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Factors associated with pretreatment and treatment dropouts: comparisons between Aboriginal and non-Aboriginal… Li, Xin; Sun, Huiying; Marsh, David C; Anis, Aslam H Dec 10, 2013

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RESEARCH Open AccessFactors associated with pretreatment andtreatment dropouts: comparisons betweenAboriginal and non-Aboriginal clients admittedto medical withdrawal managementXin Li1, Huiying Sun2, David C Marsh3 and Aslam H Anis2,4*AbstractBackground: Addiction treatment faces high pretreatment and treatment dropout rates, especially amongAboriginals. In this study we examined characteristic differences between Aboriginal and non-Aboriginal clientsaccessing an inpatient medical withdrawal management program, and identified risk factors associated with theprobabilities of pretreatment and treatment dropouts, respectively.Methods: 2231 unique clients (Aboriginal = 451; 20%) referred to Vancouver Detox over a two-year period wereassessed. For both Aboriginal and non-Aboriginal groups, multivariate logistic regression analyses were conductedwith pretreatment dropout and treatment dropout as dependent variables, respectively.Results: Aboriginal clients had higher pretreatment and treatment dropout rates compared to non-Aboriginal clients(41.0% vs. 32.7% and 25.9% vs. 20.0%, respectively). For Aboriginal people, no fixed address (NFA) was the only predictorof pretreatment dropout. For treatment dropout, significant predictors were: being female, having HCV infection, andbeing discharged on welfare check issue days or weekends. For non-Aboriginal clients, being male, NFA, alcoholas a preferred substance, and being on methadone maintenance treatment (MMT) at referral were associated withpretreatment dropout. Significant risk factors for treatment dropout were: being younger, having a preferred substanceother than alcohol, having opiates as a preferred substance, and being discharged on weekends.Conclusions: Our results highlight the importance of social factors for the Aboriginal population compared tosubstance-specific factors for the non-Aboriginal population. These findings should help clinicians and decision-makersto recognize the importance of social supports especially housing and initiate appropriate services to improve treatmentintake and subsequent retention, physical and mental health outcomes and the cost-effectiveness of treatment.Keywords: Aboriginal, Housing, Pretreatment dropout rate, Treatment dropout rate, Withdrawal management,Substance use disorders, DetoxificationBackgroundSubstance use disorders (SUD) are a common problemand a major issue of concern for Canada’s Aboriginalpopulation [1]. Aboriginal people are also overrepre-sented among HIV and AIDS cases in Canada. They rep-resented 3.8% of the Canadian population [2], and yetaccounted for 8.0% of all prevalent HIV infections and12.5% of new infections in 2008. The estimated newinfection rate among Aboriginal people was about 3.6times higher than that among non- Aboriginal people.In addition, the proportion of estimated new HIV infec-tions in 2008 among Aboriginal people who inject drugs(66%) was also much higher than that among all Canadians(17%) [3].British Columbia (BC) had the second largest Aboriginalpopulation among all Canadian provinces, representing 5%of the provincial population, and the census metropolitan* Correspondence: aslam.anis@ubc.ca2Centre for Health Evaluation and Outcome Sciences, 588-1081 BurrardStreet, Vancouver, B.C. V6Z 1Y6, Canada4School of Population and Public Health, University of British Columbia,Vancouver, B.C. V6Z 1Y6, CanadaFull list of author information is available at the end of the article© 2013 Li 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.Li et al. Harm Reduction Journal 2013, 10:38http://www.harmreductionjournal.com/content/10/1/38area of Vancouver had the largest Aboriginal population ofany city in BC [2]. Vancouver’s Downtown Eastside (DTES)is the most impoverished urban neighborhood in Canadaand is the centre of the injection drug epidemic in Vancou-ver; 4,700 injection drug users (IDUs) were estimated tolive in DTES in 2000 [4]. Previous studies on Vancouverhave shown that Aboriginal people are overrepresentedamong injection drug users (IDUs) in DTES, are becomingHIV positive at twice the rate of non-Aboriginal IDUs,have a six-fold higher incidence of acute hepatitis C infec-tion (HCV) and are more likely to be co-infected with HIVand HCV compared to the non-Aboriginal population.In addition, they also have higher rates of drug-induceddeaths [5].Although previous