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Journal of Urban Health
Published in: Journal of Urban Health 6/2008

01-11-2008

Estimating the Prevalence of Injection Drug Use among Black and White Adults in Large U.S. Metropolitan Areas over Time (1992–2002): Estimation Methods and Prevalence Trends

Authors: Hannah L. F. Cooper, ScD, Joanne E. Brady, Samuel R. Friedman, Barbara Tempalski, Karla Gostnell, Peter L. Flom

Published in: Journal of Urban Health | Issue 6/2008

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Abstract

No adequate data exist on patterns of injection drug use (IDU) prevalence over time within racial/ethnic groups in U.S. geographic areas. The absence of such prevalence data limits our understanding of the causes and consequences of IDU and hampers planning efforts for IDU-related interventions. Here, we (1) describe a method of estimating IDU prevalence among non-Hispanic Black and non-Hispanic White adult residents of 95 large U.S. metropolitan statistical areas (MSAs) annually over an 11-year period (1992–2002); (2) validate the resulting prevalence estimates; and (3) document temporal trends in these prevalence estimates. IDU prevalence estimates for Black adults were calculated in several steps: we (1) created estimates of the proportion of injectors who were Black in each MSA and year by analyzing databases documenting injectors’ encounters with the healthcare system; (2) multiplied the resulting proportions by previously calculated estimates of the total number of injectors in each MSA and year (Brady et al., 2008); (3) divided the result by the number of Black adults living in each MSA each year; and (4) validated the resulting estimates by correlating them cross-sectionally with theoretically related constructs (Black- and White-specific prevalences of drug-related mortality and of mortality from hepatitis C). We used parallel methods to estimate and validate White IDU prevalence. We analyzed trends in the resulting racial/ethnic-specific IDU prevalence estimates using measures of central tendency and hierarchical linear models (HLM). Black IDU prevalence declined from a median of 279 injectors per 10,000 adults in 1992 to 156 injectors per 10,000 adults in 2002. IDU prevalence for White adults remained relatively flat over time (median values ranged between 86 and 97 injectors per 10,000 adults). HLM analyses described similar trends and suggest that declines in Black IDU prevalence decelerated over time. Both sets of IDU estimates correlated cross-sectionally adequately with validators, suggesting that they have acceptable convergent validity (range for Black IDU prevalence validation: 0.27 < r < 0.61; range for White IDU prevalence: 0.38 < r < 0.80). These data give insight, for the first time, into IDU prevalence trends among Black adults and White adults in large U.S. MSAs. The decline seen here for Black adults may partially explain recent reductions in newly reported cases of IDU-related HIV evident in surveillance data on this population. Declining Black IDU prevalence may have been produced by (1) high AIDS-related mortality rates among Black injectors in the 1990s, rates lowered by the advent of HAART; (2) reduced IDU incidence among Black drug users; and/or (3) MSA-level social processes (e.g., diminishing residential segregation). The stability of IDU prevalence among White adults between 1992 and 2002 may be a function of lower AIDS-related mortality rates in this population; relative stability (and perhaps increases in some MSAs) in initiating IDU among White drug users; and social processes. Future research should investigate the extent to which these racial/ethnic-specific IDU prevalence trends (1) explain, and are explained by, recent trends in IDU-related health outcomes, and (2) are determined by MSA-level social processes.
Appendix
Available only for authorised users
Footnotes
1
While MSAs are constructed using counties in almost all U.S. regions, in New England, MSAs are based on cities and towns. New England County Metropolitan Areas (NECMAs), however, are county-based areas. To ensure comparability across the sample, we used NECMAs in New England. For brevity’s sake, we refer to NECMAs as MSAs henceforth.
 
2
For each database and race/ethnicity, cells were defined by year and MSA (11 years × 95 MSAs = 1,045 cells).
 
3
Notably, between 2000 and 2002, PEP counted individuals who identified as belonging to multiple racial/ethnic groups as multiple people (e.g., a single individual who self-identifies as non-Hispanic Black and non-Hispanic White will appear in the PEP database during these years as two distinct people, one of each racial/ethnic group). In contrast, multiracial individuals appear only once in 1992–1999 PEP data, either in the single racial/ethnic category they identify with most closely or in a “more than one race/other race” group. TEDS, APIDS, and CTS all used the latter classification method throughout the time period. Given that only about 1% of residents of the MSAs in our sample identified themselves as belonging to more than one racial/ethnic group in the 2000 Census, this shift should have a negligible impact on our estimates.
 
4
These fatalities include those arising from harmful drug use, dependence, poisonings (accidental, intentional, and of undetermined intent), and from drug-related mental and behavioral disorders.
 
5
Visual inspection of quantile–quantile plots for each racial/ethnic-specific IDU estimation method indicated deviations from normality for some MSAs. Removing these MSAs did not affect our substantive findings, and so we report results calculated with the full dataset.
 
6
Tables reporting index-based estimates of IDU prevalence for Black adults and for White adults for each MSA and year of the study period are available in this paper’s online “Appendix”.
 
7
The CDC’s AIDS-related database does not report the date of death. Instead, it records the date of AIDS diagnosis for each case and an indicator of whether the individual was alive in 1999. Deaths occurring after 1999 are not recorded.
 
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Metadata
Title
Estimating the Prevalence of Injection Drug Use among Black and White Adults in Large U.S. Metropolitan Areas over Time (1992–2002): Estimation Methods and Prevalence Trends
Authors
Hannah L. F. Cooper, ScD
Joanne E. Brady
Samuel R. Friedman
Barbara Tempalski
Karla Gostnell
Peter L. Flom
Publication date
01-11-2008
Publisher
Springer US
Published in
Journal of Urban Health / Issue 6/2008
Print ISSN: 1099-3460
Electronic ISSN: 1468-2869
DOI
https://doi.org/10.1007/s11524-008-9304-9

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