Methadone Maintenance Treatment Discontinuation Among Young People who use Opioids in Vancouver, Canada.

OBJECTIVE: Retaining adolescents and young adults (AYA) in medications for opioid use disorder (MOUD), like methadone maintenance treatment (MMT), is critical to reducing toxic drug fatalities. This analysis sought to identify factors associated with MMT discontinuation among AYA. METHOD: Data were derived from the At-Risk Youth Study, a prospective cohort study of street-involved AYA in Vancouver, Canada, between December 2005 and June 2018. Multivariable extended Cox regression identified factors associated with time to MMT discontinuation among AYA who recently initiated MMT. In subanalysis, multivariable extended Cox regression analysis identified factors associated with time to "actionable" MMT discontinuation, which could be addressed through policy changes. RESULTS: A total of 308 participants reported recent MMT during the study period. Participants were excluded if they reported MMT in the past 6 months at baseline and were retained in MMT (n = 94, 30.5%); were missing MMT status data (n = 43, 14.0%); or completed an MMT taper (n = 11, 3.6%). Of the remaining 160 participants who initiated MMT over the study period, 102 (63.8%) discontinued MMT accounting for 119 unique discontinuation events. In multivariable extended Cox regression, MMT discontinuation was positively associated with recent weekly crystal methamphetamine use (adjusted hazard ratio [AHR] = 1.67, 95% confidence interval [CI]: 1.19 to 2.35), but negatively associated with age of first "hard" drug use (per year older) (AHR = 0.95, 95% CI: 0.90 to 1.00) and female sex (AHR = 0.66, 95% CI: 0.44 to 0.99). In subanalysis, recent weekly crystal methamphetamine use (AHR = 4.61, 95% CI: 1.78 to 11.9) and weekly heroin or fentanyl use (AHR = 3.37, 95% CI: 1.21 to 9.38) were positively associated with "actionable" MMT discontinuation, while older age (AHR = 0.87, 95% CI: 0.76 to 0.99) was negatively associated. CONCLUSIONS: Efforts to revise MMT programming; provide access to a range of MOUD, harm reduction, and treatments; and explore coprescribing stimulants to AYA with concurrent stimulant use may improve treatment retention and reduce toxic drug fatalities.

Impact of the international collaborative addiction medicine research fellowship on physicians' future engagement in addiction research.

Background: To evaluate how an international one-year intensive research training program for addiction medicine physicians contributed to subsequent research involvement and productivity. Methods: We prospectively compared addiction medicine physician fellows admitted to a one-year training program with non-admitted controls, using baseline questionnaire and peer-reviewed publication data. Participants' publication activity was assessed from fellowship application date onwards using biomedical databases (e.g., PubMed, Embase). Results: Between July 2014 and June 2020, which is six years of cohorts, 56 (39 women) physicians, both fellows (n = 25) and non-admitted applicants (n = 31), were observed and included in the study, contributing 261 person-years of observation. At baseline, in the fellows' cohort: 76% of participants (19/25) reported past research involvement, 24% (6/25) had one or more advanced graduate degrees (e.g., MPH), and the median number of peer-reviewed, first author publications was one (Interquartile Range [IQR] = 0-2). At baseline, in the controls' cohort: 84% of participants (26/31) reported past research involvement, 39% (12/31) had one or more advanced graduate degrees, and the median number of peer-reviewed, first author publications was zero. The physicians' training included internal medicine (n = 8), family medicine (n = 33), psychiatry (n = 5) and others (n = 4). At follow up, there was a significant difference between fellows (n = 25) and controls (n = 31) in total number of publications (Rate Ratio [RR] = 13.09, 95% Confidence Interval [CI], 5.01 - 34.21, p < 0.001), as well as first author publications (RR = 5.59, 95% CI, 2.23 - 14.06, p < 0.001). Conclusion: In the six-year observation period, fellows' productivity indicates undertaking this fellowship was associated with significant research outputs in comparison to controls, signaling successful training of addiction physicians to help recruit addiction medicine physicians to participate in addiction research.

