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Evaluating methamphetamine use and risks of injection initiation among street youth: the ARYS study Wood, Evan; Stoltz, Jo-Anne; Montaner, Julio S; Kerr, Thomas May 24, 2006

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchEvaluating methamphetamine use and risks of injection initiation among street youth: the ARYS studyEvan Wood*1,2, Jo-Anne Stoltz1, Julio SG Montaner1,2 and Thomas Kerr1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver BC V6Z 1Y6, Canada and 2Department of Medicine, University of British Columbia, 3300 - 950 West 10th Avenue, Vancouver BC V5Z 4E3, CanadaEmail: Evan Wood* - ewood@cfenet.ubc.ca; Jo-Anne Stoltz - jstoltz@cfenet.ubc.ca; Julio SG Montaner - jmontaner@cfenet.ubc.ca; Thomas Kerr - tkerr@cfenet.ubc.ca* Corresponding author    AbstractMany Canadian cities are experiencing ongoing infectious disease and overdose epidemics amonginjection drug users (IDU). These health concerns have recently been exacerbated by theincreasing availability and use of methamphetamine. The challenges of reducing health-relatedharms among IDU have led to an increased recognition that strategies to prevent initiation intoinjection drug use must receive renewed focus. In an effort to better explore the factors that mayprotect against or facilitate entry into injection drug use, the At Risk Youth Study (ARYS) hasrecently been initiated in Vancouver, Canada. The local setting is unique due to the significantinfrastructure that has been put in place to reduce HIV transmission among active IDU. The ARYSstudy will seek to examine the impact of these programs, if any, on non-injection drug users. Inaddition, Vancouver has been the site of widespread use of methamphetamine in general and hasseen a substantial increase in the use of crystal methamphetamine among street youth. Hence, theARYS cohort is well positioned to examine the harms associated with methamphetamine use,including its potential role in facilitating initiation into injection drug use. This paper provides somebackground on the epidemiology of illicit drug use among street youth in North America andoutlines the methodology of ARYS, a prospective cohort study of street youth in Vancouver,Canada.BackgroundIt is estimated that approximately 340,000 Americans [1]and 100,000 Canadians are current injection drug users(IDU) [2]. Injection drug use can lead to overdose, infec-tious disease, loss of social and economic functioning andextensive engagement in criminal activity. In addition tothe morbidity and mortality associated with infectiousdiseases [3], overdose fatalities (usually opioid) amongIDU have been a leading cause of death within the generalwhere approximately one overdose death per day wasrecorded throughout the late 1990s [6]. At a societal level,injection drug use has created public health and fiscal cri-ses, with multiple costs to public health care and auxiliaryservices as well as the welfare and criminal systems [7-9].Costs associated with treatment of human immunodefi-ciency virus (HIV) and hepatitis C virus (HCV) infectionare also high [10]. In recent years, injection drug use hasbeen estimated to account for approximately 25% of newPublished: 24 May 2006Harm Reduction Journal 2006, 3:18 doi:10.1186/1477-7517-3-18Received: 23 March 2006Accepted: 24 May 2006This article is available from: http://www.harmreductionjournal.com/content/3/1/18© 2006 Wood 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)population in many urban areas in North America inrecent years [4,5], including British Columbia, Canada,HIV infections and 63% of new HCV infections in Can-ada, with similar rates observed in the US [11,12]. In Van-Harm Reduction Journal 2006, 3:18 http://www.harmreductionjournal.com/content/3/1/18couver, an explosive outbreak of HIV infection wasdocumented among IDU during the mid- to late-1990s,characterized by an HIV incidence rate of 18 per 100 per-son-years in 1997, one of the highest rates ever reportedin the developed world [13].Recent reports of increasing injection drug use and high-risk behavior by street youth in North America highlightthe growing risk of HIV transmission among younger agegroups and the urgent need to evaluate and inform pri-mary prevention strategies among this population [14].Street youth are particularly vulnerable to experiencinghealth-related harms for a variety of reasons. Theseinclude: lack of education about drug use, sexual healthrisks; sexual and physical violence; poverty and neglect;and precarious living conditions, either on the street or inrisky relationships, or both [15,16]. Not surprisingly,injection drug use has become a growing problem amongthis population. In the US, estimates of the prevalence ofinjection drug use among street youth range from 30% to40% [17-19], while a national study from the US foundapproximately 28% of street youth and a further 10% ofyouths living in shelters had participated in prostitution[20]. Estimates of the number of street youth in Canadahave ranged as high as 150,000 [21], with injection druguse reported by 38% and 54% of these individuals in Van-couver [22] and Montreal [23], respectively. As a conse-quence, street youth are increasingly recognized as beingamong the highest at risk of those sub-populations at riskfor HIV and HCV infection.Studies of factors associated with initiation of injectiondrug