Hospitalization among street-involved youth who use illicit drugs in Vancouver, Canada: a longitudinal analysis

Background: Street-involved youth who use illicit drugs are at high risk for health-related harms; however, the profile of youth at greatest risk of hospitalization has not been well described. We sought to characterize hospitalization among street-involved youth who use illicit drugs and identify the most frequent medical reasons for hospitalization among this population. Methods: From January 2005 to May 2016, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Multivariable generalized estimating equation (GEE) was used to identify factors associated with hospitalization. Results: Among 1216 participants, 373 (30.7%) individuals reported hospitalization in the previous 6 months at some point during the study period. The top three reported medical reasons for hospital admission were the following: mental illness (37.77%), physical trauma (12.77%), and drug-related issues (12.59%). Factors significantly associated with hospitalization were the following: past diagnosis of a mental illness (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [95% CI] 1.47–2.33), frequent cocaine use (AOR = 2.15; 95% CI 1.37–3.37), non-fatal overdose (AOR = 1.76; 95% CI 1.37–2.25), and homelessness (AOR = 1.40; 95% CI 1.16–1.68) (all p < 0.05). Conclusions: Findings suggest that mental illness is a key driver of hospitalization among our sample. Comprehensive approaches to mental health and substance use in addition to stable housing offer promising opportunities to decrease hospitalization among this vulnerable population.Medicine, Faculty ofOther UBCNon UBCFamily Practice, Department ofMedicine, Department ofReviewedFacult

Gender Influences on Hepatitis C Incidence Among Street Youth in a Canadian Setting

Purpose Few studies have examined gender-based differences in the risk of hepatitis C (HCV) infection among street-involved youth. We compared rates of HCV infection among male and female street-involved youth in a Canadian setting. Methods The At-Risk Youth Study (ARYS) is a prospective cohort of drug-using, street-involved youth. Study recruitment and follow-up occurred in Vancouver, Canada, between September 2005 and November 2011. Eligible participants were illicit drug-using youth aged 14–26 years at enrollment, recruited by street-based outreach. We evaluated rates of HCV antibody seroconversion, measured every six months during study follow-up, and used Cox proportional hazards regression to compare risk factors for HCV incidence between male and female street youth. Results Among 512 HCV-seronegative youth contributing 836 person-years of follow-up, 56 (10.9%) seroconverted to HCV. Among female participants, the incidence density of HCV infection was 10.9 per 100 person-years and in males 5.1 per 100 person-years (p = 0.009). In multivariate analyses, female gender was independently associated with a higher rate of HCV seroconversion (Adjusted Hazard Ratio (AHR) = 2.01; 95% Confidence Interval [CI], 1.18 – 3.44). Risk factors were similar in gender stratified analyses and included injection heroin and injection crystal methamphetamine, although syringe sharing was only associated with HCV incidence among males. Conclusions Among street-involved youth in this setting, females had double the incidence of HCV seroconversion demonstrating the need for gender focused HCV prevention interventions for this population.Medicine, Faculty ofOther UBCNon UBCMedicine, Department ofReviewedFacultyResearche

Impact of incarceration on rates of methadone use in a community recruited cohort of injection drug users

Background: Despite barriers to its use in many settings, opioid agonist therapy with methadone has become the standard of care for treating opioid (e.g. heroin) use disorder. Since people with opioid use disorders have an increased incidence of incarceration, we undertook the present study to evaluate the association between incarceration and methadone maintenance therapy among a cohort of injection drug users in a Canadian setting. Methods: A cohort of people who inject drugs was prospectively followed between May 1996 and May 2013 in Vancouver, Canada. We investigated the relationship between recent incarceration and methadone use using multivariate generalized estimating equation (GEE) logistic regression analysis. Results: Overall, 2758 individuals were recruited during the study period and followed for a median of 64 (interquartile range: 23–106) months. After adjusting for various potential confounders in the multivariate GEE model, being incarcerated remained independently associated with a lower likelihood of having received methadone treatment (Adjusted Odds Ratio: 0.87, 95% confidence interval: 0.81–0.93). Conclusions: Our study demonstrates that incarceration was independently associated with a significantly lower likelihood of being on methadone. Given the role of methadone in reducing the harms of heroin use, including drug acquisitive crime and recidivism, these data suggest a need to scale-up methadone provision for incarcerated injection drug users.Medicine, Faculty ofOther UBCFamily Practice, Department ofMedicine, Department ofReviewedFacultyResearche

Cannabis use in patients treated for opioid use disorder pre- and post-recreational cannabis legalization in Canada

Background: As the legalization of recreational cannabis becomes more widespread, its impact on individuals with substance use disorders must be studied. Amidst an ongoing opioid crisis, Canada’s legalization of recreational cannabis in October 2018 provides an important setting for investigation. We examined changes to cannabis use patterns in patients receiving medication-assisted treatment (MAT) for opioid use disorder (OUD) following legalization. Methods: This study includes cross-sectional data from 602 participants recruited 6 months pre-legalization and 788 participants recruited 6 months post-legalization, providing information on cannabis use. Regression analysis was used to estimate the association between legalization and cannabis use patterns. We collected longitudinal urine drug screens (UDSs) detecting cannabis-metabolites for 199 participants recruited pre-legalization and followed prospectively post-legalization. Conditional logistic regression was used to assess the association between legalization and UDS results. Results: Past-month cannabis use was self-reported by 54.8 and 52.3% of participants recruited pre- and post-legalization, respectively. Legalization was not associated with changes in any measured cannabis characteristics: cannabis use (OR 0.91, 95% CI 0.73–1.13), days of use/month (B -0.42, 95% CI - 2.05-1.21), money spent, or cannabis source. There was no association between legalization and prevalence of cannabis use on UDS (OR 1.67, 95% CI 0.93–2.99) or percentage of cannabis-positive UDSs (OR 1.00, 95% CI 0.99–1.01). Participants overwhelmingly reported that legalization would have no impact on their cannabis use (85.7%). Conclusions: Amongst patients treated for OUD, no significant change in cannabis use was observed following legalization; however, high rates of cannabis use are noted.Medicine, Faculty ofNon UBCFamily Practice, Department ofReviewedFacult

