Interest in low-threshold employment among people who inject illicit drugs: implications for street disorder

Main problems experienced by the neighbors of open drug scenes, Tehran, Iran: a mixed-method study

BACKGROUND

Despite law enforcement and health interventions, open drug scenes have led to problems in many countries. The problems are, however, insufficiently explored. There are different types of drug scenes in Iran. This study aimed to explore the issues related to neighbors of one of the drug scenes in Tehran known as Farahzad.

METHODS

Data were generated via semi-structured interviews in the first step of the current mixed-method study (2020-2021). Interviewees were people who use drugs (PWUDs), residents and business owners (N = 25). In the next step, a quantitative observation was conducted for eight days. The results were analyzed using conventional content analysis and descriptive statistics.

RESULTS

The perceived problems were ambivalent attitudes about drug scene-related activities, violate of the territory of the self of the effected residents, and everyday concerns. The observation results indicated that men who use drugs are involved in drug scene-related activities more than women are. PWUDs try to hide their activities from the public view. Their efforts were considered "self-regulatory strategies" in the drug scene.

CONCLUSIONS

Despite efforts of PWUDs to keep their activities invisible, drug scene-related issues are intolerable for neighbors. Neighbors and PWUDs have ambivalent attitudes. While they are concerned about the human rights of each other, drug scene-related activities have disturbed the neighbor's daily life and economic activities. Although law enforcement and harm reduction interventions reduce some of the problems, one of the approaches should be improving the coexistence between the neighbors and the residents of the drug scene to achieve broader and more sustainable compromises.

Luminescence-based detection and identification of illicit drugs

Luminescence-based sensing is capable of being used for the sensitive, rapid, and in some cases selective detection of chemicals. Furthermore, the method is amenable to incorporation into handheld low-power portable detectors that can be used in the field. Luminescence-based detectors are now commercially available for explosive detection with the technology built on a strong foundation of science. In contrast, there are fewer examples of luminescence-based detection of illicit drugs, despite the pervasive and global challenge of combating their manufacture, distribution and consumption and the need for handheld detection systems. This perspective describes the relatively nascent steps that have been reported in the use of luminescent materials for the detection of illicit drugs. Much of the published work has focused on detection of illicit drugs in solution with less work on vapour detection using thin luminescent sensing films. The latter are better suited for handheld sensing devices and detection in the field. Illicit drug detection has been achieved via different mechanisms, all of which change the luminescence of the sensing material. These include photoinduced hole transfer (PHT) leading to quenching of the luminescence, disruption of Förster energy transfer between different chromophores by a drug, and chemical reaction between the sensing material and a drug. The most promising of these is PHT, which can be used for rapid and reversible detection of illicit drugs in solution and film-based sensing of drugs in the vapour phase. However, there are still significant knowledge gaps, for example, how vapours of illicit drugs interact with the sensing films, and how to achieve selectivity for specific drugs.

Improving Harm Reduction Services: A Qualitative Study on the Perspectives of Highly Marginalized Persons Who Inject Drugs in Montreal

Harm reduction (HR) is an alternative to the moralization of drug use and a pragmatic public health approach aimed at minimizing harms associated with use. This study sought to gain the perspectives of persons who inject drugs (PWID) on the adequacy of services provided by HR organizations in Montreal. Twenty-two semi-structured interviews and two focus groups were conducted with 30 participants. Some of the key advantages of HR perceived by participants include access to injection equipment, psychosocial support, and reduced social isolation. However, many wanted more opportunities for social insertion and greater value to be placed on their knowledge and life experiences (e.g., experiential knowledge of the street scene, drug use, sex work, or homelessness). This study suggests that PWID who access HR services in Montreal are interested in paid work opportunities in environments that promote power sharing, and activities that are conducted and managed by and for them.

Cohort Profile: The Assessing Economic Transitions (ASSET) Study-A Community-Based Mixed-Methods Study of Economic Engagement among Inner-City Residents

The Assessing Economic Transitions (ASSET) study was established to identify relationships between economic engagement, health and well-being in inner-city populations given that research in this area is currently underdeveloped. This paper describes the objectives, design, and characteristics of the ASSET study cohort, an open prospective cohort which aims to provide data on opportunities for addressing economic engagement in an inner-city drug-using population in Vancouver, Canada. Participants complete interviewer-administered surveys quarterly. A subset of participants complete nested semi-structured qualitative interviews semi-annually. Between April 2019 and May 2022, the study enrolled 257 participants ages 19 years or older (median age: 51; 40% Indigenous, 11.6% non-Indigenous people of colour; 39% cis-gender women, 3.9% transgender, genderqueer, or two-spirit) and 41 qualitative participants. At baseline, all participants reported past daily drug use, with 27% currently using opioids daily, and 20% currently using stimulants daily. In the three months prior to baseline, more participants undertook informal income generation (75%) than formal employment (50%). Employed participants largely had casual jobs (42%) or jobs with part-time/varied hours (35%). Nested qualitative studies will focus on how inner-city populations experience economic engagement. The resulting evidence will inform policy and programmatic initiatives to address socioeconomic drivers of health and well-being.

How much demand for money laundering services does drug selling create? Identifying the key parameters

BACKGROUND

The illegal drug trade is often, and plausibly, asserted to be the largest illegal market, globally and in many individual countries. It is also claimed that a large share of its revenues is laundered, though there are no estimates of that volume. We provide rough estimates of that proportion and its primary determinants.

METHODS AND DATA

This paper presents a model of a multi-tiered drug distribution network that is parameterized with data based on one typical, well-studied case, namely British Colombia's market for illegal opioids, supplemented by a corresponding economic interpretation of what determines the share of drug trade revenues that need to be laundered. Sensitivity with respect to key parameters is analyzed.

FINDINGS

We suggest that less than half and perhaps no more than a quarter of revenues from established drug markets need laundering. Key parameters governing this proportion include the price mark-up across distribution levels, transaction volumes at each market level, and the capacity of market participants to spend cash on daily living expenses.

CONCLUSION

This model permits estimation of the scale of money laundering associated with a particular drug market. It suggests that there are limits on money laundering controls as a way of reducing drug supply - although money laundering investigations may still be an effective way to identify and investigate high-level drug traffickers.

Indicators of Drug-Related Community Impacts of Open Drug Scenes: A Scoping Review

INTRODUCTION

Places where people deal and/or use drugs publicly are known as open drug scenes (ODSs). Drug-related community impacts (DRCIs) refer to drug-related issues that negatively influence public and individual health, communities, businesses, and recreational and public space enjoyment. There are no well-established criteria for identification of DRCIs. We therefore performed a scoping review of literature to determine DRCIs indicators associated with ODSs.

METHODS

The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScP). We searched English articles in PubMed, Scopus, Web of Science, and EMBASE databases from 1990 to 2021. The keywords were drug-related crime, drug-related offense, misconduct, social marginalization, homeless drug users, open drug scene, drug-related street disorder, public nuisance, and community impact.