Migration Patterns from an Open Illicit Drug Scene and Emergency Department Visits among People Who Use Illicit Drugs in Vancouver, Canada.

BACKGROUND: People who use illicit drugs (PWUD) experience various adverse health outcomes leading to increased healthcare service utilization. PWUD are also a highly mobile population which poses challenges to healthcare delivery. The objective of this study was to identify migration patterns from the Downtown Eastside (DTES), an urban illicit drug scene in Vancouver and to estimate the impact of different migration patterns on two outcomes: a) emergency department (ED) visits and b) ED visits resulting in inpatient admission among PWUD. METHODS: Three prospective cohorts of PWUD in Vancouver were linked with regional ED data. We defined the optimal number of trajectory groups that best represented distinct patterns of migration from Vancouver's DTES using a latent class growth analysis. Then, generalized estimating equations were used to estimate the effect of migration patterns on the two ED outcomes. RESULTS: Four distinct migration trajectory patterns were identified among the 1210 included participants: PWUD who consistently lived in the DTES, those who migrated out of DTES early, those who migrated out of DTES late, and those who frequently revisited the DTES. Participants who frequently revisited the DTES had higher odds of an ED visit (adjusted odds ratio = 1.62; 95% confidence interval: 1.28-2.06). There was no significant association between migration patterns and inpatient admission. CONCLUSIONS: We found that PWUD who frequently revisited the DTES were more likely to have utilized the ED, suggesting that there may be a subgroup of PWUD who are at increased risk of experiencing negative health outcomes.Supplemental data for this article is available online at 10.1080/10826084.2021.1958849.

[Clinical characteristics and molecular genetics of seven neonates with congenital nephrogenic diabetes insipidus].

OBJECTIVE: To explore the clinical characteristics, genetic basis and clinical treatment of seven neonates with congenital nephrogenic diabetes insipidus (NDI). METHODS: Clinical data of the patients were collected. High-throughput sequencing was carried out to detect potential variants. Sanger sequencing was used to verify the results. RESULTS: The patients were all males, with the age of onset being 10 to 21 days. All patients were admitted to the hospital for intermittent fever as the first symptom during the neonatal period. Additional symptoms had included polydipsia and polyuria. After the treatment, 5 patients had recovered, the remainders still had NDI symptoms and developmental retardation. Five children were found to harbor pathogenic variants of the AVPR2/AQP2 gene, which included one in-frame mutation of c.645_646insGCACCTACCCTGGGTATCGCC, two missense mutations of c.541C>T and c.419C>A, and two hemizygous deletions of the AVPR2/AQP2 gene. Among these, two were unreported previously. Cases 6 and 7 were a pair of twins. Both had carried homozygous missense variants of c.538G>A of the AVPR2/AQP2 gene, which was known to be pathogenic. CONCLUSION: AVPR2/AQP2 is the main pathogenic gene for congenital NDI, for which two novel pathogenic variants have been discovered in this study. Above results have provided a basis for clinical diagnosis and genetic counseling for the affected pedigrees.

Frequent Cannabis Use and Cessation of Injection of Opioids, Vancouver, Canada, 2005-2018.

Objectives. To evaluate the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID).Methods. Three prospective cohorts of PWID from Vancouver, Canada, provided the data for these analyses. We used extended Cox regression analysis with time-updated covariates to analyze the association between cannabis use and injection cessation and injection relapse.Results. Between 2005 and 2018, at-least-daily cannabis use was associated with swifter rates of injection cessation (adjusted hazard ratio [AHR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). A subanalysis revealed that this association was only significant for opioid injection cessation (AHR = 1.26; 95% CI = 1.12, 1.41). At-least-daily cannabis use was not significantly associated with injection relapse (AHR = 1.08; 95% CI = 0.95, 1.23).Conclusions. We observed that at-least-daily cannabis use was associated with a 16% increase in the hazard rate of injection cessation, and this effect was restricted to the cessation of injection opioids. This finding is encouraging given the uncertainty surrounding the impact of cannabis policies on PWID during the ongoing opioid overdose crisis in many settings in the United States and Canada.

