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Sex work involvement among women with long-term opioid injection drug dependence who enter opioid agonist… Marchand, Kirsten; Oviedo-Joekes, Eugenia; Guh, Daphne; Marsh, David C; Brissette, Suzanne; Schechter, Martin T Jan 25, 2012

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RESEARCH Open AccessSex work involvement among women with long-term opioid injection drug dependence whoenter opioid agonist treatmentKirsten Marchand1, Eugenia Oviedo-Joekes1,2*, Daphne Guh1, David C Marsh3,4, Suzanne Brissette5 andMartin T Schechter1,2AbstractBackground: Substitution with opioid-agonists (e.g., methadone) has shown to be an effective treatment forchronic long-term opioid dependency. Survival sex work, very common among injection drug users, has beenassociated with poor Opioid Agonist Treatment (OAT) engagement, retention and response. Therefore, this studywas undertaken to determine factors associated with engaging in sex work among long-term opioid dependentwomen receiving OAT.Methods: Data from a randomized controlled trial, the North American Opiate Medication Initiative (NAOMI),conducted in Vancouver and Montreal (Canada) between 2005-2008, was analyzed. The NAOMI study comparedthe effectiveness of oral methadone to injectable diacetylmorphine or injectable hydromorphone, the last two on adouble blind basis, over 12 months. A research team, independent of the clinic services, obtained outcomeevaluations at baseline and follow-up (3, 6, 9, 12, 18 and 24 months).Results: A total 53.6% of women reported engaging in sex work in at least one of the research visits. At treatmentinitiation, women who were younger and had fewer years of education were more likely to be engaged in sexwork. The multivariate logistic generalized estimating equation regression analysis determined that psychologicalsymptoms, and high illicit heroin and cocaine use correlated with women’s involvement in sex work during thestudy period.Conclusions: After entering OAT, women using injection drugs and engaging in sex work represent a particularlyvulnerable group showing poorer psychological health and a higher use of heroin and cocaine compared towomen not engaging in sex work. These factors must be taken into consideration in the planning and provision ofOAT in order to improve treatment outcomes.Trial Registration: NCT00175357.Keywords: Sex work, opioid dependence, substitution treatment1. BackgroundOpioid dependence, frequently manifested as heroindependence, is a chronic illness that, when untreated,can result in adverse health consequences such asblood-borne viral infections, endocarditis and drug over-doses [1,2]. Illicit opioid use is also associated withsevere psychosocial problems such as homelessness,unemployment, loss of family bonds, and illegal activity[3]. Survival sex work is very common among streetdrug users and has been associated with increased drugrelated harms [4-7]. Although data indicate that womenas well as men using drugs engage in sex work, womenwho use injection drugs are more likely to be involvedin survival sex work compared to men [4,8,9].Data suggest that women who are injection drug users(IDU) and engage in sex work present greater vulner-abilities compared to non-sex workers using injectiondrugs. For example, they are more likely to have* Correspondence: eugenia@mail.cheos.ubc.ca1Centre for Health Evaluation & Outcome Sciences, Providence Health Care,St. Paul’s Hospital 620B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, CanadaFull list of author information is available at the end of the articleMarchand et al. Harm Reduction Journal 2012, 9:8http://www.harmreductionjournal.com/content/9/1/8© 2012 Marchand et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.unstable housing [4,10], higher rates of incarceration[4,10-12] and fewer years of education [12]. Thesewomen are also more likely to report daily injection her-oin use [10], higher rates of cocaine use [4] and bingedrug use [13]. These observations suggest that womenwho use injection drugs and engage in sex work may bemore vulnerable to adverse physical and psychologicalconsequences of injection drug use.Chronic health conditions and infectious diseases,such as human immunodeficiency virus (HIV) infection[14,15], hepatitis C [16] and sexually transmitted infec-tions (STI) are highly prevalent among female sex work-ers using injection drugs. This has been supported bystudies showing