Pathways linking drug use and labour market trajectories: the role of catastrophic events

Disentangling opioids-related overdose syndemics: a scoping review

This article reviews research investigating the synergistic interaction of opioid-related morbidity and mortality with other social, psychiatric, and biological conditions, to describe how and why it is syndemic. Opioid-related overdose syndemics are driven by commercial interests, emerging in communities facing social and economic disadvantage, and interacting with a range of other health conditions. We included articles that empirically investigated an opioid-related syndemic, discussed syndemic co-factors associated with opioid use, or framed opioid consumption conceptually in relation to syndemics. Most articles were conducted in and first authored by investigators from North America. These articles were published in journals focused on general public health (n = 20), drug use and addiction (n = 18), and infectious disease or HIV (n = 15). Most original research articles (n = 60) employed quantitative methods. Unlike scholarship from other disciplines, specifically the controversial "Deaths of Despair" (DoD) framework, most research on opioid-related overdose syndemics fails to fully articulate the macro-structural drivers of localized disease clustering. Instead, the syndemics scholarship emphasizes the clinical manifestations of opioid and substance use, illustrating a problem in translation at the heart of syndemic theory. Moreover, syndemics scholarship on opioid impacts remains largely disconnected from the wider DoD discourse, which represents a missed opportunity for equity-oriented research. Re-directing attention to the sociopolitical forces that shape opioid-related overdose syndemics is necessary to prevent future commercially-driven health crises and repair lives harmed by these deadly syndemics.

Cohort Profile: The Assessing Economic Transitions (ASSET) Study-A Community-Based Mixed-Methods Study of Economic Engagement among Inner-City Residents

The Assessing Economic Transitions (ASSET) study was established to identify relationships between economic engagement, health and well-being in inner-city populations given that research in this area is currently underdeveloped. This paper describes the objectives, design, and characteristics of the ASSET study cohort, an open prospective cohort which aims to provide data on opportunities for addressing economic engagement in an inner-city drug-using population in Vancouver, Canada. Participants complete interviewer-administered surveys quarterly. A subset of participants complete nested semi-structured qualitative interviews semi-annually. Between April 2019 and May 2022, the study enrolled 257 participants ages 19 years or older (median age: 51; 40% Indigenous, 11.6% non-Indigenous people of colour; 39% cis-gender women, 3.9% transgender, genderqueer, or two-spirit) and 41 qualitative participants. At baseline, all participants reported past daily drug use, with 27% currently using opioids daily, and 20% currently using stimulants daily. In the three months prior to baseline, more participants undertook informal income generation (75%) than formal employment (50%). Employed participants largely had casual jobs (42%) or jobs with part-time/varied hours (35%). Nested qualitative studies will focus on how inner-city populations experience economic engagement. The resulting evidence will inform policy and programmatic initiatives to address socioeconomic drivers of health and well-being.

Income generation and the patterning of substance use: A gender-based analysis

BACKGROUND

Previous research has demonstrated how income-generating activities among marginalized people who use drugs (PWUD)-including employment, income assistance, street-based activities, sex work, and illegal activities-can provide both benefit (e.g., additional income) and harm (e.g., violence, criminalization). However, little is known about gender differences in factors such as drug use patterns that are associated with income-generating activities among PWUD.

METHODS

Using data from prospective cohorts of HIV-positive and HIV-negative PWUD in Vancouver, Canada, we conducted exploratory gender-stratified analyses of associations between substance use patterns and income-generating activities, using generalized linear mixed-models.

RESULTS

Participants reported income sources as employment (23.4 %), income assistance (88.1 %), street-based activities (24.9 %), sex work (15.2 %), drug dealing (31.5 %), or other illegal activities (13.9 %). GLMM results showed gendered patterns of engagement in specific income-generating activities and some diverging patterns of substance use. For instance, men receiving income assistance were less likely to use opioids (Adjusted odds ratio(AOR) = 0.64; 95 % confidence interval(CI) = 0.50-0.82) and women engaged in sex work were more likely to use crack-cocaine (AOR = 2.74, 95 % CI = 2.22-3.37). However, results reflected primarily converging patterns of substance use between women and men across income-generating activities, particularly for drug dealing and other illegal activities.

CONCLUSIONS

Our results suggest that substance use patterns may be more closely associated with income generation context than gender. Given potential harms associated with some income generation activities, results highlight the need for further investigation of the social and structural context of income generation, its intersections with gender and substance use, and the expansion of low-threshold work opportunities.

