The relationship between alcohol use and injecting drug use: impacts on health, crime and wellbeing

Prevalence and Correlates of Heavy Alcohol use among People Living with HIV who use Unregulated Drugs in Vancouver, Canada

Among people living with HIV (PLWH), heavy alcohol use is associated with many negative health consequences. However, the impacts of heavy alcohol use are not well described for PLWH who use drugs. Thus, we investigated the prevalence and correlates of heavy alcohol use among a cohort of people who use drugs (PWUD) living with HIV in Vancouver, Canada. We accessed data from an ongoing community-recruited prospective cohort of PLWH who use drugs with linked comprehensive HIV clinical monitoring data. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods of heavy alcohol use between December 2005 and December 2019. Of the 896 participants included, 291 (32.5%) reported at least one period with heavy alcohol use. Periods of recent incarceration (Adjusted Odds Ratio [AOR] = 1.48, 95% Confidence Interval [CI]: 1.01-2.17), encounters with police (AOR = 1.87, 95% CI: 1.37-2.56), and older age (AOR = 1.05, 95% CI: 1.02-1.07) were positively associated with heavy alcohol use. Engagement in drug or alcohol treatment (AOR = 0.54, 95% CI: 0.42-0.70) and male gender (AOR = 0.46; 95% CI: 0.27-0.78) were negatively associated with heavy alcohol use. We observed that heavy alcohol use was clearly linked to involvement with the criminal justice system. These findings, together with the protective effects of substance use treatment, suggest the need to expand access for drug and alcohol treatment programs overall, and in particular through the criminal justice system to reduce alcohol-related harms among PLWH who use drugs.

Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

Mortality in the SuperMIX cohort of people who inject drugs in Melbourne, Australia: a prospective observational study

AIMS

To measure mortality rates and factors associated with mortality risk among participants in the SuperMIX study, a prospective cohort study of people who inject drugs.

DESIGN

A prospective observational study using self-reported behavioural and linked mortality data.

SETTING

Melbourne, Australia.

PARTICIPANTS/CASES

A total of 1209 people who inject drugs (67% male) followed-up between 2008 and 2019 for 6913 person-years (PY).

MEASUREMENTS

We linked participant identifiers from SuperMIX to the Australian National Death Index and estimated all-cause and drug-related mortality rates and standardized mortality ratios (SMRs). We used Cox regression to examine associations between mortality and fixed and time-varying socio-demographic, alcohol and other drug use and health service-related exposures.

FINDINGS

Between 2008 and 2019 there were 76 deaths in the SuperMIX cohort. Of those with a known cause of death (n = 68), 35 (51%) were drug-related, yielding an all-cause mortality rate of 1.1 per 100 PY [95% confidence interval (CI) = 0.88-1.37] with an estimated SMR of 16.64 (95% CI = 13.29-20.83) and overall accidental drug-induced mortality rate of 0.5 per 100 PY (95% CI = 0.36-0.71). Reports of recent use of ambulance services [adjusted hazard ratio (aHR) = 3.77, 95% CI =1.78-7.97] and four or more incarcerations (aHR = 2.78, 95% CI = 1.55-4.99) were associated with increased mortality risk.

CONCLUSIONS

In Melbourne, Australia, mortality among people who inject drugs appears to be positively associated with recent ambulance attendance and experience of incarceration.

Emergency department presentations in the first weeks following release from prison among men with a history of injecting drug use in Victoria, Australia: A prospective cohort study

OBJECTIVE

Rates of emergency department (ED) use are higher among people released from prison than in the general population. However, little is known about ED presentations specifically among people with a history of injecting drug use (IDU) leaving prison. We measured the incidence of ED presentation in the three months following release from prison, among a cohort of men with histories of IDU, and determined pre-release characteristics associated with presenting to an ED during this period.

METHODS

We analysed linked survey and administrative data from the Prison and Transition Health (PATH) study (N = 400) using multiple-failure survival analysis.

RESULTS

Twenty-one percent (n = 81/393) of the cohort presented to an ED at least once within the three months after release from prison. The incidence of ED presentation was highest in the first six days after release. Cox proportional hazards modelling showed that a history of in-patient psychiatric admission and housing instability were associated with increased hazard of an ED presentation, and identifying as Aboriginal and Torres Strait Islander was associated with decreased hazard.

