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Abstract Objectives Widespread health service disruptions resulting from the COVID-19 pandemic coincided with a dramatic increase in overdose deaths among people who use drugs (PWUD) in Vancouver, Canada. Those with a history of injection drug use are known to be at heightened risk of substance-associated harms. Drug use patterns and associated sociodemographic and health care utilization trends have been understudied in this population since the pandemic onset. We sought to understand patterns of drug use initiation and/or re-initiation among people with a history of injection drug use (IVDU). Methods Data were obtained from three harmonized prospective cohort studies of PWUD in Vancouver. Participants with a lifetime history of IVDU who responded to a survey between June 2021 and May 2022 were included. The primary outcome variable was a composite of substance use initiation and re-initiation over the study period, labelled as drug (re)-initiation. A multivariable generalized linear mixed-effects model was used to examine factors associated with self-reported (re)-initiation of substance use over the past six months. Results Among 1061 participants, the median age was 47 years at baseline and 589 (55.5%) identified as men. In total, 183 (17.2%) participants reported initiating and/or re-initiating a drug, with 44 (4.1%) reporting new drug initiation and 148 (14.0%) reporting drug re-initiation (9 participants responded ‘yes’ to both). Overall, unregulated stimulants (e.g., crystal methamphetamine and cocaine) were the most common drug class (re-)initiated (n = 101; 55.2%), followed by opioids (n = 74; 40.4%) and psychedelics (n = 36; 19.7%). In the multivariable analysis, (re-)initiation of drug use was independently associated with recent IVDU (adjusted odds ratio [AOR] 2.62, 95% confidence interval [CI] 1.02, 6.76), incarceration (AOR 3.36, CI 1.12, 10.14) and inability to access addiction treatment (AOR 4.91, 95% CI 1.22, 19.75). Conclusions In an era impacted by the intersecting effects of the COVID-19 pandemic and the overdose crisis, nearly one in five PWUD with a history of IVDU began using a new drug and/or re-started use of a previous drug. Those who reported drug (re-)initiation exhibited riskier substance use behaviours and reported difficulty accessing treatment services. Our findings underscore the need to provide additional resources to support this high-risk population.

Abstract Background The COVID-19 pandemic had a disproportionate impact on the health and wellbeing of people who use drugs (PWUD) in Canada. However less is known about jurisdictional commonalities and differences in COVID-19 exposure and impacts of pandemic-related restrictions on competing health and social risks among PWUD living in large urban centres. Methods Between May 2020 and March 2021, leveraging infrastructure from ongoing cohorts of PWUD, we surveyed 1,025 participants from Vancouver (n = 640), Toronto (n = 158), and Montreal (n = 227), Canada to describe the impacts of pandemic-related restrictions on basic, health, and harm reduction needs. Results Among participants, awareness of COVID-19 protective measures was high; however, between 10 and 24% of participants in each city-specific sample reported being unable to self-isolate. Overall, 3–19% of participants reported experiencing homelessness after the onset of the pandemic, while 20–41% reported that they went hungry more often than usual. Furthermore, 8–33% of participants reported experiencing an overdose during the pandemic, though most indicated no change in overdose frequency compared the pre-pandemic period. Most participants receiving opioid agonist therapy in the past six months reported treatment continuity during the pandemic (87–93%), however, 32% and 22% of participants in Toronto and Montreal reported missing doses due to service disruptions. There were some reports of difficulty accessing supervised consumption sites in all three sites, and drug checking services in Vancouver. Conclusion Findings suggest PWUD in Canada experienced difficulties meeting essential needs and accessing some harm reduction services during the COVID-19 pandemic. These findings can inform preparedness planning for future public health emergencies.

Introduction The Road to Recovery (R2R) Initiative is an innovative model of substance use care that seeks to increase treatment capacity by creating approximately 100 new addiction treatment beds to provide on-demand addiction care in Vancouver, British Columbia, for patients with substance use disorders. The new model also coordinates the region’s existing clinical substance use services to support patients across a care continuum that includes traditional office-based addiction treatment and harm reduction services, early withdrawal management and more intensive abstinence-based treatment programming. To understand the impact of offering on-demand and coordinated substance use care, an observational cohort of individuals who access any R2R clinical service will be created to examine health and social outcomes over time.Methods and analysis This prospective mixed-methods study will invite individuals from Vancouver, Canada, who access substance use treatment through the R2R model of care to (1) complete a baseline and 12-month follow-up quantitative questionnaire that solicits sociodemographic, substance use and previous addiction treatment data and (2) provide consent to the use of participants’ personal identifiers to access health records for chart review and for annual linkage to select health and administrative databases to allow for ongoing (virtual) community follow-up over 5 years. Additionally, a purposive sample of cohort participants will be invited to participate in baseline and 12-month follow-up qualitative interviews to share their experiences accessing R2R and identify challenges and opportunities associated with the implementation of R2R.Ethics and dissemination The study was approved by the University of British Columbia Providence Health Care Research Ethics Board in September 2023. Results from the proposed study will be published in peer-reviewed journals, presented at national and international scientific conferences and disseminated through regular meetings with policymakers, individuals with lived and living experience, and other high-level stakeholders, academic presentations and lay media.

