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Hunger and associated harms among injection drug users in an urban Canadian setting Anema, Aranka; Wood, Evan; Weiser, Sheri D; Qi, Jiezhi; Montaner, Julio S; Kerr, Thomas Aug 26, 2010

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RESEARCH Open AccessHunger and associated harms among injectiondrug users in an urban Canadian settingAranka Anema1,2, Evan Wood1,2, Sheri D Weiser3,4, Jiezhi Qi1, Julio SG Montaner1,2, Thomas Kerr1,2*AbstractBackground: Food insufficiency is often associated with health risks and adverse outcomes among marginalizedpopulations. However, little is known about correlates of food insufficiency among injection drug users (IDU).Methods: We conducted a cross-sectional study to examine the prevalence and correlates of self-reported hungerin a large cohort of IDU in Vancouver, Canada. Food insufficiency was defined as reporting “I am hungry, but don’teat because I can’t afford enough food”. Logistic regression was used to determine independent socio-demographic and drug-use characteristics associated with food insufficiency.Results: Among 1,053 participants, 681 (64.7%) reported being hungry and unable to afford enough food. Self-reported hunger was independently associated with: unstable housing (adjusted odds ratio [AOR]: 1.68, 95%confidence interval [CI]: 1.20 - 2.36, spending ≥ $50/day on drugs (AOR: 1.43, 95% CI: 1.06 - 1.91), and symptoms ofdepression (AOR: 3.32, 95% CI: 2.45 - 4.48).Conclusion: These findings suggest that IDU in this setting would likely benefit from interventions that work toimprove access to food and social support services, including addiction treatment programs which may reduce theadverse effect of ongoing drug use on hunger.BackgroundThere were between 155 and 250 million illicit drugusers worldwide in 2009 [1], including an estimated16 million injection drug users (IDU) [2]. IDU face mul-tiple structural and behavioral barriers to accessinghealth care and social support services, which collec-tively serve to compound health risks and exacerbatepoor health outcomes [3]. IDU are known to be vulner-able to developing nutritional deficiencies, and oftensimultaneously experience numerous forms of microand macronutrient deficiencies [4,5].Insufficient consumption of food among IDU has beenassociated with an array of harms. Caloric insufficiencyhas been correlated with decreased immune function [6]and elevated risk of receiving a positive tuberculin test[7]. Insufficient caloric intake has been additionally asso-ciated with increased risk of various health complica-tions including invasive candidiasis, viral hepatitis,bacterial pneumonia, and various infections includingsubcutaneous and perianal abscesses among IDU [5].Studies evaluating the prevalence of nutritional deficien-cies among IDU have tended to focus on HIV-infectedpopulations [8,9]. In high resource settings, self-reportedhunger, a marker of food insufficiency, has been foundto be particularly elevated among IDU living with HIV/AIDS [10]. Self-reported hunger has been additionallycorrelated with unprotected sex and risk of HIV trans-mission, which is believed to be a result of survivalsex-trade involvement [11].Little is known about the social and behavioral riskfactors, independent of HIV infection, that contribute tofood insufficiency among IDU. We therefore sought toevaluate the prevalence of and socio-demographic anddrug-using characteristics associated with self-reportedhunger in a cohort of HIV-negative IDU in BritishColumbia, Canada.MethodsThe Vancouver Injection Drug Users Study (VIDUS)was initiated in May 1996. VIDUS has been described indetail previously [12]. Briefly, participants were eligiblefor inclusion in VIDUS if they had injected illicit drugs* Correspondence: uhritk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, BC, CanadaFull list of author information is available at the end of the articleAnema et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:20http://www.substanceabusepolicy.com/content/5/1/20© 2010 Anema et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.at least once in the past month, lived in the GreaterVancouver region and if