RESULTS

Sixty-four studies were identified. Twenty-five studies were included. Two studies (8%) were about drug-related public nuisance, 1 (4%) considered drug-related social problems, 2 (8%) focused on drug-related social disorder, and 18 studies (72%) discussed indicators of community impacts such as crime, drug-related litter, safety, noise, and drug use in public. Two studies (8%) included the frequency of drug use in ODSs.

DISCUSSION

DRCI indicators are heterogenic, and various factors affect the indicators. The factors include social mores, political discourse, and historical approaches to dealing with and using drugs. Some societies do not tolerate the existence of ODSs. In contrast, many countries have adopted harm reduction programs to manage DRCIs. Identified DRCI indicators were drug using and dealing in public, drug-related litter, crime, drug-related loitering, street-based income generation activities, noise, and unsafety feelings in inhabitants. To solve the problems associated with DRCIs and to make a major change in ODSs, it is necessary to pay attention to the improvement of the economic conditions (e.g., employment opportunities), amendment (e.g., determine the limits of criminalization in drug use), and adoption of social policies (e.g., providing low-threshold and supportive services for homeless drug users).

Income generation and the patterning of substance use: A gender-based analysis

BACKGROUND

Previous research has demonstrated how income-generating activities among marginalized people who use drugs (PWUD)-including employment, income assistance, street-based activities, sex work, and illegal activities-can provide both benefit (e.g., additional income) and harm (e.g., violence, criminalization). However, little is known about gender differences in factors such as drug use patterns that are associated with income-generating activities among PWUD.

METHODS

Using data from prospective cohorts of HIV-positive and HIV-negative PWUD in Vancouver, Canada, we conducted exploratory gender-stratified analyses of associations between substance use patterns and income-generating activities, using generalized linear mixed-models.

RESULTS

Participants reported income sources as employment (23.4 %), income assistance (88.1 %), street-based activities (24.9 %), sex work (15.2 %), drug dealing (31.5 %), or other illegal activities (13.9 %). GLMM results showed gendered patterns of engagement in specific income-generating activities and some diverging patterns of substance use. For instance, men receiving income assistance were less likely to use opioids (Adjusted odds ratio(AOR) = 0.64; 95 % confidence interval(CI) = 0.50-0.82) and women engaged in sex work were more likely to use crack-cocaine (AOR = 2.74, 95 % CI = 2.22-3.37). However, results reflected primarily converging patterns of substance use between women and men across income-generating activities, particularly for drug dealing and other illegal activities.

CONCLUSIONS

Our results suggest that substance use patterns may be more closely associated with income generation context than gender. Given potential harms associated with some income generation activities, results highlight the need for further investigation of the social and structural context of income generation, its intersections with gender and substance use, and the expansion of low-threshold work opportunities.

Sociodemographic Factors Associated With HIV/HCV High-Risk Behaviors Among People Who Use Drugs on Methadone Maintenance Treatment: A 10-Year Observational Study

Background: Sociodemographic factors have an impact worldwide on the behavior of people who use drugs (PWUD). This study attempts to clarify the sociodemographic factors related to HIV/HCV high-risk behaviors (injection drug use, syringe sharing, and multiple sex partners) among PWUD on methadone maintenance treatment (MMT) in the long term. Methods: The 13,300 PWUD recruited into the MMT program were followed during 2006-2015. Generalized estimating equations were used to examine the relationship between sociodemographic characteristics and HIV/HCV high-risk behaviors. Results: We found that male (vs. female), living alone (vs. living with family or relatives), temporary income, financial support from family/friends, and financial support from social welfare (vs. regular salary) were positively associated with injection drug use. Age of initial drug use was negatively associated with injection drug use and syringe sharing. For both genders, being unmarried (vs. married or in cohabitation), living with friends, living alone (vs. living with family or relatives), temporary income, financial supports from family/friends (vs. regular salary), being employed (vs. unemployed/between jobs) was positively associated. In contrast, age at baseline was negatively associated with having multiple sexual partners for both genders. Ethnic of non-Han (vs. Han) was positively associated with having multiple sexual partners simply for males. Being divorced or widowed (vs. married or cohabitated) was positively associated with having multiple sexual partners merely for females. Conclusion: HIV/HCV high-risk behaviors correlated with certain sociodemographic factors of PWUD receiving MMT. There is a need for improving the well-being, employment, and housing status of PWUD on MMT to reduce their HIV/HCV risk behaviors.

Long term pre-treatment opioid use trajectories in relation to opioid agonist therapy outcomes among people who use drugs in a Canadian setting

BACKGROUND

Opioid agonist therapy (OAT) models are generally provided without consideration of how pre-treatment characteristics may be associated with outcome. Therefore, we aimed to first characterize longitudinal trajectories of opioid use before initiating OAT. Then we explored the impact of OAT on opioid use across these pre-treatment trajectories.

METHODS

Data were derived from three prospective cohort studies involving people who use drugs in Vancouver, Canada. Latent class growth analysis was applied to identify opioid use trajectories based on individual-level observations three years before starting OAT. Multivariable generalized linear mixed model was used to examine whether engaging in OAT was associated with lower risk of illicit opioid use among participants with different pre-treatment opioid use trajectories.

RESULTS

464 participants were included in the study between September 2005 and November 2018. Two pre-treatment opioid use trajectories were identified: high frequency users (246, 53.0%) and gradually increasing frequency users (218, 47.0%). We observed different strengths of association between OAT engagement and illicit opioid use among high frequency users (adjusted odds ratio [AOR] = 0.36, 95% Confidence Interval [CI]: 0.20 - 0.63) and gradually increasing frequency users (AOR = 0.91, 95% CI: 0.53 - 1.56). Unstable housing, any stimulant use, experiencing violence, drug dealing, sex work involvement, and incarceration were independently and positively associated with ongoing illicit opioid use.

CONCLUSIONS

Distinct pre-treatment opioid use trajectories are likely to influence treatment outcomes. Research is required to determine if tailored strategies specific to people with different pre-treatment opioid use patterns have potential to improve outcomes of OAT.

Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting

The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.

Transitions in income generation among marginalized people who use drugs: A qualitative study on recycling and vulnerability to violence

BACKGROUND

Income is an important determinant of health among people who use drugs (PWUD). However, understanding transitions between differing types of income generation within the formal and informal economy and how they can be shaped by vulnerability to risk and harm remain poorly understood. This study examines how transitions in income-generating activities are shaped by and influence exposure to violence among marginalised PWUD, in Vancouver, Canada's, Downtown Eastside (DTES) neighbourhood.

METHODS

Qualitative interviews were conducted with twenty-six individuals engaged in informal and illegal income-generating activities in the DTES. Interview transcripts were analyzed thematically, focusing on relationships between income generation and violence during the study period between January 2014 to April 2015 and drew upon concepts of social violence when interpreting these themes.

