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The longstanding association between addiction, crime, and mortality has become increasingly severe in Canada, affecting larger numbers of individuals and communities. Diverse and irreconcilable courses of action have been proposed involving the decriminalization of drug possession, expanded resources to promote recovery from addiction, or both. The current review used the PICOTS method to identify peer-reviewed publications that reported outcomes of reducing the criminal consequences of drug possession and the specific relationship between law reform and the well-being of people who are at greatest risk for poisoning. We separately included notable reports and grey literature discussing outcomes associated with the Portuguese National Drug Strategy. Over 2,500 articles were retrieved from three databases, with six meeting all inclusion/exclusion criteria. An additional five manuscripts were retrieved specific to Portugal. The evidence reviewed indicates that drug decriminalization alone is associated with potential harms to drug users and their communities, and that potential benefits may be realized when law reform is closely coordinated with the provision of evidence-based resources that promote recovery from addiction. The evidence summarized in this review supports careful consideration of the factors necessary to promote social reintegration among people who are at highest risk for drug-related harms, including repeated criminal offending and death.

People experiencing homelessness and serious mental illness exhibit high rates of criminal justice system involvement. Researchers have debated the causes of such involvement among people experiencing serious mental illness, including what services to prioritize. Some, for example, have emphasized mental illness while others have emphasized poverty. We examined factors associated with criminal convictions among people experiencing homelessness and serious mental illness recruited to the Vancouver At Home study. Participants were recruited between October 2009 and June 2011. Comprehensive administrative data were examined over the five-year period preceding study baseline to identify risk and protective factors associated with criminal convictions among participants (n = 425). Eight variables were independently associated with criminal convictions, some of which included drug dependence (RR = 1.53; P = 0.009), psychiatric hospitalization (RR = 1.44; P = 0.030), an irregular frequency of social assistance payments (compared to regular payments; 1.75; P P

Additional file 2:. Screener questionnaire; description of data: provides details of the questionnaire and lists its items.

IntroductionMore than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance. ObjectivesTo comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison. MethodsWe created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology. ResultsThe combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up. ConclusionsThe consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population. Key wordsMortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Background Opioid overdose deaths have become a public health crisis in North America, and those who are homeless are particularly vulnerable. Methadone maintenance treatment (MMT) may prevent overdose and death among homeless people with opioid dependence, but suboptimal medication adherence is a common limitation. Previous research found that Housing First (HF) increases antipsychotic medication adherence among formerly homeless people. However, no experimental trials have examined whether HF has a significant impact on MMT adherence. We examined the intervention effect of HF on MMT adherence in a randomized sample of homeless adults experiencing mental illness and opioid dependence in Vancouver, Canada. Methods Comprehensive administrative and self-reported data from homeless adults living with serious mental illness recruited to the Vancouver At Home study were analyzed. Only methadone recipients were included (n = 97). The medication possession ratio (MPR) was utilized as the measure of adherence, and relevant data were obtained from provincial administrative pharmacy records. Study arms were HF and treatment as usual (TAU). Student t -tests were used to test for differences in MMT MPR between HF and TAU. Results No significant differences were observed in MMT MPR between participants in HF and TAU (0.52 vs. 0.57, p = 0.559) in the post-randomization period. Conclusion HF was not associated with significantly different MMT MPR compared to TAU. Additional interventions are indicated as HF alone was insufficient to facilitate improved MMT adherence among formerly homeless adults experiencing concurrent opioid dependence and serious mental illness.

