The Impact of Childhood Emotional Abuse on Pain Interference Among People with Chronic Pain who Inject Drugs in Vancouver, Canada.

OBJECTIVE: High levels of chronic pain interference with daily activities are known to negatively impact quality of life. Although mental health conditions have been associated with pain interference and child abuse, research has been mixed regarding it acting as a mediator, with even less known among people who inject drugs. Therefore, we sought to explore childhood emotional abuse and pain interference among this population. METHODS: Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver, Canada, between June 2014 and November 2016. We employed multivariable generalized estimating equations to examine the relationship between childhood emotional abuse and pain interference in the past six months. We also conducted a mediation analysis to examine whether mental health disorder diagnoses mediated this association. RESULTS: Among 822 eligible participants, 341 (41.5%) reported childhood emotional abuse. In a multivariable analysis, experiencing childhood emotional abuse remained independently associated with pain interference (adjusted odds ratio = 1.33, 95% confidence interval [CI] = 1.05-1.70) after adjusting for a range of confounders. Results from the mediation analysis yielded a statistically significant positive average causal mediation effect (ß = 0.01, 95% CI = 0.001-0.02). Approximately 12% of the effect was due to mediation. CONCLUSIONS: Our results demonstrate among people who inject drugs with chronic pain, those who experienced childhood emotional abuse were more likely to report pain interference, which was partially mediated by mental health disorder diagnosis history. These findings highlight the importance of incorporating screening and appropriate treatment for mental illness into chronic pain treatment.

High Prevalence of Self-Reported Exposure to Adulterated Drugs Among People Who Experienced an Opioid Overdose in Canada: A Cohort Study.

BACKGROUND: In North America, rates of overdoses are increasing largely due to the adulteration of illicit drugs by illicit synthetic opioids. OBJECTIVES: We sought to examine the prevalence and correlates of self-reported exposure to adulterated drugs among people who experienced a non-fatal opioid overdose. METHODS: Data were derived from three prospective cohort studies of people who use drugs in Vancouver, Canada between June and November 2016. Multivariable logistic regression analyses were used to examine the prevalence and correlates of self-reported exposure to adulterated drugs. RESULTS: Among 117 participants who reported symptoms consistent with a non-fatal opioid overdose, 78 (66.7%) reported believing the drug was adulterated during their last overdose. Of those, 42 (53.8%) had not perceived adulteration prior to overdose. In the multivariable analysis, engagement in opioid agonist therapy (Adjusted Odds Ratio [AOR] = 2.79, 95% Confidence Interval [CI]: 1.10, 7.45) was independently associated with having not perceived adulteration prior to overdose. Daily heroin use (AOR = 5.28; 95% CI: 1.92, 15.97) and reporting supervised injection site staff were present at most recent overdose (AOR = 6.16; 95% CI: 1.25, 47.27) were independently associated with having perceived adulteration prior to overdose. Conclusions/Importance: We found a high prevalence of believing adulterated drugs were present for the most recent overdose. Further, the high prevalence of unperceived adulteration prior to overdose supports the need to lower the risk of overdose by providing individuals with options to consume drugs in a safer manner, including supervised consumption sites.

Declining rates of health problems associated with crack smoking during the expansion of crack pipe distribution in Vancouver, Canada.

BACKGROUND: Crack cocaine smoking is associated with an array of negative health consequences, including cuts and burns from unsafe pipes, and infectious diseases such as HIV. Despite the well-established and researched harm reduction programs for injection drug users, little is known regarding the potential for harm reduction programs targeting crack smoking to reduce health problems from crack smoking. In the wake of recent crack pipe distribution services expansion, we utilized data from long running cohort studies to estimate the impact of crack pipe distribution services on the rates of health problems associated with crack smoking in Vancouver, Canada. METHODS: Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2005 and November 2014. We employed multivariable generalized estimating equations to examine the relationship between crack pipe acquisition sources and self-reported health problems associated with crack smoking (e.g., cut fingers/sores, coughing blood) among people reported smoking crack. RESULTS: Among 1718 eligible participants, proportions of those obtaining crack pipes only through health service points have significantly increased from 7.2% in 2005 to 62.3% in 2014 (p < 0.001), while the rates of reporting health problems associated with crack smoking have significantly declined (p < 0.001). In multivariable analysis, compared to those obtaining pipes only through other sources (e.g., on the street, self-made), those acquiring pipes through health service points only were significantly less likely to report health problems from smoking crack (adjusted odds ratio: 0.82; 95% confidence interval: 0.73-0.93). CONCLUSIONS: These findings suggest that the expansion of crack pipe distribution services has likely served to reduce health problems from smoking crack in this setting. They provide evidence supporting crack pipe distribution programs as a harm reduction service for crack smokers.

