A COMPARISON OF EMPLOYED AND UNEMPLOYED INDIVIUDALS SEEKING TREATMENT FOR SUBSTANCE USE IN FINLAND
Lucy Wu Master’s thesis Public Health School of Medicine
Faculty of Health Sciences University of Easter Finland December 2015
ACKNOWLEDGEMENT
I would like to thank Ifeoma N. Onyeka and Jussi Kauhanen for supervising and having confidence in me for this thesis. I am grateful to Ifeoma for sharing her knowledge of the data and the topic, without it this thesis would not have been possible. Thank you to Sohaib Khan for the patience and support throughout this process, and for introducing me to my
supervisors.
To my coordinator Annika Männikkö, I am thankful for her constant encouragement and counselling. I am extremely grateful to my friends and family for their unwavering faith in me, for the motivational talks and for listening to me for hours on end about this thesis.
All these people have been instrumental in the completion of this thesis and have all contributed to my growth as a researcher, an academic and as a person. This was a unique experience that will remain in my memory for many years to come.
‘Nada cambia si no cambiamos nada’
Abbreviations
AIDS Acquired Immuno-deficiency Syndrome
DSM – 5 Diagnostic and Statistical Manual of Mental Disorders version 5 DSM – IV Diagnostic and Statistical Manual of Mental Disorders version 4 EAPs Employee Assistance Programs
EMCCDA European Monitoring Center for Drugs and Drug Addiction
GDP Gross Domestic Product
HDI Helsinki Deaconess Institute
HIV Human Immuno-deficiency Virus
HUUTI Huumehoito tietokanta
ICD International Classification of Diseases ILO International Labour Organization
IV Intravenous
NCADD National Council on Alcoholism and Drug Dependence
SD Standard Deviation
SPSS Statistical Package for Social Sciences
WHO World Health Organization
UNIVERSITY OF EASTERN FINLAND
Faculty of Health Sciences, Institute of Public Health and Clinical Nutrition Public Health
WU, LUCY Y.Q.: A comparison of employed and unemployed individuals seeking treatment for substance use in Finland
Master’s thesis, 60 pages.
Instructors: Ifeoma N. Onyeka, MBBS, MScPH, MBA, and Jussi Kauhanen, MD, PhD, MPH December 2015
Key words: HUUTI, Substance use, substance use, employed, unemployed, mental health, Finland
A COMPARISON OF EMPLOYED AND UNEMPLOYED INDIVIDUALS SEEKING TREATMENT FOR SUBSTANCE USE IN FINLAND
Globally and within Finland, substance use is a prominent health issue and a target area for public health interventions. Differences between employed and unemployed treatment seeking substance users is less studied. This study describes the sociodemographic characteristics, substance use habits and treatment of employed and unemployed individuals who sought care in the Greater Helsinki Area from 2001 to 2008. It also assessed the trend of employed and unemployed individuals accessing treatment over the period.
A cross-sectional analysis was conducted on baseline data from 1688 employed and unemployed individuals who accessed treatment at the Helsinki Deaconess Institute between 2001 and 2008. A total of 325 (19.3%) were employed and 1363 (80.7%) were unemployed.
The data for this study was collected as part of routine clinical procedures, where clinicians interviewed each individuals using a structured questionnaire at the initial visit. The Mann- Whitney Test was used for continuous variables, and Chi-Squared Test or Fisher’s Exact Test was used for categorical variables.
Those employed were found to have higher levels of education (P<0.001), used substances mainly via an oral route (P<0.001) and used them less frequently than the unemployed (P=0.001). Of the unemployed individuals, it was found that they mainly gained income through income support or through unemployment benefit (P<0.001), were more likely to live with other substance users (P<0.001) and have psychotic symptoms (P=0.038), and used substances primarily via an IV route (P<0.001). Both groups were similar in gender (P=0.501), marital status (P=0.114), polydrug use (P=0.356), depressive symptoms (P=0.509) and suicidal thoughts (P=0.240). Those unemployed (41.2%) were more likely to use opiates as their primary drug of use compared to employed (30.8%, P<0.001). For secondary drug of use, both reported cannabis as the most common substance however in the employed stimulants (25.8%) were second, while medication (24.5%) use was second in the unemployed, (P<0.001). Self- referral (P<0.001) was the primary route of entry into treatment, and out-patient treatment (P<0.001) was the most common method of treatment for both employed and unemployed. The treatment seeking trend from 2001-2008 was fairly stable with the majority being unemployed (P=0.731), though the total population of treatment seekers per year declined.
This study found that unemployed individuals had lower levels of education, more mental health issues, used substances more frequently and were more likely to live with other substance users compared to the employed. These all contribute to a reduced capacity to gain employment.
Table of Contents
1. Introduction ... 7
2. Literature Review ... 9
2.1 Substance use ... 9
2.2 Employment ... 11
2.3 Demographics of the Substance User ... 12
2.4 Mental Health of the Substance User ... 14
2.5 Unemployment and Substance Use ... 16
2.6 Employment Challenges of Substance Users ... 17
2.7 Impact of Employing Substance Users ... 20
2.8 Integration of Substance Users into the Workforce ... 23
2.9 The Working Substance User ... 24
2.10 Motivation for Substance Use at Work ... 26
2.11 The Effect of Substance use on the Work Environment ... 28
2.12 The Effect of Substance use on Society ... 28
2.13 Addressing Substance use Among Workers ... 29
3. Significance of the study ... 31
4. Objectives ... 32
4.1 Overall Objective ... 32
4.2 Specific Objectives ... 32
5. Methodology ... 33
5.1 Study Design and Participants ... 33
5.2 Data Collection ... 35
5.3 Statistical Analysis ... 35
5.4 Ethical Consideration ... 35
6. Results ... 36
6.1 Distribution of Study Population ... 36
6.2 Sociodemographic Characteristics ... 37
6.3 Mental Health Status ... 39
6.4 Drug Usage ... 40
6.4.1 Primary Drug of Use ... 40
6.4.2 Secondary Drug of Use ... 41
6.5 Treatment ... 43
6.5.1 Trend in Treatment Seeking ... 43
6.5.2 Differences in Referral Type and Method of Treatment ... 44
7. Discussion ... 46
7.1 Findings and Methodology ... 46
7.2 Strengths and Weaknesses ... 50
7.3 Implications and Recommendations ... 51
8. Conclusion ... 52
9. References ... 53
1. INTRODUCTION
Globally and within Finland, substance use is a prominent health issue and is a target area for public health. Around 15.3 million people have a substance use disorder in the word, with about 20,000 living in Finland [European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) 2015a; World Health Organization (WHO) 2015a]. Substances include alcohol, illicit drugs and pharmaceutical drugs (WHO 2015b). The excessive or toxic use of these substances lead to various physical and mental health issues that make everyday life challenging for the individual. This in turn has an effect on their relationships, social life, working life and on society as a whole.
