Declining rate of substance abuse throughout the month

An ecological study of the correlation between COVID-19 support payments and overdose events in British Columbia, Canada

BACKGROUND

Pandemic income support payments have been speculatively linked to an increased incidence of illicit drug poisoning (overdose). However, existing research is limited.

METHODS

Collating Canadian Emergency Response Benefit (CERB) payment data with data on paramedic attended overdose and illicit drug toxicity deaths for the province of British Columbia at the Local Health Area (LHA) level, we conducted a correlation analysis to compare overdose rates before, during and after active CERB disbursement.

RESULTS

There were 20,014,270 CERB-entitled weeks identified among residents of British Columbia for the duration of the pandemic response program. Approximately 52 % of all CERB entitled weeks in the study were among females and approximately 48 % were among males. Paramedic-attended overdoses increased uniformly across the pre-CERB, CERB and post-CERB periods, while illicit drug toxicity deaths sharply increased and then remained high over the period of the study. Correlation analyses between overdose and CERB-entitled weeks approached zero for both paramedic-attended overdoses and illicit drug toxicity deaths.

CONCLUSIONS

These findings suggest that attributing the pandemic increase in overdose to income support payments is unfounded. Sustained levels of unacceptably high non-fatal and fatal drug poisonings that further increased at the start of the pandemic are reflective of complex pre-existing and pandemic-driven changes to overdose risk.

Drug-related harm coinciding with income assistance payments: results from a community-based cohort of people who use drugs

BACKGROUND AND AIMS

Income assistance is critical to the health and wellbeing of socio-economically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined socio-demographic, health and drug use-related correlates of payment-coincident drug-related harm.

DESIGN

This observational study uses data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018.

SETTING

Vancouver, British Columbia, Canada.

PARTICIPANTS

A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants and 685 (42.7%) people living with HIV.

MEASUREMENTS

The primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher-frequency substance use, non-fatal overdose and service barriers or interruptions. Subanalyses disaggregated this outcome.

FINDINGS

Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation [adjusted odds ratio (aOR) = 1.48, 95% confidence interval (CI) = 1.26-1.74, P < 0.001], sex work (aOR = 1.66, 95% CI = 1.35-2.04, P < 0.001), illegal income generation (aOR = 1.57, 95% CI = 1.35-1.83 P < 0.001), homelessness (aOR = 1.34, 95% CI = 1.13-1.58, P < 0.001), exposure to violence (aOR = 1.31, 95% CI = 1.03-1.66, P = 0.032), daily crack cocaine use (aOR = 1.99, 95% CI = 1.59-2.50, P <  0.001), heavy alcohol use (aOR = 1.64, 95% CI = 1.37-1.97, P < 0.001) and injection drug use (aOR = 2.55, 95% CI = 2.01-3.23, P < 0.001). In subanalyses, specific harms were more likely among individuals reporting social, structural and health vulnerabilities.

CONCLUSIONS

In Vancouver, Canada, people who use illicit drugs who receive income assistance report high prevalence of payment-coincident drug-related harm, particularly people experiencing socioeconomic and structural marginalization or engaging in high-intensity drug use.

Deconstructing the 'cheque effect': short-term changes in injection drug use after receiving income assistance and associated factors

BACKGROUND AND AIMS

Disbursement of income assistance has been temporally associated with intensified drug use and related harms (coined the 'cheque effect'). However, relationships to injection drug use (IDU) remain understudied. We examined short-term 'cheque effects' and associated factors among people who inject drugs (PWID).

DESIGN

Cross-sectional analysis nested within a cohort study.

SETTING

Montreal, Quebec, Canada.

PARTICIPANTS

PWID receiving income assistance, with no employment income. A total of 613 PWID (median age 41, 83% male) contributed 3269 observations from 2011 to 2017.

MEASUREMENTS AND METHODS

At each cohort visit, an interviewer-administered questionnaire captured retrospective reports of injection-related behaviour during the 2-day periods (i) before and (ii) including/after receiving last month's income assistance payment (number of injections; drugs injected; any receptive syringe-sharing). The relative likelihood (odds) and magnitude (rate) of an increase in injection frequency ('cheque effect') were estimated in relation to social and behavioural factors using logistic and negative binomial regression in a covariate-adjusted two-part model.