CONCLUSIONS

In our study, ED presentations following release from prison among people with a history of IDU was linked to acute health risks related to known mental health and social vulnerabilities in this population. Greater collaboration and systems integration between prison and community health and support services is needed to reduce presentations to ED and associated morbidities among people with a history of IDU after release from prison.

The association between history of civil commitment for severe substance use and future imprisonment: A Swedish registry study

BACKGROUND

Civil commitment for individuals with severe substance use is fairly common and a part of many treatment systems worldwide. In Sweden, individuals with severe substance use and experience with civil commitment are more likely to use higher levels of alcohol and drugs, to be younger, and be more socially marginalized compared to their counterparts. The study examined whether civil commitments for severe substance use increased the likelihood of imprisonment following the civil commitment.

METHOD

Baseline ASI-data merged with national registry data on prison sentences (2007 through 2016). Cox regression was used to estimate, for a Swedish sample of 12,044 adults assessed for risky substance use, the importance of having a history of civil commitment for severe substance use, controlling for age, gender and baseline assessment of ASI composite scores in seven areas (alcohol, drugs other than alcohol, legal, mental- and physical health, family & social relationships and employment) on the likelihood of future imprisonment.

RESULTS

The regression showed that being a male, those with experience of civil commitment and elevated ASI composite scores for both legal and employment were significantly associated with imprisonment post-civil commitment. Civil commitment for severe substance use showed 1.29 (HR = 1.29, 95% CI: 1.03-1.49, p < 0.001) increased likelihood of imprisonment post-civil commitment.

CONCLUSION

Having been in treatment through civil commitment due to severe substance use was strongly associated with imprisonment post-civil commitment episode. This is concerning since civil commitment is supposed to mediate against the consequences of severe substance use and promote voluntary treatment participation. Those with severe substance use and a history of civil commitment are in need of a well-coordinated and integrated system of extensive aftercare services to reduce the likelihood of imprisonment.

The predictability of the Addiction Severity Index criminal justice assessment instrument and future imprisonment: A Swedish registry study with a national sample of adults with risky substance use

OBJECTIVE

In Sweden, social workers uses the Addiction Severity Index (ASI) as their main assessment tool when assessing individuals with risky substance use (RSU) or substance use disorder. The aim of this study is to identify among individuals with RSU, the associations of ASI Composite Scores (CSs) with future imprisonment controlling for age, education level and gender.

METHOD

Baseline ASI-data was merged with national registry data on prison sentences (2003-2016). Cox regression was used to estimate the associations between CSs for alcohol, drugs other than alcohol, legal, family and social relationships, employment, mental- and physical health and future imprisonment for adults (n = 14,914) assessed for RSU.

RESULTS

The regression showed that all ASI CSs, age, education level and gender were significantly associated with imprisonment post ASI base-line assessment. The variables with the strongest association with imprisonment were ASI legal CS, followed by ASI drugs other than alcohol CS, ASI employment CS and being a male. ASI legal score showed the strongest association with imprisonment, with a 6 time increase in likelihood of imprisonment.

DISCUSSION

Given the findings in this study, the strong significant association between ASI legal CS and future imprisonment, it seems as that the ASI-assessment instrument is a reliable and trustworthy assessment tool to use in clinical work. This should motivate social workers and other clinical health professionals to use and rely on the ASI assessment in their intervention planning for clients with RSU, to hopefully reduce future imprisonment and improve their social situation.

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis

AIMS

To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

DESIGN

Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

SETTING AND PARTICIPANTS

People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

MEASUREMENTS

Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

FINDINGS

Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

CONCLUSIONS

People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.

The Associations between Risky Psychosocial Environment, Substance Addiction Severity and Imprisonment: A Swedish Registry Study