that HIV risk behaviours, includingsharing injection equipment [4,10,11,17] and inconsis-tent condom use with clients [10,17] are common riskbehaviours. Moreover, a recent study found that enga-ging in risky injection practices (e.g., sharing injectionequipment) was more likely among female sex workerswith psychological distress [17], indicating an associationbetween psychological health and disease risk. Psycholo-gical health has previously been measured among sexworkers and non-sex workers accessing opioid agonisttherapy (OAT). In a sample of injection drug usingwomen accessing MMT [12], it was determined that sexworkers had greater psychological symptoms includingdepression, anxiety, psychosis and hostility, compared towomen not involved in sex work.OAT (for example with methadone or buprenorphine) iswidely considered the most effective intervention foropioid dependency [18]. OAT has been proven effective atreducing illicit drug use and illegal activities, HIV infec-tions, as well as improving general health and psychosocialadjustment [2,18-20]. There is evidence showing thatinvolvement in sex work may be negatively associated withOAT access and outcomes, including reduced access tocare [4,21,22] and early withdrawal from a low-thresholdprogram [23]. Moreover, a recent randomized clinical trial(RCT) comparing Heroin Assisted Treatment (HAT) toMethadone Maintenance Treatment (MMT) found femalesex workers had higher illicit drug use and poorer healthoutcomes after 12 months of treatment relative to thosenot engaged in sex work [8].The studies described above suggest that amongwomen using injection drugs, sex work is a factor thatmay deter women from being engaged, retained andresponding to OAT. However, the factors that are asso-ciated with engaging in sex work after entering treat-ment are not well understood. The present study aimsto determine if health (physical, mental, social), illicitdrug use and treatment retention were associated withengaging in sex work after initiating OAT in a cohort oflong-term opioid injection drug users.2. MethodsDesign, Setting and ParticipantsThe North American Opiate Medication Initiative(NAOMI) was an open-label, phase III RCT comparingsupervised injected diacetylmorphine (the active ingredi-ent in heroin) and oral methadone in the treatment oflong-term opioid dependence. Participants’ profile, studydesign, methodology and results of the parent study havebeen published elsewhere [24-26]. Briefly, eligible partici-pants were at least 25 years of age, with a minimum of 5years of opioid dependence, current daily injection ofopioids, at least two prior treatment attempts for opioiddependence (including at least one OAT), and no enrol-ment in OAT within the prior 6 months.A total of 251 individuals were randomized to receiveoral methadone (n = 111) or injectable opioids (on adouble blind basis: diacetylmorphine, n = 115; hydro-morphone, n = 25). Oral methadone was dispensed dailyand injectable medications were administered up tothree times daily under the supervision of nursing staff.Participants were also offered psychosocial services andprimary care on site and all services were delivered in apatient-centred fashion [27]. Medications were providedfor 12 months. Since injectable medications were notlicensed for addiction treatment, an additional 3-monthperiod was provided to taper and transition those in theinjection group to other treatment modalities (primarilymethadone). All participants provided written informedconsent and the study was approved by the Universityof British Columbia/Providence Health Care and Centrede Recherche du Centre Hospitalier de l’université deMontréal research ethics boards.MeasuresA research team, independent of the clinic services,obtained outcome evaluations at baseline and follow-up(3, 6, 9, 12, 18 and 24 months), using the EuropeanAddiction Severity Index ([EuropASI]; [28]), the Mauds-ley Addiction Profile ([MAP]; [29]) and health relatedquality of life instrument- Euroquol ([EQ5D]; [30]). Forthe purpose of the present study, participants were con-sidered retained at each evaluation if they receivedaddiction treatment on at least 20 of the 30 days in themonth prior to the evaluation.Information related to sex work was obtained fromthe Employment/Support Status questionnaire of theEuropASI. Participants responded dichotomously towhether or not they received money from ‘Prostitution’in the prior 30 days.AnalysisContinuous variables were