RESULTS

Participants' engagement in informal and illegal income-generating activities represented a means to negotiate survival given multiple barriers to formal employment and inadequate economic supports. Our findings highlight how informal and illegal income-generating activities in the DTES are characterized by structural, symbolic and everyday violence, while transitions from 'high risk' (e.g., sex work, drug dealing) to perceived 'low risk' (e.g., recycling) activities represent attempts to reduce exposure to violence. However, participants emphasized how informal income generation was nonetheless shaped by structural violence (e.g., gendered hierarchies and police harassment), experienced as everyday violence, and introduced exposure to alternate risks.

CONCLUSION

Our findings underscore the critical role of income generation in shaping exposure to violence, highlighting the need for low-threshold employment interventions targeting PWUD as a central component of harm reduction strategies.

Informal recycling, income generation and risk: Health and social harms among people who use drugs

BACKGROUND

Informal recycling refers to the street-based collection of discarded materials for reuse, resale, or return to a recycling facility for money. While qualitative research has explored experiences and perceptions of informal recycling, little is known about the scope and exposures associated with informal recycling among people who use drugs (PWUD).

METHODS

Using data from two prospective longitudinal cohorts of PWUD, we examined the prevalence of informal recycling and its association with social, structural and health risks, including criminal justice system involvement.

RESULTS

Between June 2010 and May 2015, of 1664 participants, 557 (33.5%) reported engaging in informal recycling during the study period. In multivariable generalised estimating equations (GEE) analyses, informal recycling was positively associated with injection drug use (Adjusted Odds Ratio (AOR) = 1.43, 95% Confidence Interval (CI) 1.21-1.68), public injection (AOR = 1.27, 95% CI 1.09-1.49), methamphetamine use (AOR = 1.35, 95% CI 1.05-1.72), difficulty finding harm reduction equipment (AOR = 1.16, 95% CI 1.02-1.32), and police interactions (AOR = 1.35, 95% CI 1.18-1.55). Sub-analyses revealed PWUD engaged in informal recycling were more likely to be told to move on, ticketed, stopped for jaywalking, and directed to services by police.

CONCLUSIONS

These findings suggest informal recycling as a situated practice for PWUD, with potential indications for higher-risk drug use, experiencing greater surveillance, and difficulty accessing health and addiction treatment services. This research highlights the significance of the broader risk environment and the need for health-promoting policies for socioeconomically marginalised PWUD engaged in informal recycling.

The perspectives of structurally vulnerable people who use drugs on volunteer stipends and work experiences provided through a drug user organization: Opportunities and limitations

BACKGROUND

While drug user organizations (DUO) have received public health attention as a means to potentially reduce the harms associated with drug use, there is a lack of research on the compensation and structural forces that promote or inhibit participation in DUO. Against the backdrop of structural vulnerability experienced by people who use drugs (PWUD), we examined the impact of monetary 'volunteer stipends' provided through a DUO and explore their role in providing low-threshold employment opportunities and shaping participation in DUO.

METHODS

Participants were purposively sampled to reflect a range of perspectives and experiences volunteering at Vancouver Area Network of Drug Users (VANDU) and receiving stipends. Semi-structured qualitative interviews were conducted with 23 members of VANDU. Interview transcripts were coded in Atlas.ti 7 for key a priori themes and emergent categories from the data and analyzed thematically.

RESULTS

Stipends provided participants with symbolic and material recognition of the time, effort, and expertise they contribute to the organization, and functioned to facilitate ongoing participation. Payments that rewarded, skills, labour and drug-related knowledge reduced participant's perception of stigma against PWUD. Paid work in VANDU further provided participants with non-material benefits commonly attributed to regular employment, including social connections and a sense of purpose. Participants also identified the low level of pay as a limitation of VANDU's paid participation program. The daily demands of survival (accessing shelter, food, and drugs) posed more complex structural vulnerabilities to participate in VANDU, as small stipends were not sufficient to address these needs.

CONCLUSION

Low threshold employment opportunities within DUO may provide significant individual and public health benefits. However, these benefits are constrained by the small size of stipends. Therefore, to ensure better inclusion of PWUD, our findings recommend the development and expansion of equitable, accessible, well-paying employment programs for PWUD.

Tranquilizer misuse among active cocaine users: Predictors of initiation

INTRODUCTION AND AIMS

Tranquilizer use is associated with negative health outcomes among people who use drugs. This paper aims to estimate the incidence rate (initiation) and identify predictors of tranquilizer misuse (TM) among cocaine users.

DESIGN AND METHODS

A prospective cohort study was conducted in Montreal, Canada. Interviewer-administered questionnaires were carried out at 3-month intervals. Initiation was defined as misusing a tranquilizer for the first time during follow-up. 'Lasting-initiation', defined as reporting TM at the next visit following first use, was also examined. Cox proportional hazard regression analyses were carried out to assess predictors of initiation to TM.

RESULTS

Among the 245 participants who were eligible for the initiation analyses, 123 started TM during follow-up for an incidence rate of 40.49 per 100 person-years (95% confidence interval, CI: 33.80-48.15). Of the 123 initiates, 35.7% were still using at the interview following initiation for an incidence rate of 14.70 per 100 person-years (95% CI: 10.82-19.56). Multivariate models showed that independent predictors of initiation and 'lasting initiation' were identical as having had a criminal activity as the main source of income, having been recently in treatment for a substance use disorder (SUD) and reporting non-medical use of prescription opioids.

DISCUSSION AND CONCLUSIONS

The incidence rate of TM initiation was high among a sample of cocaine users. Initiation was predicted by a problematic drug use pattern involving polydrug use, involvement in the street economy and having been in treatment for a SUD. These findings have implications for prevention and harm reduction strategies.

Socio-demographic and sexual practices associated with HIV infection in Kenyan injection and non-injection drug users

Background

Substance use is increasingly becoming prevalent on the African continent, fueling the spread of HIV infection. Although socio-demographic factors influence substance consumption and risk of HIV infection, the association of these factors with HIV infection is poorly understood among substance users on the African continent. The objective of the study was to assess socio-demographic and sexual practices that are associated with HIV infection among injection drug users (IDUs), non-IDUs, and non-drug users (DUs) at an urban setting of coastal Kenya.

Methods

A cross-sectional descriptive study was conducted among 451 adults comprising HIV-infected and -uninfected IDUs (n = 157 and 39); non-IDUs (n = 17 and 48); and non-DUs (n = 55 and 135); respectively at coastal, Kenya. Respondent driven sampling, snowball and makeshift methods were used to enroll IDUs and non-IDUs. Convenience and purposive sampling were used to enroll non-DUs from the hospital’s voluntary HIV testing unit. Participant assisted questionnaire was used in collecting socio-demographic data and sexual practices.

