Participants also reported substantial amounts of substance use. On the NIDA Quick Screen, 69% of participants reported binge drinking, 78% tobacco use, 29% prescription drugs for non-medical reasons, and 51% illegal drugs in the past year. Of the 55 participants who reported use of illegal drugs or of prescription drugs for nonmedical reasons on the NIDA Quick Screen, 54 then responded to the NIDA-Modified ASSIST, and SSIS were calculated . Mean SSIS scores were in the moderate-risk range for every substance except prescription stimulants, which was low-risk. The mean SSIS was 20.6 for street opiates, 19.0 for methamphetamines, and 9.5 for cocaine. Exposure to abuse, neglect, or household dysfunction during childhood showed a moderate or strong correlation only with “other substances,” but this correlation was not statistically significant . All other substances had low and non-significant correlations with ACEs. PTSD symptoms were moderately correlated with stimulants , prescription opioids , and street opioids . PTSD symptoms were also associated with sedatives and inhalants, but these correlations were not statistically significant. Anxiety symptoms were moderately associated with prescription opioids , sedatives , and stimulants , however associations with street opioids and inhalants were not significant. Symptoms of depression were moderately associated with prescription opioids and stimulants , however moderate associations with inhalants, street opioids,plant cultivation solutions and other substances were not significant.We explored correlations between trauma and mental health symptoms , and SSIS substance use scores . Our study indicated high rates of ACEs, substance use, and current mental health symptoms among homeless TAY in San Francisco.
Although substance use was not significantly correlated with trauma, it was significantly correlated with mental health symptoms, suggesting that a person’s response to trauma, and their lack of resources to process the trauma, may lead to unhealthy coping through substance use. This population may have even fewer resources than their housed counterparts to cope in healthy ways. These findings are consistent with existing scientific literature . TAY experiencing homelessness in this study reported a mean of 5.9 adverse childhood experiences before the age of 18, and over three-quarters of participants reported more than 4 ACEs. This finding parallels other research on childhood trauma exposure among these youth . Participants also reported high rates of mental health symptoms, with many reaching diagnostic thresholds for PTSD, depression, and/or anxiety, again similar to existing research . Most participants lived in and around San Francisco’s Tenderloin neighborhood, an area with high rates of poverty and violence, which may have contributed to their experiences of trauma and mental health symptoms. Although we measured experiences of trauma prior to the age of 18 years, and all participants were over the age of 18, living in an area with high rates of poverty and violence puts individuals at additional risk for trauma. This serves as a barrier to accessing care for the sequelae of traumas experienced previously. Homeless TAY frequently have difficulty accessing services such as shelter, medical care, mental health services, and employment due to stigma, a lack of knowledge about available resources, and a lack of services targeted to young individuals . Rates of substance use among our participants were high, and while much of their use fell within the range of moderate-risk of harm, adolescence and young-adulthood are times of life during which the risk of developing substance misuse problems and disorders is high, making even moderate-risk use worrisome .
At the same time, youth misuse of substances may increase their risk for experiencing trauma, violence, and injury, and for contracting communicable diseases such as HIV and Hepatitis C . TAY whose substance use behavior falls within moderate-risk levels of harm are a population in high need of monitoring and interventions to minimize substance use as well as co-occurring issues. Our findings also indicated that substance use was significantly correlated with current PTSD symptoms. An integrative review examining literature on the relationship between early life stress, childhood trauma and abuse, substance use, and addiction found strong evidence that interpersonal childhood trauma is associated with an increased vulnerability to substance use disorders . Reasons for this may be due to the permanent changes to the brain’s stress circuitry formed by early life stressors . This may help explain at the individual-level why our findings show a significant relationship between trauma symptoms and substance use. Interestingly, in our sample we did not identify correlations between ACEs and most types of substance use, although this has been observed in other literature. A community study recruiting youth ages 18-25 years found specific scores and types of ACEs to be significantly associated with substance use . Participants who have high or multiple exposures to ACEs were at higher risk for alcohol related problems, current substance use, and mental health symptoms when compared to participants who have none to low ACEs . The lack of correlation in the current study may be due to the high number of ACEs reported by our participants, on average. While there was little correlation between ACEs and substance use, there was a significant correlation between the longer-term consequences of trauma – PTSD, depression, anxiety – and substance use.We conducted a cross-sectional study, which limits our ability to conclude whether exposure to trauma or experiencing mental health symptoms directly influences participant use of substances.