described by means, median,standard deviations and interquartile range, whileMarchand et al. Harm Reduction Journal 2012, 9:8http://www.harmreductionjournal.com/content/9/1/8Page 2 of 7frequencies and proportions summarized categoricalvariables. A multivariate logistic regression model esti-mated by generalized estimating equations (GEE) algo-rithm for repeated measures was used to determinefactors (socio-demographic, substance use, treatmenthistory, physical and psychological health, etc.) asso-ciated with reporting sex work at baseline. To evaluatethe relationship between sex work and study variablesmeasured during the 12 month treatment period and upto 24 months follow-up, a bivariate logistic regressionanalysis, adjusted by baseline sex trade involvement (i.e.,a logistic regression model with baseline sex trade invol-vement and one additional independent variable) wasused. Variables that were determined significant at pvalue ≤ 0.1 in bivariate analyses were included in theadjusted multivariate logistic regression model, esti-mated by generalized estimating equations (GEE) algo-rithm for repeated measures. Ethnicity, age, study site,randomization arm and treatment retention were addedthroughout the group variable and final model selec-tions. Odds ratios (OR) and 95% confidence intervals(CI) were calculated. Missing observations were consid-ered as missing in the analysis.Only four of 154 (1.3%) men reported engaging in sexwork; therefore, analyses were performed for womenonly. Of the 97 women entering treatment, we obtainedoutcome measures for 81 women at 24 months (83.5%).3. ResultsA total of 52 (53.6%) women receiving oral and inject-able medications reported being involved in sex work inat least one of the seven research visits (Table 1). Thir-teen women who were not engaged in sex work at base-line reported doing so at some point during the follow-up period, while 10 of the 52 women were consistentlyinvolved in sex work at each of the seven research visits.The multivariate analysis of factors associated with base-line sex work indicated that younger women (OR forevery 5 year increase in age = .76; 95% CI = .57,1.00; p= .05) and women with less education (OR for eachadditional year of education = .81; 95% CI = .66,1.01; p= .055) were more likely to engage in sex work.The bivariate logistic regression analysis, adjusted bybaseline sex trade (Table 2), indicated that treatmentretention and health related quality of life were inverselyassociated with sex work. Sex work was more likelyamong women with poorer scores in social relations,greater physical and psychological health symptoms andmore days of illicit heroin, cocaine and injection druguse in the prior month. Women considered to have ahigh (≥ 20) or medium (9-19) number of days of injec-tion drug use in the past 30 days were more likely toreport sex work compared to women with low days (≤8) of injection. In addition, compared to women whoinjected the least amount of times per day (≤ 3), thosewith the most frequent daily injection (≥ 7) were morelikely to report sex work in the prior 30 days. There wasa suggestion that injectable treatment had a protectiveeffect on engagement in sex work with an adjusted oddsratio of .83. However, this was not statistically signifi-cant. With only about 45 women in each arm ofNAOMI, the power to detect an odds ratio of .8 is vir-tually non-existent.In the multivariate logistic regression GEE model(Table 3), women with more days of heroin (OR = 1.26;95% CI = 1.05, 1.15; p = .01) and cocaine use (OR =1.36; 95% CI = 1.16, 1.60; p < .001) and greater psycho-logical symptoms (OR = 1.07; 95% CI = 1.03, 1.11; p <.001) in the prior month were more likely to engage insex work compared to those with less psychologicalsymptoms, and days of heroin and cocaine use.4. DiscussionThe aim of this study was to determine factors asso-ciated with engaging in sex work among long-termopioid injection drug users receiving OAT in the frameof a clinical trial. A higher proportion of women (53.6%)compared to men (1.3%), reported engaging in sex workTable 1 Total number of women reporting sex tradeWomen Total N = 97Sex trade n with sex trade % (out of total N) Total N with visit % (out of those with visit)Ever (a) 52 53.6 97 53.6Baseline 42 43.3 97 43.33 months 28 28.9 89 31.56 months 21 21.6 86 24.49 months 23 23.7 88 26.112 months 23 23.7 92 25.018 months 18 18.6 87 20.724 months 17 17.5 81 21.0(a) Reported ever being involved in sex trade