studies have shown that addictiontreatment programs are effective in reducing substanceuse, in improving clients’ health and social function andin reducing public health and safety risks [6-8], they facehigh pretreatment and treatment dropout rates, rangingfrom 28% to 50% [9-11] and 20% to 46% [12-14], re-spectively. Several studies have examined correlates oftreatment dropout rates from drug and alcohol detoxifica-tion programs [15-22]. Although there was no consensuson whether or not specific features of a detoxification pro-gram significantly improve client retention, these studiesdid identify several client-related factors that were relatedto the treatment dropout rate, such as age [15,16,21], edu-cation [16,18], living condition [18], presence of legalproblems [16,17], substance use pattern [15,17,19,21], andtiming of welfare payments [21]. However, little researchhas been carried out to provide clinically relevant researchon appropriate treatment for Aboriginal populations. Theonly study, which examined risk factors associated withdropout among Aboriginal people, found that a preferreddrug other than alcohol and self-referral were two signi-ficant predictors of treatment dropout for this group ofpeople [20].Vancouver has a wide range of addiction services in-cluding a multilevel withdrawal management continuum[23]. The aim of this study was to examine characteristicdifferences between Aboriginal and non-Aboriginal cli-ents accessing an inpatient medical withdrawal manage-ment program in Vancouver. In addition, we identifiedrisk factors associated with pretreatment and treat-ment dropout rates for the two populations. Specific-ally, based on previous literature, the present studyhypothesized that in addition to the factors such as socio-demographics, current substance use, and IDU-relateddiagnoses, day of discharge in relation to treatment drop-out might also affect treatment dropout as it is possiblethat different staffing on weekdays versus weekendsor some special events, such as once-a-month welfarecheck issuance (welfare Wednesday), might contribute toclient dropout.MethodsStudy sampleThe sample consisted of 2231 individuals who calledACCESS 1 requesting service at Vancouver Detox (VD)between July 1, 2003 and June 30, 2005. For those clientswho called multiple times, only the first referral duringthe study period was included. Despite the multicul-tural nature of Vancouver, no ethnic group other thanEuropean/White and Aboriginal represented 5% or moreof the total in our sample, therefore, the present study fo-cused on the Aboriginal versus non-Aboriginal groups.Ethical Approval was obtained from the Behavioural Re-search Ethics Board at the University of British Columbia.Treatment settingVD offers a medically managed 24-bed mixed-gender in-patient withdrawal management treatment in Vancouver,British Columbia. It is staffed by a multidisciplinaryteam, consisting of addiction medicine physicians, nurses,health care workers, intake workers, and alcohol and drug(A&D) counselors. It provides 24-hour nursing staff, onsitemedical assessment and treatment, and medical manage-ment of withdrawal symptoms and other identified healthconcerns. Vancouver Detox can be accessed free of chargeby anyone registered with a provincial medical servicesplan and living in the Vancouver Coastal Health catchmentarea. Thus, there are no financial barriers to treatment.The entry point to VD is by ACCESS 1, a central tele-phone intake service. After an initial telephone screen-ing, ACCESS 1 determines whether the client is eligiblefor the service. The main eligibility criteria for VD are:1) above the age of fifteen, 2) having unstable medical orpsychiatric conditions, and/or 3) having a history pre-dictive of severe withdrawal, and 4) not pregnant at thetime of call. If the client meets the criteria for VD, he/sheis either admitted to VD immediately or placed on a wait-list for a bed to become available. Once admitted, the clin-ical staff complete a comprehensive assessment anddevelop an individualized treatment plan. During the ad-mission, the client participates in various rehabilitative pro-grams, including such activities as: individual counseling,educational groups, 12-step programs, acupuncture andother alternate therapies. Clients admitted on methadonemaintenance are maintained on this medication through-out the admission. Clients are either discharged by success-fully completing the program or voluntarily dropping outby terminating against medical advice (AMA). Upon dis-charge clients are referred to other services as required.DataDuring the initial phone interview, ACCESS1 