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Factors associated with premature mortality among young injection drug users in Vancouver Miller, Cari L; Kerr, Thomas; Strathdee, Steffanie A; Li, Kathy; Wood, Evan Jan 4, 2007

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchFactors associated with premature mortality among young injection drug users in VancouverCari L Miller*1, Thomas Kerr1,2, Steffanie A Strathdee1,3, Kathy Li1 and Evan Wood1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada, 2University of British Columbia, Department of Medicine, Vancouver, Canada and 3University of California at San Diego, Division of International and Cross-Cultural Medicine, San Diego, USAEmail: Cari L Miller* - cmiller@cfenet.ubc.ca; Thomas Kerr - tkerr@cfenet.ubc.ca; Steffanie A Strathdee - sstrathdee@ucsd.edu; Kathy Li - kathyli@cfenet.ubc.ca; Evan Wood - ewood@cfenet.ubc.ca* Corresponding author    AbstractBackground: Young injection drug users (IDUs) may be at increased risk of premature mortalitydue to the health risks associated with injection drug use including overdoses and infections.However, there has been little research conducted on mortality causes, rates and associationsamong this population. We undertook this study to investigate patterns of premature mortality,prior to age 30 years, among young IDUs.Methods: Since 1996, 572 young (≤29 years) IDUs have been enrolled in the Vancouver InjectionDrug Users Study (VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and hepatitis C (HCV).Mortality data have been continually updated through linkages with the Provincial Coroner's Office.Crude and age-specific mortality rates, standardized mortality ratios, and life expectancy measureswere calculated using person-time methods. Predictors of mortality were identified using Coxregression analyses.Findings: Twenty-two participants died prior to age 30 years during the follow-up period for anoverall crude mortality rate of 1,368 per 100,000 person-years. Overall, young IDUs were 16.4times (95% confidence interval [CI]; 9.1–27.1) more likely to die; young women IDUs were 54.1times (95%CI; 29.6–90.8) and young men IDUs were 12.9 times (95%CI; 5.5, 25.3) more likely todie when compared to the Canadian non-IDU population of the same age. The leading observedcause of death among females was: homicide (N = 9); and among males: suicide (N = 3) andoverdose (N = 3). In Cox regression analyses, factors associated with mortality were, HIV infection(Hazard Ratio [HR]: 4.55; CI: 1.92–10.80) and sex work (HR: 2.76; CI: 1.16–6.56).Interpretation: Premature mortality was 13 and 54 times higher among young men and womenwho use injection drugs in Vancouver than among the general population in Canada. The majorityof deaths among the women were attributable to homicide, suggesting that interventions shouldoccur not only through harm reduction services but also through structural interventions at thePublished: 04 January 2007Harm Reduction Journal 2007, 4:1 doi:10.1186/1477-7517-4-1Received: 10 August 2006Accepted: 04 January 2007This article is available from: http://www.harmreductionjournal.com/content/4/1/1© 2007 Miller 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 7(page number not for citation purposes)legal and policy level.Harm Reduction Journal 2007, 4:1 http://www.harmreductionjournal.com/content/4/1/1BackgroundPremature mortality among injection drug users (IDUs) ishigher than in the general population with rates of mor-tality estimated to range between 0.8–3.26/100 person-years [1,2]. Young IDUs are at higher risk for a number ofadverse health outcomes, including blood-borne infec-tion, than among young people in the general popula-tion[3]. In a study of new onset injection drug users,mortality rates varied by calendar year, were elevated incomparison to the general population and were estimatedto be 3.3 per 100-preson years [2]. In 2002, Roy et al.reported that street youth in Montreal, Quebec, aged 29years and younger, had a standardized mortality ratio of11.4 and one of the independent predictors of mortalitywas injection drug use [4]. Younger IDUs represent animportant group to examine with respect to mortality dueto their higher risk for drug related harms [5,6] and theopportunity to offer new information regarding avenuesfor prevention among this vulnerable population.Recent studies in the United States and Scotland havefound that mortality rates peaked among IDUs in themid-1990s due to an increase in HIV/AIDS related deathsand have since declined [2,7]. Mortality among IDUs typ-ically result from infectious diseases, overdose and inju-ries [8-10]. Overdose is a leading cause of death amongIDUs [11] and varies between