at some point during the evaluation periodMarchand et al. Harm Reduction Journal 2012, 9:8http://www.harmreductionjournal.com/content/9/1/8Page 3 of 7in at least one of the seven research visits from baselineto 24 months. At treatment entry, age and educationwere associated with sex work, while during the studyperiod, psychological symptoms and frequent heroinand cocaine use in the prior 30 days were associatedwith sex work.At treatment initiation, women who were younger andhad fewer years of education were more likely to beengaged in sex work, factors which have previously beenassociated with sex work among women using injectiondrugs [4,10,12]. Housing, ethnicity and incarcerationshave also been documented in previous studies [4]. Thelack of such associations in the present study reflectsthe homogeneity of the NAOMI sample, possibly due tostudy inclusion criteria.When examining factors associated with sex workinvolvement during the study period, women withpoorer treatment outcomes were more likely to engagein sex work. Specifically, lower treatment retention,poorer scores in social relations and health relatedquality of life, more days of illicit drug use, injectiondrug use, and more frequent daily injection in theprior 30 days. These findings indicate that sex workwas more likely among a subgroup of women who didnot fully benefit from OAT, a noteworthy finding con-sidering that OAT has shown to reduce many of theharms associated with long-term heroin use [2,18].Moreover, in the present study women who wereretained successfully in OAT were less likely to beinvolved in sex work and therefore experienced areduced vulnerability to harms caused by injectiondrug use. While this is not a causal association, it indi-cates that those involved in sex work were more likelyto drop-out of treatment.In the multivariate model, psychological symptomsand high illicit heroin and cocaine use in the prior 30days were associated with sex work. Similarly, previousstudies have found that sex workers accessing MMT[12] and syringe exchange programs [10] presented withhigher psychological distress compared to women notengaged in sex work. In addition, a higher use of sub-stances [13], including more frequent daily heroin andcocaine use [4,10] has also been reported among injec-tion drug using women who also engage in sex work.The results of the present study complement priorresearch in the context of a prospective design thatallowed us to capture predictors of sex work involve-ment over a 24 month study period. After engagingthese participants in OAT, women who continued enga-ging in sex work were more likely to continue usingheroin and cocaine, independent of OAT retention.Thus, many women continued engaging in survival sexwork and using illicit heroin, despite that OAT improvesretention and reduces illicit heroin use. The complexityTable 2 Univariate logistic regression analysis, adjustedby baseline sex trade, of variables associated withengaging in sex trade after baselineVariable (a) OR p-value(95% CI)Treatment Retention: (b) 0.41 0.001Yes vs. No (0.24, 0.68)Social Relations: (c) 1.08 0.009Every 0.2 unit increase (1.02, 1.14)Days injecting drugs: (c) 6.40 < 0.001High (≥ 20) vs. Low (≤ 8) (3.37,12.18)3.26 0.002Medium (9-19) vs. Low (≤ 8) (1.53, 6.95)Times injecting on a typical day: (d) 5.40 0.001High (≥ 7) vs. Low (≤ 3) (2.05, 14.22)Days with heroin use: 5.12 < 0.001Every 5 day increase (2.76, 9.52)Days with cocaine use: 5.92 < 0.001Every 5 day increase (2.77, 12.66)EQ5D: (e) 0.99 0.019Every 0.1 unit increase (0.98, 1.00)Physical health symptoms: (d) 1.05 0.02Every 1 unit increase (1.01, 1.09)Psychological symptoms: (d) 1.09 < 0.001Every 1 unit increase (1.06, 1.13)OR: Odds ratios; CI: Confidence Interval(a) All variables refer to the prior month;(b) Retention to treatment: at least 20 out of prior 30 days;(c) EuropASI (European version of the Addiction Severity Index). Sub-scalescores range from 0 to 1; higher scores are indicative of more severeproblems;(d) MAP (Maudsley Addiction Profile). Scores range from 0 to 40; higher scoresare indicative of more symptoms;(e) EQ5D (Euroquol) Scores range from 0 to 1; higher scores are indicative ofless severe problems; EQ5D index score with U.S. weights.Table 3 Multivariate GEE model of predictors ofengaging in sex trade after baselineVariable (a) OR p-value(95% CI)Heroin use: 1.26 0.01Every 5 day increase (1.05, 1.15)Cocaine use: 1.36 < 0.001Every 5 day increase (1.16, 1.60)Psychological symptoms: (b) 1.07 < 0.001Every 1 unit increase (1.03, 1.11)OR: Odds ratios; CI: Confidence Interval;Model adjusted by ethnicity, interaction between age and randomization arm,treatment retention (not significant) and study site and baseline sex work(significant).