FINDINGS

Prevalence of IDU and syringe-sharing were, respectively, 1.80 and 2.50 times higher in the days following versus preceding cheque receipt (P < 0.001). Among people with past-month IDU, most observations showed increased injection frequency (52%) or no change in injection frequency (44%). The likelihood of a 'cheque effect' was positively associated with cocaine injection [versus injection of other substances, odds ratio (OR) = 2.639, 95% confidence interval (CI) = 2.04-3.41], unstable housing (OR = 1.272, 95% CI = 1.03-1.57) and receiving opioid agonist therapy (OR =1.597, 95% CI = 1.27-2.00) during the same month. Magnitude of the 'cheque effect' was positively associated with cocaine injection [rate ratio (RR) = 1.795, 95% CI = 1.43-2.16], unstable housing (RR = 1.198, 95% CI = 1.02-1.38) and frequent injection (RR = 2.938, 95% CI = 2.43-3.44), but inversely associated with opioid agonist therapy (RR = 0.817, 95% CI = 0.68-0.95) and prescription opioid injection (RR = 0.794, 95% CI = 0.66-0.93).

CONCLUSION

Among people who inject drugs in Montreal, Canada, injection drug use and receptive syringe-sharing appear to be more prevalent in the 2 days after versus before receiving income assistance. The odds and rate of individual-level increases in injection frequency appear to be positively associated with cocaine injection (versus injection of other substances) and unstable housing.

Integrated knowledge translation to strengthen public policy research: a case study from experimental research on income assistance receipt among people who use drugs

BACKGROUND

Solutions to complex public health issues should be informed by scientific evidence, yet there are important differences between policy and research processes that make this relationship challenging. Integrated knowledge translation (IKT) is a strategy of sustained stakeholder engagement that intends to address barriers to evidence use. We highlight an example of an IKT project alongside a randomized controlled trial of a public policy intervention that tested different disbursement patterns of income assistance among people who use drugs in Vancouver, British Columbia.

METHODS

A case study design was used where an IKT strategy led by a knowledge broker embedded within the research team acts as the case. This case study evaluates the process and effectiveness of the integrated knowledge translation project by measuring intermediate outcomes within a Theory of Change created to map pathways to impact. Content analysis was performed using an evaluation template through document review, post-event evaluations, and detailed tracking of media, knowledge translation activities and requests for information.

RESULTS

A host of knowledge translation products synthesized existing research about the harms of synchronized income assistance disbursement and supported stakeholder engagement, facilitating conversation, relationship building and trust with stakeholders. Engagement improved knowledge of the contextual feasibility for system change, and contributed experiential knowledge to study findings. A combination of access to information and stakeholder and media engagement led to increased acknowledgement of the issue by policy makers directly involved in the income assistance system.

CONCLUSIONS

This project shows how a multipronged approach to IKT addressed barriers to evidence-informed public policy and successfully contributed to increased public discourse around income assistance policy reform. Additionally, sustained engagement with diverse stakeholders led to improved contextual knowledge and understanding of potential community level impacts that, along with scientific results, improved the evidence available to inform system change. This case study provides insight into the role IKT can play alongside research aimed at public policy improvements.

TRIAL REGISTRATION

This IKT project was embedded within the study titled: The impact of Alternative Social Assistance Disbursement on Drug-Related Harm (TASA), known as Cheque Day Study, registered on ClinicalTrials.gov ( NCT02457949 ) May 29, 2015.

Emergency Department visits for depression following police killings of unarmed African Americans

Previous literature on racism and adverse mental health largely focuses on individual-level exposures. We investigate whether and to what extent structural racism, as measured by police killings of unarmed African Americans, affect a severe and acute mental health outcome among African Americans: depression-related Emergency Department (ED) visits. We used police killings of unarmed African Americans as our exposure and depression-related ED visits (per 100,000 population) as our outcome. We examined the relation across 75 counties from five US states between 2013 and 2015 (2700 county-months). Linear fixed effect analyses controlled for time-invariant county-factors as well as the number of hospitals and arrests for violent crimes (per 100,000 population). Police killings of unarmed African Americans correspond with an 11% increase in ED visits per 100,000 population related to depression among African Americans in the concurrent month and three months following the exposure (p < 0.05). Researchers and policymakers may want to consider prevention efforts to reduce racial bias in policing and implement surveillance of fatal police encounters. These encounters, moreover, may worsen mental health and help-seeking in the ED among African Americans not directly connected to the encounter.

Temporal Trends and Predictors of Pancreatitis Patients Who Leave Against Medical Advice: A Nationwide Analysis

Background

Acute pancreatitis is the leading gastrointestinal cause of hospital admissions. Our study aims to determine the trends and predictors of discharge against medical advice (AMA).