Abstract Background During the early period of the COVID-19 pandemic, public health orders disrupted income generation in numerous sectors and many governments provided emergency financial support. Access to government support and changes in engagement in sex work during the early period of the pandemic among people who use drugs (PWUD) are not well described. In the present study, we investigate the prevalence and correlates of engaging in sex work during the COVID-19 pandemic, among PWUD in Vancouver, Canada. Methods Data derived from three harmonized cohorts of PWUD. Using multivariable logistic regression, we characterized factors associated with engaging in sex work in the last month between July 17 and November 30, 2020. Reports of changes in frequency of engagement in sex work since the pandemic were also collected. Results Of the 864 individuals included in this analysis, 55 (6.4%) reported sex work engagement in the last month. Among these participants, 40.7% reported receiving COVID-19 income support in the past month vs. 52.7% of the rest of the sample, though receipt of income support in the past six months was similar between the two groups (72.2% vs. 75.7%, p = 0.624). In multivariable analysis, receipt of financial support in the last month was negatively associated with engagement in sex work in the last month (adjusted odds ratio [AOR] = 0.44 [95% confidence interval [CI]: 0.24–0.81]). Among 69 participants who responded to a question regarding changes in engagement in sex work, 38 (55.1%) reported a decrease, 11 (15.9%) reported an increase, 19 (27.5%) reported no change, and 1 (1.4%) reported cessation. Conclusions Findings document that engagement in sex work appears to have declined early in the pandemic. Participants who received income support in the past month were less likely to report recent engagement in sex work. Findings suggest that recent receipt of income support may have contributed to reductions in engagement in sex work. Additional investigation is warranted.

Abstract Background People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs. Methods We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied. Results Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97–0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04–3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22–1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09–1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05–1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates. Conclusions A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.

Abstract We sought to evaluate the rates and predictors of SARS-CoV-2 vaccination among members of a structurally-marginalized population of people who use drugs (PWUD) during a targeted, community-wide, vaccination campaign in Vancouver, Canada. Interviewer-administered data were collected from study participants between June 2021 and March 2022. Generalized estimating equation analysis was used to identify factors associated with SARS-CoV-2 vaccine uptake, ascertained through a province-wide vaccine registry. Among 223 PWUD, 107 (48.0%) reported receipt of at least two SARS-CoV-2 vaccine doses at baseline and this increased to 151 (67.7%) by the end of the study period. Using social media as a source of vaccine information was negatively associated with SARS-CoV-2 vaccine uptake (Adjusted odds ratio [AOR] 0.27, 95% confidence interval [CI] 0.09–0.81) and HIV seropositivity (AOR 2.68, 95% CI 1.12–6.39) and older age (AOR 1.27, 95% CI 1.07–1.51) were positively associated with SARS-CoV-2 vaccine uptake. These findings suggest that the targeted vaccination campaign in Vancouver may be an effective model to promote SARS-CoV-2 vaccination in other jurisdictions. However, using social media as a source of vaccine information likely reduced SARS-CoV-2 vaccine uptake in PWUD arguing for further efforts to promote accessible and evidence-based vaccine information among marginalized populations.

Abstract Objective: To examine prevalence and factors associated with food insecurity among people who use drugs (PWUD) during the first year of the COVID-19 pandemic and the overdose crisis. Design: This cross-sectional study employs multivariable logistic regression to identify factors associated with self-reported food insecurity. Participants: PWUD who are part of three community-recruited cohorts. Setting: Interviews conducted in Vancouver, Canada, via phone between July and November 2020 in adherence to COVID-19 safety procedures. Results: Among 765 participants, including 433 (56·6 %) men, eligible for this study, 146 (19·1 %; 95 % CI: 16·3 %, 21·9 %) reported food insecurity in the past month. Of the participants reporting food insecurity, 114 (78·1 %) reported that their hunger levels had increased since the beginning of the pandemic. In multivariable analyses, factors independently and positively associated with food insecurity included: difficulty accessing health or social services (adjusted OR (AOR) = 2·59; 95 % CI: 1·60, 4·17); having mobility difficulties (AOR = 1·59; 95 % CI: 1·02, 2·45) and engaging in street-based income generation (e.g. panhandling and informal recycling) (AOR = 2·31; 95 % CI: 1·45, 3·65). Conclusion: Approximately one in five PWUD reported food insecurity during this time. PWUD with mobility issues, who experienced difficulty accessing services and/or those engaged in precarious street-based income generation were more likely to report food insecurity. Food security is paramount to the success of interventions to prevent COVID-19 and drug toxicity deaths. These findings suggest a need for a more unified state response to food insecurity that prioritises and incorporates accessibility and autonomy of the communities they serve.

Abstract Background Several jurisdictions in Canada have recently considered decriminalizing possession of illicit drugs for personal use (henceforth, simple possession) as part of their responses to the ongoing drug toxicity/overdose crisis. In this context, we sought to examine an early implementation case of a de facto depenalization policy of simple possession offences in Vancouver, Canada, that was enacted in 2006. Specifically, we characterized experiences of people who use drugs (PWUD) whose drugs were discretionally seized by police without arrest. Methods Data were derived from three prospective cohorts of community-recruited PWUD in Vancouver over 16 months in 2019–2021. We conducted multivariable generalized estimating equations analyses to determine the prevalence of and factors associated with drug seizure. Sub-analyses used data collected in 2009–2012 and examined the trends over time. Results Among 995 participants who were interviewed in 2019–2021, 63 (6.3%) had their drugs seized by police at least once in the past 6 months. In multivariable analyses, factors significantly associated with drug seizure included: homelessness (adjusted odds ratio [AOR]: 1.98; 95% confidence interval [CI] 1.09–3.61), working in the unregulated drug market (AOR: 4.93; 95% CI 2.87–8.49), and naloxone administration (AOR: 2.15; 95% CI 1.23–3.76). In 2009–2012, 67.8% reported having obtained new drugs immediately after having their drugs seized by police. Odds of drug seizure were not significantly different between the two time periods (2019–2021 vs. 2009–2012) (AOR: 0.93; 95% CI: 0.64–1.35). Conclusions Despite the depenalization policy, the Vancouver Police Department has continued to seize illicit drugs from PWUD, even in cases where no arrest occurred. This policing practice may create health and safety risks for PWUD as it forces PWUD to increase the engagement with the unregulated illicit drug market. Our findings support calls for abolishing this often-undocumented discretionary policing practice that may exacerbate ongoing health inequities and interfere with peer-based overdose prevention efforts.