Experimental (Re)structuring: The Clinical Trial as Turning Point Among Medical Research Participants

Amid the growth of addiction medicine randomized controlled trials (RCTs), scholars have begun examining participants' study experiences, highlighting facilitators and barriers to enrollment. However, this work can overlook the interplay between trial participation and social-structural dimensions among people with substance use disorders linked to the social nature of use, socioeconomic marginalization, and time demands of substance procurement and use. To effectively conduct RCTs with this unique population, it is necessary to examine the broader social context of study participation. We conducted nested qualitative interviews with 22 participants involved in an RCT testing a treatment for alcohol and opioid use disorders in HIV clinics. Thematic analyses revealed social-structural circumstances shaping RCT participation as well as how participation constitutes a turning point, prompting individuals to reconfigure social networks, reorient to spatial environments, and reorganize day-to-day life-with implications for how substance use disorder RCTs should be approached by researchers.

"Running myself ragged": stressors faced by peer workers in overdose response settings

Background

Peer workers or “peers” (workers with past or present drug use experience) are at the forefront of overdose response initiatives, and their role is essential in creating safe spaces for people who use drugs (PWUD). Working in overdose response settings has benefits for peer workers but is also stressful, with lasting emotional and mental health effects. Yet, little is known about the stressors peer workers face and what interventions can be implemented to support them in their roles.

Methods

This project used a community-based sequential mixed-methods research design. Eight peer researcher-led focus groups (n = 31) were conducted between November 2018 and March 2019 to assess needs of peer workers. The transcripts were thematically coded and analysed using interpretative description. These results informed a survey, which was conducted (n = 50) in September 2019 to acquire quantitative data on peer workers’ perception of health, quality of life, working conditions and stressors. Frequency distributions were used to describe characteristics of participants. X² distribution values with Yates correction were conducted to check for association between variables.

Results

Five themes emerged from the focus groups that point to stressors felt by peer workers: (1) financial insecurity; (2) lack of respect and recognition at work; (3) housing challenges; (4) inability to access and/or refer individuals to resources; and (5) constant exposure to death and trauma. Consistent with this, the factors that survey participants picked as one of their “top three stressors” included financial situation, work situation, and housing challenges.

Conclusion

Peer workers are faced with a diversity of stressors in their lives which often reflect societal stigmatization of drug use. Recognition of these systemic stressors is critical in designing interventions to ease the emotional, physical and financial burden faced by peer workers.

The Association between Living Status Transitions, Behavior Changes and Family Relationship Improvement among Methadone Maintenance Treatment Participants in Guangdong, China

The quality of family relationships is important for individual and family well-being. Improving family relationships is also an important goal in methadone maintenance treatment (MMT). Little is known about factors associated with the improvement of family relationships among MMT clients. This study aimed to identify factors associated with family relationship improvement in MMT. We retrospectively analyzed existing data from 2006 to 2014 at 15 MMT clinics in Guangdong, China, including 2171 subjects with 4691 follow-ups. Generalized estimating equations were used to investigate the association between living status transitions, behavior changes and family relationship improvement, with covariates controlled for. Family relationship improvement was found in 23.1% of all follow-up intervals. Participants who began living with family, living on a regular wage, and gained employment were more likely to have improved family relationships. The quality of family relationships also improved among participants who ceased contact with drug-addicted fellows, ceased drug use, and those who were sexually active. These results suggest that improvement in living status, positive changes in drug use, and sexual activity are associated with family relationship improvement and corresponding interventions may be developed to facilitate clients' recovery.

Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting

The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.

Curb Heroin In Plants (C.H.I.P.): Revisiting a Mid-1970s Intervention Into Workplace Heroin Addiction Created and Led by Detroit Autoworkers

This article analyzes archival records to revisit Curb Heroin In Plants (C.H.I.P.), a public health intervention focusing on drug dependence that was created and led by Detroit, Michigan, autoworkers during the mid-1970s. Responding to widespread heroin use in Detroit auto plants, C.H.I.P. combined methadone maintenance with counseling on and off the job to treat heroin dependence while supporting autoworkers in continuing in employment and family life. Although C.H.I.P. ultimately failed, it was a promising attempt to transcend medical/punitive approaches and treat those with substance use disorder in a nonstigmatizing way, with attention to the workplace dimensions of their disorder and recovery. I argue that revisiting C.H.I.P. speaks to current public health debates about the intersection between the workplace and harmful drug use and how to create effective interventions and policies that are mindful of this intersection. For historians, C.H.I.P. is a valuable example of the crucial role of workplace actors in the early war on drugs and of an early methadone program that was not strongly concerned with crime reduction but incorporated social externalities (specifically job performance) to measure success.

Transitions in income generation among marginalized people who use drugs: A qualitative study on recycling and vulnerability to violence

BACKGROUND

Income is an important determinant of health among people who use drugs (PWUD). However, understanding transitions between differing types of income generation within the formal and informal economy and how they can be shaped by vulnerability to risk and harm remain poorly understood. This study examines how transitions in income-generating activities are shaped by and influence exposure to violence among marginalised PWUD, in Vancouver, Canada's, Downtown Eastside (DTES) neighbourhood.