staffcollect some basic information such as age, gender, ad-dress, and conduct a brief addiction assessment using aVancouver Coastal Health Authority on-line, real-timeLi et al. Harm Reduction Journal 2013, 10:38 Page 2 of 7http://www.harmreductionjournal.com/content/10/1/38system, Primary Access Regional Information System(PARIS) database. Once a client is admitted to the VD,an intake worker verifies the information inputted byACCESS1 and completes a more comprehensive assess-ment which is entered into the database. During the ad-mission, the VD staff update the clinical information inPARIS until the client is discharged.The PARIS database is comprehensive and includesmany variables. For the purpose of this study the follow-ing variables were extracted: clients’ unique identification(PARIS number), demographic information (age, gender,ethnicity, parenting status), housing information (no fixedaddress (NFA) vs. others), system characteristics (referral,admission, and discharge dates), substance use disorder-related information (substances recently used, primarypreferred substance(s), discharge reason, if on existingmethadone maintenance, and pre-existing IDU-relateddiagnoses such as hepatitis C (HCV) or HIV infection).Statistical analysesContingency table analysis (the Chi-square test) and theWilcoxon rank-sum test were used for bivariate compar-isons of categorical and continuous variables, respect-ively. For both Aboriginal and non-Aboriginal groups,logistic regression analyses were performed separatelywith pretreatment dropout and treatment dropout as thedependent variables. For comparison purpose, variablesthat were significant at p < 0.25 in either bivariate analysiswere subsequently entered into the multivariate logisticregression models for both Aboriginal and non-Aboriginalgroups. Odds ratios (ORs) and 95% confidence intervals(CIs) were computed. All statistical analyses were per-formed using SAS 8.2 software program [24].ResultsAmong 2231 unique clients who were referred byACCESS1 to VD during the study period, 451 (20%)clients self identified as Aboriginal. Compared withthe non-Aboriginal group at referral, the Aboriginalgroup was younger, more likely to be female and NFA,and had higher rates of HIV and HCV. In addition, theAboriginal group had proportionately more poly-drugusers (Table 1).Among the referred clients, 767 (34%) dropped outwithout engaging in treatment. Among these, 185 clientswere Aboriginal. The pretreatment dropout rate forAboriginals was therefore 41%, whereas the rate was32.7% for the non-Aboriginal group. For 1464 clientswho initiated treatment, 309 (21.1%) left the serviceAMA. Among these, 69 were Aboriginal. As a result, thetreatment dropout rates for the Aboriginal and non-Aboriginal groups were 25.9% and 20.0%, respectively. Inaddition, our data indicated that the pretreatment dropoutsaccounted for the major proportion of total dropouts forboth groups, representing 72.8% for the Aboriginal groupand 70.8% for the non-Aboriginal group.Results of the bivariate and multivariate analyseson pretreatment dropout for both the Aboriginal andnon-Aboriginal groups are presented in Table 2. For theAboriginal group, without fixed address (OR = 1.75, 95%CI 1.10 – 2.79) was the only significant predictor of pre-treatment dropout. For the non-Aboriginal group, ourresults showed that females (OR = 0.72, 95% CI 0.57 –0.91) were less likely to be pretreatment dropouts thantheir counterparts. On the other hand, the probability ofpretreatment dropout was higher for people withoutfixed address (OR 1.87, 95% CI 1.40 – 2.48). Clients whoseprimary preferred substance was alcohol were more likelyto be pretreatment dropouts than clients whose pre-ferred substance was other than alcohol (OR = 1.77,95% CI 1.36 – 2.30). In addition, clients on methadonemaintenance treatment (MMT) at referral had higherprobability of pretreatment dropout (OR = 2.30, 95% CI1.40 – 3.79).Table 3 presents the bivariate and multivariate analyseson treatment dropout for both the Aboriginal and non-Aboriginal groups. Our final multivariate logistic analysisshowed that for the Aboriginal group, females (OR = 2.07,95% CI 1.03 – 4.15) and clients who reported to have HCV(OR = 4.91, 95% CI 2.43 – 9.94) were more likely to dropout of treatment. In addition, compared to clients who dis-charged in other days, clients who discharged during theweekend (OR = 2.28, 95% CI 1.04 – 5.01) or during 3-daywelfare check issue periods (OR = 2.84, 95% CI 1.06 –7.59) were more likely to be treatment dropouts. Inthe non-Aboriginal group, older clients (annual changeOR = 0.97, 95% CI 0.96 – 