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Methamphetamine use and rates of incarceration among street-involved youth in a Canadian setting: a cross-sectional… Milloy, M-J; Kerr, Thomas; Buxton, Jane; Montaner, Julio; Wood, Evan Aug 12, 2009

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ralSubstance Abuse Treatment, ssBioMed CentPrevention, and PolicyOpen AcceResearchMethamphetamine use and rates of incarceration among street-involved youth in a Canadian setting: a cross-sectional analysisM-J Milloy†1,2, Thomas Kerr†1,4, Jane Buxton†2,3, Julio Montaner†1,4 and Evan Wood*†1,4Address: 1BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada , 2School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada , 3Department of Epidemiology, BC Centre for Disease Control, 655 12th Avenue West, Vancouver, BC, V5Z 4R4, Canada  and 4Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada Email: M-J Milloy - mjmilloy@cfenet.ubc.ca; Thomas Kerr - uhri-tk@cfenet.ubc.ca; Jane Buxton - jane.buxton@bccdc.ca; Julio Montaner - jmontaner@cfenet.ubc.ca; Evan Wood* - uhri-ew@cfenet.ubc.ca* Corresponding author    †Equal contributorsAbstractBackground: Given concerns over rising use of methamphetamine, especially among street-involved youth, and the links between exposure to the correctional system and the production ofdrug-related harm, we sought to assess the relationship between ever using methamphetamine andreporting ever being incarcerated in the At-Risk Youth Survey (ARYS) in Vancouver, Canada.Methods: The relationship between ever being imprisoned and ever using methamphetamine wasestimated using a multivariate logistic regression analysis while also considering potentiallyconfounding secondary demographic, social and behavioural variables.Results: Of the 478 youth recruited into ARYS between September 2005 and October 2006, 385(80.5%) reported ever being incarcerated overnight or longer. In the multivariate model,methamphetamine use was independently associated with ever being incarcerated (Adjusted OddsRatio: 1.79, 95% Confidence Interval [CI]: 1.03 – 3.13).Conclusion: Incarceration was very common in this cohort and strongly linked with ever usingmethamphetamine. This finding is of concern and, along with the previously identified risks of drug-related harm associated with incarceration, supports the development of novel public policy, suchas community-based drug treatment, to address the use of methamphetamine among street youth.BackgroundThe use of methamphetamine in Western settings is ofincreasing concern [1,2], especially among street-involvedyouth [3,4], a vulnerable population already burdened byphetamine now constitutes the second most commonlyused illicit drug internationally, second only to marijuana[7].Published: 12 August 2009Substance Abuse Treatment, Prevention, and Policy 2009, 4:17 doi:10.1186/1747-597X-4-17Received: 10 March 2009Accepted: 12 August 2009This article is available from: http://www.substanceabusepolicy.com/content/4/1/17© 2009 Milloy et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6(page number not for citation purposes)high levels of morbidity and mortality [5,6]. According tothe United Nations Office on Drugs and Crime, metham-For older drug users, especially those who use injectiondrugs (IDU), the dynamics linking drug use, marginalisa-Substance Abuse Treatment, Prevention, and Policy 2009, 4:17 http://www.substanceabusepolicy.com/content/4/1/17tion and imprisonment are well described [8-10]. Arrestand imprisonment is a common experience, with a his-tory of incarceration reported by at least 75% of partici-pants in community-recruited samples of IDU in Europe[11], Thailand [12] and the United States [13]. Incarcera-tion may be a risk factor for drug related harm amongIDU, since exposure to correctional environments hasconsistently been associated with an increased likelihoodof HIV risk behavior and HIV infection [14,15] as well asincreased risk of fatal overdose upon release [16].Sparked by the growing use of methamphetamine andconcerns over links to initiation of injection drug use [17],we have previously reported that over 75% of participantsin a local cohort of street-involved youth said they hadpreviously used methamphetamine [4]; 25% of all injec-tion initiation experiences involved methamphetamine[4]; and 13% of local overdose events among homelessyouth involve the use of methamphetamine [18]. Vancou-ver is the site of an explosive outbreak of HIV among IDUwith current prevalence estimated at 20% [19]; approxi-mately 3% of