Methods

We utilized the Nationwide Inpatient Sample (2003 - 2016) to identify patients admitted with pancreatitis. We compared in-hospital complications and determined predictors of discharge AMA using a multivariate logistic regression.

Results

A total of 7,158,894 patients were admitted with pancreatitis. Of those, 199,351 left AMA. Discharge AMA increased over time from 2.3% to 3.2%. Patients who left AMA were more likely to be younger, male, black, and a lower socioeconomic status (SES). They had a greater prevalence of depression, cirrhosis, smoking, drug abuse, and human immunodeficiency virus (HIV) infection. Alcohol use was the most likely etiology of pancreatitis among those leaving AMA. In a multivariate regression, patients more likely to leave AMA included: age 18 - 44, male, and black. Patients with a history of depression, drug abuse, and HIV infection were also more likely to be discharged AMA.

Conclusions

Discharges AMA increased over time. Predictors of AMA include patients who are younger, male, black, lower socioeconomic status, and have a history of depression, HIV infection, alcohol and drug use. Future studies are necessary to examine the reasons for discharge AMA among this population.

Increased drug use and the timing of social assistance receipt among people who use illicit drugs

BACKGROUND

The monthly disbursement of social assistance (SA) payments to people who use illicit drugs (PWUD) has been temporally associated with increases in drug-related harm. Yet, whether SA receipt changes drug use intensity compared to levels of use at other times in the month has not been established. We therefore examined this relationship among PWUD in Vancouver, Canada (2005-2013).

METHODS

Data were derived from prospective cohorts of HIV-positive and HIV-negative PWUD. Every six months, participants were asked about their illicit drug use during the last 180 days and the past week. We determined whether SA receipt occurred within the assessment's one-week recall period. We employed generalized estimating equations controlling for confounders to examine the relationship between SA receipt and the change in drug use intensity, defined as a 100% increase in the average times per day a given drug was used in the last week compared to the previous 6 months. We tested the robustness of this relationship by stratifying analyses by whether individuals primarily used stimulants, illicit opioids or engaged in polydrug use and examining the timing of SA receipt relative to date of assessment.

RESULTS

Our study included 2661 individuals (median age 36, 32% female) with 1415 (53.2%) reporting SA receipt occurring within the one-week recall period of the assessment at least once. SA receipt was independently associated with intensified drug use (Adjusted Odds Ratio [AOR]: 1.79; 95% Confidence Interval [CI]: 1.53, 2.09), and remained significant when stratified by primary use of stimulants (AOR: 1.87; 95% CI: 1.54, 2.26), opioids (AOR: 1.96; 95% CI: 1.23, 3.13) and polydrug use (AOR: 1.53; 95% CI: 1.11, 2.10).

CONCLUSION

We found a temporal association between SA receipt and drug use intensification. While the health and social benefits of SA are significant, these findings suggest that alternative disbursement strategies, such as staggered or smaller and more frequent SA payments may be able to mitigate drug-related harm. Alternatives should be tested rigorously.

Protocol of the impact of alternative social assistance disbursement on drug-related harm (TASA) study: a randomized controlled trial to evaluate changes to payment timing and frequency among people who use illicit drugs

Background

Government social assistance payments seek to alleviate poverty and address survival needs, but their monthly disbursement may cue increases in illicit drug use. This cue may be magnified when assistance is disbursed simultaneously across the population. Synchronized payments have been linked to escalations in drug use and unintended but severe drug-related harms, including overdose, as well as spikes in demand for health, social, financial and police services.

Methods/design

The TASA study examines whether changing payment timing and frequency can mitigate drug-related harm associated with synchronized social assistance disbursement. The study is a parallel arm multi-group randomized controlled trial in which 273 participants are randomly allocated for six assistance cycles to a control or one of two intervention arms on a 1:1:1 basis. Intervention arm participants receive their payments: (1) monthly; or (2) semi-monthly, in each case on days that are not during the week when cheques are normally issued. The study partners with a community-based credit union that has developed a system to vary social assistance payment timing. The primary outcome is a 40 % increase in drug use during the 3 days beginning with cheque issue day compared to other days of the month. Bi-weekly follow-up interviews collect participant information on this and secondary outcomes of interest, including drug-related harm (e.g. non-fatal overdose), exposure to violence and health service utilization. Self-reported data will be supplemented with participant information from health, financial, police and government administrative databases. A longitudinal, nested, qualitative parallel process evaluation explores participant experiences, and a cost-effectiveness evaluation of different disbursement scenarios will be undertaken. Outcomes will be compared between control and intervention arms to identify the impacts of alternative disbursement schedules on drug-related harm resulting from synchronized income assistance.