Problematic substance use has been linked with unemployment and mental health issues. In Finland, the social welfare system provides for those who are unable to provide for themselves (Statistics Finland 2015a). In the case of substance users, they are often supported through various benefits for daily necessities and receive free health services should they need it. As substance use has been linked to unemployment, the current increase in unemployment of 6.3%
from 2014 to 2015 accumulating to an 8.7% unemployment rate may result in an increased cost for the state to bare (Statistics Finland 2015b). Furthermore there has been evidence that substance users have more coexisting health needs thus resulting in higher usage of health services and resources (Kemp & Neale 2005). In Finland the drug-related expenditure in 2012 was 61% on public order and safety, 25% on social protection and 13% on healthcare which used 0.2% of the Gross Domestic Product (GDP) (EMCDDA 2015b). In light of these facts, unemployed substance users are consuming resources of the state from a health and financial perspective while not participating in society or the economy of the country.
Of the employed substance users, the individual may have an accident at work that could place themselves and others in harm. This may also cause the employer to suffer losses in productivity and costs related to the accident, such as sick pay and replacement staff [Australian Drug Foundation 2015; National Council on Alcoholism and Drug Dependence (NCAAD) 2015]. A study in the United States found that occupational accidents cost, direct and indirect, over $100 billion US dollars annually, the percentage allocated to substance use is hard to specify (Leigh 2000). However, it is a percentage that needn’t be there.
Gaining a better understanding of the differences in sociodemographic, mental health and drug use characteristics between employed and unemployed substance users have implications for regulations, policies and development of effective interventions to address drug use among employees. Comprehensive literature searches revealed that in Finland there are no other studies on employment status and problematic drug use at present. The aim of this study is to compare and describe employed and unemployed substance users who sought treatment within the Greater Helsinki Area from 2001 to 2008.
2. LITERATURE REVIEW
2.1 Substance Use
Substance use is a phenomenon that occurs worldwide and is a pressing health issue. The World Health Organization (WHO) defined substance abuse as a “persistent or sporadic excessive drug use inconsistent with or unrelated to acceptable medical practice” in 1969, and it is still the definition employed by the WHO today. Substances include alcohol, illicit drugs, and pharmaceutical drugs. (WHO 2015b)
The term ‘abuse’ is shrouded in ambiguity thus is not used in the International Classification of Diseases (ICD-10) and no longer employed in the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-5). In the DSM-IV there were separate categories for substance abuse and dependence, however due to the ambiguity of the terms and their differences, in the DSM-5 they were combined under the title ‘substance use disorder’. (American Psychiatric Association 1994; American Psychiatric Association 2013)
The DSM-5 defines a substance use disorder as having at least 2 of the 11 criteria as grouped into four categories as seen below in Table 1. The more criteria fulfilled indicates the severity of use - mild (2-3), moderate (4-5) and severe (6+). (American Psychiatric Association 2013)
Table 1. Categories and criteria defining a substance use disorder (American Psychiatric Association 2013)
Impaired Control - Taking more or for longer than intended - Unsuccessful efforts to stop or reduce use
- Spending large amounts of time obtaining, using, or recovering from use
- Craving for substance
Social Impairment - Failure to fulfill major obligations due to use
- Continued use despite problems caused or exacerbated by use - Important activities are given up or reduced because of substance use
Risky Use - Recurrent use in hazardous situations
- Continued use despite physical or psychological problems caused or exacerbated by substance use
Pharmacologic Dependence
- Tolerance to effects of the substance
- Withdrawal symptoms when not using or using less
Taking these factors into account, a general explanation of problematic substance use can be summed up as the harmful or hazardous use of psychoactive substances including but not limited to alcohol, opiates, cannabis and stimulants (WHO 2015a; WHO 2015b).
At least 15.3 million people in the world have a substance use disorder (WHO 2015a). Of these individuals, the majority are young and male with the highest prevalence of substance use disorders clustered in the Americas, primarily concentrated in South America. Colombia holds the highest percentage of males and females with substance use disorders above 15 years of age in the Americas at 3.14% and 1.04% respectively (WHO 2012).
In Finland, the rates are 0.23% and 0.07% for substance use disorders in over 15-year-old males and females respectively (WHO 2012). This is relatively low compared to other countries in Europe. Over the past years, the rate of use and sociodemographic characteristics of users in Finland has been fairly constant at around 20,000 problematic substance users (EMCDDA 2015a). However, it is important to note that the National Institute for Health and Welfare report on the drug situation in Finland in 2014 states that there has been an increase in annual deaths related to drugs (Varjonen 2015). Globally and in Finland substance users typically have low education attainment (WHO 2012; EMCDDA 2015c).
Another aspect to consider is poly-drug use. Poly-drug use is when an individual uses multiple types of substances, either on their own or in conjunction with other drugs (Department of Health 2008). Within Finland, poly-drug use is very common in treatment-seeking individuals with 62% claiming to use at least three different substances (Varjonen 2015). The illegal nature of psychoactive substances causes barriers to access that may result in individuals taking other substances when their preferred substance is inaccessible. Whether it is interception of a supply by police or increased cost due to low supply, there will be times when the individuals’
substance of choice is unavailable. Thus, they turn to an alternative to getting high. A typical combination is of a depressant (e.g. Heroin) and a stimulant (e.g. ecstasy) to counter balance the undesired effects and produce a different high. (Leri et al. 2003; Varjonen 2015) Individuals may simply enjoy the effects of multiple types of substances or the combined effects. Another school of thought is that they are taking substances in an environment where other substances are around, and when they are under the influence of a substance, they could be more susceptible to taking other substances. For example, when individuals are under the influence of alcohol they are more likely to take other substances. (Staines et al. 2001; Department of Health Australia 2008)
2.2 Employment
The employable population in Finland is defined as economically active. Students, persons less than 14 years of age, pensioners, conscripts and other are defined as economically inactive thus not of interest to this study. The ‘other’ population includes those who are unable to participate economically due to disability; physical and/or mental. (Statistics Finland 2015c)
In Finnish employment legislation the common groupings within the employable population are employed and unemployed. The employed include full-time and part-time work while unemployed encompasses the rest of the employable population. Those in the unemployed population can include casual, seasonal or atypical work. (International Labour Organization (ILO) 2015; Statistics Finland 2015c) A few examples of atypical work include recycling, panhandling or illegal dealings (Debeck et al. 2011).
The regulation of Finnish labour is highly organized with a very comprehensive and detailed legislation that encompasses specifics on contracts of employment, hours of work, and equality as outlined in section 6 of the Finnish Constitution (Ministry of Justice Finland 2011; ILO 2015). Occupation of employment is also an area to consider as different occupations have differing work environments and social norms (Seddon 2006; Richardson et al. 2012).
Full time and part time work provide the individual with a routine, social network and a stable source of income that may have an effect on the individual’s perspective on life, priorities, motivations and lifestyle choices (Seddon 2006; Richardson et al. 2012). This highlights the importance of the quantity of hours of work and leisure. From another perspective, the quality of work and the work environment are also important factors. They determine the value or lack of value the individual places on their work such as tasks, relationships and the company; and influences their psychosocial wellbeing. (Hämäläinen et al. 2005; Frone 2008)
2.3 Demographics of the Substance User
Studies have shown that substance use disproportionately affects males over females. There are multiple mechanisms and factors influencing the higher proportion of males abusing substances. From the historical and social perspective, throughout history males have had more control over society, as illustrated by their dominance in governance positions and their personal lives creating an inherited inequality in today’s population. Females in many cultures have a more passive role, for example being a housewife was and still is a common norm in many societies whereas its counterpart, the househusband, is a comparatively new concept.
