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Increases and decreases in drug use attributed to housing status among street-involved youth in a Canadian… Cheng, Tessa; Wood, Evan; Nguyen, Paul; Kerr, Thomas; DeBeck, Kora Apr 10, 2014

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BRIEF REPORT Open AccessIncreases and decreases in drug use attributed tohousing status among street-involved youth in aCanadian settingTessa Cheng1,2, Evan Wood1,3, Paul Nguyen1, Thomas Kerr1,3 and Kora DeBeck1,4*AbstractBackground: Among a cohort of drug-using street-involved youth, we sought to identify the prevalence of reportingincreases and decreases in illicit drug use due to their current housing status and to identify factors associated withreporting these changes.Findings: This longitudinal study was based on data collected between June 2008 and May 2012 from a prospectivecohort of street-involved youth aged 14–26 in Vancouver, Canada. At semi-annual study follow-up visits, youth wereasked if their drug use was affected by their housing status. Using generalized estimating equations, we identifiedfactors associated with perceived increases and decreases in drug use attributed to housing status. Among our sampleof 536 participants at baseline, 164 (31%) youth reported increasing their drug use due to their housing situation and71 (13%) reported decreasing their drug use. In multivariate analysis, factors that were positively associated withperceived increases in drug use attributed to housing status included the following: being homeless, engaging in sexwork and drug dealing. Regular employment was negatively associated with increasing drug use due to housing status.Among those who reported decreasing their drug use, only homelessness was significant in bivariate analysis.Conclusion: Perceived changes in drug use due to housing status were relatively common in this setting and wereassociated with being homeless and, among those who increased their drug use, engaging in risky income generationactivities. These findings suggest that structural factors, particularly housing and economic opportunities, may becrucial interventions for reducing or limiting drug use among street-involved youth.Keywords: Homelessness, Drug use, Street-involved youth, Stable housing, Risk behaviour, EmploymentFindingsIntroductionHousing instability among street-involved youth remainsa community and public health concern. Previous re-search has found that housing instability often precedessubstance use [1] and is also linked to increased inten-sity of drug use [2], including initiation into injectiondrug use [3,4]. Furthermore, a loss of housing stabilityhas been associated with higher intensity alcohol andcrystal methamphetamine use among youth [5]. Incontrast, residential stability appears to be protectiveagainst a range of risky drug and sexual behaviours [6,7].Although housing is recognized to have an influenceon substance use, few studies have explored whetheryouth attribute their housing status directly to changesin their drug use and if reporting this relationship is as-sociated with risky behaviours or other factors. Thisstudy sought to identify the prevalence of street-involvedyouth who attribute changes in drug use to their housingstatus and factors associated with these relationships.MethodsData for this study were obtained from the At-RiskYouth Study (ARYS), a prospective cohort study ofstreet-involved youth in Vancouver, Canada. The studyhas been previously described in detail [8]. In brief,snowball sampling and extensive street-based outreach* Correspondence: uhri-kd@cfenet.ubc.ca1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada4School of Public Policy, Simon Fraser University, 515 West Hastings Street,Suite 3271, Vancouver, BC V6B 5K3, CanadaFull list of author information is available at the end of the article© 2014 Cheng 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 credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Cheng et al. Harm Reduction Journal 2014, 11:12http://www.harmreductionjournal.com/content/11/1/12methods were employed. To be eligible, participants atrecruitment had to be aged 14–26 years, use illicit drugsother than marijuana in the past 30 days, provide writteninformed consent and be street-involved, defined as be-ing homeless (having no fixed address, sleeping on thestreet or staying in a shelter or hostel) or having used ser-vices designated for street-involved youth in the last6 months [8-10]. At enrollment, and on a bi-annual basis,participants completed an interviewer-administered ques-tionnaire that included questions related to demographicinformation