Results

Binary logistic regression analysis indicated that higher likelihood of HIV infection was associated with sex for police protection (OR, 9.526; 95% CI, 1.156-78.528; P = 0.036) and history of sexually transmitted infection (OR, 5.117; 95% CI, 1.924-13.485; P = 0.001) in IDUs; divorced, separated or widowed marital status (OR, 6.315; 95% CI, 1.334-29.898; P = 0.020) in non-IDUs; and unemployment (OR, 2.724; 95% CI, 1.049-7.070; P = 0.040) in non-drug users. However, never married (single) marital status (OR, 0.140; 95% CI, 0.030-0.649; P = 0.012) was associated with lower odds for HIV infection in non-drug users.

Conclusion

Altogether, these results suggest that socio-demographic and sexual risk factors for HIV transmission differ with drug use status, suggesting targeted preventive measures for drug users.

Socioeconomic factors associated with cessation of injection drug use among street-involved youth

Background

Although the initiation of injection drug use has been well characterized among at-risk youth, factors that support or impede cessation of injection drug use have received less attention. We sought to identify socioeconomic factors associated with cessation of injection drug use among street-involved youth.

Methods

From September 2005 to May 2015, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Multivariate extended Cox regression was utilized to identify socioeconomic factors associated with cessation of injection drug use for six months or longer among youth who were actively injecting.

Results

Among 383 participants, 171 (44.6%) youth reported having ceased injection (crude incidence density 22 per 100 person-years; 95% confidence interval [CI], 19–26) at some point during study follow-up. Youth who had recently dealt drugs (adjusted hazard ration [AHR], 0.50; 95% CI, 0.29–0.87), engaged in prohibited street-based income generation (AHR, 0.41; 95% CI, 0.24–0.69), and engaged in illegal income generating activities (AHR, 0.19; 95% CI, 0.06–0.61) were significantly less likely to report cessation of injection drug use.

Conclusions

Our findings suggest that socioeconomic factors, in particular engagement in prohibited street-based and illegal income generating activities, may pose barriers to ceasing injection drug use among this population. Effort to improve access to stable and secure income, as well as employment opportunities may assist youth in transitioning away from injection drug use.

Trial registration

Our study is not a randomized controlled trial; thus the trial registration is not applicable.

Examining the link between cocaine binging and individual, social and behavioral factors among street-based cocaine users

AIMS

To estimate the prevalence of cocaine binging and examine associated factors, to characterize binge episodes and to study the relationship between cocaine binging and HIV and HCV risk behaviors among street-based cocaine users.

METHODS

A prospective cohort study was conducted in Montréal, Canada. Interviewer-administered questionnaire were carried out at 3-month intervals. Cocaine binging was defined as using large quantities of cocaine, without stopping, over a limited period of time, until resources run out or until being physically incapable of consuming. Generalized Estimation Equations (GEE) analyses were used. Covariates considered included demographic, behavioral, mental health and social risk factors.

FINDINGS

In total, 605 participants were recruited. Prevalence of cocaine binging over the month prior to recruitment was 24.5%. Correlates of cocaine binging were older age (AOR 1.46), homelessness (AOR 1.44), criminal/marginal income strategies (AOR 1.61), high psychological distress (AOR 1.31), high cocaine dependence (AOR 3.71), drug overdoses (AOR 1.56) and smoking as the main route of cocaine administration (AOR 1.38). Additional GEE analyses showed that cocaine binging was significantly associated with the sharing of drug paraphernalia (AOR 1.35) and sexual relations under the influence of cocaine (AOR 1.21).

CONCLUSION

Cocaine binging is frequent among street-based cocaine users and is associated with markers of vulnerability. It is also associated with increased odds of both sexual and drug use risk behaviors. Interventions need to be tailored in order to help cocaine bingers develop personal strategies that could prevent binging. Harm reduction programs should help cocaine bingers adequately assess their drug equipment needs.

Drug dealing and drug using behaviors among people who inject drugs in Colombia: A cross-sectional study

Introduction

People who inject drugs (PWID) are highly exposed to drug-dealing networks. In Colombia, a recent dramatic increase in drug consumption has been reported. However, involvement of PWID in drug dealing, their demographics, and drug using behaviors has not been studied.

Methods

A cross-sectional study involving 1,099 PWID recruited by Respondent Driven-Sampling in five Colombian cities was conducted in 2014. Correlates of demographic characteristics, drug dealing, and injection behaviors were examined by multivariate analysis, and a binary logistic regression model.

Results

Drug-dealing PWID were predominantly male (86%) with a mean age of 26 years. 56% of participants-of whom 64% had low familial socioeconomic status-had been involved in drug dealing in the previous six months. Compared to non-drug-dealing PWID, drug-dealing PWID reported higher daily injection rate (AOR: 1.3), higher odds of injection equipment confiscation by the police (AOR: 1.4), and were less likely to pay for the drugs they injected (AOR: 0.6).

Conclusions

Involvement of Colombian PWID in drug dealing was higher than previously reported, and drug-dealing PWID presented sociodemographic vulnerabilities and risky injection practices. Addressing these findings may lead to effective policy design and implementation, decreased drug-dealing involvement, harm reduction, and consumption prevention.

Community-based participatory research in a heavily researched inner city neighbourhood: Perspectives of people who use drugs on their experiences as peer researchers

Community-based participatory research (CBPR) has become an increasingly common approach to research involving people who use(d) drugs (PWUD), who are often employed as peer researchers on these projects. This paper seeks to understand the impact of CBPR on PWUD, particularly those living in heavily researched and stigmatized neighbourhoods where CBPR projects are often located. This study draws on 14 in-depth interviews with PWUD who had previous experience as both peer researchers and research participants in CBPR projects conducted between July 2010 and February 2011. The study employed a CBPR approach in its study design, recruitment, interviewing, and analysis. Our analysis indicates that participants were supportive of CBPR in principle and described the ways in which it helped contest stigmatizing assumptions and researcher bias. Participants also reported positive personal gains from participation in CBPR projects. However, many participants had negative experiences with CBPR projects, especially when CBPR principles were implemented in a superficial or incomplete manner. Participants emphasized the importance of inclusiveness and active deconstruction of hierarchy between researchers and community members to successful CBPR among drug using populations. CBPR has been widely adopted as a research approach within marginalized communities but has often been implemented inconsistently. Still, CBPR can empower communities to contest forms of social stigma that are often reproduced through academic research on marginalized communities. Our findings describe how the benefits of CBPR are maximized when CBPR principles are consistently applied and when community-based researchers are supported in ways that reduce power hierarchies. This suggests a need for capacity building within affected communities to develop independent support, training, and grievance processes for peer researchers.

Income generation and attitudes towards addiction treatment among people who use illicit drugs in a Canadian setting

INTRODUCTION

Socioeconomically marginalized people who use illicit drugs (PWUD) often engage in alternative income generating activities to meet their basic needs. These activities commonly carry a number of health and social risks, which may prompt some PWUD to consider addiction treatment to reduce their drug use or drug-related expenses. We sought to determine whether engaging in certain forms of income generation was independently associated with self-reported need for addiction treatment among a cohort of PWUD in Vancouver, Canada.