Aims To estimate and test the difference in rates of violent and non-violent crime during medicated and non-medicated methadone treatment episodes. Design, Setting and Participants The study involved linkage of population level administrative data (health and justice) for all individuals (n = 14 530) in British Columbia, Canada with a history of conviction and who filled a methadone prescription between 1 January 1998 and 31 March 2015. Methadone maintenance treatment was the primary independent variable and was treated as a time-varying exposure. Each participant's follow-up (mean: 8 years) was divided into medicated (methadone was dispensed) and non-medicated (methadone was not dispensed) periods with mean durations of 3.3 and 4.6 years, respectively. Measurements Socio-demographics of participants were examined along with the main outcomes of violent and non-violent offences. Findings During the first 2 years of treatment (≤ 2.0 years), periods in which methadone was dispensed were associated with a 33% lower rate of violent crime [0.67 adjusted hazard ratio (AHR), 95% confidence intervals (CI) = 0.59, 0.76] and a 35% lower rate of non-violent crime (0.65 AHR, 95% CI = 0.62, 0.69) compared with non-medicated periods. This equates to a risk difference of 3.6 (95% CI = 2.6, 4.4) and 37.2 (95% CI = 33.0, 40.4) fewer violent and non-violent offences per 100 person-years, respectively. Significant but smaller protective effects of dispensed methadone were observed across longer treatment intervals (2.0 to ≤ 5.0 years, 5.0 to ≤ 10.0 years). Conclusions Among a cohort of Canadian offenders, rates of violent and non-violent offending were lower during periods when individuals were dispensed methadone compared with periods in which they were not dispensed methadone.

Background: Homeless individuals with mental illness are challenging to recruit and retain in longitudinal research studies. The present study uses information from the Vancouver site of a Canadian multi-city longitudinal randomized controlled trial on housing first interventions for homeless individuals. We were able to recruit 500 participants and retain large number of homeless individuals with mental illness; 92% of the participants completed the 6-month follow up interview, 84% the 24-month follow up, while 80% completed all follow-up visits of the study. Purpose: In this article, we describe the strategies and practices that we considered as critical for successful recruitment and retention or participants in the study. Methods: We discuss issues pertaining to research staff hiring and training, involvement of peers, relationship building with research participants, and the use of technology and social media, and managing challenging situations in the context of recruitment and retention of marginalized individuals. Conclusions: Recruitment and retention of homeless participant with mental illness in longitudinal studies is feasible. It requires flexible, unconventional and culturally competent strategies. Longitudinal research projects with vulnerable and hidden populations may benefit from extensive outreach work and collaborative approaches that are based on attitudes of mutual respect, contextual knowledge and trust. Keywords: Housing first intervention, Homelessness, Mental illness, Recruitment, Retention, Longitudinal study

Indigenous people are over represented among homeless populations worldwide and the prevalence of Indigenous homelessness appears to be increasing in Canadian cities. Violence against Indigenous women in Canada has been widely publicized but has not informed the planning of housing interventions. Despite historical policies leading to disenfranchisement of Indigenous rights in gender-specific ways, little is known about contemporary differences in need between homeless Indigenous men and women. This study investigated mental health, substance use and service use among Indigenous people who met criteria for homelessness and mental illness, and hypothesized that, compared to men, women would have significantly higher rates of trauma, suicidality, substance dependence, and experiences of violence. This study was conducted using baseline (pre-randomization) data from a multi-site trial. Inclusion in the current analyses was restricted to participants who self-reported Indigenous ethnicity, and combined eligible participants from Vancouver, BC and Winnipeg, MB. Logistic regression analyses were used to model the independent associations between gender and outcome variables. In multivariable regression models among Indigenous participants (n = 439), female gender was predictive of meeting criteria for PTSD, multiple mental disorders, current high suicidality and current substance dependence. Female gender was also significantly associated with reported physical (AOR: 1.52, 95% CI = 1.10–2.23) and sexual (AOR: 6.31, 95% CI = 2.78–14.31) violence. Our analyses of Indigenous men and women who are homeless illustrate the distinct legacy of colonization on the experiences of Indigenous women. Our findings are consistent with the widely documented violence against Indigenous women in Canada. Housing policies and services are urgently needed that take Indigenous historical contexts, trauma and gender into account. This trial has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374 ; ISRCTN57595077 ; ISRCTN66721740 .