Objective: Both childhood and adult psychosocial stressors have been identified as links to both increased risk for substance use disorder (SUD) and increased risk of imprisonment. The aim of this retrospective study is to identify, for a sample of 14,914 adults who all were assessed for risky substance use or a SUD, the importance of having a history of psychosocial stressors compared to current addiction severity. The analyses control for age, gender and education on the likelihood of future imprisonment. Method: Baseline Addiction Severity Index data (ASI) were merged with national registry data on prison sentences from 2003 to 2016. In the analysis, a Cox regression was used to study the association between independent variables and the likelihood of future imprisonment. Results: In the regression, five variables showed significant association to increased risk of imprisonment: ASI drugs other than alcohol Composite Score (positive relationship), ASI alcohol Composite Score (negative relationship), age (younger), education (lower) and parental problems with drugs other than alcohol. The factor with strongest association with imprisonment was the ASI drugs other than alcohol Composite Score, which showed the highest HR = 10.63 (3.50-32.31) for women and HR = 5.52 (3.77-8.08) for men to predict the likelihood of imprisonment. Discussion: Research is needed on why individuals with history of psychosocial stressors have a higher likelihood of imprisonment compared to their counterparts. Findings indicate that a high ASI Composite Score for drugs other than alcohol are strong predictors of future criminality and criminal justice system involvement.

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).

Comparison of subjective wellbeing in substance users and the parents or partners of substance users

INTRODUCTION AND AIMS

There is growing interest in the impact of substance use on both the individual consumer's subjective wellbeing (SWB) and the reduced SWB of those closely connected to him or her. The study aimed to compare SWB among substance users ('consumers') and the parents or partners affected by another's substance use, and to evaluate the effect of counselling on changed SWB to 6 months.

DESIGN AND METHODS

The study used longitudinal data from a not-for-profit treatment service based in Perth, Australia. Subjective wellbeing was assessed with the Personal Wellbeing Index (PWI) at baseline and 6 months. Data were compared to national norms (mean 75.97) with one sample t tests. Change in PWI scores was assessed with generalised linear mixed models, controlling for age, gender, group (consumers versus parents or partners), psychological distress (Kessler-10) and social connectedness (Lubben).

RESULTS

Of 220 participants, 136 (62%) were consumers and 84 (38%) were parents or partners. At 6 months 123 (56%) were re-interviewed. At baseline, both consumers (mean 53.7) and parents or partners (mean 66.1) had significantly lower PWI scores than national norms. At 6 months, only the substance users' PWI scores remained significantly lower (mean 67.8). Subjective wellbeing significantly increased with time (β = 5.52; 95% confidence interval 3.15, 7.90), with no significant time by group interaction.

DISCUSSION AND CONCLUSIONS

Both groups showed significant decrements in SWB compared with the general population but with improvements over the study period. However, the lack of a control group prevents definitive assertions on causality for improved SWB.

Longitudinal changes in personal wellbeing in a cohort of people who inject drugs

Aims

To determine whether the self-reported personal wellbeing of a cohort of people who inject drugs (PWID) changes over time, and to identify longitudinal correlates of change.

Methods

We used Personal Wellbeing Index (PWI) scores reported between April 2008 and February 2015 by 757 PWID (66% male) enrolled in the Melbourne Injecting Drug Use Cohort Study (2,862 interviews; up to seven follow-up waves). A mixed-effects model was used to identify correlations between changes in temporal variables and changes in individual PWI scores while controlling for demographic variables.

Results

The cohort’s mean PWI score did not significantly differ over time (between 54.4/100 and 56.7/100 across the first four interview waves), and was 25–28% lower than general Australian population scores (76.0/100). However, there were large variations in individuals’ PWI scores between interviews. Increased psychological distress, moving into unstable accommodation, reporting intentional overdose in the past 12 months and being the victim of assault in the past six months were associated with declines in PWI scores.

Conclusions

Participants experienced substantially lower levels of personal wellbeing than the general Australian population, influenced by experiences of psychological distress, assault, overdose and harms related to low socioeconomic status. The results of this study suggest a need to ensure referral to appropriate housing and health support services for PWID.

Frequent emergency department presentations among people who inject drugs: A record linkage study

BACKGROUND

People who inject drugs (PWID) have been described as frequent users of health services such as emergency departments (EDs), however few studies have described demographic factors, patterns of substance use and previous health service use associated with frequent use of EDs in this population.

METHODS

Using a combination of self-reported data from a cohort of PWID and administrative ED data obtained through record linkage, we identified longitudinal factors associated with the use of ED services. Bivariate and multivariate analyses were conducted using negative binomial regression to identify exposures associated with both cumulative ED presentations, and logistic regression to identify exposures of frequent ED presentations (defined as three or more annual presentations).