Prevalence and Correlates of Reporting Difficulty Taking Antiretroviral Treatment Among HIV-Positive Illicit Drug Users in Vancouver, Canada: A Longitudinal Analysis.

People living with HIV who use illicit drugs continue to experience high rates of suboptimal treatment outcomes from antiretroviral therapy (ART). Although previous studies have identified important behavioural, social and structural barriers to ART adherence, the effects of patient-level factors have not been fully evaluated. Thus, we sought to investigate the prevalence and correlates of reporting ART was difficult to take among a cohort of illicit drug users in Vancouver, Canada. We accessed data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), an ongoing prospective cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring records. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods in which individuals reported they found ART difficult to take. Between December 2005 and May 2014, 746 ART-exposed illicit drug users were recruited and contributed at least one study interview. Finding ART hard to take was reported by 209 (28.0%) participants at baseline, and 460 (61.7%) participants throughout the study period. Patients ingesting a greater daily pill count (adjusted odds ratio [AOR] = 1.12 per pill, 95% confidence interval [CI] 1.08-1.17) and experiencing barriers to healthcare (AOR = 1.64, 95% CI 1.34-2.01) were more likely to report difficulty taking ART. Patients less likely to report satisfaction with their HIV physician (AOR = 0.76, 95% CI 0.58-1.00) and achieve a non-detectable HIV viral load (AOR = 0.62, 95% CI 0.51-0.74) were more likely to report finding ART hard to take. In this community-recruited cohort of ART-exposed illicit drug users, a substantial proportion reported they found HIV treatment hard to take, which was clearly linked to higher dissatisfaction with healthcare experiences and, most importantly, a lower likelihood of experiencing optimal virologic outcomes. Our findings reveal a number of opportunities to improve HIV treatment experiences and outcomes for people who use illicit drugs, including the use of treatment regimens with lower pill burdens, as well as reducing barriers to healthcare access.

Engagement in Maximally-Assisted Therapy and Adherence to Antiretroviral Therapy Among a Cohort of Indigenous People Who Use Illicit Drugs.

Throughout the world, Indigenous populations experience a disproportionate burden of HIV infection. Maximally-assisted therapy (MAT) is an interdisciplinary care intervention that includes ART dispensation to support individuals with a history of addiction and homelessness. This study sought to longitudinally evaluate the relationship between engagement in MAT and achieving optimal adherence using data from an ongoing cohort of HIV-positive individuals who use drugs in Vancouver, Canada, where HIV/AIDS treatment is offered at no cost. Between December 2005 and November 2016, 354 HIV-positive Indigenous participants were enrolled and data were analyzed using generalized mixed-effects (GLMM) and marginal structural modeling. In both multivariable analyses, engagement in MAT was independently associated with optimal adherence to ART (GLMM: AOR = 4.92, 95% CI 3.18-7.62; marginal structural model: AOR = 5.76, 95% CI 3.34-9.96). MAT-based programmes could be a part of a renewed evidence-base to elevated levels of preventable HIV/AIDS-associated morbidity, mortality and viral transmission among Indigenous peoples in Canada.

Street-involved youth engaged in sex work at increased risk of syringe sharing.