The current study investigated whether a previously reported beneficial effect of methadone maintenance therapy (MMT) on antiretroviral adherence is also present in relation to antipsychotic treatment for schizophrenia. Administrative data were linked over a 17-year period for 1996 people who were dually diagnosed with schizophrenia and opioid dependence and, as an indicator of further marginalization, experienced at least one episode of correctional supervision in British Columbia. Adherence was estimated using the medication possession ratio (MPR ≥ 0.80), calculated in each 120-day period beginning with the first date of concurrent use of MMT and antipsychotic medication. Generalized Estimating Equations were used to estimate the association between independent and dependent variables. The probability of antipsychotic adherence doubled in periods that were preceded by a period of MMT adherence (AOR: P: 2.07; 95% CI: 1.90-2.26). Subgroup and sensitivity analyses yielded results similar to those derived through the primary analysis, examining: conviction history; length of follow-up; initiation of MMT prior to antipsychotic induction; excluding participants who died during the study period; and restricted to participants who received methadone exclusively as part of a MMT program. Despite a strong temporal association between MMT and antipsychotic adherence, overall MPRs for both prescriptions remained0.50 throughout the study period. Antipsychotic adherence was more than twice as likely following periods of adherence to MMT among dually-diagnosed patients. Research is needed to identify the conditions responsible for MMT adherence, and to further clarify the relationship between opioid agonist treatment and antipsychotic pharmacotherapy in this vulnerable and under-studied population.

Key Points Question Is adherence to methadone associated with a lower risk of hospital admission among individuals with criminal convictions? Findings In this cohort study including 11 401 Canadian individuals, periods during which methadone was dispensed were associated with lower rates of any acute hospital admission. Meaning Adherence to methadone among individuals with criminal convictions may contribute to lower rates of acute hospitalization., Importance People with criminal histories experience high rates of opioid dependence and are frequent users of acute health care services. It is unclear whether methadone adherence prevents hospitalizations. Objective To compare hospital admissions during medicated and nonmedicated methadone periods. Design, Setting, and Participants A retrospective cohort study involving linked population-level administrative data among individuals in British Columbia, Canada, with provincial justice contacts (n= 250 884) and who filled a methadone prescription between April 1, 2001, and March 31, 2015. Participants were followed from the date of first dispensed methadone prescription until censoring (date of death, or March 31, 2015). Data analysis was conducted from May 1 to August 31, 2018. Exposures Methadone treatment was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analyzed as a time-varying exposure. Main Outcome and Measures Adjusted hazard ratios (aHRs) of acute hospitalizations for any cause and cause-specific (substance use disorder [SUD], non–substance-related mental disorders [NSMDs], and medical diagnoses [MEDs]) were estimated using multivariable Cox proportional hazards regression. Results A total of 11 401 people (mean [SD] age, 34.9 [9.4] years; 8230 [72.2%] men) met inclusion criteria and were followed up for a total of 69 279.3 person-years. During a median follow-up time of 5.5 years (interquartile range, 2.8-9.1 years), there were 19 160 acute hospital admissions. Dispensed methadone was associated with a 50% lower rate of hospitalization for any cause (aHR, 0.50; 95% CI, 0.46-0.53) during the first 2 years (≤2.0 years) following methadone initiation, demonstrating significantly lower rates of admission for SUD (aHR, 0.32; 95% CI, 0.27-0.38), NSMD (aHR, 0.41; 95% CI, 0.34-0.50), and MED (aHR, 0.57; 95% CI, 0.52-0.62). As duration of time increased (2.1 to ≤5.0 years; 5.1 to ≤10.0 years), methadone was associated with a significant but smaller magnitude of effect: SUD (aHR, 0.43; 95% CI, 0.36-0.52; aHR, 0.47; 95% CI, 0.37-0.61), NSMD (aHR, 0.51; 95% CI, 0.41-0.64; aHR, 0.60; 95% CI, 0.47-0.78), and MED (aHR, 0.71; 95% CI, 0.65-0.77; aHR, 0.85; 95% CI, 0.76-0.95). Conclusions and Relevance In this study, methadone was associated with a lower rate of hospitalization among a large cohort of Canadian individuals with histories of convictions and prevalent concurrent health and social needs. Practices to improve methadone adherence are warranted., This cohort study compares the risk of substance-related acute hospital admission during periods of methadone-medicated vs nonmedicated periods in individuals in Canada with a history of criminal conviction.