RESULTS

Among 612 PWID, over half (58%) presented to EDs at least once and over a third (36%) presented frequently between January 2008 and June 2013. Frequent and cumulative ED presentations were associated with reporting the main drug of choice as cannabis (AOR:1.42, 95%CI:1.07-1.89 and AIRR:2.96, 95%CI:1.44-6.07 respectively) or methamphetamine (AOR:1.62, 95%CI:1.17-2.2 and AIRR:2.42, 95%CI:1.08-5.46 respectively) compared to heroin, and past month use of mental health (AOR:1.42, 95%CI:1.08-1.85 and AIRR:3.32, 95%CI:1.69-6.53 respectively) and outpatient services (AOR:1.47, 95%CI: 1.00-2.16 and AIRR:0.95, 95%CI 1.52-10.28 respectively).

CONCLUSION

PWID who are frequent users of EDs are likely to have complex health and substance use-related needs. EDs should actively refer people who present with cannabis and methamphetamine dependence to harm reduction services. Harm reduction services should ensure people referred from EDs are screened for co-occurring mental health conditions and receive adequate support.

Longitudinal changes in psychological distress in a cohort of people who inject drugs in Melbourne, Australia

BACKGROUND

Previous research into psychological distress among people who inject drugs (PWID) is predominantly cross-sectional; we determined longitudinal predictors of change in psychological distress among a cohort of PWID.

METHOD

We examined Kessler Psychological Distress Scale (K10) scores from 564 PWID (66% male) enrolled in the Melbourne Injecting Drug User Cohort Study. Gender-stratified linear models with fixed effects for each participant were used to examine correlates of change in individual K10 scores. Further linear regressions of adjusted K10 scores were used to measure correlations between demographic variables.

RESULTS

Participants reported higher K10 scores (higher psychological distress) than the general Australian population (mean K10 scores 23.4 (95%CI 22.6-24.2) and 14.5 (95%CI 14.3-14.7) respectively). The cohort's mean K10 score did not significantly differ over time, but individual variations were common. Women reported higher K10 scores than men (mean baseline K10 scores 25.2 (95%CI 23.9-26.6) and 22.4 (95%CI 21.5-23.3) respectively), however no significant differences remained after controlling for temporal factors. Key predictors of increases in K10 scores were being the victim of an assault in the past six months (P<0.001 for women and men) and intentionally overdosing in the past 12 months (P=.010 for women and P<0.001 for men).

CONCLUSIONS

PWID experience higher levels of psychological distress than the general population. Temporal rather than individual factors may account for the higher levels of psychological distress reported among women. Interventions to reduce rates of assault and/or intentional overdose should be explored to reduce high levels of psychological distress among PWID.

Hazardous Alcohol Use Associated with Increased Sexual Risk Behaviors Among People Who Inject Drugs

BACKGROUND

Alcohol is associated with a multitude of severe health consequences. While risk behaviors related to illicit drug use are commonly studied among people who inject drugs (PWID), the role of alcohol use has received substantially less attention in this population. We explored whether drug and sexual risk behaviors as well as experiences of violence were associated with hazardous alcohol use in a cohort of PWID.

METHODS

Analyses were conducted using observational data from a prospective cohort of community-recruited HIV-negative PWID in Vancouver, Canada. We used the U.S. National Institute on Alcohol Abuse and Alcoholism definition of hazardous alcohol use (i.e., >14 drinks/wk or >4 drinks on 1 occasion for men, and >7 drinks/wk or >3 drinks on 1 occasion for women). We used multivariable generalized estimating equations (GEE) to identify the factors associated with hazardous alcohol use.

RESULTS

Between 2006 and 2012, 1,114 HIV-negative individuals were recruited, and 186 (16.7%) reported hazardous alcohol use in the previous 6 months at baseline. In multivariable GEE analyses, having multiple sex partners (adjusted odds ratio [AOR] = 1.25), history of sexually transmitted infection (AOR = 1.50), experiencing violence (AOR = 1.36), and incarceration (AOR = 1.29) were each independently associated with hazardous alcohol use. Caucasian ethnicity (AOR = 0.56), ≥ daily heroin injection (AOR = 0.81), and engagement in addiction treatment (AOR = 0.84) were negatively associated with hazardous alcohol use (all p < 0.05).

CONCLUSIONS

A considerable proportion of PWID reported hazardous alcohol use, which was independently associated with reporting sexual, but not drug-related, HIV risk behaviors and experiencing recent violence. Findings suggest a need to integrate regular screening and evidence-based alcohol interventions into treatment efforts for PWID.