METHODS

Qualitative interviews were conducted with twenty-six individuals engaged in informal and illegal income-generating activities in the DTES. Interview transcripts were analyzed thematically, focusing on relationships between income generation and violence during the study period between January 2014 to April 2015 and drew upon concepts of social violence when interpreting these themes.

RESULTS

Participants' engagement in informal and illegal income-generating activities represented a means to negotiate survival given multiple barriers to formal employment and inadequate economic supports. Our findings highlight how informal and illegal income-generating activities in the DTES are characterized by structural, symbolic and everyday violence, while transitions from 'high risk' (e.g., sex work, drug dealing) to perceived 'low risk' (e.g., recycling) activities represent attempts to reduce exposure to violence. However, participants emphasized how informal income generation was nonetheless shaped by structural violence (e.g., gendered hierarchies and police harassment), experienced as everyday violence, and introduced exposure to alternate risks.

CONCLUSION

Our findings underscore the critical role of income generation in shaping exposure to violence, highlighting the need for low-threshold employment interventions targeting PWUD as a central component of harm reduction strategies.

Informal recycling, income generation and risk: Health and social harms among people who use drugs

BACKGROUND

Informal recycling refers to the street-based collection of discarded materials for reuse, resale, or return to a recycling facility for money. While qualitative research has explored experiences and perceptions of informal recycling, little is known about the scope and exposures associated with informal recycling among people who use drugs (PWUD).

METHODS

Using data from two prospective longitudinal cohorts of PWUD, we examined the prevalence of informal recycling and its association with social, structural and health risks, including criminal justice system involvement.

RESULTS

Between June 2010 and May 2015, of 1664 participants, 557 (33.5%) reported engaging in informal recycling during the study period. In multivariable generalised estimating equations (GEE) analyses, informal recycling was positively associated with injection drug use (Adjusted Odds Ratio (AOR) = 1.43, 95% Confidence Interval (CI) 1.21-1.68), public injection (AOR = 1.27, 95% CI 1.09-1.49), methamphetamine use (AOR = 1.35, 95% CI 1.05-1.72), difficulty finding harm reduction equipment (AOR = 1.16, 95% CI 1.02-1.32), and police interactions (AOR = 1.35, 95% CI 1.18-1.55). Sub-analyses revealed PWUD engaged in informal recycling were more likely to be told to move on, ticketed, stopped for jaywalking, and directed to services by police.

CONCLUSIONS

These findings suggest informal recycling as a situated practice for PWUD, with potential indications for higher-risk drug use, experiencing greater surveillance, and difficulty accessing health and addiction treatment services. This research highlights the significance of the broader risk environment and the need for health-promoting policies for socioeconomically marginalised PWUD engaged in informal recycling.

The impact of employment on perceived recovery from opiate dependence

Purpose

Less than 15 per cent of people starting opiate substitution treatment (OST) in England are employed, but few gain employment during treatment. Increasingly punitive approaches have been tried to encourage individuals with substance dependence into employment in the hope of facilitating recovery. It is not clear which factors are associated with the successful maintenance of employment whilst receiving OST, and whether this group can be said to be “in recovery”. The paper aims to discuss these issues.

Design/methodology/approach

A cross-sectional study of the OST population in one English region was conducted between January and April 2017. Measures of physical health, employment patterns, drug use, mental health, recovery capital, and dependence severity were administered to 55 employed and 55 unemployed clients.

Findings

Those in employment had higher levels of “recovery capital”, better physical and mental health, fewer drug problems, and less severe dependence, despite reporting heroin use at a similar level. Three variables were significantly associated with employment: longest period of employment (OR=1.01, p=0.003); number of chronic medical conditions (OR=0.44, p=0.011); and number of days of psychological problems in the last month (OR=0.95, p=0.031).

Practical implications

These results suggest that abstinence may not be required in order to maintain stable employment when OST is in place. Different treatment strategies are required for clients receiving OST already in employment compared with those who are unemployed.

Originality/value

This is the first UK study to the author’s knowledge to focus on people receiving OST who are also in employment.

