, neuropsychiatric effects, cognitive clouding and perception as “the most difficult and refractory people to treat” (Jumper-Thurman et al 1995) make positive outcomes unusual.

Aetiology of severe substance misuse and associated mental health issues in core members of the group, D, S, Su and K, appears to be linked to extreme negligence and early childhood physical and sexual abuse in the dysfunctional, pathological or absent families that abound in the literature (Oetting & Webb 1992, Wu et al, 2004, Wu & Howard 2007), and the subsequent repetition of traumatic events on the street. The author believes interrelated combinations of mood and personality disorders manifested at puberty concurrently with their slide into street prostitution and severe substance misuse, which in turn exacerbated deviant life-style and mental health problems.

There is a pressing need for more detailed ethnographic and clinical research into inhalant abuse and its relationship to mental health, sexual exploitation and risk behaviour in adolescents and young people and for the development of suitable intervention, harm reduction and treatment programmes.

References and bibliography:

Anderson, H. R., Macnair, R. S. & Ramsey, J. D. (1985) Deaths from abuse of volatile substances: a national epidemiological study. British Medical Journal 290(6464): 304–307.

Department of Health (2002) Dual Diagnosis Good Practice Guide, Department of Health, London

Department of Health (2005) Volatile Substance Abuse Today: A Qualitative Study, Department of Health, London

Duque, L.F., Rodríguez, E., Rivero, D.C. & Huertas, J. (1992) Consumo de Sustancias Inhalables en Colombia, DNE, Bogota

Harris, D. (2008) Volatile Substance Abuse, Archives of Disease in Childhood: Education and Practice, 91: 93-100

Johns, A. (1991) Volatile Substance Abuse and 963 Deaths, Addiction 86(9): 1053-1056

Judd, A. & Fitch, C. (1998) National Surveys of Drug Use, in: Stimson, G., Fitch, C. & Judd, A. (eds.) Drug Use in London, Centre for Research on Drugs and Health Behaviour, London

Jumper-Thurman, P., Plested, B. & Beauvais, F. (1995) Treatment Strategies for Volatile Solvent Abusers in the United States, in: Kozel, N., Sloboda, Z. & De la Rosa, M., Epidemiology of Inhalant Abuse: A International Perspective, NIDA, Rockville

Inciardi, J. (1984) Little Girls and Sex: A Glimpse at the World of the "Baby Pro", Deviant Behavior 5:71-78

May, P.A., & Del Vecchio, A.M. (1997) The Three Common Behavioral patterns of Inhalant/Solvent Abuse: Selected Findings and Research Issues, in: Beauvais, F. & Trimble, J.E, (eds.) Sociocultural Perspectives on Volatile Solvent Use, Hayworth, New York

McSherry, T.M. (1988) Program Experiences With the Solvent Abuser in Philadelphia, in: Rider, R.A. & Crouse, B.A., (eds.) Epidemiology of Inhalant Abuse: An Update, NIDA, Rockville

Neumark, Y.D., Delva, J. & Anthony, J.C. (1998) The Epidemiology of Inhalant Drug Involvement, Archives of Pediatric and Adolescent Medicine, 152: 781-786

Oetting, E.R.. & Beauvais, F.(1987) Peer cluster theory, socialization characteristics and adolescent drug use: A path analysis. Journal of Counseling Psychology 34(2): 205-213

Oetting, E.R., Edwards, R.W. & Beauvais, F. (1988) Social and Psychological Factors Underling Inhalant Abuse, in: Rider, R.A. & Crouse, B.A., (eds.) Epidemiology of Inhalant Abuse: An Update, NIDA, Rockville

Oetting, E.R. & Webb, J. (1992) Psychosocial Characteristics and Their Links With Inhalants: A Research Agenda, in: Sharp, C. W., Beauvais, F. & Spence R. (eds.) Inhalant Abuse: A Volatile Research Agenda, NIDA, Rockville

Rodríguez, E. (1996) Consumo de sustancias psicoactivas en Colombia, DNE, Bogota

Sakai, J.T., Hall, S.K., Mikulich-Gilbertson, S.K. & Crowley, T.J. (2004) Inhalant Use, Abuse, and Dependence Among Adolescent Patients: Commonly Comorbid Problems, Journal of the American Academy of Child & Adolescent Psychiatry 43 (9): 1080-1088

Sakai. J.T., Mikulich-Gilbertson, D.K., Croley, T.J. (2006) Adolescent inhalant use among male patients in treatment for substance and behavior problems: two-year outcome, American Journal of Drug and Alcohol Abuse. 32(1): 29-40.

Secretaria Distrital de Salud (2008) Informe de VIH 2008, SDS, Bogotá

Sharp, C.W. & Brehm, M.L. (1977) Review of Inhalants: Euphoria to Dysfunction, NIDA, Rockville

UCPI (1994) Consumo de Sustancias Psicoactivas en Santafe de Bogota, D.C. Alcaldía Mayor, Bogota

Wu, L.T., Pilowsky, D.J. & Schlenger, W.E. (2004) Inhalant Abuse and Dependence Among Adolescents in the United States, Journal of the American Academy of Child and Adolescent Psychiatry 43(10): 1206-1204

Wu, L.T. & Howard, M. O. (2007) Psychiatric Disorders in Inhalant Users: Results from the National Epidemiologic Survey on Alcohol and Related Disorders, Drug and Alcohol Dependence, 88(2-3): 146-155