(Ramsey et al. 2001; Frone 2003; Neale 2004; Frone 2008; Frone 2012; Fattore et al. 2014;
Kuhn 2015) This line of thought could also contribute to the differences in employment.
Males were also more likely to be in situations where they would encounter illicit substances as shown by male dominance in fields of science historically. A more recent example of gender- related exposure is during the Vietnam War; mainly males were deployed for duty where many began to use substances to find relief from the effects of war (Tsuang et al. 1998). There may also be gender-related personality or developmental traits placing males more at risk of using and abusing substances than females (Lengua & Stormshak 2000; Fattore et al. 2014; Kuhn 2015). Fattore et al. (2014) and Kuhn (2015) both support the notion of differences in gender based on biological reasons, especially hormonal differences. Overall research has been consistent in the male to female ratio with regards to using and abusing substances, regardless of employment status (Lengua & Stormshak 2000; Neale 2004). On account of these reasons, the difference in gender distribution can logically be attributed to a cumulative protective effect of gender norms on females.
Age can be an indicator of substance usage as there is a general downward trend of substance use as age increases (Macdonald & Pudney 2000a; Frone 2008; Frone 2012). This has been conceptualized as simply growing or maturing out of a phase due to the demands of life (Frone 2008). As mentioned previously, hormonal mechanisms may also contribute to the relationship between age and usage (Fattore et al. 2014; Kuhn 2015). Individuals often encounter and begin exploring substances during adolescence. During this period, there are developmental characteristics that may predispose them to increased or problematic use, particularly as there is often a lag between first usage and problematic usage. The majority of problematic substance users are in their 20’s. (Buchmueller & Zuvekas 1998; Macdonald & Pudney 2000a)
Studies have shown that employment has differing connotations for different age groups. Based on literature there are differences between adolescent and adult substance users that are employed. For adolescents, typically of high school age (14-18) there are a few areas to take into consideration (Osilla et al. 2013). Frone (2003) highlights that adolescence is a vital developmental period where individuals begin to participate in the economy, and initiated into the culture of the workforce. Taking note that the workplace influences the path of development which may be harder to alter once the individual is older and established in the workforce.
In adolescence, the brain is not yet fully developed and some biological reasons can contribute to sensation seeking, impulsivity and self-control difficulties (Potenza 2013). When adolescents are working it is likely that they will be in contact with older coworkers that practice more adult
recreational activities such as alcohol and substance use, thus introducing it to them (Osilla et al. 2013). These aforementioned factors combined with the urge to sensation seek may ensue substance use.
Adolescents who are employed, particularly those with high work intensity, have an income to support substance use, less parental supervision, more opportunities to use substances, and more contact with individuals who use substances (Osilla et al. 2013). Therefore, for some individuals it may be unwise to gain employment during adolescence. Despite this, there are still many merits to obtaining employment during adolescence that support growth and development of skills beneficial for later life.
An interesting study conducted in the United States by Johnson (2004) found that as the amount of work increased the amount of substance use increased for white adolescents. There was no conclusive relationship for minority groups, including African-Americans and Asian Americans. The reasoning behind these results is indicative of the employment opportunities of the area they live in. For example, low socioeconomic areas have fewer job opportunities, and adolescents may struggle to compete against older applicants. Those adolescents who gain employment may have to help support their family and pay for schooling expenses. As a result, they have less spending money to purchase substances. The employed adolescents identify themselves as being responsible and independent which can make them more inclined or repel them from substance use. Those individuals from more affluent areas that gain employment may not need the income for daily life and thus can use it to purchase substances. This study indicated that obtaining employment during adolescence might provoke substance use in some groups but not others.
2.4 Mental Health of the Substance User
Among substance users, disorders related to mental health are highly prevalent. This can be associated with the effects of the substance itself or changes in behaviour causing disturbances in their usual daily routines and relationships. (DeSimone 2002; Frone 2003; Onyeka et al.
2013; Sledge & Lazar 2014) For example, cocaine produces an immense high and a sense of euphoria due to the effect on the nervous system, when the effect wears off the individual may experience feelings of low mood or depression. To relieve themselves from the low and return
to a state of euphoria they seek another dose of cocaine, thus creating a cycle that is hard to break. (DeSimone 2002; Phillips et al. 2013)
Societal social norms have been shown to have a strong effect on the individual. Phillips et al.
(2013) showed that patterns of substance use occurred mainly outside of work hours regardless of employment status. As a society, we do not accept substance use as a norm, thus pushing them to the edge of society where they are often excluded and isolated. These feelings associated with being essentially rejected by society are a psychological burden that may increase their usage of substances to find a sense of relief or escape. (Kemp & Neale 2005;
Seddon 2006) Overall these individuals lack social support networks, feel ostracised by society and, as a result, may turn to substances as a coping mechanism (Luoto et al. 1998; Frone 2003).
Individuals rejected by society are often clustered together meaning that they influence each other in their habits, such that they may begin using substances together (Seddon 2006). These individuals may feel helpless and become hopeless as society seems to be uninterested or perceived to have given up on them further worsening their mental health and motivation to participate in society by gaining employment (Kemp & Neale 2005). Mental health itself is a limiting factor for finding employment, and in conjunction with substance use the task of finding employment becomes increasingly challenging.
When an individual is unemployed they have more free time, may spend more time alone becoming increasingly bored which could compromise their mental health (Macdonald &
Pudney 2000b; Seddon 2006). A study by Hämäläinen et al. (2005) found that current and long- term unemployment was linked to an increased risk of depressive episodes that was further increased by frequent alcohol intoxication. In lieu of this, it can be reasoned that when the individual is an unemployed and a substance user they are more at risk of mental health issues as depicted in Figure 1.
Figure 1. Relationship between substance use, employment and mental health
2.5 Unemployment and Substance Use
Previous research has supported the link between unemployment and substance use (e.g. Luoto et al. 1998; MacDonald & Pudney 2000a; Hämäläinen et al. 2005; Rivera et al. 2013; Compton et al. 2014). The relationship between the two is very complex with many variables all affecting each other making it challenging to differentiate the cause and effect.