Syringe sharing places street-involved young people at risk of acquiring HIV and hepatitis C. While markers of economic marginalization, such as homelessness, have been linked with syringe sharing and have led to targeted interventions, the relationship between syringe sharing and other markers of economic vulnerability, such as sex work, are not well documented among young people. This study examines whether those engaged in sex work are at increased risk of syringe borrowing and syringe lending among street-involved youth who use injection drugs in Vancouver, Canada. Between September 2005 and May 2014, data was collected from the At-Risk Youth Study (ARYS), a prospective cohort of street involved youth aged 14-26. Generalized estimating equations with a confounding model building approach was used to examine the relationship between sex work and syringe borrowing and lending. 498 youth reported injecting drugs at some point during the study period and were therefore included in the analysis. In multivariable analysis, youth who engaged in sex work were at an elevated risk of both syringe borrowing (Adjusted Odds Ratio (AOR) = 2.17, 95% Confidence Interval [CI] = 1.40-3.36) and syringe lending (AOR = 1.66, 95% CI = 1.07-2.59). Our study found that youth engaged in street-based sex work were at a significantly higher risk of both syringe borrowing and lending among youth who use injection drugs in Vancouver. Ready access to clean syringes, safer working conditions for sex workers to enable risk reduction measures, and increased access to addiction treatment are identified as promising opportunities for reducing syringe sharing in this setting.

Increased burden of suicidality among young street-involved sex workers who use drugs in Vancouver, Canada.

BACKGROUND: The risks of suicidality among street-involved youth who use drugs and engage in sex work are not well described. This study sought to evaluate if street-involved youth who engage in sex work were at an elevated risk for attempting suicide. METHODS: Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth who use drugs in Vancouver, Canada. Multivariable generalized estimating equation analyses were employed to examine whether youth who engaged in sex work were at elevated risk of attempting suicide, controlling for possible confounders. RESULTS: Between September 2005 and May 2015, 1210 youth were recruited into the cohort, of whom, 173 (14.3%) reported recently attempting suicide at some point during the study period. In multivariable analysis, youth who engaged in sex work were significantly more likely to report a recent suicide attempt (adjusted odds ratio = 1.93; 95% confidence interval: 1.28-2.91). CONCLUSIONS: Street-involved youth who engage in sex work were observed to be at a significantly higher risk for suicidality. Systematic discrimination and unaddressed trauma may contribute to the observed increased burden of suicidality among this population. Interventions that support the mental health and well-being of street-involved youth who engage in sex work are urgently needed.

In-hospital training in addiction medicine: A mixed-methods study of health care provider benefits and differences.

Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.

Childhood Trauma and the Inability to Access Hospital Care Among People who Inject Drugs.

Childhood traumatic experiences can disrupt attachment, influence personality development, and precipitate chronic disease. Although the repercussions of these experiences may also pose a barrier to healthcare, few studies have examined the association between childhood trauma and access to healthcare. Therefore, we sought to investigate whether a history of childhood trauma is associated with self-reported inability to access hospital care among persons who inject drugs (PWID). Data were derived from two prospective cohorts of PWID in Vancouver, Canada. We used multivariable generalized estimating equations to examine associations between five types of childhood trauma and self-reported inability to access hospital care, both overall and specifically due to perceived mistreatment by hospital staff. In total, 300 participants (18.3%) reported having tried but being unable to access hospital care in the previous 6 months at some point during the study period; the primary reason was perceived mistreatment by hospital staff (32.1%). In multivariable analyses, childhood emotional abuse was independently associated with self-reported inability to access hospital care, adjusted odds ratio (AOR) = 1.51, 95% CI [1.03, 2.20]. Childhood physical neglect was also independently associated with inability to access care due to perceived mistreatment by hospital staff, AOR = 1.80, 95% CI [1.11, 2.93]. This suggests potentially damaging consequences of early trauma in adult PWID populations. Further, this study emphasizes the need for trauma-informed models of care as well as the need to improve therapeutic alliances with survivors of childhood trauma in the PWID population.

Increasing availability of illicit and prescription opioids among people who inject drugs in a Canadian setting, 2010-2014.

