Overdose Risk and Acquiring Opioids for Nonmedical Use Exclusively from Physicians in Vancouver, Canada.

BACKGROUND: A primary response to the alarming rise in overdose and mortality due to nonmedical prescription opioid (PO) use has been to restrict opioid prescribing; however, little is known about the relationship between obtaining opioids from a physician and overdose risk among people who use POs nonmedically and illicit street drugs. Objectives: Investigate the relationship between non-fatal overdose and acquiring POs exclusively from physicians for the purposes of engaging in nonmedical PO use. Methods: Data were collected between 2013 and 2016 among participants in two harmonized prospective cohort studies of people who use drugs in Vancouver: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Analyses were restricted to participants who engaged in nonmedical PO use and used generalized estimating equations. Results: Among 599 participants who used POs nonmedically, 82 (14%) individuals reported acquiring POs exclusively from a physician and 197 (33%) experienced a non-fatal overdose at some point over the study period. Acquiring POs exclusively from physicians was significantly and negatively associated with non-fatal overdose in the bivariate analysis (Odds Ratio = 0.60, 95% Confidence Interval (CI): 0.39-0.94) but not the final multivariate analysis (Adjusted Odds Ratio =0.87, 95% CI: 0.53-1.44). Conclusions: Compared to individuals who acquired POs from friends or the streets, participants who acquired POs exclusively from a physician were not at an increased risk of non-fatal overdose. Although responsible opioid prescribing is an important priority, additional strategies to address nonmedical PO use are urgently needed to reduce overdose and related morbidity and mortality.

A gender-based analysis of nonmedical prescription opioid use among people who use illicit drugs.

BACKGROUND: Research investigating the unique impacts associated with engaging in nonmedical prescription opioid use (NMPOU) among males and females who also use illicit drugs is needed. METHODS: Data were collected between 2013 and 2017 from two linked prospective cohort studies in Vancouver: the At-Risk Youth Study and Vancouver Injection Drug Users Study. Generalized estimating equations were used to identify factors associated with engaging in NMPOU among females and males separately. RESULTS: Among 1459 participants, 534 were female (37%). Similar proportions of females (46%) and males (48%) engaged in NMPOU at their first visit during the study period. In multivariable analyses, factors associated with NMPOU among both males and females included heroin use, overdose, drug dealing, and difficulty accessing health and social services. Among females, those who engaged in NMPOU were more likely to report Caucasian or white ethnicity, cocaine use, crystal methamphetamine use, and sex work; among males, those who engaged in NMPOU were older, reported crack use and engaged in binge drug use (all p < 0.05). CONCLUSION: The prevalence of NMPOU was similar among males and females who use illicit drugs in Vancouver, and NMPOU was independently associated with markers of vulnerability among both genders. Findings highlight the need for a comprehensive public health approach to address NMPOU that integrates overdose prevention and reversal services, employment opportunities, and better access to services for both women and men.

Perceived Devaluation among a Cohort of Street-Involved Youth in Vancouver, Canada.

BACKGROUND: Perceived devaluation is a barrier to seeking mental and physical health services among people who use illicit drugs. OBJECTIVE: Assessing the prevalence and correlates of perceived devaluation within a cohort of street-involved youth. METHODS: Data were drawn from an open prospective cohort of street-involved youth who use illicit drugs (aged 14-26 at study enrollment) between December 2013 and May 2015 in Vancouver, Canada. Perceived devaluation was measured using an adapted version of Perceived Devaluation and Discrimination scale. Multivariable generalized estimating equations were constructed to examine factors independently associated with high perceived devaluation. RESULTS: Among 411 street-involved youth, 95.1% reported high perceived devaluation at some point during the study period. In a multivariable analysis, youth who reported high perceived devaluation were significantly more likely to engage in: unprotected sex (Adjusted Odds Ratio [AOR] = 1.56, 95% Confidence Interval 1.03-2.37); heavy alcohol use (AOR = 2.31, 95% CI 1.22-4.36); and daily heroin use (AOR = 2.07, 95% CI 1.16-3.70). Youth who resided in the Downtown Eastside neighborhood were significantly less likely to report high perceived devaluation (AOR = 0.41, 95% CI 0.26-0.65). CONCLUSIONS: Perceived devaluation was extremely prevalent among street-involved youth in our sample. We also observed that youth most in need of health and social services were significantly more likely to report high levels of perceived devaluation which may result in a reluctance to seek out key services and supports. These findings highlight the need to implement stigma reduction interventions for vulnerable youth in this setting.