Abstract Objectives People who use drugs (PWUD) experience disproportionately high rates of violent victimization. Emerging research has demonstrated that the COVID-19 pandemic has exacerbated violence against some priority populations (e.g., women), however there is limited research examining the impact of the pandemic on the experiences of violence of PWUD. Methods Using data collected between July and November 2020 from three prospective cohort studies of PWUD in Vancouver, Canada, we employed multivariable logistic regression stratified by gender to identify factors associated with recent experiences of violence, including the receipt of COVID-19 emergency income support. Results In total, 77 (17.3%) of 446 men, and 54 (18.8%) of 288 women experienced violence in the previous six months. Further, 33% of men and 48% of women who experienced violence reported that their experience of violence was intensified since the COVID-19 pandemic began. In the multivariable analyses, sex work (Adjusted Odds Ratio [AOR] = 2.15, 95% confidence interval [CI]: 1.06–4.35) and moderate to severe anxiety or depression (AOR = 3.00, 95% CI: 1.37–6.57) were associated with experiencing violence among women. Among men, drug dealing (AOR = 1.93, 95%CI: 1.10–3.38), street-based income sources (AOR = 1.93, 95%CI: 1.10–3.38), homelessness (AOR = 2.54, 95%CI: 1.40–4.62), and regular employment (AOR = 2.97, 95% CI: 1.75–5.04) were associated with experiencing violence. Conclusion Our study results suggest economic conditions and gender were major factors associated with experiencing violence among our sample of PWUD during COVID-19. These findings highlight criminalization of drug use and widespread socioeconomic challenges as barriers to addressing violence among PWUD during periods of crisis.

Objective: We describe the prevalence of COVID-19 vaccine uptake, substance use, and other factors associated with vaccine hesitancy among participants from nine North American cohort studies following a diverse group of individuals at risk for or living with HIV. Methods: Between May 2021 and January 2022, participants completed a survey related to COVID-19 vaccination. Participants included those with and without substance use. Those responding as ‘no’ or ‘undecided’ to the question “Do you plan on getting the COVID-19 vaccine?” were categorized as vaccine hesitant. Differences between groups were evaluated using chi-square methods and multivariable log-binomial models were used to calculate prevalence ratios (PR) of COVID-19 vaccine hesitancy with separate models for each substance. Results: Among 1,696 participants, COVID-19 vaccination was deferred or declined by 16%. Vaccine hesitant participants were younger, with a greater proportion unstably housed (14.8% vs. 10.0%; p = 0.02), and not living with HIV (48.% vs. 36.6%; p

Abstract Background The COVID-19 pandemic and consequent public health response may have undermined key responses to the protracted drug poisoning crisis, including reduced access to opioid agonist therapy (OAT) among people with opioid use disorder. Our study objectives were to estimate the prevalence of and identify factors associated with inability to contact OAT prescribers when in need among people on OAT in a Canadian setting during the dual public health crises. Methods Survey data were collected from three prospective cohort studies of community-recruited people who use drugs between July and November 2020, in Vancouver, Canada. A multivariable logistic regression analysis was used to identify potential factors associated with inability to contact OAT prescribers among patients who accessed OAT in the past 6 months. Results Among 448 respondents who reported accessing OAT in the past 6 months, including 231 (54.9%) men, 85 (19.0%) reported having been unable to contact OAT prescribers when needed, whereas 268 (59.8%) reported being able to talk to their prescriber when needed, and 95 (21.2%) reported that they did not want to talk to their medication prescriber in the previous 6 months. Among those who reported inability to contact prescribers, 45 (53.6%) reported that their overall ability to contact prescribers decreased since the start of the pandemic. In multivariable analyses, factors independently associated with inability to talk to OAT prescribers included: chronic pain (Adjusted Odds Ratio [AOR] = 1.82; 95% Confidence Interval [CI] 1.02, 3.27), moderate to severe symptoms of depression or anxiety (AOR = 4.74; 95% CI 2.30, 9.76), inability to access health/social services (AOR = 2.66; 95% CI 1.41, 5.02), and inability to self-isolate or socially distance most or all of the time (AOR = 2.13; 95% CI 1.10, 4.14). Conclusions Overall, approximately one fifth of the sample reported inability to contact their OAT prescribers when needed, and those people were more likely to have co-occurring vulnerabilities (i.e., co-morbidities, inability to access health/social services) and higher vulnerability to COVID-19. Interventions are needed to ensure optimal access to OAT and mitigate the deepening health inequities resulting from the COVID-19 pandemic and the escalating drug poisoning crisis.