Compton et al. (2014) discuss the idea that substance use is a reaction or coping mechanism to the event of losing employment or persistent unemployment. Individuals who use substances to cope with the daily stressors of life are more likely to increase usage during employment hardship indicating that internal traits may be manifested in substance use and employment status. The effect of problematic substance use on health, physically and mentally, has also been argued as an explanation of unemployment (Henkel 2011). Substance use is commonly seen as a risk factor for unemployment, especially long-term use, due to the psychological reasons behind substance usage. For example, research has suggested that substance users are less concerned with conforming to societal norms of education and career progression thus unmotivated in gaining employment. Said differently, those using substances are likely also to be unemployed. (Luoto et al. 1998; MacDonald & Pudney 2000a; MacDonald & Pudney 2001;
Compton et al. 2014)
Substance use
Employment challenges Mental health
issues
Individuals who are governed by their substance using routines face difficulties in seeking or maintaining jobs, leading to long-term unemployment. Those with long-term unemployment are more likely only to gain jobs that are insecure, mundane and undesirable, hence further deterring them from job seeking. (MacDonald & Pudney 2001; Hämäläinen et al. 2005; Henkel 2011)
On the societal level, those who are unemployed and their dependents are provided for by the state. Though the financial support may not be substantial, substance users may forego daily necessities to fund their addiction and not make an active effort to seek employment. Health and social services for substance users are provided free of charge by the state meaning when the individual is unemployed and using substances, they are consuming more state resources than the employed substance user. (DeSimone 2002) Even though in Finland the number of substance users is not very high compared to the European average, the costs to society may be substantial (EMCDDA 2015a; EMCDDA 2015c).
Gascon & Spiller (2009) found that the overall trend of unemployment was indicative of substance use. Hence, the current upward trend of unemployment in Finland shown by an increase in unemployment rate of 6.3% from 2014 to 2015 accumulating to 8.7% in October 2015 may result in increased costs for the state to bare (Statistics Finland 2015b).
2.6 Employment Challenges of Substance Users
Substance users have many disadvantages and, as a result, face multiple challenges to gain employment as outlined in Table 2. At the individual level, many internal reasons make it hard to obtain employment such as low morale, reduced confidence, concentration and motivation.
A lack of motivation to pursue employment is an onerous task to overcome and may be reinforced by feedback that they are unwanted as shown by long-term or frequent unemployment. (Hasluck 2001; Kemp & Neale 2005; Henkel 2011) Difficulties in regulating affect and anxiety contribute to troubles in building social connections needed for gaining employment (Hasluck 2001).
Individuals are often consumed by their substance of use and may go to extreme lengths to maintain their destructive lifestyle that can result in criminal offences such as theft; the individual may serve a jail or community service sentence. The destructive lifestyle often leads
to homelessness, poor general health, incapacity due to the effects of substances as seen in Table 2. Those who are receiving treatment for substance use are often incapacitated due to the effects of the substitution drug or withdrawal symptoms making them unable to participate in the economy. (Hasluck 2001; Kemp & Neale 2005; DeBeck et al. 2011)
Individuals tend to be young individuals with low education and have a lack of work specific skills (Kemp & Neale 2005). This is increasingly problematic at present where there are highly educated and skilled individuals struggling to find jobs. Gascon & Spiller (2009) found that the trend in unemployment was more indicative of opiate usage than the actual employment rate.
This is reasoned to be as a result of the perceived job opportunities available, and ease of gaining employment in a dismal job market. Hence users are less motivated to seek employment.
Another issue is the lack of suitable jobs for substance users, as mentioned previously certain occupations can be especially dangerous for the individual or co-workers (Kemp & Neale 2005;
DeBeck et al. 2011).
Substance users may have histories of crime or hold a criminal record as a result of their substance use (Kemp & Neale 2005). This is another barrier to gaining employment as many employers simply do not hire individuals with criminal records (Kemp & Neale 2005; DeBeck et al. 2011). Substance using individuals are commonly thought to be untrustworthy, unreliable and unsafe resulting in employers being unwilling to hire them (Klee et al. 2002). These points are summarised in Table 2 below.
Table 2. Barriers to employment of substance users
Individual Internal
- Reduced confidence - Lack of motivation - Poor affect regulation - Anxiety
- Poor concentration - Difficulty socialising - Low moral
External
- Lack of skills - Lack of education
- Criminal history (e.g. theft, assault, fraud)
- Mental health issues (e.g. depression, suicidal tendencies, schizophrenia)
- Other illness (e.g. HIV/AIDS, abscesses, hepatitis)
- Incapacitating effects of substances to function efficiently and safely - Substance use treatment effects (e.g. substitution drug causing them
unable to work, withdrawal symptoms)
- Atypical/disruptive lifestyle (e.g. sleep-wake cycles, poor diet) - Homelessness or lack of stable residence
- Long-term or frequent unemployment Organization - Policy on employee profile
- Discrimination - Lack of suitable jobs Society - Poor economic climate
- Discrimination
(Sources: MacDonald & Pudney 2000a; MacDonald & Pudney 2000b; Hasluck 2001; Kemp
& Neale 2005; DeBeck et al. 2011; Henkel 2011)
2.7 Impact of Employing Substance Users
Multiple studies have indicated that employment has a positive impact on the substance user concerning treatment outcomes and overall general health (Cebulla et al. 2004; DeFulio 2009;
Storti et al. 2011). Table 3 provides a synopsis of components in the studies. As mentioned earlier having a lot of free time could lead to substance use, thus when the individual is working they have less free time to use substances. They also gain social connections that require time as well as their presence. Having more social connections also provides the individual with more purpose and improves their reality that may reduce their desire to escape or alter it through substances. These connections also increase their mental health, and in turn reduce the likelihood of mental health induced usage. (Cebulla et al. 2004; Storti et al. 2011)
Having an employment status may be beneficial for substance users, especially those seeking to quit. When the economic landscape is not plentiful jobs are harder to find and requires a lot of persistence, time and commitment. It may be that having a job gives the individual a reason to stop using and put their energy into work. (Kidorf et al.1998; Augutis et al. 2015)
Cebulla et al. (2004) identified that employment can be a catalyst for the individual to reclaim their life from substance use. As seen in Table 3, in the short term the individual may experience increased motivation and self perception that in turn contribute to increasing independence and self-discipline to use their time more constructively. Overall these factors support their ability to create a lifestyle free of drugs. (Stori et al. 2011)
Having an income gives the individual a sense of independence, achievement and control over their life (Cebulla et al. 2004; Storti et al. 2011). However, there is also the risk that they may use this newfound income to purchase substances (Osilla et al. 2013). Given that many substance users want to gain employment and they are aware it is much harder for them to find a job, they may be deterred from doing things that may place their job at risk (DeBeck et al.
2011).
The majority of the abusing population is young meaning that early intervention is key to preventing long-term problems in health (WHO 2012; EMCDDA 2015c). Buchmueller &
Zuvekas (1998) concluded that harmful effects of substance use accumulate over time; hence supporting the theory that early intervention will minimize harm to the individual and society.
Successful intervention allows the individual the possibility of a long work career and the
ability to contribute constructively to society. Over time, communities and society may become safer and more productive. Employment of substance users reduces the likelihood of them working in unstable or atypical occupations thus reducing the amount of street disorder and petty crime (DeBeck et al. 2011).