An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada.

BACKGROUND: Nonmedical prescription opioid use (NMPOU) is a serious public health problem in North America. At a population-level, previous research has identified differences in the prevalence and correlates of NMPOU among younger versus older age groups; however, less is known about age-related differences in NMPOU among people who use illegal drugs. METHODS: Data were collected between 2013 and 2015 from two linked prospective cohort studies in Vancouver, Canada: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Factors independently associated with NMPOU among younger (ARYS) and older (VIDUS) participants were examined separately using bivariate and multivariate generalized estimating equations. RESULTS: A total of 1162 participants were included. Among 405 eligible younger participants (Median age = 25; Inter-Quartile Range [IQR]: 22-28), 40% (n = 160) reported engaging in NMPOU at baseline; among 757 older participants (Median age = 48, IQR: 40-55), 35% (n = 262) reported engaging in NMPOU at baseline. In separate multivariate analyses of younger and older participants, NMPOU was positively and independently associated with heroin use (younger: Adjusted Odds Ratio [AOR] = 3.12, 95% Confidence Interval [CI]: 2.08-4.68; older: AOR = 2.79, 95% CI: 2.08-3.74), drug dealing (younger: AOR = 2.22, 95% CI: 1.58-3.13; older: AOR = 1.87, 95% CI: 1.40-2.49), and difficulty accessing services (younger: AOR = 1.47, 95% CI: 1.04-2.09; older: AOR = 1.74, 95% CI: 1.32-2.29). Among the youth cohort only, NMPOU was associated with younger age (AOR = 1.12, 95% CI: 1.05-1.19), crack use (AOR = 1.56, 95% CI: 1.06-2.30), and binge drug use (AOR = 1.41, 95% CI: 1.00-1.97); older participants who engaged in NMPOU were more likely to report crystal methamphetamine use (AOR = 1.97, 95% CI: 1.46-2.66), non-fatal overdose (AOR = 1.76, 95% CI: 1.20-2.60) and sex work (AOR = 1.49, 95% CI: 1.00-2.22). DISCUSSION: The prevalence of NMPOU is similar among younger and older people who use drugs, and independently associated with markers of vulnerability among both age groups. Adults who engage in NMPOU are at risk for non-fatal overdose, which highlights the need for youth and adult-specific strategies to address NMPOU that include better access to health and social services, as well as a range of addiction treatment options for opioid use. Findings also underscore the importance of improving pain treatment strategies tailored for PWUD.

Nonmedical prescription opioid use and illegal drug use: initiation trajectory and related risks among people who use illegal drugs in Vancouver, Canada.

OBJECTIVE: We investigated the prevalence of and risk factors associated with initiating nonmedical prescription opioid use (NMPOU) before and after illegal drugs using data from two linked cohort studies of street youth and adults who use illegal drugs in Vancouver, Canada. All participants who attended a study visit between 2013 and 2016 were eligible for the primary analyses. RESULTS: Among 512 youth and 833 adult participants, the prevalence of NMPOU was extremely high (88% among street youth; 90% among adults), and over one-third of those who reported engaging in NMPOU had initiated NMPOU before illegal drug use (vs. transitioning from illegal drugs to NMPOU). Participants who reported either transitioning to or from NMPOU had higher risk profiles, particularly related to substance use, when compared with those who reported never engaging in NMPOU. Sub-analyses restricted to only those who engaged in NMPOU found few statistically significant differences between those who initiated NMPOU prior to illegal drugs versus those who initiated illegal drugs prior to NMPOU. Findings suggest that among people who use illegal drugs, early NMPOU trajectories do not appear to critically shape future patterns and practices.

Between a rock and a hard place: Prescription opioid restrictions in the time of fentanyl and other street drug adulterants.

Non-medical prescription opioid use (NMPOU) has increased alarmingly across Canada and resulted in strict prescribing restrictions on opioids. Despite a clear need to reduce opioid prescriptions in response to this crisis, few other policies have been implemented and this singular focus is incongruent with the known characteristics of substance use disorders, negative effects of supply reduction policies, and realities of pain management. Given the recent rise of fentanyl and other dangerous adulterants in street drugs, this commentary argues that a comprehensive response to NMPOU that includes improvements to addiction management and harm-reduction services is urgently needed.