(a) All variables refer to the prior month;(b) MAP (Maudsley Addiction Profile). Scores range from 0 to 40; higher scoresare indicative of more symptoms.Marchand et al. Harm Reduction Journal 2012, 9:8http://www.harmreductionjournal.com/content/9/1/8Page 4 of 7of the relationship between OAT effectiveness and itsimpact on sex work engagement requires further study.Education is regarded as a strong indicator of socialand health-related inequalities [31], and women withfewer years of education were more likely to engage insex work at treatment initiation. These findings indicatethat women with less education experience further vul-nerabilities even within a population with very lowsocio-economic status. Therefore, those who provideaddiction treatment services must consider this specialcircumstance, acknowledging women’s financial needsand the stigma attached to sex work, so that servicesand policies do not further exclude these groups.The present study focuses on long-term opioid injec-tion drug using women with and without involvementin sex work. It is well known that opioid-dependentindividuals often show poor mental and physical healthas well as poor psychosocial functioning, especially afterlong-term use [3,32,33]. There is also growing researchevidence among women and men accessing OATdemonstrating that women enter treatment with worsephysical and psychological health [8,9], as well as higheropioid and stimulant use [34,35,35]. Some evidence hasalso suggested that women have poorer OAT outcomescompared to men [8,9]. Therefore, women using injec-tion drugs represent a particularly important group inthe provision of effective addiction treatment.Unexpectedly, there was no association between victi-mization (e.g., physical, emotional, and sexual abuse)and sex work in the present study. Previous studies haveshown high rates of physical and sexual abuse in sexworkers’ childhood, and later victimization by partners[12,36] and clients in adulthood [37]. Moreover, in acohort study of youth using substances, childhood sex-ual abuse was independently associated with sex work[38]. One possible explanation for the absence of thisexpected association may be related to the measure ofvictimization. The Addiction Severity Index (ASI) hasbeen used to evaluate abuse in several studies [39], mea-suring victimization with a general question (e.g., “haveyou ever been physically or sexually abused?”). There-fore, [40-42] details regarding the nature of the event,which might account for the associations between victi-mization and sex work, are undetermined [43,44].Limitations of the NAOMI study have been discussedelsewhere [24,25]. It should be noted that the analysiswere intent-to-treat, therefore, some of the higher inten-sity drug use occurred in participants who were notreceiving the treatments as provided in the study (oraland injectable arms). Several gender sensitive and sexwork specific-related questions were not part of thestudy evaluation package (e.g., partner’s use of illicitsubstances, income earned from sex work to supportheroin use), that data would have provided a moredetailed picture of the situation. In addition, the trialwas not designed to investigate factors associated withsex work and we had a small sample size; however itprovided an opportunity to obtain valuable informationon this topic in the context of women receiving OAT.In order to better conceptualize the relationshipbetween high intensity drug use and sex work, addi-tional data regarding the reasons for sex work involve-ment during treatment, the proportion of earnings usedfrom sex work to support illicit drug use, and informa-tion regarding the people who depend on an individualinvolved in sex work, should be captured..The findings presented suggest that participation inNAOMI positively affected the pattern of sex work,showing a decline from enrolment to 24 months fol-low-up. At treatment entry, all NAOMI participantshad not received any treatment for the six monthsprior to study enrolment (as per inclusion criteria);therefore considered un-treated despite the availableoptions (e.g., methadone treatment). Engagement intreatment was associated with a decline in sex workover