The purpose of this study was to investigate the level of adherence to antipsychotic prescription medication in a well-defined homeless cohort over a 15-year period. We hypothesized that adherence would be well below the recommended threshold for clinical effectiveness (80 %), and that it would be strongly associated with modifiable risk factors in the social environment in which homeless people live.Linked baseline data (including comprehensive population-level administrative prescription records) were examined in a subpopulation of participants from two pragmatic-randomized trials that investigated Housing First for homeless and mentally ill adults. Adherence to antipsychotic medication was operationalized using the medication possession ratio. Multivariable logistic regression was used to estimate effect sizes between socio-demographic, homelessness-related and illness factors, and medication possession ratio.Among the 290 participants who met inclusion criteria for the current analysis, adherence to antipsychotic prescription was significantly associated with: history of psychiatric hospitalization; receipt of primary medical services; long-acting injectable antipsychotic formulations; and duration of homelessness. Mean medication possession ratio in the pre-randomization period was 0.41. Socio-demographic characteristics previously correlated with antipsychotic non-adherence were not significantly related to medication possession ratio.This is the first study to quantify the very low level of adherence to antipsychotic medication among homeless people over an extended observation period of 15 years. Each of the four factors found to be significantly associated with adherence presents opportunities for intervention. Strategies to end homelessness for this population may represent the greatest opportunity to improve adherence to antipsychotic medication.

Elevated prevalence estimates of sexually transmitted infections and sexual risk behaviors have commonly been reported among homeless and precariously housed adults. Research has increasingly recognized the importance and impact of structural factors, such as housing, on risk behaviors. Several researchers have argued that supported housing interventions, such as Housing First (HF), may contribute to reductions in sexual risk behavior. The present study is the first analysis of a randomized controlled trial to examine the effect of HF on unprotected sex among formerly homeless and marginally housed adults with mental illness and complex comorbidities. Methods. Generalized estimating equations were used to examine between-group differences in unprotected sex. Results. Compared with treatment as usual, no association was found between HF and unprotected sex over the 24 months of follow-up. Several other variables were significantly and independently associated with unprotected sex. Conclusion. Results suggest that further interventions are needed to reduce unprotected sex among homeless and unstably housed individuals with mental illness.

Bangladesh has been grappling with the issues of improper hospital waste management. To reflect the inadequacies in existing management practices and the potential implications on the environment and health, this study evaluated the Knowledge, Attitude, and Practice (KAP) of doctors and nurses in a private and a public hospital in Chattogram city via a structured questionnaire survey. At the public hospital, 20.4% of the doctors and 6% of the nurses had occupational illnesses, compared to 36% of the doctors and 26.5% of the nurses at the private hospital. At the public hospital, 67.8% of the nurses wore PPE during waste collection, compared to 17.7% in the private hospital. Hospital wastes and occupational safety are not properly dealt with in both hospitals. An inadequacy was observed in the knowledge of hospital waste management among healthcare workers. The route of hospital wastes from the sources to the end destination was also traced via interviews and focus group discussions, which revealed that disposal practices of the hospital solid waste were environmentally unsustainable. In attempts to show opportunities for environmental and health risks from the hospital wastewater, this study also investigated the quality of the wastewater and tested it for the presence of resistant enteric pathogens. E. coli and S. aureus from both hospitals showed resistance against some common antibiotics used in Bangladesh. The physicochemical properties of the samples were nearly compliant with the Bangladesh Water Quality Standards for hospital wastewater. While more robust sampling and water quality analysis are required, this study provides basic water quality indicators and scope for future research to understand the apparent significant negative impact on the environment and health.