they provided written informedconsent. At baseline, and semiannually thereafter,VIDUS participants provide blood samples for labora-tory analysis, and completed an interviewer-adminis-tered questionnaire. The VIDUS questionnaire elicitsinformation about socio-demographic status, injectionand non-injection drug use, HIV risk behavior, incomegeneration, encounters with police, and health serviceutilization. The questionnaire is based on a previousinstrument developed for adult drug users, and has beenfound to reliably identify factors associated with HIVinfection and other harms [13]. Participants receive anhonorarium of $20 CDN for each study visit. Ethicalapproval for VIDUS is obtained on an annual basis fromthe Providence Health Care/University of British Colum-bia Research Ethics Board.Questions regarding hunger were first included in theVIDUS instrument in December 2005. All individualswho completed a baseline interview between December,2005 and March, 2009 were included in this analysis.Hunger is considered to be a severe manifestation offood insecurity [14]. Self-reported hunger, the primarydependent variable, was defined as answering ‘yes’ to thequestion: “I am hungry, but don’t eat because I can’tafford enough food”. This definition of current self-reported was extracted from a validated food insecurityscale published by Radimer/Cornell [14]. Independentfrom the validated scale, this individual statement hasbeen tested, and shown to have good specificity andsensitivity when compared to dietary proxies of foodinsufficiency in five North American settings [15].In this cross-sectional analysis, we examined the pointprevalence of self-reported hunger among IDU in rela-tion to the following socio-demographic variables: med-ian age, gender (male vs. female), ethnicity (Aboriginalvs. other), incarceration in the last 6 months (yes vs.no). We also explored several markers of socioeconomicstatus including: a) downtown eastside residency (yes vs.no), which is a community known as Canada’s poorestpostal code, and is characterized by high prevalence ofunstable housing and illicit drug use [16,17], b) unstablehousing (single-room occupancy dwelling, shelter, hos-tel, treatment centre or no fixed address vs. apartmentor house), and c) current education status (high schoolor greater vs. other). We also examined self-reportedsymptoms of depression in the past week (≥ 16 CES-Dscore vs. < 16 CES-D score). Illicit drug use behaviorsconsidered included: a) daily heroin injection in the pastsix months (yes vs. no), b) daily non-injection crack/rock in the past six months (yes vs. no), c) daily injec-tion cocaine in the past six months (yes vs. no), d) anyinjection or non-injection crystal methamphetamine inthe past six months (yes vs. no), e) any injection ornon-injection drug binge in the past six months, definedas ‘[a time when you] injected drugs more than usual,or used any non-injection drugs more than usual’ (yesvs. no), f) daily alcohol use (≥ 4 drinks vs. < 4 drinks),and g) difficulty accessing drug/alcohol treatment (yesvs. no), and h) money spent on drugs per day (≥ CAD$50 vs. < CAD$50). All behavioral variable definitionswere identical to previous reports [18].Univariate statistics were used to determine factorsassociated with self-reported hunger. Categorical expla-natory variables were analyzed using Pearson’s Chi-Square test, and continuous variables were analyzedusing the Wald test. Degrees of freedom (df) were equalto one (df = 1) for all variables, with the exception ofthe ‘symptoms of depression’ variable, which was equalto 2 (df = 2) in both unadjusted and adjusted analyses.A multivariate model was then prepared using ana priori defined approach whereby variables that wereassociated with food insufficiency (p < 0.05) in univari-ate analyses were included in a fixed logistic regressionmodel. Wald Chi-Squared tests were applied to all cate-gorical and continuous variables. The concordanceindex was used to determine the final model fit [19],and the tolerance and variance inflation factor and con-dition index were used to assess multi-collinearity of thefinal model. All statistical analyses were performedusing SAS software version 9.1 (SAS, Cary, NC). Allreported p-values were two-sided.ResultsA total of 1,053 participants were eligible for the presentanalyses. Overall, the median age was 41.6 years [inter-quartile range (IQR) 34.9 - 47.5]; 353 (33.5%) werefemale; and 307 (29.2%) self-identified as being of Abori-ginal ancestry. Overall, 544 (51.7%) of participants hadaccessed a food bank or meal program in the past sixmonths. A total of 681 (64.7%) IDU reported being hun-gry but not eating due to an inability to afford food.Socio-demographic and drug-use characteristics asso-ciated with self-reported hunger in univariate analysesare shown in Table 1. Unadjusted factors associatedwith self-reported hunger among IDU included: beingyounger in age (Odds Ratio [OR] = 0.98, 95% Confi-dence Interval [CI]: 0.97-0.99, p = 0.005); downtowneastside residency (OR 2.07, 95% CI: 1.59-2.70, p <0.001); living in unstable housing (OR 2.27, 95% CI:1.74-2.96, p < 0.0001); spending ≥ CAD$50/day ondrugs (OR: 2.00, 95% CI: 1.55-2.58, p < 0.001); andbeing incarcerated in the last six months (1.50, 95%CI:1.06-2.11, p = 0.021). Symptoms of depression in thepast week were also associated with self-reported hunger(OR 3.73, 95% CI: 2.80-4.98, p < 0.001). Drug use char-acteristics associated with self-reported hunger included:daily injection heroin in the last six months (OR 1.76,Anema et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:20http://www.substanceabusepolicy.com/content/5/1/20Page 2 of 7Table 1 Factors associated with food insufficiency among injection drug users (n = 1,053)Characteristics Yes65 (%)N = 681No35 (%)N = 372Odds Ratio(95% CI)Chi-Square†, ‡ p - valueSocio-demographicAgeMedian (IQR) 41.1 (34.5-46.7) 42.8 (35.9-49.4) 0.98 (0.97, 0.99) 7.75 0.005GenderMale 455 (66.81%) 245 (65.86%) 1.04 (0.80,1.36) 0.10 0.754Female 226 (33.19%) 127 (34.12%)Aboriginal identityYes 189 (27.75%) 118 (31.72%) 0.83 (0.63, 1.09) 1.83 0.176No 492 (72.25%) 254 (68.28%)DTES ResidencyYes 496 (72.83%) 210 (56.45%) 2.07 (1.59, 2.70) 29.22 < 0.001No 185 (27.17%) 162 (43.55%)Unstable housingYes 504 (74.01%) 207 (55.65%) 2.27 (1.74, 2.96) 36.99 < 0.0001No 177 (25.99%) 165 (44.35%)Education statusHigh school or greater 345 (50.66%) 205 (55.11) 0.84 (0.65, 1.08) 1.91 0.167Other 336 (49.34%) 167 (44.89%)Money spent on drugs per day≥ $50 422 (61.97%) 167 (44.89%) 2.00 (1.55, 2.58) 28.46 < 0.001< $50 259 (38.03%) 205 (55.11%)Incarceration **Yes 138 (20.26%) 54 (14.52%) 1.50 (1.06, 2.11) 5.33 0.021No 543 (79.74%) 318 (85.48%)ClinicalSymptoms of depression *≥ 16 CES-D 456 (66.96%) 159 (42.74%) 3.73 (2.80, 4.98) 88.19 < 0.001< 16 CES-D 136 (19.97%) 177 (47.48%)Drug UseDaily injection heroin**Yes 240 (35.24%) 88 (23.66%) 1.76 (1.32, 2.34) 15.06 < 0.001No 441 (64.76%) 284 (76.34%)Daily non-injection crack/rock **Yes 321 (47.14%) 111 (29.84%) 2.10 (1.60, 2.74) 29.75 < 0.001No 360 (52.86%) 261 (70.16%)Daily injection cocaine**Yes 69 (10.13%) 28 (7.53%) 1.39 (0.88, 2.19) 1.95 0.162No 612 (89.87%) 344 (92.47%)Any injection or non-injection crystal meth**Yes 28 (4.11%) 9 (2.42%) 1.73 (0.81, 3.71) 2.03 0.154No 653 (95.89%) 363 (97.58%)Any injection or non-injection drug binge**Yes 352 (51.69%) 146 (39.25%) 1.66 (1.28, 2.14) 14.94 0.001No 329 (48.31%) 226 (60.75%)Daily alcohol use< = 4 drinks 496 (72.83%) 279 (75.00%) 1.12 (0.84, 1.49) 0.58 0.446> 4 185 (27.17%) 93 (25.00%)Anema et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:20http://www.substanceabusepolicy.com/content/5/1/20Page 3 of 795% CI: 1.32-2.34, p < 0.001); daily non-injection crack/rock in the last six months (OR 2.10, 95% CI: 1.60-2.74,p < 0.001); and any injection or non-injection drugbinge in the past six months (OR 1.66, 95% CI: 1.28-2.14, p < 0.001).Results from the multivariate analysis are shown inTable 2. Variables independently associated with self-reported hunger in multivariate analysis included:unstable housing (adjusted odds ratio [AOR]: 1.68, 95%confidence interval [CI]: 1.20 - 2.36, p = 0.003), spend-ing > $50/day on drugs (AOR: 1.43, CI: 1.06 - 1.91, p =0.018), and symptoms of depression (AOR: 3.32, 95%CI: 2.45 - 4.48, p = < 0.001). The statistical significanceof these variables was found to be unchanged when re-estimating the multivariate