Abstract Background The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada. Methods Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS. Results Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42–58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28–5.30), active injection drug use (AOR = 4.06; 95% CI 1.38–11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24–4.85), and unstable housing (AOR = 2.14; 95% CI 1.08–4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93–0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%). Conclusions We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

Background: Among people who inject drugs, frequent injecting and experiencing withdrawal are associated with facilitating others’ first injections. As these factors may reflect an underlying substance use disorder, we investigated whether first-line oral opioid agonist treatment (OAT; methadone or buprenorphine/naloxone) reduces the likelihood that people who inject drugs help others initiate injecting. Methods: We used questionnaire data from semi-annual visits between December 2014–May 2018 on 334 people who inject drugs with frequent non-medical opioid use in Vancouver, Canada. We estimated the effect of current first-line OAT on subsequent injection initiation assistance provision (i.e., helped someone initiate injecting in the following six months) using inverse-probability-weighted estimation of repeated measures marginal structural models to reduce confounding and informative censoring by time-fixed and time-varying covariates. Results: By follow-up visit, 54–64% of participants reported current first-line OAT whereas 3.4–6.9% provided subsequent injection initiation assistance. Per the primary weighted estimate (n = 1114 person-visits), participants currently on first-line OAT (versus no OAT) were 50% less likely, on average, to subsequently help someone initiate injecting (relative risk [RR]=0.50, 95% CI=0.23–1.11). First-line OAT was associated with reduced risk of subsequent injection initiation assistance provision in participants who, at baseline, injected opioids less than daily (RR=0.15, 95% CI=0.05–0.44) but not in those who injected opioids daily (RR=0.86, 95% CI=0.35–2.11). Conclusions: First-line OAT seemingly reduces the short-term likelihood that people who inject drugs facilitate first injections. However, the extent of this potential effect remains uncertain due to imprecise estimation and observed heterogeneity by baseline opioid injecting frequency.

Abstract Background When the novel coronavirus pandemic emerged in March 2020, many settings across Canada and the USA were already contending with an existing crisis of drug overdoses due to the toxic unregulated drug supply. In response, the Canadian province of British Columbia (BC) released innovative risk mitigation prescribing (RMP) guidelines for medical professionals to prescribe pharmaceutical alternatives to unregulated drugs in an effort to support the self-isolation of people who use unregulated drugs (PWUD) in preventing both SARS-CoV-2 virus infection and overdoses. We sought to assess the level of awareness of RMP and identify factors associated with this awareness among PWUD in Vancouver, BC. Methods Cross-sectional data were derived from participants enrolled in three community-recruited prospective cohort studies of PWUD in Vancouver, interviewed between July and November 2020. Multivariable logistic regression analysis was used to identify factors associated with awareness of RMP. Results Among 633 participants, 302 (47.7%) had heard of RMP. Of those 302 participants, 199 (65.9%) had never tried to access RMP services, ten (3.3%) made an unsuccessful attempt to access RMP, and 93 (30.8%) received RMP. In the multivariable analysis, participants who had awareness of RMP guidelines were more likely to self-identify as white (adjusted odds ratio [AOR] = 1.47; 95% confidence interval [CI]: 1.01, 2.13), to have completed secondary school education or higher (AOR = 1.67; 95% CI: 1.16, 2.39), to have used drugs at a supervised consumption or overdose prevention site in the past six months (AOR = 1.66; 95% CI: 1.10, 2.52), and to have received opioid agonist therapy as treatment for opioid use disorder in the past six months (AOR = 1.51; 95% CI: 1.02, 2.24). Conclusion At least four months after the release of the guidelines, RMP was known to less than half of our study participants, warranting urgent educational efforts for PWUD, particularly among racialized groups and those who were not accessing other harm reduction services. Furthermore, the majority of participants who were aware of RMP guidelines had never tried to access the service, suggesting the need to improve perceived accessibility and knowledge of eligibility criteria.

Abstract Background Evidence suggests people who inject drugs (PWID) prescribed opioid agonist treatment (OAT) are less likely to provide injection drug use (IDU) initiation assistance. We investigated the association between OAT engagement and providing IDU initiation assistance across poly-drug use practices in Vancouver, Canada. Methods Preventing Injecting by Modifying Existing Responses (PRIMER) is a prospective study seeking to identify structural interventions that reduce IDU initiation. We employed data from linked cohorts of PWID in Vancouver and extended the findings of a latent profile analysis (LPA). Multivariable logistic regression models were performed separately for the six poly-drug use LPA classes. The outcome was recently assisting others in IDU initiation; the independent variable was recent OAT engagement. Results Among participants (n = 1218), 85 (7.0%) reported recently providing injection initiation assistance. When adjusting for age and sex, OAT engagement among those who reported a combination of high-frequency heroin and methamphetamine IDU and low-to-moderate-frequency prescription opioid IDU and methamphetamine non-injection drug use (NIDU) was associated with lower odds of IDU initiation assistance provision (Adjusted Odds Ratio [AOR]: 0.18, 95% CI: 0.05–0.63, P = 0.008). Significant associations were not detected among other LPA classes. Conclusions Our findings extend evidence suggesting that OAT may provide a population-level protective effect on the incidence of IDU initiation and suggest that this effect may be specific among PWID who engage in high-frequency methamphetamine and opioid use. Future research should seek to longitudinally investigate potential causal pathways explaining the association between OAT and initiation assistance provision among PWID to develop tailored intervention efforts.