Background Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality. Methods and findings We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23–0.33]) and external (AHR 0.41 [95% CI 0.33–0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13–0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30–0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution. Conclusions Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.

Objective To examine whether timely outpatient follow-up after hospital discharge reduces the risk of subsequent rehospitalization among people experiencing homelessness and mental illness. Data sources Comprehensive linked administrative data including hospital admissions, laboratory services, and community medical services. Study design Participants were recruited to the Vancouver At Home study based on a-priori criteria for homelessness and mental illness (n = 497). Logistic regression analysis was used to assess the relationship between outpatient care within 7 days postdischarge and subsequent rehospitalization over a 1-year period. Data extraction Data were extracted for a consenting subsample of participants (n = 433) spanning 5 years prior to study enrollment. Principal findings More than half of the eligible sample (53 percent; n = 128) were rehospitalized within 1 year following an index hospital discharge. Neither outpatient medical services nor laboratory services within 7 days following discharge were associated with a significantly reduced likelihood of rehospitalization within 2 months (AOR = 1.17 [CI = 0.94, 1.46]), 6 months (AOR = 1.00 [CI = 0.82, 1.23]) or 12 months (AOR = 1.24 [CI = 1.02, 1.52]). Conclusions In contrast to evidence from nonhomeless samples, we found no association between timely outpatient follow-up and the likelihood of rehospitalization in our homeless, mentally ill cohort. Our findings indicate a need to address housing as an essential component of discharge planning alongside outpatient care.

Aims Housing First (HF) is an established intervention for people experiencing homelessness and mental illness. We compared daily substance use (DSU) between HF and treatment as usual (TAU). Design Two concurrent randomized controlled trials with 24-month follow-up. Setting Market rental apartments with support provided by Assertive Community Treatment (ACT) or Intensive Case Management (ICM); a single building with on-site supports (CONG); TAU in Vancouver, Canada. Participants Inclusion criteria were current homelessness and mental illness. Participants were assessed as having either ‘high needs’ (HN; n = 297) or ‘moderate needs’ (MN; n = 200). MN participants were randomized to ICM (n = 100) or MN-TAU (n = 100). HN participants were randomized to ACT (n = 90), CONG (n = 107) or HN-TAU (n = 100). Interventions and comparators All HF interventions included independent housing with support services, with an emphasis on promoting client choice and harm reduction in relation to substance use. TAU included existing services and support available to homeless adults with mental illness. Measurements DSU over 24 and 12 months was derived from the Maudsley Addiction Profile. Also measured were demographics, homelessness history, psychiatric diagnoses, symptom severity, comorbid illnesses and duration of stable housing. Findings Compared with HN-TAU, neither CONG [adjusted odds (AOR) ratio = 0.73, 95% confidence interval (CI) = 0.39–1.37] nor ACT (AOR = 1.22, 95% CI = 0.61–2.45) differed on DSU at 24 months, and MN-TAU did not differ from ICM (AOR = 0.78, 95% CI = 0.37–1.63). There were no differences at 12 months, when analyses were restricted to participants who indicated substance use at baseline, or when considering the duration of stable housing. Conclusions Housing First, an intervention to support recovery for homeless people who have co-occurring mental illness and substance use disorders, did not reduce daily substance use compared with treatment as usual after 12 or 24 months.