BACKGROUND: Nonmedical use of prescription opioid and illicit opioid has been increasing at an alarming rate in North America over the past decade. OBJECTIVE: We sought to examine the temporal trends and correlates of the availability of illicit and prescription opioids among people who inject drugs (PWID) in Vancouver, Canada. METHODS: Data were derived from three prospective cohort studies of PWID in Vancouver between 2010 and 2014. In semiannual interviews, participants reported the availability of five sets of illicit and prescription opioids: (1) heroin; (2) Percocet (oxycodone/acetaminophen), Vicodin (hydrocodone/acetaminophen), or Demerol (meperidine); (3) Dilaudid (hydromorphone); (4) Morphine; (5) oxycontin/OxyNEO (controlled-release oxycodone). We defined perceived availability as immediate (e.g., available within 10 minutes) versus no availability/available after 10 minutes. The trend and correlation of immediate availability were identified by multivariable generalized estimating equations logistic regression. RESULTS: Among 1584 participants, of which 564 (35.6%) were female, the immediate availability of all illicit and prescribed opioids (except for oxycontin/OxyNEO) increased over time, independent of potential confounders. The Adjusted Odds Ratios of immediate availability associated with every calendar year increase were between 1.09 (95% confidence interval 1.05-1.12) (morphine and Dilaudid) and 1.13 (95% confidence interval 1.09-1.17) (Percocet/Vicodin/Demerol) (all p-values <0.05). CONCLUSION: The availability of most prescription opioids had continued to increase in recent years among our sample of PWID in Vancouver. Concurrent increases in the availability of heroin were also observed, raising concerns regarding combination of both illicit and prescription opioid use among PWID that could potentially increase the risk of overdose.

Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting.

BACKGROUND: Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines. METHODS: Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines. RESULTS: In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability. CONCLUSIONS: Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.

Declining Mortality Rates in HIV-Infected People Who Inject Drugs During a Seek-and-Treat Initiative in Vancouver, Canada, 1996-2014: A Prospective Cohort Study.

We estimated rates and predictors of death among a community-recruited prospective cohort of 961 human immunodeficiency virus (HIV)-infected people who inject drugs in Vancouver, Canada, between 1996 and 2014. The results demonstrated significant declines in age-adjusted all-cause and HIV-related mortality rates since 2010, coincident with the scale-up of a community-wide "seek-and-treat" campaign.

Syringe Sharing Among a Prospective Cohort of Street-Involved Youth: Implications for Needle Distribution Programs.

The sharing of previously used syringes is associated with the transmission of Hepatitis C and HIV. This longitudinal study examines syringe borrowing and syringe lending within a prospective cohort of street-involved youth in Vancouver, Canada. From September 2005 to May 2014, data were collected from the At-Risk Youth Study, a cohort of street-involved youth age 14-26 at enrollment, and analyzed using generalized estimating equations. Among 505 participants, 142 (28.1%) reported syringe borrowing and 132 (26.1%) reported syringe lending during the study period. In separate multivariable analyses, having difficulty finding clean needles and homelessness were significantly associated with syringe borrowing (Adjusted Odds Ratio (AOR) = 2.28, 95% CI 1.66-3.12 and AOR = 1.52, CI 1.05-2.21, respectively) and syringe lending (AOR = 1.89, 95% CI 1.32-2.71 and AOR = 1.65, 95% CI 1.11-2.44, respectively) (all p values < 0.05). Findings highlight gaps in syringe access for vulnerable young injectors and suggest that service delivery for youth may be suboptimal. Further examination of how needle distribution efforts might be improved to better meet the needs of young people is warranted.

Unsafe sexual behaviour associated with hazardous alcohol use among street-involved youth.