Abstract Background People who use drugs (PWUD) are known to fear calling emergency medical services (EMS) for drug overdoses. In response, drug-related Good Samaritan Laws (GSLs) have been widely adopted in the USA and Canada to encourage bystanders to call emergency medical services (EMS) in the event of a drug overdose. However, the effect of GSLs on EMS-calling behaviours has been understudied. We sought to identify factors associated with EMS-calling, including the enactment of the Canadian GSL in May 2017, among PWUD in Vancouver, Canada, a setting with an ongoing overdose crisis. Methods Data were derived from three prospective cohort studies of PWUD in Vancouver in 2014–2018. Multivariable logistic regression was used to determine factors associated with EMS-calling among PWUD who witnessed an overdose event. An interrupted time series (ITS) analysis was employed to assess the impact of GSL on monthly prevalence of EMS-calling. Results Among 540 eligible participants, 321 (59%) were males and 284 (53%) reported calling EMS. In multivariable analysis, ever having administered naloxone three or more times (adjusted odds ratio [AOR] 2.00; 95% confidence interval [CI] 1.08–3.74) and residence in the Downtown Eastside (DTES) neighbourhood of Vancouver (AOR 1.96; 95% CI 1.23–3.13) were positively associated with EMS-calling, while living in a single occupancy hotel (SRO) was negatively associated with EMS-calling (AOR 0.51; 95% CI 0.30–0.86). The post-GSL enactment period was not associated with EMS-calling (AOR 0.81; 95% CI 0.52–1.25). The ITS found no significant difference in the monthly prevalence of EMS-calling between pre- and post-GSL enactment periods. Conclusion We observed EMS being called about half the time and the GSL did not appear to encourage EMS-calling. We also found that individuals living in SROs were less likely to call EMS, which raises concern given that fatal overdose cases are concentrated in SROs in our setting. The link between many naloxone administrations and EMS-calling could indicate that those with prior experience in responding to overdose events were more willing to call EMS. Increased efforts are warranted to ensure effective emergency responses for drug overdoses among PWUD.

Abstract Background There is concern that cannabis use negatively affects vulnerable groups such as youth; however, the relationship between cannabis use and health care utilization has not been well characterized in this population. We longitudinally evaluated the association between daily cannabis use and hospitalization among a prospective cohort of street-involved youth. Methods Data were collected from the At-Risk Youth Study (ARYS) in Vancouver, Canada, from September 2005 to May 2015. Participants were interviewed semi-annually and multivariable generalized estimating equation (GEE) logistic regression was used to examine the relationship between daily cannabis use and hospitalization. Results A total of 1216 participants (31.2% female) were included in this analysis, and 373 (30.7%) individuals reported hospitalization at some point during the study period. In a multivariable GEE analysis, daily cannabis use was not significantly associated with hospitalization (Adjusted Odds Ratio [AOR] = 1.17, 95% Confidence interval [CI] = 0.84, 1.65). We did observe a significant interaction between daily cannabis use and sex (AOR = 0.51, 95% CI = 0.34, 0.77), whereby cannabis use was associated with a decreased odds of hospitalization among males (AOR = 0.60, 95% CI = 0.47, 0.78), yet was not significantly associated with hospitalization among females (AOR = 1.19, 95% CI = 0.84, 1.67). Conclusions The finding that daily cannabis use was not associated with hospitalization among street-involved youth is encouraging given the high rates of cannabis use in this population and the expansion of cannabis legalization and regulation. Future studies, however, are warranted to monitor possible changes in the consequences of cannabis use as cannabis legalization and regulation increase internationally.

Abstract Background The United States and Canada are amidst an opioid overdose crisis, with the Canadian province of British Columbia (BC) among the hardest hit. In response, drug checking services (DCS) have been introduced in this setting as a novel pilot harm reduction intervention though little is known about usage rates. Therefore, we sought to identify factors associated with drug checking uptake among people who use drugs (PWUD) in Vancouver, BC. Methods Data were derived from three ongoing prospective cohort studies of PWUD in Vancouver between June and November 2018. Multivariable logistic regression was used to determine factors associated with self-reported DCS utilization in the past 6 months among participants at high risk of fentanyl exposure (i.e., those self-reporting illicit opioid use or testing positive for fentanyl via urine drug screen). Results Among 828 eligible participants, including 451 (55%) males, 176 (21%) reported recent use of DCS. In multivariable analyses, factors significantly associated with DCS utilization included: homelessness (Adjusted Odds Ratio [AOR] 1.47; 95% Confidence Interval [CI] 1.01–2.13) and involvement in drug dealing (AOR 1.59; 95% CI 1.05–2.39). Conclusions In our sample of PWUD, uptake of DCS was low, although those who were homeless, a sub-population known to be at a heightened risk of overdose, were more likely to use the services. Those involved in drug dealing were also more likely to use the services, which may imply potential for improving drug market safety. Further evaluation of drug checking is warranted.

Objectives People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk.Design We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis.Setting Tijuana, Mexico; San Diego, USA; Vancouver, Canada.Participants A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825).Measurements The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models.Results Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I2: 52%), recent housing insecurity (I2: 39%) and recent non-injection heroin use (I2: 78%).Conclusion We identified common and site-specific factors related to PWID’s risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.

Summary: Background: People who inject drugs (PWID) are at increased risk for HIV and hepatitis C virus (HCV) infection and also have high levels of homelessness and unstable housing. We assessed whether homelessness or unstable housing is associated with an increased risk of HIV or HCV acquisition among PWID compared with PWID who are not homeless or are stably housed. Methods: In this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies published between Jan 1, 2000, and June 13, 2017. Using the same strategy as for this existing database, we searched MEDLINE, Embase, and PsycINFO for studies, including conference abstracts, published between June 13, 2017, and Sept 14, 2020, that estimated HIV or HCV incidence, or both, among community-recruited PWID. We only included studies reporting original results without restrictions to study design or language. We contacted authors of studies that reported HIV or HCV incidence, or both, but did not report on an association with homelessness or unstable housing, to request crude data and, where possible, adjusted effect estimates. We extracted effect estimates and pooled data using random-effects meta-analyses to quantify the associations between recent (current or within the past year) homelessness or unstable housing compared with not recent homelessness or unstable housing, and risk of HIV or HCV acquisition. We assessed risk of bias using the Newcastle-Ottawa Scale and between-study heterogeneity using the I2 statistic and p value for heterogeneity. Findings: We identified 14 351 references in our database search, of which 392 were subjected to full-text review alongside 277 studies from our existing database. Of these studies, 55 studies met inclusion criteria. We contacted the authors of 227 studies that reported HIV or HCV incidence in PWID but did not report association with the exposure of interest and obtained 48 unpublished estimates from 21 studies. After removal of duplicate data, we included 37 studies with 70 estimates (26 for HIV; 44 for HCV). Studies originated from 16 countries including in North America, Europe, Australia, east Africa, and Asia. Pooling unadjusted estimates, recent homelessness or unstable housing was associated with an increased risk of acquiring HIV (crude relative risk [cRR] 1·55 [95% CI 1·23–1·95; p=0·0002]; I2= 62·7%; n=17) and HCV (1·65 [1·44–1·90; p