Aims.A subset of people with co-occurring substance use and mental disorders require coordinated support from health, social welfare and justice agencies to achieve diversion from homelessness, criminal recidivism and further health and social harms. Integrated models of care are typically concentrated in large urban centres. The present study aimed to empirically measure the prevalence and distribution of complex co-occurring disorders (CCD) in a large geographic region that includes urban as well as rural and remote settings.Methods.Linked data were examined in a population of roughly 3.7 million adults. Inclusion criteria for the CCD subpopulation were: physician diagnosed substance use and mental disorders; psychiatric hospitalisation; shelter assistance; and criminal convictions. Prevalence per 100 000 was calculated in 91 small areas representing urban, rural and remote settings.Results.2202 individuals met our inclusion criteria for CCD. Participants had high rates of hospitalisation (8.2 admissions), criminal convictions (8.6 sentences) and social assistance payments (over $36 000 CDN) in the past 5 years. There was wide variability in the geographic distribution of people with CCD, with high prevalence rates in rural and remote settings.Conclusions.People with CCD are not restricted to areas with large populations or to urban settings. The highest per capita rates of CCD were observed in relatively remote locations, where mental health and substance use services are typically in limited supply. Empirically supported interventions must be adapted to meet the needs of people living outside of urban settings with high rates of CCD.

Preliminary evidence suggests that adherence to antipsychotic medication reduces criminal recidivism among patients diagnosed with schizophrenia. However, existing studies operationalize antipsychotic adherence as a binary variable (usually using a threshold of ≥80%), which does not reflect the prevalence of suboptimal adherence in real-world settings. The purpose of the current analysis was to investigate the association between successive ordinal levels of antipsychotic adherence and criminal recidivism in a well-defined sample of offenders diagnosed with schizophrenia (n = 11462). Adherence was measured using the medication possession ratio (MPR) and analyzed as a time-dependent covariate in multivariable regression models. Data were drawn from linked, comprehensive diagnostic, pharmacy and justice system records, and individuals were followed for an average of 10 years. Adjusted rate ratios (ARR) and confidence intervals (CI) are reported. Overall mean MPR was 0.41. Increasing levels of antipsychotic adherence were not associated with progressively lower rates of offending. However, when compared to the reference group (MPR ≥ 80%) all lower adherence levels were significantly associated (P < .001) with increased risk of violent (ARR = 1.58; 95% CI = 1.46–1.71) and nonviolent (ARR = 1.41; 95% CI = 1.33–1.50) offenses. Significance was replicated in separate sensitivity analyses. Previously published studies reporting reductions in crime may have been influenced by antipsychotic adherence ≥80%. Binary operationalization of adherence is an inaccurate predictor of recidivism. Future research addressing functional outcomes of antipsychotic adherence should conceptualize adherence as an incremental independent variable.

Background Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada. Material and methods Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics. Results Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051). Conclusions The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission., Highlights • Methadone treatment adherence is very low among homeless mentally ill adults. • Substance use is common among homeless mentally ill methadone recipients. • Infectious disease is prevalent among homeless mentally ill methadone recipients. • Interventions are needed immediately to increase methadone adherence.

To estimate and test the difference in rates of violent and non-violent crime during medicated and non-medicated methadone treatment episodes.The study involved linkage of population level administrative data (health and justice) for all individuals (n = 14 530) in British Columbia, Canada with a history of conviction and who filled a methadone prescription between 1 January 1998 and 31 March 2015. Methadone maintenance treatment was the primary independent variable and was treated as a time-varying exposure. Each participant's follow-up (mean: 8 years) was divided into medicated (methadone was dispensed) and non-medicated (methadone was not dispensed) periods with mean durations of 3.3 and 4.6 years, respectively.Socio-demographics of participants were examined along with the main outcomes of violent and non-violent offences.During the first 2 years of treatment (≤ 2.0 years), periods in which methadone was dispensed were associated with a 33% lower rate of violent crime [0.67 adjusted hazard ratio (AHR), 95% confidence intervals (CI) = 0.59, 0.76] and a 35% lower rate of non-violent crime (0.65 AHR, 95% CI = 0.62, 0.69) compared with non-medicated periods. This equates to a risk difference of 3.6 (95% CI = 2.6, 4.4) and 37.2 (95% CI = 33.0, 40.4) fewer violent and non-violent offences per 100 person-years, respectively. Significant but smaller protective effects of dispensed methadone were observed across longer treatment intervals (2.0 to ≤ 5.0 years, 5.0 to ≤ 10.0 years).Among a cohort of Canadian offenders, rates of violent and non-violent offending were lower during periods when individuals were dispensed methadone compared with periods in which they were not dispensed methadone.