Discussion

This structural RCT benefits from strong community partnerships, highly detailed outcome measurement, robust methods of randomization and data triangulation with third party administrative databases. The study will provide evidence regarding the potential importance of social assistance program design as a lever to support population health outcomes and service provision for populations with a high prevalence of substance use.

Trial registration

NCT02457949 Registered 13 May 2015.

Illicit drug overdose deaths resulting from income assistance payments: Analysis of the 'check effect' using daily mortality data

BACKGROUND

Although income assistance is an important source of support for low income individuals, there is evidence that adverse outcomes may increase when payments are disbursed on the same day for all recipients. The objective of this study was to assess the temporal patterns and causal relation between population-level illicit drug overdose deaths and income assistance payments using daily mortality data for British Columbia over a period of five years.

METHODS

Retrospective data on daily mortality due to illicit drug overdose, 2009-2013, were provided by the BC Coroners Service. These data were analyzed using regression models and time series tests for causality in relation to dates of income assistance payments.

RESULTS

1343 deaths due to illicit drug overdose were reported in BC during 2009-2013; 394 occurred during cheque weeks (n=60) and 949 occurred during non-cheque weeks (n=202). Average weekly mortality due to illicit drug overdose was 40% higher during weeks of income assistance payments compared to weeks without payments (P<0.001). Consistent increases in mortality appeared the day after cheque disbursement and were significantly higher for two days, and marginally higher after 3 days, even when controlling for other temporal trends. Granger causality testing suggests the timing of cheque issue was causally linked to increased drug overdose mortality (P<0.001).

CONCLUSIONS

Our findings clarify the temporal relation and causal impact of income assistance payments on illicit drug deaths. We estimate 77 avoidable deaths were attributable to the synchronized disbursement of income assistance cheques over the five year period. An important consideration is whether varying the timing of payments among recipients could reduce this excess mortality and the related demands on health and social services.

Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty

The influence of alcohol misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. Using the National Hospital Discharge Survey, a cohort representative of 8,372,232 patients (without cirrhosis) who underwent THA or TKA between 1990 and 2007 was identified and divided into two groups: (1) those who misused alcohol (n=50,861) and (2) those who did not (n=8,321,371). Differences in discharge status, comorbidities and perioperative complications were analyzed. Compared to patients with no diagnosis of alcohol misuse, alcohol misusers were nine times more likely to leave against medical advice and had longer hospital stays (P<0.001). Alcohol misuse was independently associated with higher odds of in hospital complications (OR: 1.334, range: 1.307-1.361), surgery related complications (OR: 1.293, range: 1.218-1.373) and general medical complications (OR: 1.300, range: 1.273-1.327).

Outcomes Following Primary Total Hip or Knee Arthroplasty in Substance Misusers

The influence of drug misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. The National Hospital Discharge Survey was used to identify patients who underwent primary THA or TKA between 1990 and 2007. Patients were divided into two groups: 1) those with a diagnosis of drug misuse (cannabis, opioids, cocaine, amphetamines, sedatives, inhalants or mixed combinations) (n=13,163) and 2) those with no diagnosis of misuse (n=8,366,327). Patients with a diagnosis of drug misuse had longer hospital stays (P<0.001), nearly eight times the odds of leaving against medical advice (P<0.001) and five times the mortality rate (P<0.001). Drug misuse was associated with higher odds (P<0.001) of complications including postoperative infection, anemia, convulsions, osteomyelitis, and blood transfusion.

Exhaustion of food budgets at month's end and hospital admissions for hypoglycemia

One in seven US households cannot reliably afford food. Food budgets are more frequently exhausted at the end of a month than at other points in time. We postulated that this monthly pattern influenced health outcomes, such as risk for hypoglycemia among people with diabetes. Using administrative data on inpatient admissions in California for 2000-08, we found that admissions for hypoglycemia were more common in the low-income than the high-income population (270 versus 200 admissions per 100,000). Risk for hypoglycemia admission increased 27 percent in the last week of the month compared to the first week in the low-income population, but we observed no similar temporal variation in the high-income population. These findings suggest that exhaustion of food budgets might be an important driver of health inequities. Policy solutions to improve stable access to nutrition in low-income populations and raise awareness of the health risks of food insecurity might be warranted.