calendar years dependingon factors such as purity and quality of drug availabilityand potentially on the HIV status among individuals[12,13]. Among IDUs in Edinburgh, Scotland deaths dueto overdose and suicide were higher among younger IDUsthan among older IDUs, with higher proportions ofyoung males than females dying by suicide [7]. In thestudy of street youth in Montreal, Quebec, overdosedeaths and suicide represented the leading causes of pre-mature mortality [4].Investigating causes of mortality among IDUs is impor-tant not only as a means for understanding risk amongthis population, but mortality can also be a measure ofhow well existing public health interventions are workingto address drug-related harms. Studies have shownincreased mortality rates since the advent of AIDS amongIDUs, particularly prior to the advent of HIV antiretroviraltherapy [7,14]. Nevertheless, other studies have shownthat IDUs are more likely to die without ever accessinglifesaving HIV treatment when compared to other popula-tions affected by HIV [15]. This information providespublic health agencies with knowledge regarding a gap inthe scope and effectiveness of existing systems of care.Thus, information on mortality can provide critical publichealth information for authorities to gauge how wellexisting services have been effective in addressing theThis study was designed to investigate factors associatedwith mortality prior to age 30 years among IDUs and todetermine rates and causes of premature mortality in thispopulation.MethodsStudy populationThe Vancouver Injection Drug User Study (VIDUS) is aprospective study of IDUs who have been recruitedthrough self-referral and street outreach from Vancouver'sDowntown Eastside (DTES) since May 1996. To date therehave been over 1600 IDUs enrolled, among whom over500 are young (aged ≤29 years). The Downtown Eastsideis Vancouver's poorest neighborhood where an estimated4,700 IDUs and 1,000 street youth reside in an area ofapproximately ten city blocks, and where inexpensivehousing in the form of hotels and single room occupan-cies (SROs) are abundant. The cohort has been describedin detail previously [16]. Briefly, persons were eligible forthis study if they had injected illicit drugs at least once inthe previous month confirmed by track site inspection,were aged 14 years and older and resided in the greaterVancouver region. At baseline and semi-annually, subjectsprovided venous blood samples and completed an inter-viewer-administered questionnaire. All participants pro-vided informed consent, and were given a stipend ($20CDN) at each study visit. The study has been approved bythe University of British Columbia's Research EthicsBoard.Sources of information on cause of deathThe VIDUS office is situated in the hub of the DTES andthe office serves as a drop-in where participants regularlystop by for coffee and conversation. Many of the VIDUSstaff have been working in the community for severalyears and stay connected with residents and other com-munity workers. This close community serves as an infor-mal watch where information is shared when residentsbecome missing, ill, incarcerated or die. This informal sys-tem is complemented by regular linkages with the provin-cial Coroner's Office where the coroner's report isreviewed for each confirmed death within the study. Inaddition, the provincial Vital Statistics Agency is reviewedto confirm deaths among participants twice annually.Thus, information on cause of death were obtainedthrough regular follow-up, coroner's reports, and annualelectronic linkages with BC Vital Statistics. These methodshelp to ensure the accuracy of information and avoidpotential under representation due to reporting delays.The underlying cause of death reported on each deathrecord was coded in accordance with the InternationalClassification of Diseases, Tenth Revision (ICD-10).Page 2 of 7(page number not for citation purposes)ongoing public health crisis among IDUs.Harm Reduction Journal 2007, 4:1 http://www.harmreductionjournal.com/content/4/1/1Statistical analysesSocio-demographic variables included in these analyseswere gender, ethnicity (Aboriginal vs. other) [17], HIVand HCV-positivity and homelessness. Aboriginal is self-reported and includes: First Nations people, Inuit and/orMétis people. Homelessness was defined as sleeping inthe street, shelter and/or squat. Drug and sexual risk vari-ables included in these analyses were history of sexualabuse, sex work, greater than once daily crack cocaine useand greater than once daily injection of heroin, cocaineand/or speedball (a mixture of heroin and cocaine), anduse of methadone maintenance therapy (MMT). Sex-workinvolvement was defined as exchanging