There is a decreased burden on societies resources as the individual begins to contribute to society. They can provide for their family and their individual needs. The majority of substance users are younger, and the effects will be long term as the individual is towards the beginning of their work life. This is conducive to a healthy and sustainable workforce. The material, financial and human resources that could have been used on these now working substance users could be redirected to other societal needs. (DeSimone 2002; Birnbaum et al. 2011; DeBeck et al. 2011; Richardson et al. 2012)
As outlined in Table 3, every potential benefit of gaining employment also has the possibility to have the opposite effect. For example, the individual may increase their substance use due to having more disposable income resulting in increasingly secretive behaviours to hide their habit and retain their job for as long as possible (Storti et al. 2011). It is also important to point out that not all employment opportunities are equal, and some may foster positive outcomes while others may be damaging (Richardson et al. 2012). The possible adverse effects of gaining employment are a potential explanation for why there have been mixed reviews on the impact of employment on substance use. It is imperative to state that individuals are different and the substance abusing population is not homogenous, making it hard to predict what the effect employment may have on the individual substance user. (Frone 2008; DeFulio et al. 2009;
DeBeck et al. 2011; Storti et al. 2011; Frone 2012; Varjonen 2015)
Table 3. Impact of employment on the individual and society over time
Short term
Individual Society
Positive - Increased confidence, motivation and self-esteem - More constructive use of time - Increased economic
independence
- Decreased substance usage - Development of constructive
methods of coping
- Increased likelihood of seeking or completing treatment for substance use
- Increased social inclusion - Development of substance-free
relationships
- Symbolic of the individuals’
potential to lead a substance- free lifestyle
- Reduced or cessation of consumption of state benefits - Reduced street disorder (e.g.
fewer panhandlers)
Negative - Increased purchasing power - Increased consumption of
substances
- Consumption of other substances
- Development of maladaptive coping mechanisms to work stress
- Development of risky use habits
- Risk of relapse
- Increased market for substances
- Usage in work environments or during work hours
- Risk to themselves and others at work
- Risk of losing recently gained employment
Long term
Individual Society
Positive - Increased ability to maintain a lifestyle free of substances - Increased independence and
self-perception
- Improved relationships with family and friends
- Decreased risk of adverse health outcomes
- Increased resistance to relapse
- Increased social inclusion - Contribution to society
- Fewer funds needed regarding substance use
Negative - Harmful or maladaptive coping strategies to work and life
- Maintenance of substance use habits
- Undetected and untreated substance use issues (e.g.
mental health, infectious diseases)
- Poor financial situation
- Increased market for substance - Risk of participation in illegal
activities (e.g. theft, fraud) - Increased costs for society (e.g.
sick leave, medical expenses, loss of productivity)
- Risk of unemployment
(Sources: Kidorf et al.1998; Cebulla et al. 2004; DeSimone 2002; Frone 2006; Frone 2008;
DeFulio et al. 2009; Birnbaum et al. 2011; Storti et al. 2011; Frone 2012; Richardson 2012;
Varjonen 2015; Augutis et al. 2015)
2.8 Integration of Substance Users into the Workforce
If the individual is not ready to take part in employment, no matter how much organizations and society work to provide suitable, stable and safe employment environments they will not
succeed in gaining or maintaining a job (Kemp & Neale 2005). This implies that the individual must first reach a place where they are mentally and physically prepared to take part in the workforce. In lieu of this, gaining employment may be a step in reaching that place thus an integrated approach to treatment and suitable employment is needed for successful and beneficial integration back into society. (Macdonald & Pudney 2000a; Macdonald & Pudney 2000b; DeBeck et al. 2011; Storti et al. 2011; Richardson et al. 2012)
There have been projects focused on integrating substance users into the workforce that have had mixed results. As mentioned above, those in a state where they are ready to work will often succeed in programs supporting their search for employment. However, many programs have struggled due to workers tasked with helping these individuals are ill-equipped to handle the diverse challenges that they face, often resulting in the low success of such programs (Kemp &
Neale 2005; Henkel 2011).
Frone (2006) states that employees who were not integrated into the work environment were at higher risk of using substances. Some specific work conditions to avoid include irregular working hours, little supervision or visibility, lack of policies and courses of action regarding substance use (Frone 2006). Some characteristics of suitable jobs would include positions that included working with others, opportunities to build connections with people and have a variable workload that the individual can adjust (Seddon 2006; DeBeck et al. 2011). A study in Canada by DeBeck et al. (2011) found that many substance users would stop illegal or other temporary employments if they were able to gain stable lawful employment. An essential message to note, with regards to effective integration into the workforce, is the importance of rewarding working but not punishing substance use.
2.9 The Working Substance User
When an individual is under the influence of a substance their judgment, perception and ability to make choices are impaired (Frone 2008; Varjonen 2015). There is a large variation of these effects between different substances, and these effects are on a spectrum that can range from very mild to having life revelations (WHO 2015c). This can lead to accidents at work resulting in physical harm, loss of productivity or loss of employment. Table 4 outlines some short term and long term effects of using substances while working on the individual. In the short term the individual is a liability that can place them and others in risky situations that could result in
physical harm; they also risk loosing their job by going to work under the influence (Australian Drug Foundation 2015; NCADD 2015). In the long term, they are more likely to have accidents at work and thus accumulate greater health costs, accident compensation and absences while having questionable work productivity and output (Frone 2008; Australian Drug Foundation 2015; NCAAD 2015).
Table 4. Impact of substance use while working on the individual, work and society
Short term Long term
Individual - Poor judgment
- Poor concentration and focus
- Reduced work capacity and productivity - Risk taking
- Disregard for personal safety
- Distracting/disturbing for co-workers - Tardiness
- Increased risk of harm to self - Inconsistent quality of work - Increased absences from work
- Unexplained absences during work hours - Poor compliance to work hours
- Low productivity - Strange work patterns - Financial problems Work - Difficulty integrating into work
community
- Low participation or engagement in work activities
- Increased workload for other co-workers - Strain on other workers
- Increased risk of accidents and physical harm
- Dangers related to having substances at the worksite
- Possible financial problems - Complaints from co-workers - Unpredictable work output - Loss of productivity - Burnout of co-workers
- Increase accident related expenditure and costs
- Security risks to workplace
- Reduced rapport or poor relationship with co-workers
Society - Reduced access to substances while working
- Separation from other users - Unsafe disposal of substance use paraphernalia
- Medical costs - Production losses - Risk of harm to others
- Challenges in cleaning up substance use waste products
(Sources: Quayle 1983; Frone 2008; Australian Drug Foundation 2015; NCAAD 2015)
The current economic climate may also impact the substance user. As the economy decreases they may become stressed over possibility of job loss and turn to a substance to find relief, or they may reduce substance use for fear of dismissal due to their substance use. From another perspective, when the economy is growing they may feel less stressed about their job security and not need substances to cope or on the other hand they may increase their usage as they may perceive their job position to be more secure. (Henkel 2011)
There has also been studies on the link between substance use and income. Buchueller &
Zuvekas (1998) explained their finding of a positive relationship between substance use and revenue as those who are in high earning positions are often under more stress resulting in the consumption of more substances than those with lower income. Once again, highlighting that substance users are different, face differing stressor and have differing reasons for use.