Abstract Background North America is in the midst of an opioid overdose epidemic. Although take-home naloxone and other measures have been an effective strategy to reduce overdoses, many events are unwitnessed and mortality remains high amongst those using drugs alone. While wearable devices that can detect and alert others of an overdose are being developed, willingness of people who use drugs to wear such a device has not been described. Methods Drug using persons enrolled in a community-recruited cohort in Vancouver, Canada, were asked whether or not they would be willing to wear a device against their skin that would alert others in the event of an overdose. Logistic regression was used to identify factors independently associated with willingness to wear such a device. Results Among the 1061 participants surveyed between December 2017 and May 2018, 576 (54.3%) were willing to wear an overdose detection device. Factors independently associated with willingness included ever having overdosed (adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI] 1.06–1.83), current methadone treatment (AOR = 1.86, 95% CI 1.45–2.40), female gender AOR = 1.41, 95% CI 1.09–1.84) and a history of chronic pain (AOR = 1.53, 95% CI 1.19–1.96). Whereas homelessness (AOR = 0.67, 95% CI 0.50–0.91) was negatively associated with willingness. Conclusions A high level of willingness to wear an overdose detection device was observed in this setting and a range of factors associated with overdose were positively associated with willingness. Since some factors, such as homelessness may be a barrier, further research is needed to investigate explanations for unwillingness and to evaluate real world acceptability of a wearable overdose detection devices as this technology becomes available.

Abstract Aim Individuals experience differential risks in their initiation into drug injecting based on their gender. Data suggest women are more likely to be injected after their initiator and to share injection equipment. Little is known, however, regarding how gender influences the risk that people who inject drugs (PWID) may assist others into injection initiation. We therefore sought to investigate the role of “initiator” gender in the provision of injection initiation assistance across multiple settings. Methods We employed data from PReventing Injecting by Modifying Existing Responses (PRIMER), a multi-cohort study investigating factors influencing injection initiation assistance provision. Data were drawn from three cohort studies of PWID in San Diego, USA (STAHR II); Tijuana, Mexico (El Cuete IV); and Vancouver, Canada (VDUS). Site-specific logistic regression models were fit, with lifetime provision of injection initiation assistance as the outcome and gender as the independent variable. Results Overall, 3.2% (24/746) of the women and 4.6% (63/1367) of the men reported providing injection initiation assistance. In Tijuana, men were more than twice as likely to have provided injection initiation assistance after controlling for potential confounders (adjusted odds ratio = 2.17, 95% confidence interval: 1.22–3.84). Gender was not significantly associated with providing injection initiation assistance in other sites. Conclusion We identified that being male in Tijuana, specifically, was associated with providing injection initiation assistance, which could inform targeted outreach aimed at reducing the influence of PWID populations on non-injectors in this site. This will likely require that existing interventions address gender- and site-specific factors for effectiveness.

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

BackgroundViolent victimization is common among people who use illegal drugs (PWUD) and is a source of significant health-related harm. However, little attention has been paid to how antecedent childhood trauma among PWUD may contribute to the risk of victimization in adulthood.ObjectiveThis study sought to examine the relationship between childhood physical abuse and victimization by physical assault among adult PWUD.Participants and settingData were derived from three prospective cohorts of PWUD in Vancouver, Canada between 2005 and 2018.MethodsChildhood physical abuse was assessed using the Childhood Trauma Questionnaire. Generalized linear mixed modeling was used to estimate the relationship between childhood physical abuse and subsequent violent victimization, after adjustment for potential confounders.ResultsAmong 2960 PWUD, including 1018 (34.39%) female participants, 1030 (34.8%) participants reported a history of moderate to severe childhood physical abuse, and 949 (32.06%) participants reported recent violent victimization at baseline. In a multivariate analysis, childhood physical abuse (Adjusted Odds Ratio [AOR] = 1.34, 95% confidence interval [CI]: 1.23-1.46) remained independently associated with violent victimization after adjustment for potential confounders.ConclusionsThis study found a high prevalence of childhood physical abuse and that this was associated with a higher risk of subsequent violent victimization among PWUD in this setting. Greater support for PWUD with a history of childhood physical abuse is needed to decrease existing vulnerability to violence, including screening for and treatment of childhood trauma and related violence prevention.