0.99) and clients whose primarypreferred substance was alcohol (OR 0.72, 95% CI 0.53 –0.99) were less likely to drop out of treatment. On theother hand, clients who used opiates as primary preferredsubstance (OR = 1.63, 95% CI 1.08 – 2.46), and clients whodischarged during weekend (OR = 2.44, 95% CI 1.71 –3.46) were more likely to be treatment dropouts. Therewas no significant impact of welfare issuance on non-Aboriginals.DiscussionAboriginal people in Canada are facing a lot of socialchallenges. Historical policies that legalized racial iden-tities and systemic inequity, and cast Aboriginal peopleto the margins of Canadian societies still extract consid-erable influence on the social, cultural, political and spir-itual inequities that Aboriginal people endure [25].Specifically, Aboriginal adults are more likely to experi-ence social exclusion, less likely to access economic re-sources and opportunities such as participation in paidwork and therefore more likely to have low income andbe homeless [25] and are overrepresented in custodyLi et al. Harm Reduction Journal 2013, 10:38 Page 3 of 7http://www.harmreductionjournal.com/content/10/1/38and community correctional programs [26]. In addition,Aboriginal children are overrepresented in the Canadachild welfare system [27]. Moreover, they have been shownto bear a disproportionate burden of illness, substance usedisorders, and disease in Canadian society [1]. In our sam-ple, Aboriginal individuals, who accounted for approxi-mately 5% of the BC provincial population, comprised 20%of clients in the VD. In addition, our findings showed thatAboriginal clients appeared to be different from their non-Aboriginal counterparts in terms of age, gender, housingstatus, substance use pattern and pre-existing IDU-relateddiagnoses. The multivariate logistic analyses also revealeddifferent risk factors of pretreatment and treatment drop-out rates for the two groups. These findings reinforce theneed for culturally appropriate services for Aboriginalswho are at a greater risk for negative outcomes within thecurrent addiction treatment system.It was interesting to show that rather than demo-graphic or substance use-related information, lack of afixed address was the only factor that was significantlyassociated with pretreatment dropout for Aboriginal cli-ents. To prevent attrition early in the treatment phase forthis group of clients, our findings suggest that interven-tions such as providing these homeless clients with tem-porary accommodations will allow treatment staff to moreeasily reach them once beds are available and to cater totheir immediate health needs. This could also then im-prove treatment initiation significantly. Our findings areconsistent with the findings found by “At Home” study. In2008, the Government of Canada allocated $110 million toTable 1 Comparisons between aboriginal and non-aboriginal clients who were referred to Vancouver Detox (N = 2231)Variable N Aboriginal N (%) Non-aboriginal N (%) P value2231 451 1780 .Age (years (SD)) 37.8 (9.1) 41.2 (11.4) <0.0001Female 788 207 (46.0) 581 (32.8) <0.0001Dependent children 184 40 (8.9) 144 (8.1) 0.5910Self-referrals 2126 434 (96.2) 1692 (95.1) 0.2928No fixed address (NFA) 362 105 (23.3) 257 (14.4) <0.0001HIV positive 153 71 (15.7) 82 (4.6) <0.0001Hepatitis C 671 207 (45.9) 464 (26.1) <0.0001Alcohol as primary substance of choice 1321 286 (64.6) 1035 (59.1) 0.0363Cocaine as primary substance of choice* 759 200 (45.1) 559 (31.9) <0.0001Opiates as primary substance of choice** 381 72 (16.3) 309 (17.7) 0.4889Poly-drug use 661 160 (36.2) 501 (28.6) 0.0019Methadone prescribed 92 20 (4.4) 72 (4.0) 0.7101*Cocaine group includes cocaine, crack cocaine.**opiates group includes heroin, methadone, oxycodone, other opiates.Table 2 Bivariate and multivariate logistic regression of pretreatment dropout for aboriginal and non-aboriginal clientsAboriginal (N = 451) Non-aboriginal (N = 1780)Bivariate analysis Multivariate analysis* Bivariate analysis Multivariate analysis**Variables P value OR 95% CI P value OR 95% CIAge 0.48 0.99 (0.96, 1.01) 0.16 0.99 (0.98, 1.00)Female 0.24 0.97 (0.64, 1.48) 0.00 0.72† (0.57, 0.91)Dependent children (Yes) 0.14 0.56 (0.27, 1.19) 0.04 0.73 (0.49, 1.09)No fixed address (NFA) 0.01 1.75† (1.10, 2.79) 0.00 1.87† (1.40, 2.48)Alcohol as primary substance of choice 0.01 1.40 (0.86, 2.25) 0.00 1.77† (1.36, 2.30)Cocaine as primary substance of choice 0.02 0.77 (0.49, 1.19) 0.23 1.25 (0.97, 1.61)Opiates as primary substance of choice 0.23 0.93 (0.49, 1.77) 0.38 0.99 (0.72, 1.37)Poly-drug use (Yes) 0.03 0.71 (0.43, 1.17) 0.73 0.99 (0.74, 1.32)Methadone prescribed (Yes) 0.58 1.04 (0.38, 2.83) 0.01 2.30† (1.40, 3.79)*P-value for Hosmer and Lemeshow goodness of fit test was 0.63.