HIV and the criminalisation of drug use among people who inject drugs: a systematic review.

BACKGROUND: Mounting evidence suggests that laws and policies prohibiting illegal drug use could have a central role in shaping health outcomes among people who inject drugs (PWID). To date, no systematic review has characterised the influence of laws and legal frameworks prohibiting drug use on HIV prevention and treatment. METHODS: Consistent with PRISMA guidelines, we did a systematic review of peer-reviewed scientific evidence describing the association between criminalisation of drug use and HIV prevention and treatment-related outcomes among PWID. We searched MEDLINE, Embase, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL, Web of Science, and other sources. To be included in our review, a study had to meet the following eligibility criteria: be published in a peer-reviewed journal or presented as a peer-reviewed abstract at a scientific conference; examine, through any study design, the association between an a-priori set of indicators related to the criminalisation of drugs and HIV prevention or treatment among PWID; provide sufficient details on the methods followed to allow critical assessment of quality; be published or presented between Jan 1, 2006, and Dec 31, 2014; and be published in the English language. FINDINGS: We identified 106 eligible studies comprising 29 longitudinal, 49 cross-sectional, 22 qualitative, two mixed methods, four mathematical modelling studies, and no randomised controlled trials. 120 criminalisation indicators were identified (range 1-3 per study) and 150 HIV indicators were identified (1-5 per study). The most common criminalisation indicators were incarceration (n=38) and street-level policing (n=39), while the most frequent HIV prevention and treatment indicators were syringe sharing (n=35) and prevalence of HIV infection among PWID (n=28). Among the 106 studies included in this review, 85 (80%) suggested that drug criminalisation has a negative effect on HIV prevention and treatment, 10 (9%) suggested no association, five (5%) suggested a beneficial effect, one (1%) suggested both beneficial and negative effects, and five (5%) suggested both null and negative effects. INTERPRETATION: These data confirm that criminalisation of drug use has a negative effect on HIV prevention and treatment. Our results provide an objective evidence base to support numerous international policy initiatives to reform legal and policy frameworks criminalising drug use. FUNDING: Canadian Institutes of Health Research and US National Institutes of Health.

Substance use patterns and unprotected sex among street-involved youth in a Canadian setting: a prospective cohort study.

BACKGROUND: Rates of sexually transmitted infections (STI) and unplanned pregnancy are high among youth. While the intersection between drug and alcohol use and unprotected sex is well recognized, few studies have examined the relationship between substance use patterns and unprotected sex among high risk-populations such as street-involved youth. METHODS: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth from Vancouver, Canada. Generalized estimating equations (GEE) were used to examine substance use patterns that were independently associated with unprotected sex, defined as (vaginal or anal) sexual intercourse without consistent condom use. RESULTS: Between September 2005 and May 2013, 1,026 youth were recruited into the ARYS cohort and 75% (n = 766) reported engaging in recent unprotected sex at some point during the study period. In a multivariable analysis, female gender (adjusted odds ratio [AOR] = 1.46, 95% confidence interval [CI]: 1.18-1.81), Caucasian ancestry (AOR = 1.38, 95% CI: 1.13-1.68), being in a stable relationship (AOR = 4.64, 95% CI: 3.82-5.65), having multiple sex partners (AOR = 2.60, 95% CI: 2.18-3.10) and the following substance use patterns were all independently associated with recent unprotected sex: injection or non-injection crystal methamphetamine use (AOR = 1.21, 95% CI: 1.03-1.43), injection or non-injection cocaine use (AOR = 1.20, 95% CI: 1.02-1.41), marijuana use (AOR = 1.23, 95% CI: 1.02-1.49), ecstasy use (AOR = 1.23, 95% CI: 1.01-1.48) and alcohol use (AOR = 1.31, 95% CI: 1.11-1.55) (all p < 0.05). CONCLUSIONS: Unprotected sex was prevalent among street-involved youth in this setting, and independently associated with female gender and a wide range of substance use patterns. Evidence-based and gender-informed sexual health interventions are needed in addition to increased access to youth-centered addiction treatment services. STI testing and linkages to healthcare professionals remain important priorities for street-involved youth, and should be integrated across all health and social services.

High prevalence of risky income generation among street-involved youth in a Canadian setting.