Homeless individuals represent a disadvantaged and marginalised group who experience increased rates of physical illness as well as mental and substance use disorders. Compared to stably housed individuals, homeless adults with mental disorders use hospital emergency departments and other acute health care services at a higher frequency. Housing First integrates housing and support services in a client-centred model and has been shown to reduce acute health care among homeless populations. The present analysis is based on participants enrolled in the Vancouver At Home Study (n = 297) randomised to one of three intervention arms (Housing First in a ‘congregate setting’, in ‘scattered site’ [SS] apartments in the private rental market, or to ‘treatment as usual’ [TAU] where individuals continue to use existing services available to homeless adults with mental illness), and incorporates linked data from a regional database representing six urban emergency departments. Compared to TAU, significantly lower num...

ObjectivesIndigenous people in Canada are not only over-represented among the homeless population but their pathways to homelessness may differ from those of non-Indigenous people. This study investigated the history and current status of Indigenous and non-Indigenous people experiencing homelessness and mental illness. We hypothesised that compared with non-Indigenous people, those who are Indigenous would demonstrate histories of displacement earlier in life, higher rates of trauma and self-medication with alcohol and other substances.Design and settingRetrospective data were collected from a sample recruited through referral from diverse social and health agencies in Winnipeg and Vancouver.ParticipantsEligibility included being 19 years or older, current mental disorder and homelessness.MeasuresData were collected via interviews, using questionnaires, on sociodemographics (eg, age, ethnicity, education), mental illness, substance use, physical health, service use and quality of life. Univariate and multivariable models were used to model the association between Indigenous ethnicity and dependent variables.ResultsA total of 1010 people met the inclusion criteria, of whom 439 self-identified as Indigenous. In adjusted models, Indigenous ethnicity was independently associated with being homeless at a younger age, having a lifetime duration of homelessness longer than 3 years, post-traumatic stress disorder, less severe mental disorder, alcohol dependence, more severe substance use in the past month and infectious disease. Indigenous participants were also nearly twice as likely as others (47% vs 25%) to have children younger than 18 years.ConclusionsAmong Canadians who are homeless and mentally ill, those who are Indigenous have distinct histories and current needs that are consistent with the legacy of colonisation. Responses to Indigenous homelessness must be developed within the context of reconciliation between Indigenous and non-Indigenous Canadians, addressing trauma, substance use and family separations.Trial registration numberISRCTN42520374,ISRCTN57595077,ISRCTN66721740.

This study examines community integration among homeless adults with mental illness 6 and 12 months after random assignment to Housing First (independent apartments or congregate residence) with support services or to treatment as usual (TAU). Residence in independent apartments was associated with increased 'psychological integration' for participants with less severe needs; however, no significant improvement in 'physical integration' was observed among any of the intervention groups. Analysis of individual items on the Psychological Integration subscale revealed that, compared to TAU, participants assigned to independent apartments were more likely to endorse statements related to the emotional components of community but not statements related to neighboring. Participants assigned to the congregate residence were more likely to endorse knowing their neighbors, but not interacting with neighbors or the emotional components of community. Findings are discussed in terms of housing program as well as broader contextual factors.

Abundant research confirms a high prevalence of substance use and mental disorders in correctional samples. It is unclear, however, how these contribute to the risk of repeat offending. The present study examined offense trajectories within a Canadian Provincial offender population (N 31,014), and observed that offenders with non–substance-related mental disorders were at no greater risk of recidivism than those with no diagnosis. In contrast, odds of recidivism were significantly higher among those with substance use and/or co-occurring disorders. These findings add strength to the emerging conclusion that non–substance-related mental disorders are, as a group, less likely to predict recidivism than substance use disorders. Notably, nearly 50% of repeat offenders had a physician-diagnosed substance use disorder in the 5 years prior to their index offense. Results are discussed in relation to the necessity for targeted evidence-based partnerships between health and corrections sectors that are responsive to both public health and safety.