METHODS

Data from two prospective cohorts of PWUD in Vancouver were used in generalized estimating equations to identify factors associated with self-reported need for addiction treatment, with a focus on income generating activities.

RESULTS

Between June 2013 and May 2014, 1285 respondents participated in the study of whom 483 (34.1%) were female and 396 (30.8%) indicated that they needed addiction treatment. In final multivariate analyses, key factors significantly and positively associated with self-reported need for addiction treatment included engaging in illegal income generating activities (adjusted odds ratio [AOR]=1.96, 95% confidence interval [CI}: 1.11-3.46); sex work (AOR=1.61, 95% CI: 1.05-2.47), homelessness (AOR=1.65, 95% CI: 1.22-2.25); and recent engagement in counselling (AOR=1.85, 95% CI: 1.40-2.44).

DISCUSSION

Our results suggest that key markers of socioeconomic marginalization are strongly linked with a stated need for addiction treatment. These findings underscore the need to provide appropriate and accessible addiction treatment access to marginalized PWUD and to consider alternative approaches to reduce socioeconomic disadvantage.

Increased drug use and the timing of social assistance receipt among people who use illicit drugs

BACKGROUND

The monthly disbursement of social assistance (SA) payments to people who use illicit drugs (PWUD) has been temporally associated with increases in drug-related harm. Yet, whether SA receipt changes drug use intensity compared to levels of use at other times in the month has not been established. We therefore examined this relationship among PWUD in Vancouver, Canada (2005-2013).

METHODS

Data were derived from prospective cohorts of HIV-positive and HIV-negative PWUD. Every six months, participants were asked about their illicit drug use during the last 180 days and the past week. We determined whether SA receipt occurred within the assessment's one-week recall period. We employed generalized estimating equations controlling for confounders to examine the relationship between SA receipt and the change in drug use intensity, defined as a 100% increase in the average times per day a given drug was used in the last week compared to the previous 6 months. We tested the robustness of this relationship by stratifying analyses by whether individuals primarily used stimulants, illicit opioids or engaged in polydrug use and examining the timing of SA receipt relative to date of assessment.

RESULTS

Our study included 2661 individuals (median age 36, 32% female) with 1415 (53.2%) reporting SA receipt occurring within the one-week recall period of the assessment at least once. SA receipt was independently associated with intensified drug use (Adjusted Odds Ratio [AOR]: 1.79; 95% Confidence Interval [CI]: 1.53, 2.09), and remained significant when stratified by primary use of stimulants (AOR: 1.87; 95% CI: 1.54, 2.26), opioids (AOR: 1.96; 95% CI: 1.23, 3.13) and polydrug use (AOR: 1.53; 95% CI: 1.11, 2.10).

CONCLUSION

We found a temporal association between SA receipt and drug use intensification. While the health and social benefits of SA are significant, these findings suggest that alternative disbursement strategies, such as staggered or smaller and more frequent SA payments may be able to mitigate drug-related harm. Alternatives should be tested rigorously.

Elevated risk of incarceration among street-involved youth who initiate drug dealing

Background

Street-involved youth are known to be an economically vulnerable population that commonly resorts to risky activities such as drug dealing to generate income. While incarceration is common among people who use illicit drugs and associated with increased economic vulnerability, interventions among this population remain inadequate. Although previous research has documented the role of incarceration in further entrenching youth in both the criminal justice system and street life, less is known whether recent incarceration predicts initiating drug dealing among vulnerable youth. This study examines the relationship between incarceration and drug dealing initiation among street-involved youth.

Methods

Between September 2005 and November 2014, data were collected through the At-Risk Youth Study, a cohort of street-involved youth who use illicit drugs, in Vancouver, Canada. An extended Cox model with time-dependent variables was used to examine the relationship between recent incarceration and initiation into drug dealing, controlling for relevant confounders.

Results

Among 1172 youth enrolled, only 194 (16.6%) were drug dealing naïve at baseline and completed at least one additional study visit to facilitate the assessment of drug dealing initiation. Among this sample, 56 (29%) subsequently initiated drug dealing. In final multivariable Cox regression analysis, recent incarceration was significantly associated with initiating drug dealing (adjusted hazard ratio = 2.31; 95% confidence interval (CI) 1.21–4.42), after adjusting for potential confounders. Measures of recent incarceration lagged to the prior study follow-up were not found to predict initiation of drug dealing (hazard ratio = 1.50; 95% CI 0.66–3.42).

Conclusions

These findings suggest that among this study sample, incarceration does not appear to significantly propel youth to initiate drug dealing. However, the initiation of drug dealing among youth coincides with an increased risk of incarceration and their consequent vulnerability to the significant harms associated therein. Given that existing services tailored to street-involved youth are inadequate, evidence-based interventions should be invested and scaled up as a public health priority.

Prevalence and correlates of prescription opioid residue injection

BACKGROUND

There is growing evidence of intravenous administration of prescription opioids (POs) in several countries. Preparation of POs for injection may leave residues in containers and filters used by people who inject drugs and may lead to adverse health outcomes if they are injected.

METHODS

This exploratory study used cross-sectional data from the COSMO study, a prospective cohort of out-of-treatment cocaine users carried out in Montréal (Canada) between October 2010 and August 2015. For this analysis, only one visit per participant was selected, that is, the first time the participant reported PO injection during the study. The outcome of interest, "injection of PO residues", was defined as having injected PO residues from a filter and/or a container in the last month. Correlates of this outcome were identified using logistic regression analyses.

RESULTS

Of the 122 participants who reported PO injection during the study period, 41.8% had injected PO residues. Reporting an unstable source of income (AOR=4.26; 95% CI: 1.03-17.69), a recent overdose (AOR=5.45; 95% CI: 1.50-19.88) and a preponderant use of opiates (mostly opiate use versus other drugs excluding alcohol and cannabis) (AOR=2.46; 95% CI: 1.08-5.63) increased the risk of PO residue injection. The odds of reporting PO residue injection rose by 7% per unit increase in the score of psychological distress (AOR=1.07 per unit increase; 95% CI: 1.01-1.12).

CONCLUSIONS

The findings of this study suggest that PO residue injection is associated with markers of vulnerability. Further investigation is needed in order to better understand this understudied drug injection practice.

Initiation of drug dealing among a prospective cohort of street-involved youth

BACKGROUND

Street-involved youth who use drugs may have limited income-generation options and are known to commonly become immersed in illicit drug markets to generate funds. However, little attention has been given to factors that may drive drug dealing initiation among this vulnerable population.

OBJECTIVES

This longitudinal study examines drug dealing initiation among street-involved youth.

METHODS

Data were derived from the At-Risk Youth Study from September 2005 to November 2014; a prospective cohort of 194 street-involved youth who use drugs aged 14-26, in Vancouver, Canada. Extended Cox model was used to identify factors independently associated with time to first drug dealing.