sex for money,goods, drugs, or shelter. All time-updated variables referto activities in the six months prior to each semi-annualfollow-up visit with the exception of sexual abuse, definedas ever occurring.Baseline characteristics are described in Table 1 and causesof death are described in Table 2. For the longitudinalanalyses, Table 3, the follow-up period for each partici-pant started at baseline and ended at the first of the fol-lowing events: death or age 30 years. Mortality rates werecalculated overall and by subgroups defined by variablesselected from the above listed characteristics, based on theliterature and appropriateness for the sample size. Mortal-ity rates were calculated using the person-time method(18); 95% confidence intervals (CI) were calculated usingthe Poisson distribution.Standardized mortality ratios were calculated using theindirect method of standardization by sex and age group.The comparison group was the Canadian population ofthe same age in 2000. Abridged life tables were calculatedusing methods adopted by Lopez et al. at the WorldHealth Organization [19]. Predictors of mortality wereidentified using univariable and multivariable Cox regres-sion analyses. All variables with p values ≤ 0.05 in univar-iable analyses were included in multivariable analyses.ResultsCharacteristics of the study participantsBetween May 1996 and December 2004, 572 participantsaged ≤ 29 years were enrolled into the study. Participantscompleted between 1 and 15 questionnaires (average 7per participant; 83% completed at least 1 follow-up ques-tionnaire following the baseline interview). During fol-low-up 182 participants reached 30 years of age. In total,participants accumulated 1608 person-years of follow-uptime prior to age 30 years.The median age of participants at study entry was 23.9(IQR: 20.9–26.3) and the number of years injecting was 4young people HIV and HCV infected was 16% and 57%respectively and 25% were homeless. Of the sex risk vari-ables, 40% reported a history of sexual abuse and 44%engaged in sex work. Among the young participants, 10%had smoked crack daily, 45% had injected heroin daily,33% had injected cocaine daily, 14% had injected speed-balls (heroin and cocaine combined) daily and 5% hadaccessed methadone maintenance therapy (MMT).MortalityIn total, 42 deaths occurred during the study period, 20 ofthose occurring after 30 years of age and were excludedfrom further analyses. Thus, there were 22 deaths thatoccurred during the follow-up period among participantsaged 29 years and younger. Of note, 1 of the observeddeaths was classified as "assault" and for this study weincluded it in the homicide category. Thus, amongfemales, the leading cause of death (refer to Table 2) washomicide (n = 9) and among males, suicide (n = 3) andoverdose death (n = 3). Death due directly to HIV infec-tion occurred among 2 female participants and 1 maleparticipant.The 22 deaths observed among this population duringfollow-up represented a mortality rate of 1368 per100,000 person-years. Among females, the mortality ratewas 1645 per 100,000 person-years and among males, therate was 1045 per 100,000 person years. In comparisonwith the Canadian population of the same age in 2000,young IDUs were 16.4 times (95% confidence interval[CI]; 9.1–27.1) more likely to die; women were 54.1 times(95%CI; 29.6–90.8) and men were 12.9 times (95%CI;5.5, 25.3) more likely to die. At age 15, IDUs could expectto live another 36.8 years, compared to the Canadian pop-ulation at age 15 who could expect to live another 64.8years or nearly double the life expectancy of IDUs in thisstudy population.Univariable and multivariable Cox regression analysesassessing associations between mortality and participantcharacteristics are presented in Table 3. In univariableanalyses, factors associated with mortality among thestudy population were sex work (Hazard Ratio [HR]; 2.76[95%CI; 1.16–6.56]) and HIV infection (HR; 4.55[95%CI; 1.92–10.80]). The only factor to remain signifi-cantly associated with mortality among participants inmultivariable analyses was HIV infection (HR; 4.55[95%CI; 1.92–10.80]).DiscussionThe mortality rate observed among this population ofyoung people is high. Young male and female IDUs in thissetting had rates of mortality that were 12 and 51 timesPage 3 of 7(page number not for citation purposes)(IQR: 1.5–8). As indicated in Table 1, 47% were femaleand 29% were of Aboriginal ancestry. The percentage ofhigher respectively than the Canadian population of thesame age. Life expectancy at age 15 years is half of what isHarm Reduction Journal 2007, 4:1 http://www.harmreductionjournal.com/content/4/1/1observed at a national level. Particularly concerning