local street youth are estimated to be HIV-seropositive [20]. Since exposure to the criminal justicesystem through arrest and incarceration may actuallyincrease drug-related harms [15], we conducted thepresent study to determine the prevalence of incarcerationin a cohort of community-recruited street youth andinvestigate its relationship with the use of methampheta-mine.MethodsThe At-Risk Youth Study (ARYS) is a prospective cohort ofstreet-involved youth in Vancouver, Canada, that hasbeen described in detail previously [17]. In brief, snow-ball sampling and street-based outreach were used in aneffort to derive a representative sample of street-involveddrug using youth. Individuals were eligible for inclusion ifthey were aged 14 to 26 years old at the baseline interviewand had used illegal drugs other than cannabinoids in theprevious 30 days. At baseline and every six-month follow-up, participants answer an interviewer-administered ques-tionnaire, are examined by a nurse and provide bloodsamples for serologic testing. The ARYS study has beenreviewed and approved by the University of BritishColumbia/Providence Research Ethics Board.For the present analyses, the outcome of interest wasreporting ever being incarcerated, or answering "yes" tothe question: "Have you ever been in detention, prison,the drunk tank or jail overnight or longer?" The primaryexplanatory variable of interest was reporting ever usingmethamphetamine. First, we compared individualsreporting incarceration with those reporting never incar-outcome of interest and primary explanatory variable.These secondary explanatory variables included: gender;age; ethnicity (Non-aboriginal vs. aboriginal); educationlevel (< high school vs. ≥ high school); history of fostercare (yes vs. no); history of ER use (yes vs. no); hepatitis Cvirus (HCV) seropositivity (yes vs. no); ever involved inthe sex-trade (yes vs. no); ever diagnosed with a mental ill-ness (yes vs. no); ever dealing drugs (yes vs. no); everbeing sexually or physically abused (yes vs. no); ever usingcrack cocaine (yes vs. no); ever using powder cocaine (yesvs. no); ever injecting heroin (yes vs. no); ever using can-nibinoids (i.e., marijuana, hashish) (yes vs. no). All druguse variables referred to any prior use.For univariate analyses, we used Pearson's χ2 test (dichot-omous variables) and the Mann-Whitney test (continuousvariables) to compare individuals reporting the outcomeversus others by the primary and secondary explanatoryvariables. To fit the multivariate model, we employed abackwards selection procedure we have used previously[21,22]. After beginning with a full model with all covari-ates included, we fit reduced models, each with oneunique secondary explanatory variable removed, andobserved in each model the relative change in the coeffi-cient for the term for methamphetamine in the regressionequation. We identified the reduced model with thesmallest absolute relative change in the methampheta-mine coefficient and removed its missing secondary vari-able from further consideration. The objective of this stepis to remove variables with relatively less effect on thevalue of the coefficient for methamphetamine and, witheach step, to preserve variables in the analysis with greaterinfuence on the value of the methamphetamine coeffi-cient in multivariate analysis. We continued this iterativeprocess until the smallest relative change in the metham-phetamine coefficient exceeded 5% of the value of thecoefficient. We then fit a final model including metham-phetamine use and all remaining secondary explanatoryvariables as terms in the regression equation.All statistical analyses were performed in R version 2.6.1(R Foundation for Statistical Computing, Vienna, Aus-tria). All p-values are two-sided.ResultsBetween September 2005 and October 2006, 478 individ-uals were recruited into the ARYS cohort, of whom 132(27.6%) were female, 120 (25.1%) reported Aboriginalancestry and 329 (68.8%) were Caucasian. At the baselineinterview, the median age was 22.0 (Interquartile Range[IQR]: 20.0 – 23.9).Of the 478 participants, 385 (80.5%) reported ever beingPage 2 of 6(page number not for citation purposes)cerated using individual-, social- and structural-level fac-tors we hypothesised could be associated with both theincarcerated. As shown in Table 1, social and demo-graphic characteristics associated with incarceration inSubstance Abuse Treatment, Prevention, and Policy 2009, 4:17 http://www.substanceabusepolicy.com/content/4/1/17univariate analyses were: older age (Odds Ratio [OR]:1.23, 95% Confidence Interval [95% CI]: 1.17 – 1.28, p <0.001); having less than a high school education (OR:1.66, 95% CI: 1.04 – 2.66, χ2 = 4.07 [df = 1], p = 0.032);and ever being a victim of abuse (OR: 2.10, 95% CI: 1.32– 3.34, χ2 = 9.24 [df = 1], p = 0.002). Female gender wasinversely associated with having a history of incarceration(OR: 0.19, 95% CI: 0.12 – 0.31, χ2 = 48.03 [df = 1], p <0.001). Behavioural and drug-using variables associatedwith a history of incarceration are shown in Table 2 andincluded: methamphetamine use (OR: 2.45, 95% CI: 1.53– 3.90, χ2 = 13.53 [df = 1], p < 0.001); crack use (OR: 3.08,95% CI: 1.89 – 5.03, χ2 = 20.12 [df = 1], p < 0.001);cocaine use (OR: 2.49, 95% CI: 1.33 – 4.66, χ2 = 8.02 [df= 1], p = 0.003); and drug dealing (OR: 3.19, 95% CI: 1.97– 5.19, χ2 = 22.03 [df = 1], p < 0.001).Results from the final multivariate logistic regressionmodel are displayed in Table 3. The primary explanatoryvariable, previous use of methamphetamine, was inde-pendently associated with ever being incarcerated in ainal ethnicity and crack use. Correlation between theexplanatory variables was moderate, ranging from 0.00 to0.35.DiscussionIn this survey of street-involved youth in Vancouver, Can-ada, we observed a high level of both ever being incarcer-ated and ever using methamphetamine. The level ofincarceration observed in this sample (80.5%) is substan-tially higher than other estimates in surveys of street-involved youth. In 2004, a multi-site cross-sectional studyof 1733 Canadian street youth reported 784 (45.2%) hadbeen in jail [23]. A similar level was reported by 536homeless youth in Portland, Oregon [24]. In our setting,this level of incarceration is higher (80.5% vs. 59.4%)than that observed in a cohort of adult IDU recruited froma local harm reduction facility [15]. Reasons for thisheightened level might include, proximally, the preva-lence of high-intensity drug use and involvement in thesex trade; and, ultimately, social and structural factorsincluding a dearth of affordable housing and ordnancesTable 1: Univariate analyses of social and demographic characteristics associated with reporting ever being incarcerated in ARYS (n = 478)Ever incarceratedCharacteristic No (%) Yes (%) Odds Ratio 95% Confidence Interval p-value1Age (df = 476)Median (IQR) 20.8 (17.7 – 23.4) 22.4 (18.4 – 26.3) 1.23 1.17 – 1.28 < 0.001Gender (df = 1)Male 40 (43.0) 306 (79.5)Female 53 (57.0) 79 (20.5) 0.19 0.12 – 0.31 < 0.001Ethnicity (df = 1)Non-Aboriginal 76 (81.7) 282 (73.2)Aboriginal 17 (18.2) 103 (26.8) 1.63 0.92 – 2.89 0.091Education (df = 1)≥ High school 38 (40.9) 113 (29.4)< High school 55 (59.1) 272 (70.6) 1.66 1.04 – 2.66 0.032Foster care2 (df = 1)No 52 (55.9) 183 (47.5)Yes 41 (44.1) 202 (52.5) 1.40 0.89 – 2.21 0.147HCV status (df = 1)Negative 77 (82.8) 339 (88.1)Positive 16 (17.2) 46 (11.9) 0.65 0.35 – 1.21 0.176Mental illness2 (df = 1)No 59 (63.4) 225 (58.4)Yes 34 (36.6) 160 (41.6) 1.23 0.77 – 1.97 0.378Victim of abuse2 (df = 1)No 58 (62.4) 170 (44.2)Yes 35 (37.6) 215 (55.8) 2.10 1.32 – 3.34 0.002ER use2 (df = 1)No 61 (65.6) 225 (58.4)Yes 32 (34.4) 160 (41.6) 1.36 0.84 – 2.18 0.2391. p-values based on χ-square tests of difference (for categorical variables) and the Mann-Whitney test (for continuous)2. Refers to any instance in the pastPage 3 of 6(page number not for citation purposes)model which included foster care, female gender, Aborig- targeting homeless individuals [25,26].Substance Abuse Treatment, Prevention, and Policy 2009, 4:17 http://www.substanceabusepolicy.com/content/4/1/17Although several street youth surveys include contact withthe criminal justice system as an explanatory covariate[23,27,28], we are unaware of any study that identifies thefactors associated with incarceration among street-involved youth. In the present study, we found metham-phetamine use to be independently associated with everbeing incarcerated after adjustment for a number of possi-ble social, demographic and behavioural confounders.Since it is not possible to resolve the temporal relation-ship between the dependent and primary explanatory var-iable in a cross-sectional analysis, we hypothesise theassociation is most likely the result of methamphetamineuse, and the means required to support it (e.g., sex tradeinvolvement and other criminal activity) increasing thevisibility of street youth to police, elevating the risk ofarrest and imprisonment. However, the possibility thatmethamphetamine use is a sequelae of imprisonment forsome individuals cannot be excluded. Numerous studiesreport