BackgroundInjection drug use (IDU) is associated with multiple health harms. The vast majority of IDU initiation events (in which injection-naïve persons first adopt IDU) are assisted by a person who injects drugs (PWID), and as such, IDU could be considered as a dynamic behavioral transmission process. Data suggest that opioid agonist treatment (OAT) enrollment is associated with a reduced likelihood of assisting with IDU initiation. We assessed the association between recent OAT enrollment and assisting IDU initiation across several North American settings and used dynamic modeling to project the potential population-level impact of OAT scale-up within the PWID population on IDU initiation.Methods and findingsWe employed data from a prospective multicohort study of PWID in 3 settings (Vancouver, Canada [n = 1,737]; San Diego, United States [n = 346]; and Tijuana, Mexico [n = 532]) from 2014 to 2017. Site-specific modified Poisson regression models were constructed to assess the association between recent (past 6 month) OAT enrollment and history of ever having assisted an IDU initiation with recently assisting IDU initiation. Findings were then pooled using linear mixed-effects techniques. A dynamic transmission model of IDU among the general population was developed, stratified by known factors associated with assisting IDU initiation and relevant drug use behaviors. The model was parameterized to a generic North American setting (approximately 1% PWID) and used to estimate the impact of increasing OAT coverage among PWID from baseline (approximately 21%) to 40%, 50%, and 60% on annual IDU initiation incidence and corresponding PWID population size across a decade. From Vancouver, San Diego, and Tijuana, respectively, 4.5%, 5.2%, and 4.3% of participants reported recently assisting an IDU initiation, and 49.4%, 19.7%, and 2.1% reported recent enrollment in OAT. Recent OAT enrollment was significantly associated with a 45% lower likelihood of providing recent IDU initiation assistance among PWID (relative risk [RR] 0.55 [95% CI 0.36-0.84], p = 0.006) compared to those not recently on OAT. Our dynamic model predicts a baseline mean of 1,067 (2.5%-97.5% interval [95% I 490-2,082]) annual IDU initiations per 1,000,000 individuals, of which 886 (95% I 406-1,750) are assisted by PWID. Based on our observed statistical associations, our dynamic model predicts that increasing OAT coverage from approximately 21% to 40%, 50%, or 60% among PWID could reduce annual IDU initiations by 11.5% (95% I 2.4-21.7), 17.3% (95% I 5.6-29.4), and 22.8% (95% I 8.1-36.8) and reduce the PWID population size by 5.4% (95% I 0.1-12.0), 8.2% (95% I 2.2-16.9), and 10.9% (95% I 3.2-21.8) relative to baseline, respectively, in a decade. Less impact occurs when the protective effect of OAT is diminished, when a greater proportion of IDU initiations are unassisted by PWID, and when average IDU career length is longer. The study's main limitations are uncertainty in the causal pathway between OAT enrollment and assisting with IDU initiation and the use of a simplified model of IDU initiation.ConclusionsIn addition to its known benefits on preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our modeling suggests that OAT scale-up may also reduce the number of IDU initiations and PWID population size.

Abstract Background Street-involved youth who use illicit drugs are at high risk for health-related harms; however, the profile of youth at greatest risk of hospitalization has not been well described. We sought to characterize hospitalization among street-involved youth who use illicit drugs and identify the most frequent medical reasons for hospitalization among this population. Methods From January 2005 to May 2016, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Multivariable generalized estimating equation (GEE) was used to identify factors associated with hospitalization. Results Among 1216 participants, 373 (30.7%) individuals reported hospitalization in the previous 6 months at some point during the study period. The top three reported medical reasons for hospital admission were the following: mental illness (37.77%), physical trauma (12.77%), and drug-related issues (12.59%). Factors significantly associated with hospitalization were the following: past diagnosis of a mental illness (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [95% CI] 1.47–2.33), frequent cocaine use (AOR = 2.15; 95% CI 1.37–3.37), non-fatal overdose (AOR = 1.76; 95% CI 1.37–2.25), and homelessness (AOR = 1.40; 95% CI 1.16–1.68) (all p

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

Abstract 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.

Abstract Background The distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdose fatalities among people who use drugs. However, little is known about the use of THN among youth who are street-involved. The present study explores knowledge and possession of THN among street-involved youth in a Canadian setting. Methods Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age 14–28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included items related to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors. Multivariable logistic regression models were used to identify factors independently associated with knowledge and possession of THN. Results Between December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%). While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/white ethnicity was found to be positively associated with both knowledge and possession of THN (both p

Abstract Background Syringe sharing is a high-risk practice associated with the transmission of infectious diseases, such as HIV and HCV. While youth who contend with housing instability are known to be more likely to engage in high-risk substance use, the potential relationship between being evicted from housing and syringe sharing has not been examined. This study assessed whether residential eviction was associated with syringe sharing among street-involved youth in Vancouver, Canada. Methods Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth who use drugs age 14–26 in Vancouver, Canada. The study period was June 2007 to May 2014, and the potential relationship between residential eviction and syringe sharing was analyzed using multivariable generalized estimating equations (GEE) logistic regression. Results Among 405 street-involved youth who injected drugs, 149 (36.8%) reported syringe sharing, defined as borrowing or lending a syringe, at some point during the study period. In a multivariable GEE analysis, recent residential eviction remained independently associated with syringe sharing (adjusted odds ratio (AOR) = 1.72, 95% confidence interval (CI): 1.16–2.57), after adjusting for potential confounders. Conclusions Syringe sharing was significantly elevated among youth who had recently been evicted from housing. These findings indicate that policy and programmatic interventions that increase housing stability may help mitigate high-risk substance use practices among vulnerable youth.