(Macdonald & Pudney 2000a; Macdonald & Pudney 2000b) 2.10 Motivation for Substance Use at Work
The relationship that the individual has with the substances they use also plays a role in how it affects the working life. Many individuals use substances to escape from reality or find relief of some sort. As work becomes strenuous or overwhelming the individual may crave and use more, with time the individual may need a very high dose to achieve the same level of high (Macdonald & Pudney 2000a; Frone 2008; Varjonen 2015). Should the motivation behind gaining income be to purchase substances, working would sustain or even increase their substance use (Varjonen 2015).
Frone (2003) divided the main predictors of substance use into two main categories, internal and external as illustrated in Figure 2. The external category represents aspects outside of the workplace affecting motivation for use. These are rather constant, such as age and gender for demographics, and personality traits such as impulsivity, rebelliousness and risk taking. The expected effect of the substance of choice as a predictor to use is supported by DeSimone (2002). Specifically, the effects of cocaine may be used to regulate affect, enhance work performance or endurance in the short term. This effect on mood and affect is very powerful, possibly even greater than the increased physical performance (Frone, 2003).
Internal predictors of use are factors within the workplace. The physical and social availability are both predictors of substance usage at the workplace and outside. However, the social acceptance of substance use is much more powerful and indicative of usage. (Bacharach et al.
2002; Frone 2003; Seddon 2006; Frone 2008; Frone & Brown 2010; Frone 2012) The social aspects of the work environment indicative of use include low visibility, minimal supervision, high mobility, poor relationship with the organization, lack of policies and regulations may increase the risk of usage (Frone 2003; Frone 2012). The conclusion that these all increase risk of use may reflect the psychological burden associated with aspects such as isolation, loneliness, and lack of meaningful interactions. The lack of policy and regulation on substance use, especially disciplinary action, could be linked to a workplace social norm where substances use is not vetoed. (Bacharach et al. 2002; Frone 2006; Seddon 2006; Frone & Brown 2010;
Frone 2012) In general, as work stressors increase the likelihood of substance use substances increases as well. There are a vast amount of workplace stressors concerning differing work environments. The direction of effect and causality are not static therefore it can work in both ways. (Frone 2003; Frone 2012)
Figure 2. Internal and external predictors for employee substance use (Source: Frone 2003)
Frone & Brown (2010) found that workplace norms played a role in whether an individual uses or not. In particular, intrinsic norms (internal reasoning) are powerful enough to have an effect even outside the work environment indicating an intervention in a work environment has the
Availability
Social control at work
Work stressors Internal
Demographics
Personality
Expected effect of substance External
potential to have an impact on their daily lives. The study also found that there was transference of social norm concepts of alcohol to other substances, suggesting that this can be a method for targeting those who are secret substance users.
2.11 The Effect of Substance Use on the Work Environment
The trend is that as substance use increases the likelihood that the person is employed decreases (Frone 2008; Compton et al. 2014). There is a minority of individuals who are employed and substance users. These individuals may work while under the influence of one or more substances that pose a risk to their colleagues and the work environment. As seen in Table 4, they are at risk of causing physical harm to their colleagues and damaging work property. Some work areas pose more of a risk than others such as jobs requiring the use of machinery or driving vehicles, possibly causing fatal accidents (Quayle 1983; Frone 2008). This places not only the individual but also their colleagues and possibly even bystanders at risk of harm. These incidences can cause significant stress in the work environment as when an individual is absent the other workers need to cover the workload, and over time conflicts may develop; adding more stress to the environment. In the long term, there is an increased financial burden on the company due to loss of productivity, burnout of workers, costs of repairs and health care payouts. (Leigh 2000; Australian Drug Foundation 2015; NCAAD 2015)
All workplaces have their risks and hazards, and these can be worsened when a worker is working while on substance(s). It is logical that certain occupations have more risks than others and thus working under the influence is riskier is some professions. For example, construction workers handle a lot of machinery and equipment that could cause accidents while an office worker is unlikely to have the same risks of accidents as a construction worker. (Quayle 1983;
Leigh 2000; Australian Drug Foundation 2015; NCAAD 2015) 2.12 The Effect of Substance Use on Society
On the population scale, substance use costs society in many different ways. In countries with good welfare systems, such as in Finland, there is support offered to those injured by accidents or are unemployed. In Finland, the healthcare is funded through a Beveridge model system meaning that the funds for these services are gained through taxation. (Lameire et al. 1999;
Leigh 2000) The government supports the unemployed though an unemployment benefit that
is funded by taxation; unemployed substance users may be inclined to use this to fund their substance use habits (Birnbaum 2011; Ministry of Finance 2015). When the individual is employed and has an accident, the costs of health care and the loss of productivity or costs for replacement staff are taken care of by organizations and society (MacDonald & Pudney 2000b;
Ministry of Finance 2015). As the substances used are usually illegal, should they enter the legal system they are then accumulating costs related to that such as lawyer fees, costs related to conviction and sentencing that the government pays for (Ministry of Justice 2014). Quayle (1983) points out a hidden cost that occurs in the families of substance users, that when the user is receiving treatment or has stopped, the amount of health care used by the whole family is less meaning tax dollars saved (Birnbaum 2011). There are also some specific services for substance users such as emergency housing, halfway houses, and clinics that are funded by a combination of taxation, employer and employees (AddictionLink 2015). In Finland the drug- related expenditure in 2012 was 61% on public order and safety, 25% on social protection and 13% on healthcare which used 0.2% of the GDP (EMCDDA 2015b). Hence having interventions to prevent and treat substance use, such as combined employment and rehabilitation schemes are beneficial for all, through direct or indirect cost pathways (MacDonald & Pudney 2000b).
2.13 Addressing Substance Use Among Workers
A majority of adult life is spent at work meaning that the work environment and relationships they have at work as well as internal concepts about work influence their mental health and overall wellbeing (Frone & Brown 2010). To mitigate some of these issues, several measures have been reported. For example, some businesses have implemented policies on rigorous pre- employment screening, drug testing and provision of support for its workers that are dealing with substance use problems (Ramchand et al. 2009; Varjonen 2015). Many businesses, especially those with many employees, have established employee assistance programs (EAPs) that have a holistic approach that incorporates all aspects affecting the individual’s performance (Quayle 1983; MacDonald & Pudney 2000b; DeFulio et al. 2009; Ramchand et al. 2009;
Varjonen 2015). Increasing supervision of at-risk workers and education of staff is also key to providing a safe working environment free of substances. Usage of marketing campaigns to target workplace social norms can be a way of addressing a permissive workplace culture and reaching secret users. (Bacharach et al. 2002; Frone 2008; Frone 2012) Also, it has been suggested that policies and projects targeting alcohol consumption have the possibility to
transfer onto other substances (Perkins & Craig 2006; Frone & Brown 2010). Hence promoting existing alcohol based initiatives could be a cost-effective and short-term action that has the potential to effect usage of other substances.
Unions are supportive of these programs, as they provide significant benefits in the long term well-being of workers. However not all businesses take action on this as they may not see the need for intervention or that it is simply too much investment for a possible long term gain.
(Quayle 1983; Varjonen 2015) In Finland there is heavy involvement of unions in the negotiations and agreements between employers and employees, they are a vital component in mitigating issues related to employment and substance use (ILO 2015).