a shift to higher-intensity drug use, for example theinitiation of drug use by injection, upon incarceration[12,29,30]. Similarly, in a sample of 569 street-involvedyoung men who have sex with men in New York City, con-tact with the criminal justice system was most often foundto precede beginning to use drugs such as heroin, cocaineand speed as well as involvement in the sex trade [30]. Ina detailed qualitative analysis, Vancouver street-involvedyouth described the multiple ways methamphetamine usehelped them cope with their social and environmental cir-cumstances, including mediating social contacts, main-taining vigilance over themselves and their possessions,and avoiding the use of psychiatric medications [29].Regardless of whether methamphetamine use is a predic-tor or sequelae of incarceration, the strong independentassociation observed between its use and imprisonmentin this analysis is cause for concern. As a result of the per-Table 2: Univariate analyses of behavioural and drug-using characteristics associated with reporting ever being incarcerated in ARYS (n = 478)Ever incarceratedCharacteristic No (%) Yes (%) Odds Ratio 95% Confidence Interval p-value1Methamphetamine use2 (df = 1)No 42 (45.2) 97 (25.2)Yes 51 (54.8) 288 (74.8) 2.45 1.53 – 3.90 < 0.001Crack use2 (df = 1)No 37 (39.8) 68 (17.7)Yes 56 (60.2) 317 (82.3) 3.08 1.89 – 5.03 < 0.001Heroin injection2 (df = 1)No 74 (79.7) 269 (69.9)Yes 19 (20.4) 116 (30.1) 1.68 0.97 – 2.90 0.062Cocaine use2 (df = 1)No 80 (86.0) 274 (71.1)Yes 13 (14.0) 111 (28.9) 2.49 1.33 – 4.66 0.003Cannabinoid use2 (df = 1)No 8 (8.6) 19 (4.9)Yes 85 (91.4) 366 (93.1) 1.81 0.76 – 4.28 0.169Drug dealing2 (df = 1)No 39 (41.9) 71 (18.4)Yes 54 (58.1) 314 (81.6) 3.19 1.97 – 5.19 < 0.001Sex trade2 (df = 1)No 77 (82.8) 305 (79.2)Yes 16 (17.2) 80 (20.8) 1.26 0.70 – 2.28 0.4401. p-value based on results of χ-square test of difference2. Refers to any time in the pastTable 3: Multivariate logistic regression analysis of primary and secondary factors associated with reporting ever being incarcerated in ARYS (n = 478)Characteristic Adjusted Odds Ratio 95% Confidence Interval p-value2Methamphetamine use1 (yes vs. no) 1.79 1.03 – 3.13 0.041Foster care1 (yes vs. no) 1.58 0.94 – 2.65 0.081Gender (Female vs. male) 0.17 0.10 – 0.28 < 0.001Ethnicity (Aboriginal vs. non-Aboriginal) 1.69 0.89 – 3.18 0.107Page 4 of 6(page number not for citation purposes)Crack use1 (yes vs. no) 2.45 1.38 – 4.32 0.0021. Refers to any time in the pastSubstance Abuse Treatment, Prevention, and Policy 2009, 4:17 http://www.substanceabusepolicy.com/content/4/1/17sistence of drug use by many prisoners [31] alongside thelack of harm reduction and addiction treatment opportu-nities within correctional environments [31], exposure tocorrectional environments has been linked to a higher riskfor infection with blood-borne pathogens, including HIV,in this setting [15] as others [32,33]. Thus, the frequentimprisonment of street youth who inject methampheta-mine could help sustain viral transmission in this popula-tion. Although future work should investigate therelationship between contact with police, courts and jailsand intake into alcohol and drug treatment programmesfor young drug users, the brief sentences typically servedby those designated young offenders suggests little reha-bilitative care is available [34]. These factors support thedevelopment of novel public policies to address metham-phetamine use. We recognise that a substantial segment ofpolicymakers as well as the general public supports puni-tive sanctions for illicit drug use as a signal of social disap-proval as well as a disincentive for current or future use.However, we note that little empiric evidence exists of theeffectiveness of this approach on either the individual orpopulation level despite the investment of significantpublic funds [35]. Thus, our findings add support to callsfor new policy approaches to curb illicit drug use amongmembers of the population, for example communitydiversion or expanded access to drug treatment. Somenew programmes to address methamphetamine use, espe-cially in the United States, have been developed, includ-ing education and public awareness and precursorregulation [36,37]. These initiatives should be rigourouslyevaluated before being applied to a vulnerable popula-tion.We also observed a high prevalence of ever using crackcocaine in this cohort, with 78.0% of participants report-ing ever using the drug. In the univariate analysis, crackcocaine use was strongly associated with ever being