RESULTS

Among street-involved youth who had never dealt drugs at baseline, 56 (29%) individuals initiated drug dealing during the study period for an incidence density of 13.0 per 100 person-years (95% confidence interval [CI]: 9.9-17.2). In multivariable Cox regression analysis, male gender (adjusted hazard ratio [AHR] = 1.90, 95% CI: 1.06-3.42), homelessness (AHR = 1.88, 95% CI: 1.05-3.35), crystal methamphetamine use (AHR = 2.48, 95% CI: 1.47-4.20), and crack cocaine use (AHR = 2.35, 95% CI: 1.38-4.00) were positively and independently associated with initiating drug dealing.

CONCLUSION

Homelessness and stimulant drug use were key risk factors for drug dealing initiation among street-involved youth. Findings indicate that evidence-based and innovative interventions, including youth-centric supportive housing, low threshold employment programs, and stimulant addiction treatment should be implemented and evaluated as strategies to help prevent this vulnerable population from engaging in risky illegal income generation practices.

Eviction and loss of income assistance among street-involved youth in Canada

Loss of housing and income assistance among vulnerable youth has not been well described in the literature, yet it is a crucial issue for public health. This study examines the prevalence and correlates of loss of income assistance as well as eviction among street-involved youth. We collected data from a prospective cohort of street-involved youth aged 14-26. Among 770 participants, 64.3 per cent reported having housing and 77.1 per cent reported receiving income assistance at some point during the study period. Further, 28.6 and 20.0 per cent of youth reported having been evicted and losing income assistance, respectively. In multivariable generalized estimating equations analysis, heavy alcohol use, unprotected sex, being a victim of violence, and homelessness were all independently associated with eviction. Separately, homelessness, recent incarceration, and drug dealing were independently associated with loss of income assistance. Eviction and loss of income assistance are common experiences among street-involved youth with multiple vulnerabilities. Our findings highlight the importance of improving continued engagement with critical social services.

Building recovery capital through peer harm reduction work

Purpose

– Peer harm reduction programmes engage service users in service delivery and may help peers to develop employment skills, better health, greater stability, and new goals. Thus far, peer work has not been discussed as an intervention to promote recovery. The purpose of this paper is to provide findings related to two research questions: first,do low-threshold employment programmes have the potential to contribute to positive recovery capital, and if so, how? Second, how are such programmes designed and what challenges do they face in supporting the recovery process?

Design/methodology/approach

– Using a community-based research approach, data were collected at a Toronto, Canada community health centre using in-depth interviews with peer workers (n=5), staff (n=5), and programme clients (n=4) and two focus groups with peer workers (n=12). A thematic analysis was undertaken to describe the programme model and to explore the mechanisms by which participation contributes to the development of recovery capital.

Findings

– The design of the Regent Park Community Health Centre peer work model demonstrates how opportunities for participation in community activities may spark cumulative growth in positive recovery capital within the community of PUDs. However, the recovery contagion of peer work may lose momentum with insufficient opportunities for new and experienced peer workers.

Originality/value

– Using the concept of recovery capital, the authors demonstrate how low-threshold employment interventions have the potential to contribute to the development of positive recovery capital.

Pathways linking drug use and labour market trajectories: the role of catastrophic events

People affected by substance use disorders often experience sub-optimal employment outcomes. The role of drug use in processes that produce and entrench labour market precarity among people who inject drugs (PWID) have not, however, been fully described. We recruited 22 PWID from ongoing prospective cohort studies in Vancouver, Canada, with whom we conducted semi-structured retrospective interviews and then employed a thematic analysis that drew on concepts from life course theory to explore the mechanisms and pathways linking drug use and labour market trajectories. The participants' narratives identified processes corresponding to causation, whereby suboptimal employment outcomes led to harmful drug use; direct selection, where impairment, health complications or drug-seeking activities selected individuals out of employment; and indirect selection, where external factors, such as catastrophic events, marked the initiation or intensification of substance use concurrent with sudden changes in capacities for employment. Catastrophic events linking negative transitions in both drug use and labour market trajectories were of primary importance, demarcating critical initiation and transitional events in individual risk trajectories. These results challenge conventional assumptions about the primacy of drug use in determining employment outcomes among PWID and suggest the importance of multidimensional support to mitigate the initiation, accumulation and entrenchment of labour market and drug-related disadvantage.

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.

Protective factors associated with short-term cessation of injection drug use among a Canadian cohort of people who inject drugs

INTRODUCTION AND AIMS

Strategies are needed to transition persons who inject drugs out of injecting. We undertook this study to identify protective factors associated with cessation of injection drug use.

DESIGN AND METHODS

Data were derived from three prospective cohorts of people who use illicit drugs in Vancouver, Canada, between September 2005 and November 2011. Generalised estimating equations were used to examine protective factors and 6-month cessation of injection drug use.

RESULTS

Our sample of 1663 people who inject drugs included 563 (33.9%) women, and median age was 40 years. Overall, 904 (54.4%) individuals had at least one 6-month injection cessation event. In multivariable analysis, protective factors associated with cessation of injection drug use included the following: having a regular place to stay [adjusted odds ratio (AOR) = 1.30; 95% confidence interval (CI) 1.13-1.48]; formal employment (AOR = 1.12; 95% CI 1.01-1.23); social support from personal contacts (AOR = 1.22; 95% CI 1.10-1.35); social support from professionals (AOR = 1.26; 95% CI 1.14-1.39); ability to access health and social services (AOR = 1.21; 95% CI 1.09-1.34); and positive self-rated health (AOR = 1.21, 95% CI 1.11-1.32).

DISCUSSION AND CONCLUSIONS

Over half of people who inject drugs in this study reported achieving 6-month cessation of injection drug use, with cessation being associated with a range of modifiable protective factors. Policy makers and practitioners should promote increased access to stable housing, employment, social support and other services to promote cessation of injection drug use. [Luchenski S, Ti L, Hayashi K, Dong H, Wood E, Kerr T. Protective factors associated with short-term cessation of injection drug use among a Canadian cohort of people who inject drugs Drug Alcohol Rev 2016;35:620-627].

Socioeconomic marginalization and plasma HIV-1 RNA nondetectability among individuals who use illicit drugs in a Canadian setting

OBJECTIVE

Given that people who use illicit drugs (PWUD) often engage in prohibited income generation to support their basic needs, we sought to examine the role of these activities in shaping antiretroviral therapy (ART) adherence and plasma HIV RNA-1 viral load suppression among HIV-infected PWUD.

DESIGN

Longitudinal analyses among HIV-positive, ART-exposed PWUD in the AIDS Care Cohort to evaluate Exposure to Survival Services prospective cohort study (2005-2013).

METHODS

Generalized linear mixed-effects and mediation analyses examined the relationship between prohibited income generation (e.g., sex work, drug dealing, theft, street-based income) and virologic suppression (plasma viral load ≤50 copies/ml plasma) adjusting for adherence and potential confounders.