Injection Drug Use, Unemployment, and Severe Food Insecurity Among HIV-HCV Co-Infected Individuals: A Mediation Analysis

Severe food insecurity (FI), which indicates reduced food intake, is common among HIV-hepatitis C virus (HCV) co-infected individuals. Given the importance of unemployment as a proximal risk factor for FI, this mediation analysis examines a potential mechanism through which injection drug use (IDU) is associated with severe FI. We used biannual data from the Canadian Co-infection Cohort (N = 429 with 3 study visits, 2012-2015). IDU in the past 6 months (exposure) and current unemployment (mediator) were self-reported. Severe FI in the following 6 months (outcome) was measured using the Household Food Security Survey Module. An overall association and a controlled direct effect were estimated using marginal structural models. Among participants, 32% engaged in IDU, 78% were unemployed, and 29% experienced severe FI. After adjustment for confounding and addressing censoring through weighting, the overall association (through all potential pathways) between IDU and severe FI was: risk ratio (RR) = 1.69 (95% confidence interval [CI] = 1.15-2.48). The controlled direct effect (the association through all potential pathways except that of unemployment) was: RR = 1.65 (95% CI = 1.08-2.53). We found evidence of an overall association between IDU and severe FI and estimated a controlled direct effect that is suggestive of pathways from IDU to severe FI that are not mediated by unemployment. Specifically, an overall association and a controlled direct effect that are similar in magnitude suggests that the potential impact of IDU on unemployment is not the primary mechanism through which IDU is associated with severe FI. Therefore, while further research is required to understand the mechanisms linking IDU and severe FI, the strong overall association suggests that reductions in IDU may mitigate severe FI in this vulnerable subset of the HIV-positive population.

Social causation and neighborhood selection underlie associations of neighborhood factors with illicit drug-using social networks and illicit drug use among adults relocated from public housing

Theories of social causation and social influence, which posit that neighborhood and social network characteristics are distal causes of substance use, are frequently used to interpret associations among neighborhood characteristics, social network characteristics and substance use. These associations are also hypothesized to result from selection processes, in which substance use determines where people live and who they interact with. The potential for these competing selection mechanisms to co-occur has been underexplored among adults. This study utilizes path analysis to determine the paths that relate census tract characteristics (e.g., economic deprivation), social network characteristics (i.e., having ≥ 1 illicit drug-using network member) and illicit drug use, among 172 African American adults relocated from public housing in Atlanta, Georgia and followed from 2009 to 2014 (7 waves). Individual and network-level characteristics were captured using surveys. Census tract characteristics were created using administrative data. Waves 1 (pre-relocation), 2 (1st wave post-relocation), and 7 were analyzed. When controlling for individual-level sociodemographic factors, residing in census tracts with prior economic disadvantage was significantly associated with illicit drug use at wave 1; illicit drug use at wave 1 was significantly associated with living in economically-disadvantaged census tracts at wave 2; and violent crime at wave 2 was associated with illicit drug-using social network members at wave 7. Findings from this study support theories that describe social causation and neighborhood selection processes as explaining relationships of neighborhood characteristics with illicit drug use and illicit drug-using social networks. Policies that improve local economic and social conditions of neighborhoods may discourage substance use. Future studies should further identify the barriers that prevent substance users from obtaining housing in less disadvantaged neighborhoods.

Meaningful engagement of people living with HIV who use drugs: methodology for the design of a Peer Research Associate (PRA) hiring model

Background

Community-based HIV, harm reduction, and addiction research increasingly involve members of affected communities as Peer Research Associates (PRAs)—individuals with common experiences to the participant population (e.g. people who use drugs, people living with HIV [PLHIV]). However, there is a paucity of literature detailing the operationalization of PRA hiring and thus limited understanding regarding how affected communities can be meaningfully involved through low-barrier engagement in paid positions within community-based participatory research (CBPR) projects. We aim to address this gap by describing a low-threshold PRA hiring process.

Results

In 2012, the BC Centre for Excellence in HIV/AIDS and the Dr. Peter AIDS Foundation collaborated to develop a mixed-method CBPR project evaluating the effectiveness of the Dr. Peter Centre (DPC)—an integrative HIV care facility in Vancouver, Canada. A primary objective of the study was to assess the impact of DPC services among clients who have a history of illicit drug use. In keeping with CBPR principles, affected populations, community-based organizations, and key stakeholders guided the development and dissemination of a low-barrier PRA hiring process to meaningfully engage affected communities (e.g. PLHIV who have a history of illicit drug use) in all aspects of the research project.

The hiring model was implemented in a number of stages, including (1) the establishment of a hiring team; (2) the development and dissemination of the job posting; (3) interviewing applicants; and (4) the selection of participants. The hiring model presented in this paper demonstrates the benefits of hiring vulnerable PLHIV who use drugs as PRAs in community-based research.

Conclusions

The provision of low-barrier access to meaningful research employment described herein attempts to engage affected communities beyond tokenistic involvement in research. Our hiring model was successful at engaging five PRAs over a 2-year period and fostered opportunities for future paid employment or volunteer opportunities through ongoing collaboration between PRAs and a diverse range of stakeholders working in HIV/AIDS and addictions. Additionally, this model has the potential to be used across a range of studies and community-based settings interested in meaningfully engaging communities in all stages of the research process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12954-016-0116-z) contains supplementary material, which is available to authorized users.