incar-cerated (p < 0.001). While the effect measures of second-ary adjusting variables included in confounding modelsshould be interpreted with caution, it is clear that there isa strong and likely independent effect of crack cocaine useincreasing the likelihood of incarceration. The linkbetween high-intensity cocaine use and a greater likeli-hood of drug-related harms, including incarceration, hasbeen well described in this and other settings. Recently,we reported a high level of crack use in this cohortstrongly linked with homelessness [38]. Previous researchfrom Vancouver determined that stimulant use, includingcocaine and methamphetamine, helps individuals copewith the immediate rigours of street-involved life, includ-ing diminishing feelings of hunger, improving wakefull-ness and awareness and reducing boredom [29,38].findings from this population of street-involved youthmight not be generalisable to the entire local street youthpopulation or other settings. However, it is noteworthythe demographic composition of ARYS is similar to otherstreet-youth samples in Vancouver [3,39]. Second, severalmeasures rely on self-report; thus, social desirability biasmight have led to an underestimate of the prevalence ofsome variables. However, we do not believe any bias wasdifferentially reported by history of incarceration. Finally,we were unable to consider the effect of different dura-tions or locations of incarceration nor did we gather infor-mation on the age at first incarceration; also, the cohortcontains individuals possibly exposed to either youthdetention centres, adult facilities, or both. Future researchshould consider the effect of these modifiers on drug usepatterns and other concerns.ConclusionTo conclude, this is the first study to describe such highrates of incarceration among street involved youth and toexplore risk factors for incarceration among this popula-tion. In multivariate regression analysis including severalpossible confounders, reporting a history of incarcerationwas strongly associated with ever using methampheta-mine. Given the rising prevalence of methamphetamineuse in this area as others, and the elevated risk for drug-related harms including HIV infection associated withexposure to correctional environments, these findingssupport the development of new public policy to supportthe health of drug-using and street-involved youth, andthe exploration of community diversion programs (e.g.addiction treatment) to avoid the high rates of incarcera-tion among this population.Competing interestsM-JM, JB, EW and TK declare they have no competinginterests. JM has received educational grants from, servedas an ad hoc adviser to or spoken at various events spon-sored by Abbott Laboratories, Agouron PharmaceuticalsInc., Boehringer Ingelheim Pharmaceuticals Inc., BoreanPharma AS, Bristol-Myers Squibb, DuPont Pharma,Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche,Immune Response Corporation, Incyte, Janssen-OrthoInc., Kucera Pharmaceutical Company, Merck Frosst Lab-oratories, Pfizer Canada Inc., Sanofi Pasteur, Shire Bio-chem Inc., Tibotec Pharmaceuticals Ltd. and Trimeris Inc.Authors' contributionsM-JM and EW conceived the study. EW, TK and M-JMdesigned the analysis; M-JM performed the statistical pro-cedures. M-JM wrote the manuscript and incorporated allsuggestions. JB provided information and edited a draft ofthe manuscript. JM contributed to the conception andPage 5 of 6(page number not for citation purposes)This analysis has some limitations which should beaddressed. As random sampling methods could not beemployed due to a lack of voters' lists or other registries,design of the analysis, interpretation of the data and draft-ing of the report. All authors approved the version to bepublished.Substance Abuse Treatment, Prevention, and Policy 2009, 4:17 http://www.substanceabusepolicy.com/content/4/1/17AcknowledgementsWe would particularly like to thank the ARYS participants for their willing-ness to be included in the study, as well as current and past ARYS investi-gators and staff. We would specifically like to thank Deborah Graham, Tricia Collingham, Caitlin Johnston, Steve Kain, and Calvin Lai and Leslie Rae for their research and administrative assistance. The study was sup-ported by the US National Institutes of Health and the Canadian Institutes of Health Research. Thomas Kerr is supported by the Michael Smith Foun-dation for Health Research and the Canadian Institutes of Health Research.References1. 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