Unhealthy alcohol use in primary care patients who screen positive for drug use

BACKGROUND

Unhealthy alcohol use (UAU) is common among people who use other drugs; however, little information is available about UAU among patients who screen positive for drugs in primary care, where the clinical priority might be assumed to be drug use. This study aimed at describing the occurrence of UAU and its association with substance use-related outcomes in such patients.

METHODS

This cohort study is a secondary analysis of data from a randomized trial of brief intervention for primary care patients screening positive for drug use. UAU was assessed at baseline; the main independent variable was any heavy drinking day in the past month. Outcomes including drug use characteristics and substance use-related consequences were assessed at baseline and 6 months later.

RESULTS

Of 589 primary care patients with drug use, 48% had at least 1 past-month heavy drinking day. The self-identified main drug was marijuana for 64%, cocaine for 18%, and an opioid for 16%. Any heavy drinking at baseline was negatively associated with number of days use of the main drug at 6 months (incidence rate ratio [IRR] = 0.75, 95% confidence interval [CI]: 0.62-0.91), but positively associated with the use of more than 1 drug (IRR = 1.73, 95% CI: 1.17-2.55) and unsafe sex (odds ratio [OR] = 1.90, 95% CI: 1.21-2.98).

CONCLUSION

Unhealthy alcohol use is common among patients identified by screening in primary care as using other drugs. Unexpectedly, UAU was negatively associated with days of main drug use. But, as expected, it was positively associated with other drug use characteristics and substance use-related consequences. These findings suggest that attention should be given to alcohol use among primary care patients who use other drugs.

Mortality in the Melbourne injecting drug user cohort study (MIX)

Background

There are few studies of mortality amongst people who inject drugs (PWID) in Australia. In this study, we estimate mortality in a cohort of PWID in Melbourne and examine predictors of mortality including health service use, demographic characteristics, drug use and personal wellbeing.

Findings

We linked identifiers from the Melbourne injecting drug use cohort study (MIX; n = 655) to the National Death Index from 2008 to 2012 to estimate standardised mortality ratios (SMRs). Cox regression was used to examine the bivariate relationship between exposures determined at baseline and subsequent mortality. There were 24 (3.6 %) deaths over the study period. The mortality rate in the cohort was 1.0 per 100 PY (95 % CI 0.71–1.57), with an SMR of 17.3 (95 % CI 11.6–25.8). Baseline reports of four or more lifetime incarcerations (HR 3.65, 95 % CI 1.16–11.52), past month ambulance attendance (HR 4.43, 95 % CI 1.76–11.17), past month emergency department presentation (HR 3.44, 95 % CI 1.47–8.03) and past 6-month self-reported heroin overdose (HR 3.14, 95 % CI 1.24–7.96) were associated with increased mortality risk.

Conclusions

Contact with emergency services, particularly for drug overdose, remains a lost opportunity to provide referrals for harm reduction and naloxone training programmes to PWID at greater risk of mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12954-015-0089-3) contains supplementary material, which is available to authorized users.

Social and Structural Factors Shaping High Rates of Incarceration among Sex Workers in a Canadian Setting

In light of the emphasis on enforcement-based approaches towards sex work, and the well-known negative impacts of these approaches on women's health, safety and well-being, we conducted a study to investigate the prevalence and correlates of recent incarceration among a cohort of women sex workers in Vancouver, Canada. Data were obtained from an open prospective community cohort of female and transgender women sex workers, known as An Evaluation of Sex Workers' Health Access (AESHA). Bivariate and multivariable logistic regression analyses, using generalized estimating equations (GEE), were used to model the effect of social and structural factors on the likelihood of incarceration over the 44-month follow-up period (January 2010-August 2013). Among 720 sex workers, 62.5 % (n = 450) reported being incarcerated in their lifetime and 23.9 % (n = 172) being incarcerated at least once during the study period. Of the 172 participants, about one third (36.6 %) reported multiple episodes of incarceration. In multivariable GEE analyses, younger age (adjusted odds ratio [AOR] = 1.04 per year younger, 95 % confidence interval [CI] 1.02-1.06), being of a sexual/gender minority (AOR = 1.62, 95 % CI 1.13-2.34), heavy drinking (AOR = 1.99, 95 % CI 1.20-3.29), being born in Canada (AOR = 3.28, 95 % CI 1.26-8.53), living in unstable housing conditions (AOR = 4.32, 95 % CI 2.17-8.62), servicing clients in public spaces (versus formal sex work establishments) (AOR = 2.33, 95 % CI 1.05-5.17) and experiencing police harassment without arrest (AOR = 1.82, 95 % CI 1.35-2.45) remain independently correlated with incarceration. This prospective study found a very high prevalence and frequency of incarceration among women sex workers in Vancouver, Canada, with the most vulnerable and marginalized women at increased risk of incarceration. Given the well-known social and health harms associated with incarceration, and associations between police harassment and incarceration in this study, our findings further add to growing calls to move away from criminalized and enforcement-based approaches to sex work in Canada and globally.