Integrating addiction medicine training into medical school and residency curricula

Background: The Affordable Care Act (2010) brings an opportunity to increase the integration of addiction treatment into the health care system. With the anticipated expansion of addiction care services in primary care, challenges, such as workforce training, can be expected. This presentation discusses challenges and opportunities for addiction medicine training of primary care professionals in Ireland, Canada and Portland, OR. Objectives: To explore ideas for integrating addiction medicine education into medical school, fellowship and residency curricula and to consider how implementation barriers can be addressed. Method: The presentation will outline the set up and content of some of the current addiction medicine education in medical schools and residency programs in Ireland, Canada and Portland, Oregon. Examples from three educational initiatives will be used to generate ideas applicable to each setting and help overcome integration barriers: the St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship (http://www.addictionmedicinefellowship.org), the feasibility study on alcohol SBIRT for opioid agonist patients in Ireland (PINTA), and the team-based SBIRT Oregon project (http://www.sbirtoregon.org). Scenarios that illustrate implementation strategies, such as educational outreach visits to practitioners - based on overcoming obstacles to change - and facilitators of integrating addiction medicine education into medical school and residency curricula, will be described. Conclusion: The presentation will conclude with an overview of how initiatives in which the authors have been involved may be used to improve addiction medicine education

Are patients' goals in treatment associated with expected treatment outcomes? Findings from a mixed-methods study on outpatient pharmacological treatment for opioid use disorder.

OBJECTIVES: Existing methods of measuring effectiveness of pharmacological treatment for opioid use disorder (OUD) are highly variable. Therefore, understanding patients' treatment goals is an integral part of patient-centred care. Our objective is to explore whether patients' treatment goals align with a frequently used clinical outcome, opioid abstinence. DESIGN: Triangulation mixed-methods design. SETTING AND PARTICIPANTS: We collected prospective data from 2030 participants who were receiving methadone or buprenorphine-naloxone treatment for a diagnosis of OUD in order to meet study inclusion criteria. Participants were recruited from 45 centrally-managed outpatient opioid agonist therapy clinics in Ontario, Canada. At study entry, we asked, 'What are your goals in treatment?' and used NVivo software to identify common themes. PRIMARY OUTCOME MEASURE: Urine drug screens (UDS) were collected for 3 months post-study enrolment in order to identify abstinence versus ongoing opioid use (mean number of UDS over 3 months=12.6, SD=5.3). We used logistic regression to examine the association between treatment goals and opioid abstinence. RESULTS: Participants had a mean age of 39.2 years (SD=10.7), 44% were women and median duration in treatment was 2.6 years (IQR 5.2). Six overarching goals were identified from patient responses, including 'stop or taper off of treatment' (68%), 'stay or get clean' (37%) and 'live a normal life' (14%). Participants reporting the goal 'stay or get clean' had lower odds of abstinence at 3 months than those who did not report this goal (OR=0.73, 95% CI 0.59 to 0.91, p=0.005). Although the majority of patients wanted to taper off or stop medication, this goal was not associated with opioid abstinence, nor were any of their other goals. CONCLUSIONS: Patient goals in OUD treatment do not appear to be associated with programme measures of outcome (ie, abstinence from opioids). Future studies are needed to examine outcomes related to patient-reported treatment goals found in our study; pain management, employment, and stopping/tapering treatment should all be explored

Gender Influences on Hepatitis C Incidence Among Street Youth in a Canadian Setting

PURPOSE: Few studies have examined gender-based differences in the risk of hepatitis C (HCV) infection among street-involved youth. We compared rates of HCV infection among male and female street-involved youth in a Canadian setting. METHODS: The At-Risk Youth Study (ARYS) is a prospective cohort of drug-using, street-involved youth. Study recruitment and follow-up occurred in Vancouver, Canada, between September 2005 and November 2011. Eligible participants were illicit drug-using youth aged 14–26 years at enrollment, recruited by street-based outreach. We evaluated rates of HCV antibody seroconversion, measured every six months during study follow-up, and used Cox proportional hazards regression to compare risk factors for HCV incidence between male and female street youth. RESULTS: Among 512 HCV-seronegative youth contributing 836 person-years of follow-up, 56 (10.9%) seroconverted to HCV. Among female participants, the incidence density of HCV infection was 10.9 per 100 person-years and in males 5.1 per 100 person-years (p = 0.009). In multivariate analyses, female gender was independently associated with a higher rate of HCV seroconversion (Adjusted Hazard Ratio (AHR) = 2.01; 95% Confidence Interval [CI], 1.18 – 3.44). Risk factors were similar in gender stratified analyses and included injection heroin and injection crystal methamphetamine, although syringe sharing was only associated with HCV incidence among males. CONCLUSIONS: Among street-involved youth in this setting, females had double the incidence of HCV seroconversion demonstrating the need for gender focused HCV prevention interventions for this population