We also recruited participants using convenience sampling, which increases the risk for selection bias. In examining potential selection bias, we found that our participant demographics largely mirrored the 2019 homeless youth point-in-time count, with the exception of gender; in our study, 67% of participants identified as male, but only 48% identified as male in the point-in-time count . This could affect generalizability to the larger homeless TAY population in San Francisco. Additionally, since the study was conducted in San Francisco, these results may not be generalizable to other locations. One limitation of data collection instruments such as the NIDA-Modified ASSIST is their validation for use in adult populations rather than transitional-aged participants, which may affect reliability. Participants were asked intimate questions about their childhood trauma, mental health symptoms, and current and past use of substances which may have resulted in an under reporting of trauma, mental health symptoms, and substance use due to social desirability bias. The CBO suggested that data collection be completed through face-to-face interviews,efficient farming methods and this may have resulted in social desirability bias. Future research with this population should consider data collection methods that allow for both confidentiality and participation of individuals with lower reading skills. Our study did not categorize ACEs into types of trauma nor did we separate ACEs scores into low moderate and high categories due to our sample size. Our findings could be influenced by our methodology and sample size, potentially resulting in a type II error. Another limitation in determining links between childhood trauma and substance use is the proximity in time between adolescence and young adulthood. It is difficult to determine which adverse experiences began and ended prior to the age of 18 years and which have not. This is one possible reason why we did not find any significance between ACEs and substance use when studies among older populations have found such a relationship . Due to the length of the survey, we did not measure all potential sources of trauma . Thus, we are unable to assess whether recent trauma or specific types of trauma are more correlated with substance use than generalized adverse experiences in childhood. The COVID-19 pandemic has produced major disruptions in daily life. A recent review concluded that the world population is experiencing increased stress, anxiety, and depression due to the pandemic and associated mitigation measures . In late June 2020, 40% of U.S. adults reported experiencing mental health symptoms, a stress disorder, or increasing substance use to cope with pandemic-related stress . Individuals with problematic substance use are particularly vulnerable to COVID-19 illness and psychosocial effects of the pandemic, such as stress and substance use treatment disruptions . Disruptions in treatment increase risk of overdose, a serious complication of substance use disorders . Moreover, depression and anxiety commonly co-occur with substance use disorders . Evidence suggests that in the general population, increases in alcohol consumption during COVID-19 may be driven by stress, depression, and anxiety . Effects may be even more pronounced among individuals with problematic substance use. Periods of intense stress can give light to pre-existing fissures and vulnerabilities in people’s daily lives. A better understanding of substance use problems, depressive symptoms, and anxiety during the COVID-19 pandemic among people with problematic substance use can inform intervention efforts needed now and post-pandemic.
According to behavioral economics, the COVID- 19 pandemic and associated mitigation measures may decrease the negative consequences of substance use . Many individuals are now working from home and have a more flexible schedule, making some of the negative consequences of substance use less relevant than before the pandemic. Simultaneously, the pandemic has limited the availability of alternative rewarding activities that are incompatible with substance use . Substance use and associated problems may increase if individuals are home more often and unable to engage in their usual activities, especially in the evenings . Moreover, other responsibilities at home may have increased during the pandemic. New consequences associated with substance use may emerge as lifestyles, schedules, and responsibilities shift. In sum, relationships between pandemic-related lifestyle factors, substance use, and substance use problems are likely complex and multifaceted. To better understand how individuals with problematic substance use are experiencing the pandemic, this exploratory, cross-sectional study examined associations between substance use problems, mental health symptoms, and pandemic related increased family responsibilities and stressors. Correlations between substance use problems, pandemic impacts and behaviors, and mental health symptoms are presented in Table 1. Significant correlations indicated that participants who, during COVID-19, struggled with responsibilities at home, had greater mental health impacts, greater personal growth, frequented bars or large gatherings, and reported more depression and anxiety symptoms had higher SIP-AD scores. Participants who, during COVID- 19, struggled with responsibilities at home, had difficulty getting necessities, had greater mental health impacts, and worried more about their children had higher GAD-7 and PHQ-8 scores. Anxiety and depression scores were highly correlated. Participants who lost a job or income during the pandemic had higher PHQ-8 scores. Struggling with home responsibilities was associated with job or income loss, greater difficulty getting necessities, greater pandemic mental health impacts, less personal growth during the pandemic, avoiding large gatherings, and avoiding school or work. Difficulty getting necessities was associated with greater mental health impacts. Personal growth was associated with lower likelihood of avoiding large gatherings, and worrying about one’s children was associated with greater likelihood of avoiding non-essential travel. The COVID-19 precautions were significantly associated with each other. Multi-variable analyses are presented in Table 2. Participants with greater pandemic related mental health effects had higher SIP-AD, PHQ-8, and GAD-7 scores. Younger participants had higher SIP-AD scores, and participants without a college degree had higher GAD-7 scores . Age was not associated with GAD-7 or PHQ-8 scores, and education was not associated with SIP-AD or PHQ-8 scores. Sex, race/ethnicity, marital status, and other pandemic-related variables were not associated with SIPAD, GAD-7, or PHQ-8 scores. Because only participants with children completed the “worries about children” measure, we repeated the GAD-7 and PHQ-8 models excluding this variable. In the full sample, females had higher GAD-7 scores than males . Otherwise, only pandemic-related mental health effects remained associated with GAD-7 and PHQ-8 scores. During the COVID-19 pandemic, 40.6% of surveyed adults with substance use problems reported struggling with responsibilities at home. Struggling with responsibilities at home during the pandemic was associated with more substance use problems and greater depression and anxiety symptoms. Obtaining, using, and recovering from substances can impair one’s ability to fulfill obligations. New responsibilities resulting from the pandemic, such as full-time childcare due to school closures, may be difficult to fulfill while struggling with substance use. Results are consistent with extant literature showing that unpaid care giving during COVID-19 was associated with increased substance use . Individuals struggling with substance use, anxiety, and depression may need support in meeting their own needs as well as their family’s needs during the pandemic. Additionally, frequenting bars or large gatherings, experiencing negative mental health effects, and perceiving more positive personal growth from the pandemic were associated with more substance use problems.