Cessation of injecting drug use: The effects of health service utilisation, drug use and demographic factors

BACKGROUND

Injecting drug use is associated with a range of harms, however cessation of injecting is rare. There is a lack of evidence on factors associated with cessation, notably those related to health services other than drug treatment. We examined the incidence and identified longitudinal correlates of first episode of cessation in a cohort of people who inject drugs (PWID).

METHODS

Using discrete-time survival analysis, we examined correlates of the first episode of cessation (no self-reported injecting drug use in the past 12 months), including the use of health services, socio-demographics and drug-related behaviour in a cohort of PWID recruited between 2008 and 2010.

RESULTS

The cohort of 467 participants contributed 1527 person-years from recruitment to 2014. Under a fifth (17.8%) of people reported cessation of 12 months or more, yielding a cessation rate of 5.4 events per 100 person-years. Younger age (25-29 compared to 30 and above) (adjusted hazard ratio (AHR) 1.79, 95% confidence interval (CI) 1.07-3.00) and male gender (AHR 1.67, 95% CI 2.01-2.76) were positively associated with cessation, while past year use of benzodiazepines (AHR 0.45, 95% CI 0.28-0.72), arrest in the past year (AHR 0.50, 95% CI 0.30-0.83) and low SF-8 physical dimension score (AHR 0.42, 95% CI 0.20-1.88) were negatively associated with cessation. Outpatient service use had the largest effect on cessation (AHR 2.28, 95% CI 0.94-5.48, p=0.067).

CONCLUSIONS

Low rates of cessation emphasise the need for sustained and comprehensive harm reduction services. The relationship between outpatient services and cessation suggests that further research into the use in health services among PWID is warranted.

Diagnosed alcohol dependence and criminal sentencing among British Columbian Aboriginal offenders

INTRODUCTION

Alcohol use is commonly reported as a short-term criminal risk factor; however there is minimal research on the effects of alcohol dependence on crime. Canadian Aboriginal offenders exhibit both disproportionate crime and alcohol disorder prevalence. This study aims to examine the impact of diagnosed alcohol dependence on Aboriginal ethnicity and criminal sentencing in British Columbia.

METHODS

We used an administrative linkage database of social, health and justice system variables to develop a retrospective cohort of 70,035 offenders sentenced through courts in British Columbia from 2001-2010. We used a coefficient difference mediation analysis to evaluate the mediating effect of alcohol dependence on the association between self-reported Aboriginal status and sentencing rate.

RESULTS

Aboriginal offenders had 1.92 (95% C.I.: 1.79,2.06) times higher odds of alcohol dependence than Caucasian offenders. Adjustment for health, social and demographic factors resulted in a 27% (95% Confidence Interval (CI): 15%, 33%) reduction in the association of Aboriginal ethnicity on sentencing. Adjustment for alcohol dependence resulted in only a further reduction of 2% (95% CI: -12%, 15%). Although alcohol dependence was associated both with Aboriginal ethnicity and sentencing, it did not have a significant mediating impact on sentencing rate.

CONCLUSION

Alcohol dependence was not a mediator for the relationship between sentencing rate and Aboriginal ethnicity. However, due to the proportion of offenders diagnosed with alcohol dependence, these results support alcohol misuse as an important public health policy target in this population.

Heavy alcohol use and suicidal behavior among people who use illicit drugs: A cohort study

BACKGROUND

People who use illicit drugs (PWUD) are known to experience high rates of suicidal behavior. While heavy alcohol use has been associated with suicide risk, its impact on the suicidal behavior of PWUD has not been well characterized. Therefore, we examined the relationship between heavy alcohol use and suicidal behavior among PWUD in Vancouver, Canada.