Factors Influencing the Acceptability of Nominal, Non-nominal, and Anonymous HIV Testing Options Among Young Men Living in Vancouver, Canada: A Qualitative Study.

ABSTRACT: Individuals unaware of their HIV seropositive status continue to represent a key "driver" of the HIV epidemic. Strategies to improve initiation into the HIV treatment cascade, including among young men, are required. This study assesses the acceptability of three HIV testing options among young cisgender men living in Vancouver, British Columbia. Using a modified grounded theory approach, we conducted semi-structured interviews with 45 young cisgender men ages 18-30 years to identify the factors influencing the acceptability of diverse HIV testing approaches. Participants ascribed value to non-nominal testing as a means of providing a secure pathway to HIV-related care for those who test positive while also safeguarding privacy. Anonymous HIV testing was problematized by participants as potentially creating difficulty in accessing ongoing HIV-related care. Most participants preferred non-nominal testing. Nevertheless, based on principles of equity, we argue that anonymous access to one's serostatus should be available, especially within a criminalized context.

Childhood abuse as a risk factor for injection drug use: A systematic review of observational studies.

ISSUES: Childhood abuse is a public health challenge with lifelong impacts, including future drug use. However, previous research has been mixed regarding impacts on injection drug use. This systematic review examines the impact of childhood abuse (sexual, physical and emotional) on adult injection drug use. APPROACH: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science and grey literature to identify relevant studies from database inception to 26 September 2018. Studies were eligible if: (i) they were empirical original research published in English; (ii) considered childhood abuse as potential risk factors for lifetime history of injection drug use; and (iii) included adult participants. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. KEY FINDINGS: Of the 1994 articles screened, 17 studies met the inclusion criteria. Most studies were conducted in the USA and utilised cross-sectional research designs. All of the 17 studies measured sexual abuse, six studies measured physical abuse and three studies measured emotional abuse; most (N = 11) of which reported a statistically significant and positive association between at least one sub-scale of childhood abuse and injection drug use. IMPLICATIONS: Our findings highlight the need for devising interventions to reduce the harms associated with childhood abuse. CONCLUSIONS: The evidence base suggests a significant positive association between experiences of childhood physical abuse and elevated risks of injection drug initiation with mixed results for sexual and emotional abuse.

The relationship between parental heavy drinking and non-fatal overdose among people who inject drugs in Vancouver, Canada.

BACKGROUND: Despite the acute drug-related and behavioural risk factors for experiencing a drug overdose, few remote childhood experiences have been examined as risk factors for subsequent later life overdose risk. Parental heavy drinking has been associated with some later life negative outcomes, but little is known regarding the impact on drug overdoses, especially among people who inject drugs. Given the current overdose crisis in North America, we sought to evaluate the impact of parental heavy drinking on later life non-fatal overdose among people who inject drugs in Vancouver, Canada. METHODS: Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2012 and May 2016. We employed multivariable generalized estimating equations to examine the relationship between parental heavy drinking and non-fatal overdose in the past six months. RESULTS: Among 327 eligible participants, 111 (33.9%) reported parental heavy drinking and 95 (29.1%) reported a non-fatal overdose at least once during the study period. In a multivariable analysis, experiencing parental heavy drinking remained independently associated with non-fatal overdose (adjusted odds ratio: 1.69; 95% confidence interval: 1.07-2.66) after adjustment for a range of socio-demographic and drug using confounders. CONCLUSIONS: These findings suggest long-term negative impacts of parental heavy drinking, on subsequent risk taking or other mechanisms associated with overdose. Current overdose prevention efforts may benefit from the evaluation of life course vulnerabilities that may be amenable to earlier interventions.