use have suggested that close friends introduce themajority of both males and females to injection drug use[24,25]. The mean age of individuals initiating injectionranges from 16 to 18 years, and the "introducer" is typi-cally an IDU several years older [24-26]. Roy et al. foundthat among Montreal street youth, more girls than boysrequired assistance injecting and were less likely to use aclean needle. Further, although a high proportion of newinitiates (84%) did inject with a clean needle, only 62%used clean drug preparation equipment [23]. Morerecently, prospective studies of youth transitioning fromnon-injection drug use to injection drug use have identi-fied a number of independent predictors for initiation ofinjection [15,27,28]. Fuller et al. identified race other thanAfrican American, exclusive crack smoking just prior toinitiating, smoking marijuana, high school dropout, andsex trading during the year prior to transition, particularlyamong young females, as correlates of transition fromnon-injection to injection drug use in a cohort of younghigh-risk drug users in Baltimore [27,28]. Roy et al. havereported from a cohort study in Montreal that: havingor freebase; being female with an IDU friend; and havingever experienced extra-familial sexual abuse were all asso-ciated with initiation of injection drug use by street youth[15].Nevertheless, large numbers of street youth exhibit manyof the above risk factors and do not transition into injec-tion drug use [22,29]. As such, many questions remainwith regard to why some drug users transition into injec-tion drug use and some do not [30]. In particular, there isuncertainty regarding other factors that may facilitate ini-tiation into injection drug use, such as the precise roles ofinjection drug users in one's social network [31,32]. Therole of expanded access to syringes, in settings wheresyringe exchange has become decentralized, has also notbeen explored.Although it is well documented that the environment,social networks, health policy, and accessibility of inter-ventions may contribute to or diminish the risk of HIVand HCV infection [10,13,33,34], published data aboutmacro-level risk factors associated with initiation of druginjection are scarce. Vancouver has recently initiated sev-eral secondary prevention programs aimed at reducingHIV incidence rates, including a large decentralized nee-dle distribution program with a flexible exchange policyand two medically supervised injecting clinics, yet no pro-grams are in place to evaluate the impact of these policieson street youth [35]. In addition, in recent years, evidencehas suggested that the use of methamphetamine hasgrown in western Canada, with Vancouver being the pri-mary site of this increase. Not surprisingly, methamphet-amine is commonly used by Vancouver street youth, andthe health-related harms associated with this practiceremain under-investigated.In light of the above concerns, and the fact that infectiousdiseases and other harms persist despite HIV preventionprogramming targeted towards injection drug users, it hasrecently been argued that the injection-related infectionrisk hierarchy should be updated so that the prevention ofinjection drug use is given greater priority [31,32]. Con-sistent with this call, a cohort of street youth has been ini-tiated in Vancouver, Canada. Known as the At Risk YouthStudy (ARYS, pronounced 'arise'), the study will seek toexamine the impact of the local decentralized syringe dis-tribution scheme and supervised injecting sites on therates of initiation of injection drug use. The workinghypothesis is that knowledge of and exposure to harmreduction programs among non-injecting youth will notbe associated with increased rates of initiation into injec-tion drug use. The ARYS study will also seek to examinethe impact of methamphetamine use on various health-Page 2 of 6(page number not for citation purposes)been homeless; being under 18 years of age; being tat-tooed; recent use of heroin, hallucinogens, cocaine, crack,related harms, as well as the potential role of metham-phetamine use in transitioning into injection drug use. InHarm Reduction Journal 2006, 3:18 http://www.harmreductionjournal.com/content/3/1/18this case, the working hypothesis is that smoked metham-phetamine will be associated with subsequent initiationinto injection drug use. In keeping with recent develop-ments related to improving reporting quality of non-ran-domized evaluations of behavioral and public healthinterventions [36], this paper describes the methodologybeing employed in the ARYS study to investigate risk fac-tors for initiation into injection drug use as well as poten-tial health-related harms of methamphetamine use.MethodsRecruitment and follow-upThe recruitment strategy for ARYS involves standard tech-niques for reaching hidden populations, and recruitmentwill be conducted from the city's streets and from youthagencies and services [37-39]. Since there are no registriesfrom which to draw street youth, the sample can beviewed as a convenience sample, although major effortsare being undertaken to try to maximize the representa-tiveness of the sample. This includes extensive street-based outreach, including outreach during the nighttime,and efforts to have street youth recruit their peers. Out-reach has also been systematically undertaken in a rangeof neighborhoods around the city where