RESULTS

Among 687 HIV-infected PWUD, 391 (56.9%) individuals reported prohibited income generation activity during the study period. In multivariate analyses, prohibited income generation remained independently and negatively associated with virologic suppression (adjusted odds ratio: 0.68, 95% confidence interval: 0.52-0.88) following adjustment for hypothesized confounders, including high-intensity drug use, ART adherence and homelessness. Although partially mediated by ART adherence, the relationship between prohibited income generation and virologic suppression was maintained in mediation analyses (Sobel statistic = -1.95, P = 0.05).

CONCLUSION

Involvement in prohibited income generation decreases the likelihood of virologic suppression directly and indirectly through its negative association with ART adherence. These findings suggest that linkages between socioeconomic marginalization, the criminalization of illicit drug use, and insufficient employment opportunities may produce barriers to access and retention in care. Programmatic and policy interventions that decrease socioeconomic vulnerability may therefore reduce HIV-related morbidity, mortality, and onward transmission.

Socioeconomic marginalisation in the structural production of vulnerability to violence among people who use illicit drugs

OBJECTIVE

Many people who use illicit drugs (PWUD) face challenges to their financial stability. Resulting activities that PWUD undertake to generate income may increase their vulnerability to violence. We therefore examined the relationship between income generation and exposure to violence across a wide range of income generating activities among HIV-positive and HIV-negative PWUD living in Vancouver, Canada.

METHODS

Data were derived from cohorts of HIV-seropositive and HIV-seronegative PWUD (n=1876) between December 2005 and November 2012. We estimated the relationship between different types of income generation and suffering physical or sexual violence using bivariate and multivariate generalised estimating equations, as well as the characteristics of violent interactions.

RESULTS

Exposure to violence was reported among 977 (52%) study participants over the study period. In multivariate models controlling for sociodemographic characteristics, mental health status, and drug use patterns, violence was independently and positively associated with participation in street-based income generation activities (ie, recycling, squeegeeing and panhandling; adjusted OR (AOR)=1.39, 95% CI 1.23 to 1.57), sex work (AOR=1.23, 95% CI 1.00 to 1.50), drug dealing (AOR=1.63, 95% CI 1.44 to 1.84), and theft and other acquisitive criminal activity (AOR=1.51, 95% CI 1.27 to 1.80). Engagement in regular, self-employment or temporary employment was not associated with being exposed to violence. Strangers were the most common perpetrators of violence (46.7%) and beatings the most common type of exposure (70.8%).

CONCLUSIONS

These results suggest that economic activities expose individuals to contexts associated with social and structural vulnerability to violence. The creation of safe economic opportunities which can minimise vulnerability to violence among PWUD is therefore urgently required.

Application of space-time scan statistics to describe geographic and temporal clustering of visible drug activity

Knowledge of the geographic and temporal clustering of drug activity can inform where health and social services are needed and can provide insight on the potential impact of local policies on drug activity. This ecologic study assessed the spatial and temporal distribution of drug activity in Baltimore, Maryland, prior to and following the implementation of a large urban redevelopment project in East Baltimore, which began in 2003. Drug activity was measured by narcotic calls for service at the neighborhood level. A space-time scan statistic approach was used to identify statistically significant clusters of narcotic calls for service across space and time, using a discrete Poisson model. After adjusting for economic deprivation and housing vacancy, clusters of narcotic calls for service were identified among neighborhoods located in Southeast, Northeast, Northwest, and West Baltimore from 2001 to 2010. Clusters of narcotic calls for service were identified among neighborhoods located in East Baltimore from 2001 to 2003, indicating a decrease in narcotic calls thereafter. A large proportion of clusters occurred among neighborhoods located in North and Northeast Baltimore after 2003, which indicated a potential spike during this time frame. These findings suggest potential displacement of drug activity coinciding with the initiation of urban redevelopment in East Baltimore. Space-time scan statistics should be used in future research to describe the potential implications of local policies on drug activity.

The impact of engagement in street-based income generation activities on stimulant drug use cessation among people who inject drugs

BACKGROUND

Despite the growing prevalence of illicit stimulant drug use internationally, and the widespread involvement of people who inject drugs (IDU) within street-based drug markets, little is known about the impact of different types of street-based income generation activities on the cessation of stimulant use among IDU.

METHODS

Data were derived from an open prospective cohort of IDU in Vancouver, Canada. We used Kaplan-Meier methods and Cox proportional hazards regression to examine the effect of different types of street-based income generation activities (e.g., sex work, drug dealing, and scavenging) on time to cessation of stimulant use.

RESULTS

Between December, 2005 and November, 2012, 887 IDU who use stimulant drugs (cocaine, crack cocaine, or crystal methamphetamine) were prospectively followed-up for a median duration of 47 months. In Kaplan-Meier analyses, compared to those who did not engage in street-based income generation activities, participants who reported sex work, drug dealing, scavenging, or more than one of these activities were significantly less likely to report stimulant drug use cessation (all p<0.001). When considered as time-updated variables and adjusted for potential confounders in a multivariable model, each type of street-based income generation activity remained significantly associated with a slower time to stimulant drug cessation (all p<0.005).

CONCLUSIONS

Our findings highlight the urgent need for strategies to address stimulant dependence, including novel pharmacotherapies. Also important, structural interventions, such as low-threshold employment opportunities, availability of supportive housing, legal reforms regarding drug use, and evidence-based approaches that reduce harm among IDU are urgently required.

Income level and drug related harm among people who use injection drugs in a Canadian setting

BACKGROUND

Higher income is generally associated with better health outcomes; however, among people who inject drugs (IDU) income generation frequently involves activities, such as sex work and drug dealing, which pose significant health risks. Therefore, we sought to examine the relationship between level of income and specific drug use patterns and related health risks.

METHODS

This study involved IDU participating in a prospective cohort study in Vancouver, Canada. Monthly income was categorized based on non-fixed quartiles at each follow-up with the lowest level serving as the reference category in generalized linear mixed-effects regression.

RESULTS

Among our sample of 1032 IDU, the median average monthly income over the study follow-up was $1050 [interquartile range=785-2000]. In multivariate analysis, the highest income category was significantly associated with sex work (adjusted odds ratio [AOR]=7.65), drug dealing (AOR=5.06), daily heroin injection (AOR=2.97), daily cocaine injection (AOR=1.65), daily crack smoking (AOR=2.48), binge drug use (AOR=1.57) and unstable housing (AOR=1.67). The high income category was negatively associated with being female (AOR=0.61) and accessing addiction treatment (AOR=0.64), (all p<0.05). In addition, higher income was strongly associated with higher monthly expenditure on drugs (>$400) (OR=97.8).