**P-value for Hosmer and Lemeshow goodness of fit test was 0.53.†Statistically significant at p < 0.05.Li et al. Harm Reduction Journal 2013, 10:38 Page 4 of 7http://www.harmreductionjournal.com/content/10/1/38the Mental Health Commission of Canada (MHCC) toundertake the “At Home” study, a four-year project infive cities that aimed to provide practical, meaningfulsupport to Canadians experiencing homelessness andmental health problems. The preliminary result of thestudy has shown that implementing a Housing First strat-egy can significantly improve homeless clients with mentalillness and/or SUD to access the type of care that is vitalfor recovery [28].For the non-Aboriginal group, in addition to NFA, wefound that several other factors such as being male, alco-hol as a preferred substance, and being on MMT at refer-ral were also associated with dropout before treatment.Previous studies have shown that longer delay betweenthe initial phone contact and the scheduled appointmentis negatively associated with treatment initiation [29,30].However, the tolerance for delay and reasons for delaymight vary for different clients. Specifically, those with al-cohol alone, as the problem substance, may be receivingtreatment services from a primary care physician or emer-gency room and be prescribed benzodiazepines for out-patient management of withdrawal and thus preventingthe need for admission. On the other hand, clients en-rolled in MMT at referral might have a longer wait timethan other clients because of the need to coordinate thedate and time of last dose taken in the community and tomaintain continuity of MMT.With regards to treatment dropout, our results alsoshowed completely different sets of factors that were as-sociated with treatment dropout AMA for the Aboriginaland non-Aboriginal groups. Specifically, Aboriginal butnot other clients being HCV positive was associated withincreased risk of leaving AMA compared to those whodid not have this disease. HCV + status may be a markerfor more severe dependence and injection drug use [31]as well as increased social marginalization [32,33]. Inaddition, previous literature has shown that there are sig-nificant increases in hospital admission, emergency de-partment admission, emergency calls and deaths shortlyafter the distribution of monthly welfare cheques [34,35].Our data showed that this was also a factor for Aboriginalclients at VD.In contrast to our findings, Callaghan’s study foundthat a preferred drug other than alcohol and self-referralwere significantly associated with treatment dropout forAboriginals [20]. Callaghan’s sample contained a largeproportion of Aboriginal clients who were referred tothe service by other sources such as from physicians orsocial service or mental health care providers. However, inthe present study, the majority of the Aboriginal people(96%; data not shown) were self-referred. In addition, ourstudy focused exclusively on urban Aboriginals, whereasCallaghan’s data was from a rural setting and included30% who reported their primary residence as “on-reserve”.Further study is warranted to clarify the different treat-ment needs of urban and rural Aboriginals as well as theimpact of being “Status Indians” on reservations. For thenon-Aboriginal group, our findings are in accord withother studies which found that younger patients [15,16]were more likely to leave AMA, and those with opiates asTable 3 Bivariate and multivariate logistic regression of treatment dropout for aboriginal and non-aboriginal clientsAboriginal (N = 266) Non-aboriginal (N = 1198)Bivariate analysis Multivariate analysis* Bivariate analysis Multivariate analysis**Variables P value OR 95% CI P value OR 95% CIAge 0.22 1.00 (0.96, 1.04) 0.00 0.97† (0.96, 0.99)Female 0.02 2.07† (1.03, 4.15) 0.18 1.00 (0.72, 1.37)Dependent children (Yes) 0.09 2.15 (0.83, 5.59) 0.93 1.07 (0.64, 1.80)No fixed address (NFA) 0.32 1.53 (0.71, 3.31) 0.11 1.09 (0.70, 1.70)Hepatitis C (Yes) 0.00 4.91† (2.43, 9.94) 0.02 1.41 (0.98, 2.02)HIV positive (Yes) 0.48 0.49 (0.20, 1.17) 0.22 0.47 (0.21, 1.07)Alcohol as primary substance of choice 0.04 1.21 (0.59, 2.48) 0.00 0.59† (0.40, 0.85)Cocaine as primary substance of choice 0.02 1.62 (0.77, 3.40) 0.81 0.73 (0.51, 1.05)Opiates as primary substance of choice 0.00 2.09 (0.89, 5.05) 0.00 1.63† (1.08, 2.46)Poly-drug use (Yes) 0.01 1.28 (0.59, 2.78) 0.01 0.93 (0.63, 1.39)Days of discharge‡ 0.22 0.00Weekend 2.28† (1.04, 5.01) 2.44† (1.71, 3.46)Welfare check issue period 2.84† (1.06, 7.59) 1.51 (0.96, 2.38)*P-value for Hosmer and Lemeshow goodness of fit test was 0.60. **P-value for Hosmer and Lemeshow goodness of fit test was 0.84.