street youth areknown to congregate.After initial contact is made, the nature of the study isexplained and informed consent is offered to those whowish to enroll. Although these recruitment techniques areinferior to random recruitment methods, random recruit-ment of street youth was viewed to be impractical in oursetting, and we are unaware of any large prospective studyof street youth that has employed these methods. Eligibil-ity criteria include age (14 to 26 years) and use of drugsother than marijuana in the past 30 days. Eligibility is notrestricted to those youth who have already begun inject-ing, and although ORALscreen drug test kits are beingused to assess illicit drug use levels at baseline, this screenwill not be used to exclude potential enrollees.Data collection procedures for the ARYS cohort are similarto other prospective cohort studies of illicit drug userswhereby individuals provide a baseline blood sample formeasurement of HIV and hepatitis C (HCV) antibodiesand complete an interviewer-administered questionnaire.Pre- and post-test counseling and referral to health serv-ices are provided as part of the study. To enable high ratesof follow-up, contact information is obtained and indi-viduals are requested to return to the study site every sixmonths for the duration of the study, at which time bloodis again sampled for evaluation of HIV and HCV incidenceand a detailed follow-up questionnaire is administered. Afive-dollar incentive is also offered to youth to return afterin at the three-month mark. In addition, the vast majorityof youth who have enrolled to date have provided emailaddresses for follow-up purposes.Although it was expected at the outset that follow-up withthis particular population would be challenging, it isanticipated that these strategies may prove invaluable inensuring high rates of follow-up despite the issues ofmobility common among street youth.Outcome ascertainmentOutcome ascertainment for the ARYS cohort will involveblood testing, clinical evaluation of needle tracks, andself-reported behavioral data obtained through the inter-viewer-administered questionnaire. In addition, the localsetting is unique because of the availability of confidentialrecord linkages made possible through Canada's universalhealthcare system. Specifically, administrative databasescreate an opportunity for the accurate ascertainment ofkey measures, including emergency room and hospitaluse, medication use, and contact with various harm reduc-tion services, including the city's supervised injecting facil-ity. These linkages have several advantages, since self-reported health service use has been shown to be subjectto socially desirable responding [40].Although many youth-specific indicators have had to bedeveloped, the survey instrument for the ARYS cohort islargely based on the scales that have been developed aspart of the Vancouver Injection Drug Users Study(VIDUS), a prospective cohort study of IDU that has beendescribed in detail previously [13,41-43]. The surveyinstruments have been intentionally coordinated to facil-itate the examination of the natural history of injectiondrug use through to adulthood. Both surveys include sec-tions on sources of income, non-injection and injectiondrug use (including overdose and binging), interactionswith police, incarceration, sexual activity, drug and alco-hol treatment, violence, and nutritional needs. Both sur-veys also include standardized measures for depression(Centre for Epidemiologic Studies Depression Scale [44])and childhood trauma (Childhood Trauma Question-naire [45,46]), as well as HIV knowledge scales [47] and anon-standardized self-efficacy scale to evaluate self-effi-cacy to avoid injection drug use. The youth survey alsoincludes sections on educational background and expo-sure to injection drug use. The coordination of surveyinstruments allows us to seek to explore the relationshipbetween established injectors and new initiates into injec-tion drug use.Additional data sourcesThe above prospective cohort data will be augmented byPage 3 of 6(page number not for citation purposes)three months to check in and update their contact infor-mation, and thus far the majority of youth have checkeda number of other data sources. First, quantitative activi-ties of the ARYS cohort will be informed by a newly devel-Harm Reduction Journal 2006, 3:18 http://www.harmreductionjournal.com/content/3/1/18oped qualitative research program which will involve in-depth qualitative interviews with street youth to furtherexplore areas of interest. For instance, street youth whotransition into injection drug use during follow-up will betargeted for qualitative interviews so that the circum-stances of initiation into injection drug use can be furtherexplored. Second, there will also be an active ethno-graphic research team who will undertake field observa-tions of drug use behaviors among street youth in naturalsettings. When making observations and conductingunstructured interviews in natural settings, study staff willuse a verbal script to inform potential participants aboutthe research, its purpose, and the risks involved. We willalso obtain verbal informed consent before observing andrecording data in the natural settings of parks, streets, andalleyways where drug consumption activities are occur-ring and where street youth congregate. In instances wherestreet youth express