The short-term impacts of Earned Income Tax Credit disbursement on health

BACKGROUND

There are conflicting findings regarding long- and short-term effects of income on health. Whereas higher average income is associated with better health, there is evidence that health behaviours worsen in the short-term following income receipt.Prior studies revealing such negative short-term effects of income receipt focus on specific subpopulations and examine a limited set of health outcomes.

METHODS

The United States Earned Income Tax Credit (EITC) is an income supplement tied to work, and is the largest poverty reduction programme in the USA. We utilize the fact that EITC recipients typically receive large cash transfers in the months of February,March and April, in order to examine associated changes in health outcomes that can fluctuate on a monthly basis. We examine associations with 30 outcomes in the categories of diet, food security, health behaviours, cardiovascular biomarkers, metabolic biomarkers and infection and immunity among 6925 individuals from the U.S. National Health and Nutrition Survey. Our research design approximates a natural experiment,since whether individuals were sampled during treatment or non-treatment months is independent of social, demographic and health characteristics that do not vary with time.

RESULTS

There are both beneficial and detrimental short-term impacts of income receipt.Although there are detrimental impacts on metabolic factors among women, most other impacts are beneficial, including those for food security, smoking and trying to lose weight.

CONCLUSIONS

The short-term impacts of EITC income receipt are not universally health promoting, but on balance there are more health benefits than detriments.

The 'check effect' reconsidered

AIMS

The 'check effect' refers to the use of disability payments to purchase illegal drugs or alcohol. This paper describes subsequent research concerning three interrelated issues: the check effect, whether receipt of disability payments is associated with more overall substance use, and potential policy responses to misuse of disability payments for substances.

METHODS

Review and synthesis of published papers.

RESULTS

Increased substance use at the beginning of the month has been described in a variety of settings. The tendency to purchase substances at the beginning of the month is impacted by household wealth, the tendency to discount future rewards and cyclical economic activity. However, in naturalistic observational cohort studies, beneficiaries who receive disability payments had no greater substance use than those without disability payments. Potential policy responses to mis-spending of disability checks include financial counseling that discourages spending on drugs and the assignment of a representative payee to prevent misuse of benefits for substances. Assignment of a representative payee per se has not been associated with reduced substance use, but payeeship administered by agencies that integrate payee practice into treatment has been.

CONCLUSION

Disability payments impact the timing of substance use, but receipt of disability payments is not associated with more overall substance use than unalleviated poverty. Money management-based clinical interventions, which may involve assignment of a representative payee, can minimize the purchase of substances with disability payments.

Lunar phase cycle and psychiatric hospital emergency visits, inpatient admissions and aggressive behavior

INTRODUCTION

We examined the correlation between lunar cycles and the number of psychiatric emergency visits, patients' gender, aggressive behavior, need for inpatient admission, legal referral and need for involuntary chemical restraint in a period of one calendar year.

METHOD

Charts of all psychiatric emergency room patients were reviewed retrospectively. Arabic calendar lunar months were divided based on three different models: Two 15 days sections, three 10 days, and six 5 days parts in the third model.

RESULTS

5431 patients were seen in the psychiatric emergency service (PES) during a one year period. We did not find a relationship between the visit time (day or night), gender, and legal referral in relation to moon cycles. A higher number of visits during full moon period which was not statistically significant (P>0.05) was found. Highest frequency of inpatient admissions was discovered in the first and last parts of the three part model and in the first and last segments of the six part model followed by second and fifth parts (P-values: 0.000).

CONCLUSION

This study revealed a slight increase in number of visits to psychiatric emergency room during full moon periods. In addition a highly significant increase in the severity of illness and aggressive behaviors and agitation in the beginning and end of the moon cycles were noticed. Some of the underlying possible causes such as changes in intra/extracellular fluids, neural and endocrine cell functions, hemodynamic and biological responses and changes in social dynamics and support are discussed.

"I'm going home": discharges against medical advice

Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients.