CONCLUSION

Among IDU in Vancouver, average monthly income levels were low and higher total monthly income was linked to high-risk income generation strategies as well as a range of drug use patterns characteristic of higher intensity addiction and HIV risk. These findings underscore the need for interventions that provide economic empowerment and address high intensity addiction, especially for female IDU.

Open drug scenes and drug-related public nuisance: a visual rapid assessment research study in Dublin, Ireland

The research was undertaken at a time of increasing public concerns for drug- and alcohol-related public nuisance in the city center of Dublin, Ireland. Rapid Assessment Research was conducted involving qualitative interviewing with drug service users; business, transport, community, voluntary, and statutory stakeholders (n = 61); and an environmental mapping exercise. The interplay between homelessness, loitering, an influx of drug users via city metro systems, transient open drug scenes, street drinking, drug injecting, intimidation, knife crime, and prescribed medication abuse was evident. Potential strategies to address drug and alcohol related public nuisance are advised to include the relocation of treatment services, targeted harm reduction initiatives, urban regeneration, improved community rehabilitation pathways, and heightened policing intensity.

Incarceration among street-involved youth in a Canadian study: implications for health and policy interventions

BACKGROUND

Risk factors for incarceration have been well described among adult drug using populations; however, less is known about incarceration among at-risk youth. This study examines the prevalence and correlates of incarceration among street-involved youth in a Canadian setting.

METHODS

From September 2005 to May 2012, data were collected from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14-26 who use illicit drugs. Generalized estimating equation (GEE) logistic regression was used to identify factors associated with recent incarceration defined as incarceration in the previous six months.

RESULTS

Among 1019 participants, 362 (36%) reported having been recently incarcerated during the study period. In multivariate GEE analysis, homelessness (adjusted odds ratio [AOR]=1.60), daily crystal methamphetamine use (AOR=1.56), public injecting (AOR=1.33), drug dealing (AOR=1.48) and being a victim of violence (AOR=1.68) were independently associated with incarceration (all p<0.05). Conversely, female gender (AOR=0.48), lesbian, gay, bisexual, transgender or two-spirited (LGBTT) identification (AOR=0.47) and increasing age of first hard drug use (AOR=0.96) were negatively associated with incarceration (all p<0.05).

CONCLUSION

Incarceration was common among our study sample. Youth who were homeless, used crystal methamphetamine, and engaged in risky behaviors including public injection and drug dealing were significantly more likely to have been recently incarcerated. Structural interventions including expanding addiction treatment and supportive housing for at-risk youth may help reduce criminal justice involvement among this population and associated health, social and fiscal costs.

'It's more about the heroin': injection drug users' response to an overdose warning campaign in a Canadian setting

AIMS

To assess heroin injectors' perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses.

DESIGN

Semi-structured qualitative interviews.

SETTING

Vancouver, Canada.

PARTICIPANTS

Eighteen active heroin injectors.

MEASUREMENTS

Semi-structured interview guide focussing on heroin injectors' perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations.

FINDINGS

Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages.

CONCLUSIONS

Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.

"Everything that looks good ain't good!": perspectives on urban redevelopment among persons with a history of injection drug use in Baltimore, Maryland

BACKGROUND

While urban redevelopment is intended to ameliorate urban decay, some studies demonstrate that it can negatively impact some residents. Few studies have considered its impact on persons with a history of drug use.

METHODS

A convenience sample of 25 current or former injection drug users from Baltimore, Maryland, enrolled in the AIDS Linked to the Intravenous Experience study, and reporting residence in or bordering a redeveloping neighborhood participated in 1-2 semi-structured in-depth interviews from July, 2011 to February, 2012. Interviews explored personal experiences with redevelopment and perceptions of community-wide impact. Data were analyzed using the constant comparison method.

RESULTS

Respondents rarely described urban redevelopment as solely negative or positive. Revitalization and increased security in the redeveloping area were reported as positive consequences. Negative consequences included the lack of redevelopment-related employment opportunities, disruption of social ties, and housing instability among relocated residents. Respondents also said that urban redevelopment led to the displacement of drug markets to adjacent neighborhoods and outlying counties. Residential relocation and displacement of drug markets were reported as beneficial for persons in contemplative and later stages of recovery.

CONCLUSION

These findings support a holistic approach to urban redevelopment that increases access to employment opportunities and affordable housing, and ensures equitable coverage of public services such as law enforcement.

Police confrontations among street-involved youth in a Canadian setting

BACKGROUND

Street-level policing has been recognized as a driver of health-related harms among people who inject drugs (IDU). However, the extent of interaction between police and street-involved youth has not been well characterized. We examined the incidence and risk factors for police confrontations among street-involved youth in a Canadian setting.

METHODS

Using data derived from participants enrolled in the At-Risk Youth Study (ARYS) between 2005 and 2011, we assessed factors associated with being stopped, searched, or detained by police without arrest in the previous six months using generalized estimating equations (GEE) with logit link for binary outcomes.

RESULTS

Among 991 participants followed during the study period, 440 (44.4%) reported being stopped, searched, or detained by police for an incidence density of 49.20 (95% confidence interval [CI]: 36.42-65.01) per 100 person years. In multivariate GEE analyses, factors associated with police confrontations included: male gender (adjusted odds ratio [AOR]=1.35), homelessness (AOR=2.05), recent incarceration (AOR=1.78), daily cannabis use (AOR=1.31), daily heroin injecting (AOR=1.36), crack pipe/syringe sharing (AOR=1.61), injection drug use (AOR=1.37), public drug use (AOR=2.19), sex work involvement (AOR=1.67), and drug dealing (AOR=1.49) (all p<0.05). In total, 19.0% of participants reported that police confiscated their drug paraphernalia without arresting them. Additionally, 16.9% of individuals reported experiencing violence at the hands of police.

CONCLUSION

We found that various factors, such as homelessness and markers of more severe addiction, increased the likelihood of being confronted by police, and police confrontations were associated with markers of health-related harm among street youth. These findings highlight the need for social and structural interventions that best enable police to fulfil public safety and public order objectives without negatively influencing health behaviours of street youth.

Addiction treatment-related employment barriers: the impact of methadone maintenance

Employment is commonly upheld as an important outcome of addiction treatment. To explore this attribution, we assessed whether treatment enrollment predicts employment initiation among participants enrolled in a community-recruited Canadian cohort of people who inject drugs (IDU; N = 1,579). Survival analysis initially found no association between addiction treatment enrollment and employment initiation. However, when methadone maintenance therapy (MMT) was separated from other treatment modalities, non-MMT treatment positively predicted employment transitions, whereas MMT was negatively associated with employment initiation. Subanalyses examining transitions into temporary, informal, and under-the-table income generation echo these results. Findings suggest that individual factors impacting employment transitions may systematically apply to MMT clients and that, in this setting, the impact of treatment on employment outcomes is contingent on treatment type and design. Treatment-specific differences underscore the need to expand low-threshold MMT, explore MMT alternatives, and evaluate the impact of treatment design on the social and economic activity of IDU.