The relationship between childhood emotional abuse and chronic pain among people who inject drugs in Vancouver, Canada.

BACKGROUND: People who inject drugs (PWID) often contend with chronic pain as a result of illness and trauma, and such pain is known to have significant impacts on mental health, quality of life, and substance use behaviours. Although PWID are also known to have high rates of childhood trauma, little is known about how childhood emotional abuse may be associated with chronic pain in this population. OBJECTIVE: We undertook this study to explore emotional abuse and chronic pain among PWID. PARTICIPANTS AND SETTING: This study comprised a total of 1459 participants in Vancouver, Canada between June 2014 and November 2016. METHODS: We employed multivariable generalized estimating equations with data derived from two prospective cohort studies of community-recruited PWID to examine the relationship between childhood emotional abuse and chronic pain in the past six months. RESULTS: Among eligible participants, 591 (40.5%) reported childhood emotional abuse, and 760 (52.1%) reported chronic pain in the previous six months. In a multivariable analysis, experiencing childhood emotional abuse remained independently associated with chronic pain (adjusted odds ratio: 1.25; 95% confidence interval: 1.01-1.53) after adjustment for a range of socio-demographic and drug use confounders. CONCLUSIONS: Our findings suggest that childhood emotional abuse may have lasting relationships with chronic pain among PWID, potentially through established physiological and psychological mechanisms. Current chronic pain treatment may benefit from the evaluation of life course vulnerabilities that may be amenable to earlier interventions. Further, increased availability of effective trauma-informed chronic pain treatment is needed among this vulnerable population.

Workplace violence among female sex workers who use drugs in Vancouver, Canada: does client-targeted policing increase safety?

Workplace violence, by clients or predators, poses serious negative health consequences for sex workers. In 2013, the Vancouver (British Columbia), Canada Police Department changed their guidelines with the goal of increasing safety for sex workers by focusing law enforcement on clients and third parties, but not sex workers. We sought to examine the trends and correlates of workplace violence among female sex workers (FSW) before and after the guideline change, using data collected from prospective cohorts of persons who use illicit drugs in Vancouver, Canada. Among 259 FSW, 21.0% reported workplace violence at least once during the study period between 2008 and 2014. There was no statistically significant change in rates of workplace violence after the guideline change. In our multivariable analysis, daily heroin use was independently associated with workplace violence. The 2013 policing guideline change did not appear to have resulted in decreased reports of workplace violence. Increased access to opioid agonist therapies may reduce workplace violence among drug-using FSW.

Factors associated with inability to access addiction treatment among people who inject drugs in Vancouver, Canada.

BACKGROUND: Addiction treatment is an effective strategy used to reduce drug-related harm. In the wake of recent developments in novel addiction treatment modalities, we conducted a longitudinal data analysis to examine factors associated with inability to access addiction treatment among a prospective cohort of persons who inject drugs (PWID). METHODS: Data were derived from two prospective cohorts of PWID in Vancouver, Canada, between December 2005 and November 2013. Using multivariate generalized estimating equations, we examined factors associated with reporting an inability to access addiction treatment. RESULTS: In total, 1142 PWID who had not accessed any addiction treatment during the six months prior to interview were eligible for this study, including 364 women (31.9 %). Overall, 188 (16.5 %) reported having sought but were ultimately unsuccessful in accessing addiction treatment at least once during the study period. In multivariate analysis, factors independently and positively associated with reporting inability to access addiction treatment included: binge drug use (Adjusted Odds Ratio [AOR] = 1.65), being a victim of violence (AOR = 1.77), homelessness (AOR = 1.99), and having ever accessed addiction treatment (AOR = 2.33); while length of time injecting was negatively and independently associated (AOR = 0.98) (all p < 0.05). CONCLUSIONS: These findings suggest that sub-populations of PWID were more likely to report experiencing difficulty accessing addiction treatment, including those who may be entrenched in severe drug addiction and vulnerable to violence. It is imperative that additional resources go into ensuring treatment options are readily available when requested for these target populations.