3. SIGNIFICANCE OF THE STUDY
This study, based on literature found, is the only study focusing on the differences in employed and unemployed substance abusers seeking treatment in Finland at present. The employed and unemployed individuals have many similar and contrasting characteristics that provide insight into how best to reduce barriers and improve outcomes, both in treatment and employment.
The results of this study will provide a profile of Finnish substance users who are employed and unemployed. The findings can be used as a tool to assist relevant authorities in developing effective interventions to address substance use among employees, improve treatment outcomes, and reintegration of unemployed individuals into the workforce and society.
4. OBJECTIVES OF THE STUDY
4.1 Overall Objective
To compare and describe employed and unemployed substance users who sought treatment within the Greater Helsinki Area from 2001 to 2008.
4.2 Specific Objectives
1. To compare the sociodemographic characteristic of employed and unemployed individuals
2. To analyse differences in mental health status of employed and unemployed individuals 3. To assess the treatment seeking trend from 2001 to 2008 in employed and unemployed 4. To examine the differences in drug use characteristics, and treatment in employed and
unemployed individuals
5. METHODOLOGY
5.1 Study Design and Participants
This is a cross-sectional analysis of baseline data from individuals seeking treatment from the Helsinki Deaconess Institute (HDI). HDI is a public utility foundation in Helsinki, Finland that offers drug treatment to residents of Helsinki and the surrounding municipalities that consist of the Greater Helsinki Area (about 1.3 million residents). At HDI services are rendered free to patients and service fees incurred are covered by the municipalities (Onyeka et al. 2012). The service is the primary service provider and caters for illicit drug users, those seeking treatment included minors and polydrug users (Onyeka et al. 2012). The original cohort comprised of 4817 individuals aged between 12 and 65 years who sought treatment for drug use between 1997 and 2008 at the HDI. There was no eligibility criterion, all consecutive individuals who sought treatment during the time period were included in the study and there was no attrition.
Individuals could be self-referred, referred by health services or by others.
For the purposes of this study, only data from 2001 to 2008 was used to reduce the amount of missing data for variables. Thus allowing for completeness of variables of interest and more flexibility in statistical analysis, see Figure 3. A total of 2526 individuals accessed treatment at HDI in the time between 2001 and 2008. However, in this particular study emphasis was on the comparison of individuals based on employment status. The responses to the question on employment status were categorized as employed, unemployed, student, housewife/househusband, retired or other. Individuals not normally considered in the labor force were excluded, such as student, housewife/househusband, retired and other. Therefore, only a total of 1688 individuals who were categorized as employed or unemployed were included in the final data analysis.
Figure 3. Selection of study sample.
5.2 Data Collection
This data was not originally collected for research purposes but as part of clinical practice. A detailed description of the composition of the cohort, data collection methods, and baseline characteristics have been described elsewhere (Onyeka et al. 2012; Onyeka et al. 2013). In summary as part of routine clinical procedures clinicians conducted an interview at each individuals’ initial visit using a structured questionnaire to obtain demographic information, self-reported history of drug use, social, medical, and psychiatric histories. Items on the questionnaire were adapted from the European Addiction Severity Index, the Treatment Demand Indicator Protocol and other relevant clinical questions (McLellan et al. 1992;
Scheurich et al. 2000). Individual treatment plans were then created, and various treatment methods were assigned based on their needs. (Onyeka et al. 2012).
5.3 Statistical Analysis
Statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS) version 21 for Macintosh. Descriptive data has been presented as percentages, means, and standard deviation. Analyses of differences in the characteristics of employed and unemployed individuals were conducted based on Mann-Whitney Test for continuous variables and Chi- Squared Test or Fisher’s Exact Test for categorical variables. P-value ≤ 0.05 was considered statistically significant.
5.4 Ethical Consideration
Ethical approval of the HUUTI study was approved by the research Ethics Committee of the Hospital District of North-Savo and the Ethics Committee of the Helsinki Deaconess Institute, the Ministry of Social Affairs and Health of Finland, and all other appropriate authorities of participants’ home communities comprising the Greater Helsinki area.
6. RESULTS
6.1 Distribution of Study Population
Majority of the study population are unemployed as seen in Figure 4. The employed individuals total 325 and account for 19.3% of the total population, the rest are unemployed (N=1363, 80.7%).
Figure 4. Distribution of employed (N=325, 19.3%) and unemployed (N=1363, 80.7%) individuals in the study population (N=1688).
19.3%
80.7%
Employed Unemployed
6.2 Sociodemographic Characteristics
There was a statistically significant difference in the education level between the employed and unemployed individuals (P < 0.001). It was found that a higher proportion of employed individuals had high school or higher education compared to the unemployed individuals.
While unemployed individuals had higher proportion with elementary school education than in the employed individuals as shown in Table 5.
The main source of income had a statistically significant difference (P < 0.001) as seen in Table 5. Of the employed the main source of income was a salary (88.7%), in contrast the unemployed mainly relied on income support (60.6%) followed by the unemployment benefit (22.7%) as their main source of income.
The unemployed individuals were also more likely to be living with other drug users than employed. While not living with another drug user was true for majority of both groups, it was more likely in the employed than the unemployed individuals as indicated in Table 5. These differences have a p < 0.001 indicating that they are statistically significant.
There was no statistically significant difference in the sex, municipality, nationality, marital status or age of the employed or unemployed individuals as seen in Table 5 indicated by p>0.05 for all.
Table 5. Social demographic characteristics of 1688 individuals based on employed (N=325) and unemployed (N= 1363) status
Characteristics Overall Employed Unemployed P-value*
Age, mean (SD) 26.7 (7.6) 26.7 (7.5) 26.8 (7.6) 0.831
Sex
Male 1179/1688 (69.8%) 222/325 (68.3%) 957/1363 (70.2%) 0.501 Female 509/1688 (30.2%) 103/325 (31.7%) 406/1363 (29.8%)
Municipality
Helsinki 1143/1684 (67.9%) 233/323 (71.7%) 910/1361 (66.9%) 0.116 Outside Helsinki¶ 391/1684 (23.2%) 61/323 (18.9%) 330/1361 (24.2%)
Others† 150/1684 (8.9%) 29/323 (9.0%) 121/1361 (8.9%) Nationality
Finnish 1647/1688 (97.6%) 314/325 (96.6%) 1333/1363 (97.8%) 0.213 Other§ 41/1688 (2.4%) 11/325 (3.4%) 30/1363 (2.2%)
Marital status
Married or co-habiting 160/1368 (11.7%) 43/282 (15.2%) 117/1086 (10.8%) 0.114 Not married 1087/1368 (79.5%) 215/282 (76.2%) 872/1086 (80.3%)
Separated or divorced 121/1368 (8.8%) 24/282 (8.5%) 97/1086 (8.9%) Education
Elementary school 1174/1628 (72.1%) 178/306 (58.2%) 996/1322 (75.3%) <0.001 High school or vocational 377/1628 (23.2%) 96/306 (31.4%) 281/1322 (21.3%)
University 31/1628 (1.9%) 16/306 (5.2%) 15/1322 (1.1%) Other 46/1628 (2.8%) 16/306 (5.2%) 30/1322 (2.3%) Main source of income
Salary 381/1515 (25.1%) 275/310 (88.7%) 106/1205 (8.8%) <0.001 Pension 8/1515 (0.5%) 2/310 (0.6%) 6/1205 (0.5%)
Income Support 742/1515 (49.0%) 12/310 (3.9%) 730/1205 (60.6%) Unemployment benefit 278/1515 (18.3%) 4/310 (1.3%) 274/1205 (22.7%) Other 106/1515 (7.0%) 17/310 (5.5%) 89/1205 (7.4%) Living with other drug users
No 659/1018 (64.7%) 161/210 (76.7%) 498/808 (61.6%) <0.001 Drug user 281/1018 (27.6%) 39/210 (18.6%) 242/808 (30.0%)
Alcohol user 37/1018 (3.6%) 7/210 (3.3%) 30/808 (3.7%) Drug and alcohol user 41/1018 (4.0%) 3/210 (1.4%) 38/808 (4.7%)
*Mann-Whitney Test for continuous variables and Chi-Squared Test or Fisher’s Exact Test for categorical variables. ¶Outside Helsinki refers to Espoo and Vantaa. †Other refers to Järvenpää, Kerava, Kirkkonummi, Lohja, Nurmijärvi, Porvoo, Hyvinkää, Tuusula. §Other refers to Swedish, Russian, Estonian, Vietnamese, Somalian, other. Different denominators due to missing data for some variables.