model with removal of non-significant variables.The p-value for Hosmer and Lemeshow Goodness-of-Fit Test was greater than 0.05, which indicates themodel fit the data at an acceptable level. The concor-dance index was greater than 0.5, which implies a goodprobability of concordance between predicted andobserved responses. The tolerance and variance inflationfactor were examined for each variable, all of whichwere greater than 0.2 and less than 5.0, respectively,indicating no concerns with multicollinearity in the finalmodel.DiscussionWe found a very high prevalence of self-reported hungeramong IDU in this Canadian setting, with 65% of parti-cipants meeting criteria for hunger. This is 62% higherthan the prevalence severe food insecurity reported byTable 2 Logistic Regression analysis of factors associated with food insufficiency among injection drug users(n = 1,053)Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval(95% CI)Wald Chi-Square†, ‡ p - valueAge(per year increase)0.994 (0.98 - 1.01) 0.65 0.420DTES residency(yes vs no)1.34 (0.96 - 1.89) 2.89 0.089Unstable housing(yes vs no)1.68 (1.20 - 2.36) 9.04 0.003Money spent on drugs per day(≥ $50 vs < $50)1.43 (1.06 - 1.91) 5.64 0.018Incarceration **(yes vs no)1.16 (0.79 - 1.69) 0.57 0.451Symptoms of Depression*(≥ 16 CES-D vs < 16 CES-D)3.32 (2.45 - 4.48) 62.79 < 0.001Daily injection heroin **(yes vs no)1.27 (0.92 - 1.75) 2.05 0.152Daily non-injection crack/rock **(yes vs no)1.18 (0.86 - 1.61) 1.02 0.313Any injection or non-injection drug binge **(yes vs no)1.15 (0.86 - 1.53) 0.90 0.342* Values for 125 participants missing from univariate treated as a separate category** In the past six months† All Chi-Square tests were performed with one degree of freedom (df = 1), with the exception of the’symptoms of depression’ variable, where df = 2.‡ Chi-Squared Test were applied to all categorical variables. A Wald Test was applied to the continuous’age’ variable, yielding a Wald Chi-Square value.Table 1 Factors associated with food insufficiency among injection drug users (n = 1,053) (Continued)Difficulty accessing drug/alcohol treatmentYes 38 (5.58%) 14 (3.76%) 1.51 (0.81, 2.83) 1.69 0.193No 643 (94.42%) 358 (96.24%)* Data missing for 125 participants** In the past six months† All Chi-Square tests were performed with one degree of freedom (df = 1), with the exception of the’symptoms of depression’ variable, where df = 2.‡ Chi-Squared Test were applied to all categorical variables. A Wald Test was applied to the continuous’age’ variable, yielding a Wald Chi-Square value.Anema et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:20http://www.substanceabusepolicy.com/content/5/1/20Page 4 of 7the general Canadian population [20]. Self-reportedhunger in this population was associated with low socio-economic status, symptoms of depression, and compet-ing demands for food and drugs.We found that self-reported hunger was not asso-ciated with use of specific types of illicit drugs. Rather itappeared to be predicted by the amount of drug use, asapproximated by expenditures on drugs. Sixty two per-cent of hungry IDU spent over CAD$50/day, or > CAD$18,000/year. Similar habitual drug expenditures havebeen reported by cocaine and heroin users in the UnitedStates (U.S.) [21]. Our findings build upon previous stu-dies that have found that IDU using multiple drugs, andover a long period of time, have significantly higherodds of being nutritionally deficient [4]. Drug addictionhas shown to modify eating habits, often causing indivi-dual to eat fewer meals during a usual week [22], toskip meals for an entire day [23] and to prioritize drugsover everything else, including food intake [24]. Qualita-tive interviews with inner-city drug-using women revealthat the decision to buy drugs instead of food, evenwhen hungry, is rationalized by the fact that food can beobtained for free from distribution sites, but getting a‘fix’ always costs money [25]. Our findings suggest thatIDU in this setting may benefit from improved access todrug treatment services to prevent deterioration ofnutritional status.We also found that 74% of IDU reporting hunger inour cohort were unstably housed. This proportion is ele-vated when