†Statistically significant at p < 0.05.‡The reference category was being discharged on other weekdays. Welfare check issue periods were defined as welfare Wednesday, one day before (Tuesday)and one day after (Thursday).Li et al. Harm Reduction Journal 2013, 10:38 Page 5 of 7http://www.harmreductionjournal.com/content/10/1/38primary drug of choice were more likely to not completetheir scheduled treatment [36].The following limitations merit discussion. First, theinformation on substance use and drug-related diseaseswere based on self-report. However, previous studieshave shown that patients’ self-reports of drug use arereasonably reliable and valid to provide descriptions ofdrug use, drug-related problems and the natural historyof drug use [37]. Self-reported HIV and HCV status,however, likely under-represent the true prevalence ofthese infections [38]. Second, we did not have data onmedication used during treatment and it is possible thatthis could influence treatment dropout [15]. Third, thisstudy did not include assessment of psychiatric diagno-ses, which previous literature has shown to be associatedwith both pretreatment and treatment dropouts [39,40].ConclusionsHigh pretreatment and treatment dropout rates may re-flect the fact that the current addiction treatment systemfails to retain the clients. Therefore, examining risk fac-tors that are associated with pretreatment and treatmentdropouts for Aboriginal and non-Aboriginal clients withsubstance use disorders have very important policy impli-cations. It can help policy makers better understand whythe system fails to retain the client and design and initiateculturally appropriate services to improve the current ad-diction treatment system. Specifically, our results highlightthe importance of social factors, such as homelessness andtiming of welfare check issuance for the Aboriginal popu-lation compared to substance-specific factors (drug ofchoice, for example) for the non-Aboriginal population.Although the study findings were drawn from a detox ser-vice in Vancouver DTES almost 10 years ago and sincethen social housing and addiction services in Vancouverhave expanded [27]; however, factors associated with pre-treatment and treatment dropouts, such as overrepresen-tation of the Aboriginals in Vancouver DTES, timing ofwelfare check issuance, and waiting times for detox stillexist, and therefore our findings remain pertinent in pro-viding information that can help clinicians and decision-makers design and initiate culturally appropriate servicesto minimize pretreatment and treatment dropout ratesand therefore to improve the current addiction treatmentsystem for both Aboriginal and non-Aboriginal clients,thereby improving clients’ physical and mental healthoutcomes and increasing cost-effectiveness of treatmentresources.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsXL took part in the conception of the study design and interpretation ofresults and drafted the manuscript. HS undertook statistical analyses andtook part in conceiving the study design and interpreting results. DMinterpreted results and was involved in the critical revision of the article forimportant intellectual content. AA was involved in the critical revision of thearticle for important intellectual content. All authors read and approved thefinal manuscript.AcknowledgementsWe would like to gratefully acknowledge the staffs at ACCESS 1 and VancouverDetox for their administrative support and helpful comments. In particular, JohnCollens and Mary Marlow deserve special mention.Author details1Antai College of Economics & Management, Shanghai Jiao Tong University,535 Fhuazhen Rd, Shanghai, China. 2Centre for Health Evaluation andOutcome Sciences, 588-1081 Burrard Street, Vancouver, B.C. V6Z 1Y6, Canada.3Northern Ontario School of Medicine, Vancouver, B.C. V6Z 1Y6, Canada.4School of Population and Public Health, University of British Columbia,Vancouver, B.C. 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J Behav Health Serv Res 2002, 29(2):138–143.doi:10.1186/1477-7517-10-38Cite this article as: Li et al.: Factors associated with pretreatment andtreatment dropouts: comparisons between Aboriginal and non-Aboriginal clients admitted to medical withdrawal management. HarmReduction Journal 2013 10:38.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitLi et al. Harm Reduction Journal 2013, 10:38 Page 7 of 7http://www.harmreductionjournal.com/content/10/1/38

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