wasthe number of deaths due to homicide among the womenin the study.A previous study identified mortality from homicide asthe leading cause of death among young homeless malesand females in an urban setting in the United States wherehomicide rates are generally higher than in other devel-oped nations[20]. However in this Canadian settingwhere homicide deaths rank low, young drug dependentwomen appear to be at very high risk of death by thismeans. The high number of women dying by homicidecombined with the generally low rate of homicide in thissetting warrants public health intervention, particularlydue to the preventable nature of this cause of death. In thisstudy, approximately half of the participants wereinvolved in sex work at baseline and among females, thisfigure approaches 80% (data not shown). In longitudinalanalysis, sex work was an important predictor of mortalityin this study, however this factor did not reach signifi-cance in multivariable analyses likely due to power issues.The relationship between injection drug dependency,younger age, female sex and sex work has previously beenshown [21-24].Of note, investigation of Robert Pickton for the serial mur-ders of drug dependent women from Vancouver's Down-town Eastside has recently begun [25]. This investigationmay account for the high number of homicide deathsobserved among women in this setting. Other similarinvestigations in parts of Mexico and the US (Ciudad Jua-rez and the Green River serial killer investigations) suggestthat women, and particularly young women, who engagein sex work are at high risk for being targeted by sexualpredators [26,27]. It has also been suggested by commu-nity workers that young women who deal drugs to sup-port their habits may rank low in the hierarchy of drugdealing relationships and may be at risk for death by"being made an example of" when using the drugs theyare meant to sell. The development of public health inter-ventions to reduce the risk for violence among younginjection drug dependent women who engage in sex workis important. More recently, legal reform for sex workersin this setting has been proposed and these findingsunderscore the need to support legal reform and otherharm reduction initiatives for sex workers to reduce therisk of violence and homicide death[28]. Additional pub-lic health interventions require further investigation, par-ticularly qualitative, to ascertain types of interventionsthat may be acceptable to young female IDUs who alsoTable 1: Characteristics of the 572 young (≤29 years) Vancouver injection drug user study participants at baseline.Characteristic No. (%)Females 268 (47%)Aboriginal 163 (29%)HIV Positive at Baseline 92 (16%)HCV Positive at Baseline 326 (57%)Homeless in the 6 mos. prior 144 (25%)Sex Abuse Ever 231 (40%)Sex Work in the 6 mos. prior 252 (44%)≥1 per day Crack in the 6 mos. prior 57 (10%)≥1 per day Heroin in the 6 mos. prior 260 (45%)≥1 per day Cocaine in the 6 mos. prior 188 (33%)≥1 per day Speedballs in the 6 mos. prior 78 (14%)Methadone Maintenance Therapy in the 6 mos. prior 31 (5%)Table 2: Profile of cause of death among young (≤29 years) injection drug users in Vancouver who died between 1996 and 2006 (N = 22).Cause of Death Females No. Males No. TotalHomicide 9 9Accident 1 1 2Suicide 3 3HIV 2 1 3Overdose 1 3 4Undetermined Illness 1 1Page 4 of 7(page number not for citation purposes)Total No. 14 8 22Harm Reduction Journal 2007, 4:1 http://www.harmreductionjournal.com/content/4/1/1engage in sex work. Given the potentially deadly conse-quences, considering innovative drug treatment and phar-maco-therapeutic interventions, such as prescription drugmaintenance, may help to reduce drug-related harms,including premature mortality, in this population [29].In the final Cox model, the only predictor of prematuremortality was HIV infection. Similarly, Roy et al. foundthat HIV was the strongest predictor of mortality amongMontreal street youth; however HIV represented a smallproportion of the overall causes of death [4]. The consist-ency between these results may imply that youth who arevulnerable to premature mortality are also those morevulnerable to blood-borne infections.Similar to other findings regarding mortality amongyounger age groups and males in particular, death by sui-ner reports, however other literature has indicated thatoverdose may be one of the ways that young people com-mit suicide and among IDUs, intentional suicide by over-dose may be may be hard to prove[30]. Suicide amongyoung people is always a tragic phenomenon and giventhe higher risk for suicide, community suicide preventionresources should be mobilized within this popula-tion[31]. In addition, ensuring overdose prevention