6.3 Mental Health Status
Table 6 shows that there was a statistically significant difference (P=0.038) in the presence or absence of psychotic symptoms with the unemployed individuals (22.0%) having an increased presence of psychotic symptoms than the employed individuals (16.5%). There was a weak significance of difference in suicidal attempts (P=0.052) in unemployed individuals than employed individuals (25.9% vs. 20.2% respectively). For depressive symptoms and suicidal thoughts, the two groups were similar as show by p-values of P=0.509 and P=0.240 respectively.
Table 6. Differences in mental health problems in employed and unemployed individuals
Characteristics Overall Employed Unemployed P-value*
Psychotic symptoms
Absent 1215/1536 (79.1%) 248/297 (83.5%) 967/1239 (78.0%) 0.038 Present 321/1536 (20.9%) 49/297 (16.5%) 272/1239 (22.0%)
Depressive symptoms
Absent 402/1552 (25.9%) 83/303 (27.4%) 319/1249 (25.5%) 0.509 Present 1150/1552 (74.1%) 220/303 (72.6%) 930/1249 (74.5%)
Suicidal thoughts
Absent 950/1536 (61.8%) 190/293 (64.8%) 760/1243 (61.1%) 0.240 Present 586/1536 (38.2%) 103/293 (35.2%) 483/1243 (38.9%)
Suicide attempts
Absent 1092/1453 (75.2%) 210/263 (79.8%) 882/1190 (74.1%) 0.052 Present 361/1453 (24.8%) 53/263 (20.2%) 308/1190 (25.9%)
* Chi-Squared Test for continuous variables. Different denominators due to missing data for some variables.
6.4 Drug Usage
Majority of the population were polydrug users as seen in Table 7, and this held true in both employed and unemployed groups as shown by P=0.356.
Table 7. Number of drugs used
Characteristics Overall Employed Unemployed P-value*
No. of drugs used
Single drug use 82/1688 (4.9%) 19/325 (5.8%) 63/1363 (4.6%) 0.356 Poly drug use¶ 1606/1688 (95.1%) 306/325 (94.2%) 1300/1363 (95.4%)
* Chi-Squared Test was used
¶Poly drug use refers to 2 or more drugs
7.4.1 Primary Drug of Use
The primary drug of use in the employed and unemployed individuals was statistically significantly different, p<0.001. In the unemployed group there was a higher proportion of opiate (41.2%) and stimulant (27.4%) users than the employed. In the employed individuals, alcohol and cannabis were more prevalent than in the unemployed individuals as displayed in Table 7.
The most common route of use was IV (59.2%) in unemployed while it was orally (38.7%) in the employed, with the employed also having a higher proportion using by smoking or snorting than the unemployed. These findings were statistically significant indicated by p<0.001 in Table 7.
In both groups the age of starting the primary drug of use was not statistically significant (P=0.680) with the mean starting age being 19 years for the total study population shown in Table 7.
Past month usage was found to be statistically significant with P=0.001 with those employed more likely to use less than 7 times a week than unemployed, see Table 7. However, usage of 7 or more times a week was the majority in employed (42.3%) and unemployed (54.3%).
Table 7. Primary drug use characteristics in employed and unemployed individuals
Characteristics Overall Employed Unemployed P-value*
Primary drug of use¶
Alcohol 335/1688 (19.8%) 85/325 (26.2%) 250/1363 (18.3%) <0.001 Cannabis 172/1688 (10.2%) 43/325 (13.2%) 129/1363 (9.5%)
Medication 39/1688 (2.3%) 10/325 (3.1%) 29/1363 (2.1%) Opiate 662/1688 (39.2%) 100/325 (30.8%) 562/1363 (41.2%) Stimulant 453/1688 (26.8%) 79/325 (24.3%) 374/1363 (27.4%) Other 27/1688 (1.6%) 8/325 (2.5%) 19/1363 (1.4%) Route of use
IV 879/1603 (54.8%) 114/310 (36.8%) 765/1293 (59.2%) <0.001 Smoking 173/1603 (10.8%) 44/310 (14.2%) 129/1293 (10.0%)
Orally 434/1603 (27.1%) 120/310 (38.7%) 314/1293 (24.3%) Snorting 117/1603 (7.3%) 32/310 (10.3%) 85/1293 (6.6%) Age of starting drug
Mean (SD) 19 (6.1) 19 (6.1) 18 (6.0) 0.680
Usage in past month
No use 68/1595 (4.3%) 14/307 (4.6%) 54/1288 (4.2%) 0.001 Once a week or less 219/1595 (13.7%) 56/307 (18.2%) 163/1288 (12.7%) 2-6 times a week 479/1595 (30.0%) 107/307 (34.9%) 372/1288 (28.9%) 7 or more times a week 829/1595 (52.0%) 130/307 (42.3%) 699/1288 (54.3%)
*Mann-Whitney Test for continuous variables and Chi-Squared Test for categorical variables.
¶Primary drug of use is defined as the drugs causing the client the most problems. Different denominators due to missing data for some variables.
6.4.2 Secondary Drug of Use
Unemployed individuals were more likely than employed to use medications (24.5%) and opiates (11.9%) as their secondary drug of use. While employed were more likely to use alcohol (17.3%) or stimulants (25.8%) than those unemployed. These differences were statistically significant as p<0.001. In lieu of this, the most common secondary drug of use was cannabis in both groups as seen in Table 8.
The route of use was also statistically significant with p<0.001 in Table 8. Of the unemployed IV (22.1%) and oral (42.3%) routes of use were higher compared to the employed (14.3% and 38.9% respectively), though the most common route of use for both was oral. The employed