"I'm going home": discharges against medical advice

Discharge against medical advice (AMA), in which a patient chooses to leave the hospital before the treating physician recommends discharge, continues to be a common and vexing problem. This article reviews the prevalence, costs, predictors, and potential interventions for this clinical problem. Between 1% and 2% of all medical admissions result in an AMA discharge. Predictors of AMA discharge, based primarily on retrospective cohort studies, tended to be younger age, Medicaid or no insurance, male sex, and current or a history of substance or alcohol abuse. Interventions to reduce the rate of AMA discharges have not been systematically studied. This article offers suggestions for interventions based on studies in other areas of clinical care as well as the psychiatric AMA discharge literature. Studies for this review were identified by searching the relevant MeSH heading (discharge) and key words (against medical advice, leave, elope, hospital, and self-discharge) in PubMed databases and selecting all English-language articles from 1970 through 2008 that included data on adult medical inpatients.

Medical withdrawal management in Vancouver: service description and evaluation

This study evaluates a medically managed inpatient detoxification service (Vancouver Detox (VD)) and investigates its clients' characteristics over a 1-year period. We present information on the daily operation at VD, and examine accessibility and efficiency of it from five perspectives: wait time, pretreatment attrition rate, treatment completion rate, length of stay (LOS), and occupancy rate (OR). In addition, we explore the impacts of seasonality and the monthly welfare check on the utilization of the service. Among 2294 referrals, 35% dropped out without engaging in treatment. Among those who were admitted to VD, 78% completed the treatment program. Shorter wait time and lower OR were found during the welfare check issuance period, and lower OR was found during summer. In addition, the patterns of utilization of VD were changed over the welfare check issuance period. Our analysis indicates that operational accessibility and efficiency at VD could be improved by specifically addressing these factors.

Impact of welfare cheque issue days on a service for those intoxicated in public

In British Columbia (BC), the Ministry of Human Resources issues welfare cheques to eligible recipients monthly on the last Wednesday of each month. Previous studies have indicated that there are significant increases in hospital admission, ED admission, 911 calls and deaths shortly after the distribution of the monthly welfare cheques. The objective of this analysis was to rigorously examine the impact of welfare cheque issue dates on admission to the Sobering Unit (SU), a service for the publicly intoxicated, in Vancouver, Canada. Data on 1234 consecutive admissions to the SU over a 7-month period were assessed, and the average number of daily admissions on each of the 7 days of the welfare cheque issue week and similar weekdays in other weeks were compared. A Wilcoxon rank-sum test was performed for the comparisons. Our results showed that there were significant increases in the number of admissions on the 3 days starting with "Welfare Wednesday" compared to the similar weekdays in other weeks (Welfare Wednesday vs. other Wednesdays: 8.7 vs. 5.1, p = 0.02; Welfare Thursdays vs. other Thursdays: 9.6 vs. 5.3, p = 0.02; Welfare Fridays vs. other Fridays: 8.6 vs. 5.7, p = 0.04). The demonstrated impact of welfare cheque issue dates is an important consideration for the re-design, staffing and resource allocation of services for withdrawal management and potentially for other services offered to this population.

Lack of correlation in welfare check distribution and transport patterns in a rural critical care transport service

INTRODUCTION

Understanding patterns of use of emergency medical services is important for planning adequate programs, budgets, and schedules. Understanding the factors associated with use of these services can help systems target high-risk populations or behaviors and allocate budgetary resources appropriately. Previous data have shown an association between the use of emergency health care use and distribution of welfare check distribution in both the United States and Canada. These data have limitations. In these studies, no attempt was made to investigate whether this increase in use was for particular types of complaints (medical or traumatic) or true outside of an urban community. The purpose of this study was to investigate whether there were similar monthly associations in patterns of use of a regional transport service for either medical or traumatic complaints.

METHODS

Med Flight is a regional aeromedical service operated by the University of Wisconsin. The service provides transport services to all hospitals and emergency medical services for critically ill or injured patients inside a radius of approximately 75 miles. The program transports approximately 1200 patients per year. Data for all transports for the years 1998-2004 were obtained. Daily numbers of transports were then compared for all patients and subsets of those with specifically traumatic or cardiac-related complaints.

RESULTS

There were 7756 transports during the study period: 34% of the transports were trauma related; 30% were cardiac related. There was a significant association between trauma-related flights and both month of the year (P < .0001) and day of the week (P < .001), but not for total or cardiac-related flights. There was no association between day or week of the month and transports.

CONCLUSION

In contrast to previous studies, these findings show no association between use of a regional transport service and time of the month. Determinants of use of emergency services may differ between urban and nonurban areas.

Effect of Social Security payments on substance abuse in a homeless mentally ill cohort

OBJECTIVES

To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill.

DESIGN

Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months.

DATA COLLECTION METHODS

Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings.

PRINCIPAL FINDINGS

Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits.

CONCLUSIONS

In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.