METHODS

Data are derived from two prospective cohort studies of PWUD in Vancouver, Canada, from 2005 to 2013. Participants completed questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. We used recurrent event survival analyses to estimate the independent association between at-risk/heavy drinking (based on National Institute of Alcohol Abuse and Alcoholism [NIAAA] criteria) and risk of incident, self-reported suicide attempts.

RESULTS

Of 1757 participants, 162 participants (9.2%) reported 227 suicide attempts over the 8-year study period, resulting in an incidence rate of 2.5 cases per 100 person-years. After adjusting for potential confounders, including intensive illicit drug use patterns, heavy alcohol use (adjusted hazard ratio [AHR] = 1.97; 95% confidence interval [CI] = 1.39, 2.78) was positively associated with an increased risk of suicidal behavior.

CONCLUSIONS

We observed a high burden of suicidal behavior among a community-recruited sample of PWUD. Heavy alcohol use predicted a higher risk of suicide attempt, independent of other drug use patterns. These findings demonstrate the need for evidence-based interventions to address suicide risk among PWUD, particularly those who are heavy consumers of alcohol.

Patterns of, and Factors Associated With, Illicit Pharmaceutical Opioid Analgesic Use in a Prospective Cohort of People Who Inject Drugs in Melbourne, Australia

BACKGROUND

People who inject drugs (PWID) are a key population engaging in pharmaceutical opioid analgesic (PO) use, yet little is known about patterns of illicit PO use among this group.

OBJECTIVES

The aims of this research were to measure the prevalence and frequency of lifetime and past-month illicit PO use and injection in a sample of regular PWID, to examine patterns of past-month illicit PO use within individuals over time, and to identify factors independently associated with past-month illicit PO use.

METHODS

Data were drawn from a prospective cohort study of regular PWID (N = 666) in Melbourne, Australia. Data from five waves of annual data collection (including baseline) were analyzed descriptively and using generalized estimating equations (GEE).

RESULTS

At baseline, 59% of participants reported lifetime illicit PO use and 20% reported past-month use, predominantly through injecting. Most illicit PO users at baseline transitioned to nonuse of illicit POs across the study period. In multivariable GEE analysis, factors associated with past-month illicit PO use included past-year arrest [adjusted odds ratio (AOR): 1.39], opioids other than heroin as drug of choice (AOR: 5.14), experiencing poorer physical health (AOR: 0.98) and a range of other drug use variables.

CONCLUSIONS

We found little evidence of ongoing illicit PO use among those followed up, with illicit PO use linked to polydrug use more broadly. Nonetheless, trends in illicit PO use among PWID should continue to be monitored and harm reduction interventions implemented to reduce the associated public health risks.

A cross-sectional study describing factors associated with utilisation of GP services by a cohort of people who inject drugs

Background

People who inject drugs (PWID) use healthcare services, including primary care, at a disproportionately high rate. We investigated key correlates of general practitioner (GP) related service utilisation within a cohort of PWID.

Methods

Using baseline data from a cohort of 645 community-recruited PWID based in Melbourne, Victoria, we conducted a secondary analysis of associations between past month use of GP services unrelated to opioid substitution therapy (OST) and socio-demographic and drug use characteristics and self-reported health using multivariate logistic regression.

Results

Just under one-third (29%) of PWID had accessed GP services in the month prior to being surveyed. Participants who reported living with children (adjusted odds ratio, AOR 1.97, 95% CI 1.04 - 3.73) or having had contact with a social worker in the past month (AOR 1.92, 95% CI 1.24 - 2.98) were more likely to have seen a GP in the past month. Participants who were injecting daily or more frequently (AOR 0.50, 95% CI 0.30 - 0.83) or had a weekly income of less than $400 (AOR 0.59, 95% CI 0.38 - 0.91) were less likely to report having seen a GP in the past month.

Conclusions

Our sample frequently attended GP services for health needs unrelated to OST. Findings highlight both the characteristics of PWID accessing GP services and also those potentially missing out on primary care and preventive services.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

BACKGROUND

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

METHODS

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

RESULTS

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96).

CONCLUSIONS

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.