compared to findings from a 2006 studywithin the same cohort, which found that 60% of IDUreported living in a single room occupancy hotel, shel-ter, recovery or transition house, jail, on the street or atno fixed address [16]. The association between hungerand unstable housing suggests that some IDU may notbe accessing adequate nutritional services or housingneeded to support food security. Over the past 20 years,a conflation of factors have contributed to high levels ofhomelessness in the Vancouver downtown eastside,where the majority of participants reside, including gov-ernment deinstitutionalization of people suffering men-tal illness and addiction, rapid gentrification of theneighborhood, and insufficient low-cost housing options[17]. As part of the gentrification process, illicit drugusers have also been the subject of ongoing policecrackdowns on drug use that have forced them into per-ipheral urban areas [26]. In addition to our data show-ing that IDU are not accessing housing services [16],recent studies have found that IDU in Vancouver havelimited access to essential harm reduction services [26]and delayed access to HIV clinical services [27]. Takentogether, these data suggest the need to scale up multi-ple interventions to improve the health and wellbeing ofIDU, and thereby reduce the problems of food insecurityand hunger among this population.We found that 67% of IDU reporting hunger experi-enced symptoms of depression in the past week andthat depression was strongly correlated with hunger.Cross-sectional research suggests that there is a strongassociation between household food insufficiency andadverse mental health. Food insufficiency has been asso-ciated with elevated incidence of major depressive disor-ders among women and adolescents in the general U.S.population [28,29]. Food insecurity has been associatedwith poor mental health status in HIV-positive popula-tions, which include high proportions of illicit drugusers [30-32]. No studies to our knowledge haveassessed the correlation between self-reported hungerand symptoms of depression among IDU. Our findingssuggest that this population would benefit from receiv-ing mental health screening and support services as partof a comprehensive approach to improving their foodsecurity status and mental health.There are several strengths and limitations to ourstudy. Self-reported hunger is considered to be a severemanifestation of food insecurity [14]. Our measure ofhunger has been validated in five North American set-tings, and has been associated with insufficient foodintake [15]. The elevated prevalence of self-reportedhunger among IDU in this study therefore likely indi-cates actual food inadequacy and severe food insecurity.Because this is a cross-sectional study, we were unableto determine causality, or the biological and social path-ways linking self-reported hunger and explanatory vari-ables in this cohort. Longitudinal studies would bevaluable to inform understanding of the mediating effectof socio-demographic and drug-use variables on foodinsufficiency. Longitudinal studies would additionallystrengthen the power of similar analyses by enabling theinclusion of time-variant individual differences, and byhelping to unpack the direction of causality betweenfood insecurity and relevant demographic and clinicalvariables.Common to all studies, it is possible that our studywas affected by response bias. Studies evaluating nutri-tional status have found that self-reported nutritionalmeasures are less reliable than clinical nutrition mea-sures. Research has found that individuals tend tounder-report energy intake, weight and BMI, and over-report height [33]. Self-reports of nutritional informa-tion often vary by gender and beliefs of social desirabil-ity [33].Future evaluations of food insufficiency among IDUshould seek to identify the unique social and biologicalfactors mediating hunger. This is important in light ofstudies showing that a high proportion of drug usersAnema et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:20http://www.substanceabusepolicy.com/content/5/1/20Page 5 of 7report disturbances in their social and familial networks,are underweight, and exhibit anorexia