Little information exists on the use of condoms as protective barriers to sexually transmitted infections (STIs) among indigenous people in Canada. This study explores risk factors of inconsistent condom use (during consensual sex) over time among participants in the Cedar Project, a prospective cohort study of indigenous young people living in Vancouver and Prince George, British Columbia, who use drugs. Due to the serial measurements for each study subject, generalized estimating equations modeling with logit link was used to accommodate the temporal correlation within subjects. For young women, inconsistent condom use over time was predicted by having a recent STI (adjusted odds ratio [AOR] = 1.76, 95% confidence interval [CI] [1.12, 2.79]), smoking crack daily (AOR = 1.63, 95%CI [1.02, 2.61]), and having experienced recent sexual abuse (AOR = 2.07, 95%CI [1.20, 3.56]). Among young men, living in Prince George (AOR = 1.63, 95%CI [1.14, 2.39]) and daily crack smoking (AOR = 1.56, 95%CI [1.02, 2...

Drug Treatment Courts (DTCs) integrate therapeutic interventions for substance using offenders with the administration of justice. Available evidence indicates that DTCs are effective at reducing recidivism, but it is not yet established whether they are equally effective for all subgroups of offenders. The current study investigates the comparative effectiveness of a Canadian DTC among subgroups defined by ethnicity, gender, prior offending, and the presence of a co-occurring mental disorder. Results indicate greater reductions in recidivism among female and Aboriginal participants, and no differences in recidivism associated with the presence or absence of co-occurring mental disorders or the number of prior convictions. Longer duration of involvement with the DTC program was positively associated with reduced recidivism. The effectiveness of DTCs with distinct subpopulations may be related to their composition and inclusion of expertise relevant to the needs of diverse participants.

Objective No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU). Methods Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports. Results Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p

Recent research and policy making concerning homelessness has focused on the particular challenges associated with ending chronic homelessness. It is generally assumed that individuals who have been homeless for longer durations have a greater impact on the public system of care and are in need of the most assistance. The aim of this study was to examine key sample characteristics by duration of homelessness (total lifetime duration and longest single episode) using bivariate and multivariable regression analysis. Participants (n = 425) were adults recruited in Vancouver, BC on the basis of absolute homelessness or precarious housing and a current mental disorder. Interviewer-administered questionnaires elicited details concerning demographics, mental illness, substance use, service use, and duration of homelessness. In multivariable models, “persistent” homelessness (lifetime duration of three or more years) was independently predicted by male gender, older age, younger age when first homeless, incomplet...

Co-occurring health and public safety concerns involving mental illness, substance use, and homelessness are increasingly prevalent challenges for policymakers in cities worldwide. The Hub model is a roundtable process where the combined resources of diverse agencies are used to mitigate urgent risk of crime, victimization, illness and death, by establishing immediate connections with appropriate services and supports. Initiated in Scotland, the model has been replicated in more than 60 communities across Canada since 2012. In November 2105, the Surrey Mobilization and Resiliency Table (SMART) became the first Hub in British Columbia. Little peer-reviewed research has examined the impact of Hub inter-ventions from a client perspective. We conducted semi-structured interviews with 16 SMART clients and analyzed their responses thematically. We also examined demographic- and intervention-related characteristics reported in the SMART database. Participants described positive experiences with SMART service providers, and commented that the intervention was effective at meeting relatively circumscribed needs. However, most clients reported complex and mutually exacer-bating health and social conditions, and expressed the need for ongoing structured support (e.g., Assertive Community Treatment (ACT)). Our results emphasize the beneficial role played by SMART’s coordinated, real-time approach. They also indicate demand for social policies that include substantial and enduring forms of support to prevent crises and promote community safety.