time. This particular group would have likelyremained outside of addiction treatment services, andlikely only initiated treatment for the opportunity toreceive injectable diacetylmorphine. Certainly,approaches that improve treatment engagement (suchas medically prescribed diacetylmorphine) for long-term treatment refractory heroin injectors, must besupported by current policies.5. ConclusionFindings of this study suggest that injection drug usingwomen engaged in sex work represent a highly vulner-able group with poorer psychological health and agreater use of heroin and cocaine while receiving OAT.Future research should aim to better understand the cir-cumstances around illicit drug use and sex work amongopioid-dependent individuals’ receiving OAT, as theseactivities impact treatment outcomes and the addictionrecovery process. In addition, mixed methods studiesexploring sex workers’ perceptions of OAT and barriersto treatment engagement may provide valuable informa-tion for the development of future interventions anddesign of tailored services which should aim to simulta-neously reduce the harms associated with injection druguse and sex work.AcknowledgementsThe study was funded through an operating grant by the CanadianInstitutes of Health Research (CIHR) with additional support from the CanadaFoundation for Innovation, the Canada Research Chairs Program, theUniversity of British Columbia, Providence Health Care, the University ofMontreal, Centre de Recherche et Aide aux Narcomanes, the Government ofQuebec, Vancouver Coastal Health Authority and the BC Centre for DiseaseControl. CIHR had no further role in study design; in the collection, analysisMarchand et al. Harm Reduction Journal 2012, 9:8http://www.harmreductionjournal.com/content/9/1/8Page 5 of 7and interpretation of data; in the writing of the report; or in the decision tosubmit the paper for publication.The authors wish to acknowledge the dedication of N. Laliberté, C. Gartry, K.Sayers, P-A Guevremont, P. Schneeberger, K. Lock, J. Chettiar, J. Lawlor, P.Pelletier, S. Maynard, M-I Turgeon, G. Brunelle, A. Chan, S. MacDonald, T.Corneil, J. Geller, S. Jutha, S. Chai, M. Piacsezna, S. Sizto, the many remainingstaff and members of the DSMB (A. Marlatt, N. El-Guebaly, J. Raboud, D. Roy).The authors also wish to recognize the many U.S. and Canadian (J. Rehm, B.Fischer) scientists who contributed to the early design discussions butultimately were unable to participate in the trial. Most importantly, theauthors wish to acknowledge and thank the NAOMI trial participants.Author details1Centre for Health Evaluation & Outcome Sciences, Providence Health Care,St. Paul’s Hospital 620B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.2School of Population and Public Health, University of British Columbia, 2206East Mall Vancouver, BC, V6T 1Z3, Canada. 3Centre for Addiction ResearchBC, University of Victoria, 2300 McKenzie Ave, Victoria, BC, V8P 5C2, Canada.4Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON,P3E 2C6, Canada. 5Centre de Recherche du Centre Hospitalier de l’Universitéde Montréal (CHUM), 1058 St-Denis Montréal, QC, H2X 3J4 Canada.Authors’ contributionsMTS, SB, DM made substantial contributions to conception and design ofthe study; MTS, SB, DM, EOJ and DG made substantial contributions toacquisition of data, and analysis and interpretation of data; KM madesubstantial contributions to analysis and interpretation of data. The first (KM),second (EOJ) and last author (MTS) wrote the first draft of the paper, thesenior statistician (DG) performed the data analyses. All authors criticallyrevised the manuscript for important intellectual content. The final decisionabout publishing the paper was made by all the authors.Competing interestsThe authors declare that they have no competing interests.Received: 30 May 2011 Accepted: 25 January 2012Published: 25 January 2012References1. Kuyper LM, Hogg RS, Montaner JSG, Schechter MT, Wood E: The Cost ofInaction on Hiv Transmission Among Injection Drug Users and thePotential for Effective Interventions. Journal of Urban Health-Bulletin of theNew York Academy of Medicine 2004, 81:655-660.2. Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R: Substitution treatmentof injecting opioid users for prevention of HIV infection. CochraneDatabase Syst Rev 2008, CD004145.3. March JC, Oviedo-Joekes E, Romero M: Drugs and social exclusion in tenEuropean cities. 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