with poor foodand drink consumption [5]. Further studies should con-sider exploring the impact of social support systems onsubjective and objective measures of food insufficiency.A comprehensive nutritional evaluation, including diet-ary recall and body mass index (BMI) would also bevaluable given the association between fasting appetitesensations with weight loss [34].ConclusionWe found a high prevalence of self-reported hungeramong IDU in this marginalized urban setting. Hungerin this population is associated with poor socio-eco-nomic status, symptoms of depression and competingdemands for food and illicit drugs. Our findings supportthe need for targeted social, mental health and nutri-tional support strategies for IDU, including addictiontreatment programs that may reduce the adverse effectof ongoing drug use on hunger, and visa versa. Furtherstudies should seek to identify behavioral and biologicalpathways leading to food insufficiency in this popula-tion, and evaluate the effectiveness of support servicesin mitigating this adverse outcome.Statement of Authors’ contributionsAll authors read and approved the final manuscript. AA,TK and SW designed research (project conception,development of overall research plant, and study over-sight); JQ performed statistical analysis; AA, TK and SWwrote and made major contributions to the manuscript;JM and EW provided essential critical feedback on themanuscript; and TK had primary responsibility for finalcontent.AcknowledgementsWe would like to thank VIDUS participants for their contribution to thisstudy. We also thank Brandon Marshall and M-J Milloy for theiradministrative support. We would particularly like to thank the VIDUSparticipants for their willingness to be included in the study, as well ascurrent and past VIDUS investigators and staff. We would specifically like tothank Deborah Graham, Tricia Collingham, Caitlin Johnston, Steve Kain, andCalvin Lai for their research and administrative assistance. The study wassupported by the US National Institutes of Health (R01 DA011591) and theCanadian Institutes of Health Research (RAA-79918). Aranka Anema issupported by the Canadian Institutes of Health Research. Thomas Kerr issupported by the Michael Smith Foundation for Health Research and theCanadian Institutes of Health Research.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, BC, Canada. 2Department of Medicine, Faculty of Medicine,University of British Columbia, Vancouver, BC, Canada. 3Center for AIDSPrevention Studies, University of California San Francisco (UCSF), SanFrancisco, CA, USA. 4Positive Health Program, San Francisco General Hospital,University of California San Francisco (UCSF), San Francisco, CA, USA.Competing interestsThe authors declare that they have no competing interests.Received: 27 May 2010 Accepted: 26 August 2010Published: 26 August 2010References1. United Nations Office on Drugs and Crime (UNODC): World Drug Report.2010 [http://www.unodc.org/unodc/en/data-and-analysis/WDR-2010.html].2. International Harm Reduction Association (IHRA): The Global State of HarmReduction 2010: Key issues for broadening the response. 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Vogenthaler NS, Hadley C, Rodriguez AE, Valverde EE, Del Rio C, Metsch LR:Depressive Symptoms and Food Insufficiency Among HIV-Infected CrackUsers in Atlanta and Miami. AIDS Behav 2010.33. Gorber SC, Tremblay M, Moher D, Gorber B: A comparison of direct vs.self-report measures for assessing height, weight and body mass index:a systematic review. Obesity Reviews 2007, 8(4):307-326.34. Drapeau V, King N, Hetherington M, Doucet E, Blundell J, Tremblay A:Appetite sensations and satiety quotient: predictors of energy intakeand weight loss. Appetite 2007, 48(2):159-66.doi:10.1186/1747-597X-5-20Cite this article as: Anema et al.: Hunger and associated harms amonginjection drug users in an urban Canadian setting. Substance AbuseTreatment, Prevention, and Policy 2010 5:20.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/submitAnema et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:20http://www.substanceabusepolicy.com/content/5/1/20Page 7 of 7


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