While risky sexual behaviours related to illicit drug use among street youth have been explored, the impacts of alcohol use have received less attention. This longitudinal study examined hazardous alcohol use among a population of street-involved youth, with particular attention to sexual and drug-related risk behaviours. Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth in Vancouver, Canada. The outcome of interest was hazardous alcohol use defined by the US National Institute on Alcohol Abuse and Alcoholism. We used generalized estimating equations (GEEs) analyses to identify factors associated with hazardous alcohol use. Between 2005 and 2014, 1149 drug-using youth were recruited and 629 (55%) reported hazardous alcohol use in the previous 6 months during study follow-up. In multivariable GEE analyses, unprotected sex (adjusted odds ratio [AOR] = 1.28, 95% confidence interval [95% CI] = 1.12-1.46) and homelessness (AOR = 1.35, 95% CI = 1.19-1.54) were independently associated with hazardous alcohol use (all p < .001). Older age (AOR = 0.95, 95% CI = 0.92-0.99), Caucasian ethnicity (AOR = 0.74, 95% CI = 0.61-0.90), daily heroin use (AOR = 0.53, 95% CI = 0.42-0.67), daily crack cocaine smoking (AOR = 0.73, 95% CI = 0.59-0.91), and daily crystal methamphetamine use (AOR = 0.52, 95% CI = 0.42-0.64) were negatively associated with hazardous alcohol use (all p < .05). In sub-analysis, consistent dose-response patterns were observed between levels of alcohol use and unprotected sex, homelessness, and daily heroin injection. In sum, hazardous alcohol use was positively associated with unsafe sexual behaviour and negatively associated with high-intensity drug use. Interventions to address hazardous alcohol use should be central to HIV prevention efforts for street-involved youth.

Perceived Devaluation and STI Testing Uptake among a Cohort of Street-Involved Youth in a Canadian Setting.

Perceived devaluation has been shown to have adverse effects on the mental and physical health outcomes of people who use drugs. However, the impact of perceived devaluation on sexually transmitted infections (STI) testing uptake among street-involved youth, who face multiple and intersecting stigmas due to their association with drug use and risky sexual practices, has not been fully characterized. Data were obtained between December 2013 and November 2014 from a cohort of street-involved youth who use illicit drugs aged 14-26 in Vancouver, British Columbia. Multivariable generalized estimating equations were constructed to assess the independent relationship between perceived devaluation and STI testing uptake. Among 300 street-involved youth, 87.0% reported a high perceived devaluation score at baseline. In the multivariable analysis, high perceived devaluation was negatively associated with STI testing uptake after adjustment for potential confounders (Adjusted Odds Ratio = 0.38, 95% Confidence Interval 0.15-0.98). Perceived devaluation was high among street-involved youth in our sample and appears to have adverse effects on STI testing uptake. HIV prevention and care programs should be examined and improved to better meet the special needs of street-involved youth in non-stigmatizing ways.

The relationship between hazardous alcohol use and violence among street-involved youth.

BACKGROUND AND OBJECTIVES: Alcohol is a major contributor to premature disability and death among youth, often due to physical trauma, violence, and suicide. The purpose of this study was to longitudinally examine the association between hazardous alcohol use and experiences of violence among a cohort of street-involved youth. METHODS: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth who use illicit substances in Vancouver, Canada. The outcome of interest was hazardous alcohol use defined by the US National Institute on Alcohol Abuse and Alcoholism as >14 drinks/week or >5 drinks on one occasion for men, and >7 drinks/week or >4 drinks on one occasion for women. We used Generalized Estimating Equations (GEE) analyses to examine factors independently associated with hazardous alcohol use. RESULTS: Between 2005 and 2014, 1,149 drug-using youth were recruited and 423 (36.8%) reported hazardous alcohol use in the previous 6 months at study baseline. In multivariable GEE analyses, intimate partner violence (Adjusted Odds Ratio [AOR] = 1.53, 95% Confidence Interval [95%CI] = 1.12-2.10), and non-partner physical assault (AOR = 1.39, 95%CI = 1.21-1.59) were independently associated with hazardous alcohol use after adjusting for multiple potential confounders. DISCUSSION AND CONCLUSIONS: A considerable proportion of youth in this setting reported hazardous alcohol use, which was independently associated with experiencing recent intimate and non-partner violence. SCIENTIFIC SIGNIFICANCE: Combined interventions for violence and hazardous alcohol use should be integrated into service provision programs for street-involved youth. (Am J Addict 2017;26:852-858).

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.

The association between residential eviction and syringe sharing among a prospective cohort of street-involved youth.

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.