Abstract Background Urban drug “scenes” have been identified as important risk environments that shape the health of street-entrenched youth. New knowledge is needed to inform policy and programing interventions to help reduce youths’ drug scene involvement and related health risks. The aim of this study was to identify how young people envisioned exiting a local, inner-city drug scene in Vancouver, Canada, as well as the individual, social and structural factors that shaped their experiences. Methods Between 2008 and 2016, we draw on 150 semi-structured interviews with 75 street-entrenched youth. We also draw on data generated through ethnographic fieldwork conducted with a subgroup of 25 of these youth between. Results Youth described that, in order to successfully exit Vancouver’s inner city drug scene, they would need to: (a) secure legitimate employment and/or obtain education or occupational training; (b) distance themselves – both physically and socially – from the urban drug scene; and (c) reduce their drug consumption. As youth attempted to leave the scene, most experienced substantial social and structural barriers (e.g., cycling in and out of jail, the need to access services that are centralized within a place that they are trying to avoid), in addition to managing complex individual health issues (e.g., substance dependence). Factors that increased youth’s capacity to successfully exit the drug scene included access to various forms of social and cultural capital operating outside of the scene, including supportive networks of friends and/or family, as well as engagement with addiction treatment services (e.g., low-threshold access to methadone) to support cessation or reduction of harmful forms of drug consumption. Conclusions Policies and programming interventions that can facilitate young people’s efforts to reduce engagement with Vancouver’s inner-city drug scene are critically needed, including meaningful educational and/or occupational training opportunities, ‘low threshold’ addiction treatment services, as well as access to supportive housing outside of the scene.

Abstract 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.

BACKGROUND:Urban drug scenes are characterized by high prevalence of illicit drug dealing and use, violence and poverty, much of which is driven by the criminalization of people who use illicit drugs (PWUD) and the associated stigma. Despite significant public health needs, little is understood about patterns of moving into urban drug scenes among PWUD. Therefore, we sought to identify trajectories of residential mobility (hereafter 'mobility') among PWUD into the Downtown Eastside (DTES), an urban neighbourhood with an open drug scene in Vancouver, Canada, as well as characterize distinct trajectory groups among PWUD. METHODS:Data were derived from three prospective cohort studies of community-recruited PWUD in Vancouver between 2005 and 2016. We used latent class growth analysis (LCGA) to identify distinct patterns of moving into the DTES among participants residing outside of DTES at baseline. Multivariable multinomial logistic regression was used to determine baseline factors associated with each trajectory group. RESULTS:In total, 906 eligible participants (30.9% females) provided 9,317 observations. The LCGA assigned four trajectories: consistently living outside of DTES (52.8%); early move into DTES (11.9%); gradual move into DTES (19.5%); and move in then out (15.8%). Younger PWUD, those of Indigenous ancestry, those who were homeless or living in a single-room occupancy hotel (SRO), and those injecting drugs daily were more likely to move in then out of DTES (all p

BACKGROUND & AIMS:People who inject drugs (PWID) living with hepatitis C virus (HCV) infection often experience barriers to accessing HCV treatment and care. New, safer and more effective direct-acting antiviral-based therapies offer an opportunity to scale-up HCV-related services. Methadone maintenance therapy (MMT) programs have been shown to be effective in linking PWID to health and support services, largely in the context of HIV. The objective of the study was to examine the relationship between being enrolled in MMT and having access to regular physician care regarding HCV among HCV antibody-positive PWID in Vancouver, Canada. DESIGN:Three prospective cohort studies of people who use illicit drugs. SETTING:Vancouver, Canada. PARTICIPANTS:We restricted the study sample to 1627 HCV-positive PWID between September 2005 and May 2015. MEASUREMENTS:A marginal structural model using inverse probability of treatment weights was used to estimate the longitudinal relationship between being enrolled in MMT and having a regular HCV physician and/or specialist. FINDINGS:In total, 1357 (83.4%) reported having access to regular physician care regarding HCV at least once during the study period. A marginal structural model estimated a 2.12 (95% confidence interval [CI]: 1.77-2.20) greater odds of having a regular HCV physician among participants enrolled in MMT compared to those not enrolled. CONCLUSIONS:HCV-positive PWID who enrolled in MMT were more likely to report access to regular physician care regarding HCV compared to those not enrolled in MMT. These findings demonstrate that opioid agonist treatment may be helpful in linking PWID to HCV care, and highlight the need to better engage people who use drugs in substance use care, when appropriate.

People who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) infection. Trends in HCV incidence and associated risk factors among PWID recruited between 1996 and 2012 in Vancouver, Canada were evaluated.Data were derived from a long-term cohort of PWID in Vancouver. Trends in HCV incidence were evaluated. Factors associated with time to HCV infection were assessed using Cox proportional hazards regression.Among 2,589, 82% (n = 2,121) were HCV antibody-positive at enrollment. Among 364 HCV antibody-negative participants with recent (last 30 days) injecting at enrollment, 126 HCV seroconversions were observed [Overall HCV incidence density: 8.6 cases/100 person-years (py); 95% confidence interval (95% CI): 7.2, 10.1; HCV incidence density among those with injecting during follow-up: 11.5 cases/100 py; 95% CI 9.7, 13.6]. The overall HCV incidence density declined significantly from 25.0/100 py (95% CI: 20.2, 30.3) in 1996-99, as compared to 6.0/100 py (95% CI: 4.1, 8.5) in 2000-2005, and 3.1/100 py (95% CI: 2.0, 4.8) in 2006-2012. Among those with injecting during follow-up, the overall HCV incidence density declined significantly from 27.9/100 py (95% CI: 22.6, 33.6) in 1996-99, as compared to 7.5/100 py (95% CI: 5.1, 10.6) in 2000-2005, and 4.9/100 py (95% CI: 3.1, 7.4) in 2006-2012. Unstable housing, HIV infection, and injecting of cocaine, heroin and methamphetamine were independently associated with HCV seroconversion.HCV incidence has dramatically declined among PWID in this setting. However, improved public health strategies to prevent and treat HCV are urgently required to reduce HCV-associated morbidity and mortality.