BACKGROUND: Previous research has found a range of barriers to mainstream employment among street-involved youth; however, less is known about the characteristics of street-involved youth who engage in risky income generation and the potential role of substance use in perpetuating engagement in these activities. METHODS: Data were collected between 2005 and 2012 from the At-Risk Youth Study (ARYS), which is a prospective cohort study of street-involved youth aged 14-26 in Vancouver, Canada. Generalized estimating equations were used to identify factors associated with risky quasi-legal and illegal income generation. Participants also reported their willingness to give up these sources of income if they were not using drugs. RESULTS: Among 1008 participants, 826 (82%) reported engaging in risky income generation activities during the study period. Factors associated with risky income generation included: homelessness, binge drug use, injection drug use, crack use, crystal methamphetamine, overdose, interactions with police, and experiencing violence; regular employment was negatively associated with this outcome (all p<0.05). Among those who reported risky income generation, 440 (53%) were willing to give up these income sources if they were not using drugs. CONCLUSION: Risky income generation was alarmingly prevalent in our sample, and associated with higher intensity drug use and other markers of vulnerability. The majority of participants (53%) reported willingness to give up their risky income sources if they were not using drugs; however, a substantial proportion of youth (47%) indicated that they would continue to engage in risk income generation regardless of their substance use suggesting that both substance use and economic insecurity likely perpetuate risky income generation among our sample. Findings highlight opportunities to reduce risky income generation by addressing problematic substance use through better access and engagement with evidence-based addiction treatment, and exploring, monitoring and evaluating innovative interventions to improve the overall economic security of street-involved youth.

Implementation of HIV treatment as prevention strategy in 17 Canadian sites: immediate and sustained outcomes from a 35-month Quality Improvement Collaborative.

BACKGROUND: Rapid scale-up of effective antiretroviral therapy (ART) is required to meet global targets to eliminate new HIV infections and AIDS-related deaths. Yet, gaps persist in all nations striving for these targets. In the intervention setting of British Columbia (BC), Canada, where ART is publicly funded, 73% of HIV-diagnosed were on ART in 2011, and only 49% were achieving viral suppression. METHODS: An observational case descriptive study of HIV care sites in BC recruited to participate in a 35-month Breakthrough Series Quality Improvement Collaborative and sustainability network. Sites collected four quality indicators, qualitative change descriptions and implemented the chronic care model (CCM) and HIV care and treatment guidelines. Two reviewers assigned monthly implementation scores to evaluate site progress (January 2011-2012). All quality indicators were pooled and analysed using probability-based run chart rules. RESULTS: Seventeen teams with a pooled median population of 2296 HIV patients joined the initiative. Comprehensive CCM implementation and evidence of improvement was achieved by 29% of sites (implementation score of 4.0 or higher on 5.0 scale). Evidence of sustained improvement was observed for patient engagement (88.8-90.4%), ART uptake among patients unequivocally in need (92.9-94.8%), and ART uptake (≥6 months) and achieving viral suppression (57.3-78.4%) (all p<0.05). CONCLUSIONS: This study shows evidence of sustained improvements in HIV care processes and treatment outcomes for an estimated population of 2296 HIV patients in 17 BC sites. Overall success points to opportunities for other high-income countries seeking to improve HIV health outcomes.

High Prevalence of Assisted Injection Among Street-Involved Youth in a Canadian Setting.

Many people who inject illicit drugs receive manual assistance when injecting, and this practice has been linked to increased risk of HIV infection and other harms. Little is known, however, about this practice among youth. This study uses a multivariate generalized estimating equation to identify factors associated with receiving assistance with injecting among a cohort of street-involved youth aged 14-26 in Vancouver, Canada. A total of 253 participants reported injecting drugs during the study period, and 49 % (n = 125) of these youth reported receiving assistance with injecting in the past 6 months. In multivariate analysis, younger age, female gender, binge drug use, heroin injecting, cocaine injecting, crystal methamphetamine injecting, and syringe sharing were positively and independently associated with assisted injection (all p < 0.05). These findings underscore the need for expanding substance abuse treatment alongside HIV prevention and health promotion interventions to empower youth to enact safer injection practices.

Crack pipe sharing among street-involved youth in a Canadian setting.