that they are not willing to beobserved or participate, the researcher will remove him/herself from the immediate vicinity and attempt to engagewith street youth in another locale. Individuals participat-ing in unstructured qualitative interviews go through asimilar informed consent process before interviews areundertaken and field notes are recorded.Results and discussionEnrollment into ARYS began in October 2005, andapproximately 324 youth have been recruited to date. Pre-liminary evaluation of the cohort shows that participantsare approximately 72% male, 25% Aboriginal, and themedian age is 22 (inter-quartile range is 21–24). Notably,50% of all participants report either currently being orhaving been injection drug users.Unique ethical issues relating to methodology arise whenworking with a cohort that includes legal minors. Becauseone of the objectives of the study is to expand our currentunderstanding of the relationship between childhood sex-ual and physical abuse and initiation of injection druguse, questions of that nature are included on the question-naire. However, because of the legal duty to report abuseof persons under the age of 19 in our jurisdiction (BritishColumbia), researchers are placed in the position of hav-ing to carry out that legal duty in the course of collectingthese data from minors. This limitation to confidentialityis spelled out in the consent form, and participants areassured that they can refuse to answer questions aboutabuse (or any other topic) if they choose. When partici-pants under age 19 choose to disclose abuse in the courseof answering survey questions, interviewers are trained tofollow up on the duty to report. All efforts are made toreport with the participant's consent and full knowledge,and participants are offered referrals to free and availablethat participants would be more comfortable disclosingand participating in reporting the abuse with an experi-enced community health nurse. Further, two of the study'sinvestigators hold doctoral degrees in counseling psychol-ogy and are available for clinical supervision when disclo-sure of abuse occurs. Extensive consultation with thegovernment ministry responsible for investigating reportsof abuse occurred before the study commenced, as well aswith the chair of the research ethics board prior to submit-ting the application for ethics approval of the study. Thechallenge in terms of methodology is to collect theseimportant data from participants within a research proto-col that satisfies the legal duty to report abuse of minorsand ensures a standard of care in the process.ConclusionIn summary, the recent reports of increasing injectiondrug use and high-risk behavior by street youth in NorthAmerica highlight the growing risk of HIV transmissionamong younger age groups and the urgent need to evalu-ate and inform primary prevention strategies within thispopulation [14]. At present, many questions remain withregard to why some drug users transition into injectiondrug use and some do not [30], and it has recently beenargued that the injection-related infection risk hierarchyshould be updated so that the importance of preventionof injection drug use is emphasized [31,32].Vancouver, Canada, has recently initiated several second-ary prevention programs, including a large decentralizedneedle distribution program as well as two medicallysupervised injecting clinics, aimed at reducing HIV inci-dence rates among active injection drug users [35]. Inaddition, the city has experienced a substantial increase inmethamphetamine use among street youth. In responseto the above issues, the ARYS cohort has been developedto examine risk factors for initiation into injection druguse and the harms of methamphetamine use among streetyouth in this environment. Using the methodologydescribed above, recruitment was initiated in October2005, and initial reports from the ARYS cohort areexpected in the summer of 2006.Competing interestsThe author(s) declare that they have no competing inter-ests.Authors' contributionsEW, JS, TK drafted the manuscript and addressed thereviewers' helpful suggestions. All authors participated inthe drafting of the manuscript and approved the final ver-sion.Page 4 of 6(page number not for citation purposes)community counseling services. Questions about abuseare situated within the nurse's questionnaire, as it was feltAcknowledgementsWe thank the ARYS participants for volunteering their time to participate in the study. We also thank Deborah Graham, John Charette, Megan Ole-Harm Reduction Journal 2006, 3:18 http://www.harmreductionjournal.com/content/3/1/18son, Trevor Logan, Amir Abubaker, Steve Kain, Caitlin Johnston, Aaron Edie, and Laura Housden. 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Wood E, Li K, Miller CL, Hogg RS, Montaner JS, Schechter MT, KerrT: Baseline self-perceived risk of HIV infection independentlyPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2006, 3:18 http://www.harmreductionjournal.com/content/3/1/18predicts the rate of HIV seroconversion in a prospectivecohort of injection drug users.  Int J Epidemiol 2005, 34:152-158.43. Wood E, Kerr T, Small W, Li K, Marsh DC, Montaner JS, Tyndall MW:Changes in public order after the opening of a medicallysupervised safer injecting facility for illicit injection drugusers.  CMAJ 2004, 171:731-734.44. 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