edu-cation and available tools are accessible to younger IDUsmay be important for prevention of premature mortalityin this population.There are several limitations that should be consideredwith regards to the data presented here. First, this studysample was relatively small and although a smallernumber of associations were considered, power issuesmay have constrained the longitudinal analyses. The sec-Table 3: Mortality rates and cox regression analyses of mortality among young (≤29 years) injection drug users (N = 572) in Vancouver between 1996 and 2006.Characteristic No. of Deaths Mortality Rate per 100,000 Person YearsUnadjusted Hazard Ratio (95% CI)Adjusted Hazard Ratio (95% CI)Older than 24 yrs.YesNo1391,6791,2131.41 [0.60–3.30]FemaleYesNo1481,6451,0571.77 [0.74–4.22]AboriginalYesNo7151,2821,4121.07 [0.44–2.62]HIVYesNo1393,1371,0354.55 [1.92–10.80] 4.01 [1.67–9.56]HCVYesNo1571,6899590.96 [0.37–2.51]HomelessnessYesNo5171,2201,4121.19 [0.44–3.25]Sex WorkYesNo1662,1596922.76 [1.16–6.56] 1.97 [0.80–4.84]Sexual AbuseYesNo12101,8291,0501.66 [0.72–3.84]≥1 per day HeroinYesNo10121,3891,3510.84 [0.35–1.97]≥1 per day CocaineYesNo8141,5011,3021.40 [0.58–3.37]≥1 per day CrackYesNo5172,9591,1812.41 [1.00–5.81] 1.94 [0.79–4.80]Page 5 of 7(page number not for citation purposes)cide and overdose were common[30]. In this study, thedeaths by overdose were not deemed intentional by coro-ond limitation may be the potential for misclassificationbias relating to self-reported behaviours, however theHarm Reduction Journal 2007, 4:1 http://www.harmreductionjournal.com/content/4/1/1interviewers are trained to probe for any misleading infor-mation and every precaution is taken to assure the partic-ipant of confidentiality. Third, there is a possibility thatthe number of deaths occurring were underestimated, par-ticularly if the participant was lost to follow-up or thedeath occurred out-of-province. Finally, in this setting, ahigher number of homicides were found among youngwomen than in other studies suggesting that these resultsmay represent an anomaly. However, the experiences ofsex workers who work without legal protection, such as inmost North American settings and other settings world-wide, violence and the risk of predation is high and fordrug dependent women, the risks may be evengreater[32]. There is a need for more research on violenceand predation among young women involved in sex workand a need for better protection of their human rights.Mortality among IDUs may be an assumed risk conse-quential to a high-risk behaviour. However the data pre-sented here suggests that the majority of risk forpremature mortality among young IDUs is resulting, notdirectly from injection drug use, but indirectly from pre-ventable causes. Clearly, better public health interven-tions must be implemented targeting this populationincluding emergency and long term housing options,alternative employment training for young sex workersand accessible substitution therapies for young IDUs. Inaddition, given the ongoing harms associated with sexwork, structural changes including legal and policy reformare warranted. The high rates of mortality presented hereshould send a clear message to public health agencies thatyoung IDUs have unique risk profiles and innovativeinterventions are required to avert preventable prematuremortality among this population.References1. Zacharelli M, Gattari P, Rezza G, Conti S, Spizzichino L, Vlahov D, LelliV, Valenzi C: Impact of HIV infection on non-AIDS mortalityamong Italian injecting drug users.  Aids 1994, 8:345-350.2. Vlahov D, Wang CL, Galai N, Bareta J, Mehta SH, Strathdee SA, Nel-son KE: Mortality risk among new onset injection drug users.Addiction 2004, 99(8):946-954.3. Sherman SG, Fuller CM, Shah N, Ompad DV, Vlahov D, Strathdee SA:Correlates of initiation of injection drug use among youngdrug users in Baltimore, Maryland: the need for early inter-vention.  Journal of Psychoactive Drugs 2005, 37(4):437-443.4. Roy E, Haley N, Leclerc P, Sochanski B, Boudreau JF, Boivin JF: Mor-tality in a cohort of street youth in Montreal.  Jama 2004,292(5):569-574.5. 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Havens JR, Strathdee SA, Fuller CM, Ikeda R, Friedman SR, JarlaisDCD, Morse PS, Bailey S, Kerndt P, Garfein RS: Correlates ofattempted suicide among young injection drug users in amulti-site cohort.  Drug and alcohol Dependence 2004,75(3):261-269.32. Surratt HL, Inciardi JA, Kurtz SP, Kiley MC: Sex work and drug usein a subculture of violence.  Crime and Delinquency 2004,50(1):43-59.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 7 of 7(page number not for citation purposes)

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