INTRODUCTION AND AIMS: Crack pipe sharing is a risky practice that has been associated with the transmission of hepatitis C and other harms. While previous research has exclusively focused on this phenomenon among adults, this study examines crack pipe sharing among street-involved youth. DESIGN AND METHODS: From May 2006 to May 2012, data were collected from the At-Risk Youth Study, a cohort of street-involved youth aged 14-26 in Vancouver, Canada. Survey data from active crack smokers were analysed using generalised estimating equations logistic regression. RESULTS: Over the study period, 567 youth reported smoking crack cocaine and contributed 1288 observations, among which 961 (75%) included a report of crack pipe sharing. In multivariate analysis, factors that were associated with crack pipe sharing included difficulty accessing crack pipes [adjusted odds ratio (AOR) = 1.58, 95% confidence interval (CI) 1.13-2.20]; homelessness (AOR = 1.87, 95% CI 1.43-2.44); regular employment (AOR = 1.53, 95% CI 1.15-2.04); daily non-injection crystal methamphetamine use (AOR = 2.04, 95% CI 1.11-3.75); daily crack smoking (AOR = 1.37, 95% CI 1.01-1.85); encounters with the police (AOR = 1.42, 95% CI 1.01-1.99); and reporting unprotected sex (AOR = 1.95, 95% CI 1.47-2.58). DISCUSSION AND CONCLUSIONS: The prevalence of crack pipe sharing was high among our sample and independently associated with structural factors including difficulty accessing crack pipes and homelessness. Crack pipe sharing was also associated with high-intensity drug use and a number of other markers of risk and vulnerability. Collectively, these findings highlight opportunities for health services to better engage with this vulnerable group and reduce this risky behaviour.

Increases and decreases in drug use attributed to housing status among street-involved youth in a Canadian setting.

BACKGROUND: Among a cohort of drug-using street-involved youth, we sought to identify the prevalence of reporting increases and decreases in illicit drug use due to their current housing status and to identify factors associated with reporting these changes. FINDINGS: This longitudinal study was based on data collected between June 2008 and May 2012 from a prospective cohort of street-involved youth aged 14-26 in Vancouver, Canada. At semi-annual study follow-up visits, youth were asked if their drug use was affected by their housing status. Using generalized estimating equations, we identified factors associated with perceived increases and decreases in drug use attributed to housing status. Among our sample of 536 participants at baseline, 164 (31%) youth reported increasing their drug use due to their housing situation and 71 (13%) reported decreasing their drug use. In multivariate analysis, factors that were positively associated with perceived increases in drug use attributed to housing status included the following: being homeless, engaging in sex work and drug dealing. Regular employment was negatively associated with increasing drug use due to housing status. Among those who reported decreasing their drug use, only homelessness was significant in bivariate analysis. CONCLUSION: Perceived changes in drug use due to housing status were relatively common in this setting and were associated with being homeless and, among those who increased their drug use, engaging in risky income generation activities. These findings suggest that structural factors, particularly housing and economic opportunities, may be crucial interventions for reducing or limiting drug use among street-involved youth.

Compassion and contamination. Cultural differences in vegetarianism.

A growing body of research has shown that Western vegetarians report more concern for animal welfare and environmental sustainability, and endorse more liberal values than do Western omnivores. However, despite the prevalence of Indian vegetarianism, its psychological associations and underpinnings remain largely unexamined. In Study 1, we find that Euro-American vegetarians are more concerned than omnivores with the impact of their daily food choices on the environment and animal welfare, show more concern for general animal welfare, and endorse universalistic values more, yet among Indian participants, these differences are not significant. In Study 2, we show that Indian vegetarians more strongly endorse the belief that eating meat is polluting, and show a heightened concern for the conservative ethics of Purity, Authority, and Ingroup relative to their omnivorous peers, whereas these differences are largely absent among Euro-Canadians and Euro-Americans.

Transitions into and out of homelessness among street-involved youth in a Canadian setting.

The impact of transitions in housing status among street youth have not been well explored. This study uses a generalized linear mixed effects model to identify factors associated with transitions into and out of homelessness among a prospective cohort of 685 drug-using street-involved youth aged 14-26. In multivariate analysis, high intensity substance use, difficulty accessing addiction treatment, incarceration, sex work, and difficulty accessing housing (all p<0.05) either significantly facilitated or hindered housing transitions. Findings highlight the importance of external structural factors in shaping youth's housing status and point to opportunities to improve the housing stability of vulnerable youth.