and drug use patterns. At each study visit,participants were provided with a stipend (Canadian $20)for their time. The study has been approved by the Uni-versity of British Columbia's Research Ethics Board.For the present analyses, ARYS participants were eli-gible if they completed at least one study visit betweenJune 2008 and May 2012. Our two outcomes of interestwere ‘perceived increases in drug use attributed to hous-ing status’ and ‘perceived decreases in drug use attrib-uted to housing status’, where the term ‘housing status’refers to a participant's housing situation (e.g. living inan apartment, a hotel, house, shelter or the street). Datafor our outcomes were based on responses to the ques-tion: ‘Considering your drug use and your housing in thepast 6 months, do you think that your housing situationaffected your drug use?’ Participants who responded ‘yes’or ‘sometimes’ were asked to specify if they thought theyhad generally ‘used more’ or ‘used less’ drugs in responseto their housing situation. Youth who reported perceivedincreases in drug use were included in the outcome cat-egory for analysis 1, and those who perceived decreasesin their drug use were included in the outcome categoryfor analysis 2. Participants who perceived no change intheir drug use were included as controls for both analyses.Given that our outcomes were determined by repeatedmeasures, participants who changed their response overstudy follow-up may be included in both analyses.Drug use patterns among the study sample wereassessed using baseline data for the following: daily non-injection crystal methamphetamine use (yes vs. no), dailycrack cocaine smoking (yes vs. no), daily non-injectioncocaine use (yes vs. no) and daily non-injection heroinuse (yes vs. no). In order to assess high-intensity druguse, we included binge drug use, defined as a period ofusing injection or non-injection drugs more often thanusual (yes vs. no), and any injection drug use (yes vs.no). All drug use variables refer to activities in the past6 months.To identify factors associated with attributing housingstatus with our two outcomes of interest (perceived in-creases in drug use and decreases in drug use), we con-sidered a number of explanatory variables of interestincluding the following socio-demographic factors: gen-der (female vs. male); age (per year older); ethnicity(Caucasian vs. other); currently being in a stable rela-tionship, defined as being legally married, common lawor having a regular partner (yes vs. no); and homeless-ness, defined as having no fixed address, sleeping on thestreet or staying in a shelter or hostel (as compared to‘not homeless’, which included living in a house, apart-ment, single-room occupancy unit, treatment, recoveryhouse or jail) (homeless vs. not homeless). Other vari-ables considered included the following: regular employ-ment, defined as having at least one source of incomefrom a regular job, temporary work or self-employment(yes vs. no); engaging in sex work, defined as exchangingsex for money, drugs, gifts, food, clothes, shelter or fa-vours (yes vs. no); and participation in drug dealing (yesvs. no). All behavioural variables refer to activities in thepast 6 months.Generalized estimating equations (GEE) with a logitlink function and exchangeable correlation structurewere used in two separate analyses to model factors as-sociated with attributing housing status to perceived in-creases in drug use and decreases in drug use. The GEEmethod is a conventional analysis for longitudinal corre-lated within-subject data [11,12]. We performed bivari-ate GEE analyses to determine factors associated withperceived increases in drug use and decreases in druguse attributed to housing status. To adjust for potentialconfounding factors and identify factors that were inde-pendently associated with our two outcomes of interest(perceived increase in drug use and decrease in druguse), all variables that were significant at p < 0.10 in bi-variate analyses were considered for inclusion in fullmultivariate models. For each multivariate model, abackward model selection procedure was used to iden-tify the model with the best overall fit as indicated bythe lowest quasilikelihood under the independencemodel criterion value [13]. All statistical analyses wereperformed using the SAS software version 9.3 (SAS,Cary, NC, USA). All p values are two-sided.ResultsDuring the study period, 561 participants were recruitedinto ARYS, among whom 536 answered all questionsrelevant for this analysis. This group included 171 (32%)women and 352 (66%) persons of Caucasian ethnicity,and the median age of participants was 22 years (inter-quartile range [IQR] = 20–24). Among our sample atbaseline, 164 (31%) attributed increased drug use to theirhousing status, 301 (56%) reported no change and 71(13%) reported a decrease in drug use due to their hous-ing status. Over the study period, 261 (49%) participantsperceived an increase in their drug use due to theirhousing situation, 425 (79%) perceived no change intheir drug use and 198 (37%) perceived a decrease intheir drug use. The overall number of study observationsCheng et al. Harm Reduction Journal 2014, 11:12 Page 2 of 6http://www.harmreductionjournal.com/content/11/1/12collected over the study period was 1,724, with 387(22%) including a report of increased drug use due tohousing status, 1,056 (61%) including a report of nochange and 281 (16%) including a report of decreaseddrug use due to housing status. Among the analytic sam-ple of 536, 382 (71%) participants had at least onefollow-up visit, with a median number of follow-up visitsof 3 (IQR = 2–4) and median duration of time understudy follow-up of 28 months (IQR = 17–35). Analysesof whether the participants who contributed more thanone study visit were significantly different with regard toage, gender or homelessness from those with just onestudy visit revealed no statistically significant differencesbetween the two groups (all p > 0.10).The characteristics and drug use patterns of this studysample at their first study visit during the study periodare presented in Table 1, stratified by the attributed ef-fect of drug use on housing status. The bivariate andmultivariate GEE analyses of socio-demographic, behav-ioural and other risk variables associated with perceivedincreases in drug use are presented in Table 2. In multi-variate analysis, factors that remained positively associatedwith perceived increases in drug use included the follow-ing: homelessness (adjusted odds ratio [AOR] = 2.45, 95%Table 1 Characteristics of street-involved youth at baseline (n = 536)Drug use affected by housingaTotal (%) Drug use increased (%) No change in drug use (%) Drug use decreased (%)(n = 536) (n = 164) (n = 301) (n = 71)CharacteristicAgeMedian (IQR) 22 (20–24) 22 (20–24) 21 (19–23) 22 (20–24)Gender(Female vs. male) 171 (31.90) 53 (32.32) 100 (33.22) 18 (25.35)Caucasian ethnicity(Yes vs. no) 352 (65.67) 110 (67.07) 194 (64.45) 48 (67.61)Stable relationship (currently)(Yes vs. no) 190 (35.45) 62 (37.80) 103 (34.22) 25 (35.21)Homelessa(Homeless vs. not homeless) 357 (66.60) 131 (79.88) 177 (58.80) 49 (69.01)Employmenta(Yes vs. no) 228 (42.54) 58 (35.37) 134 (44.52) 36 (50.70)Sex worka(Yes vs. no) 41 (7.65) 16 (9.76) 21 (6.98) 4 (5.63)Drug dealinga(Yes vs. no) 244 (45.52) 84 (51.22) 125 (41.53) 35 (49.30)Drug use variablesDaily crystal meth usea,b(Yes vs. no) 45 (8.40) 22 (13.41) 19 (6.31) 4 (5.63)Daily crack smokinga,b(Yes vs. no) 86 (16.04) 37 (22.56) 39 (12.96) 10 (14.08)Daily cocaine usea,b(Yes vs. no) 12 (2.24) 6 (3.66) 5 (1.66) 1 (1.41)Daily heroin usea,b(Yes vs. no) 20 (3.73) 7 (4.27) 11 (3.65) 2 (2.82)Binge drug usea,c(Yes vs. no) 180 (33.58) 69 (42.07) 91 (30.23) 20 (28.17)Injection drug usea(Yes vs. no) 167 (31.16) 56 (34.15) 89 (29.57) 22 (30.99)aRefers to activities in the past 6 months; brefers to non-injection drug use; crefers to injection and non-injection drug use.Cheng et al. Harm Reduction Journal 2014, 11:12 Page 3 of 6http://www.harmreductionjournal.com/content/11/1/12confidence interval [CI] 1.89–3.17), involvement in sexwork (AOR = 1.65, 95% CI 1.02–2.67) and drug dealing(AOR = 1.79, 95% CI 1.38–2.31), while regular employ-ment was negatively associated with increased drug use(AOR = 0.77, 95% CI 0.60–1.00). In the bivariate analysesfor those who perceived decreases in their drug use(Table 3), homelessness was the only significant factor(odds ratio = 1.60, 95% CI 1.20–2.11), and therefore, amultivariate model was not constructed for this outcome.DiscussionIn the present study, 22% of study observations includeda report of perceived increase in drug use, 16% includeda report of perceived decrease in drug use and 61% re-ported no change in drug use due to the participant'scurrent housing situation. Homelessness and prohibitedincome-generating activities, specifically drug dealingand sex work, were positively associated with perceivedincreases in drug use, while regular employment wasnegatively associated with perceived increases in druguse attributed to housing status. Homelessness was theonly factor associated with perceived decreasing druguse attributed to housing status in the bivariate analysis.The relationship between homelessness and perceivedincreases in drug use is consistent with existing researchsuggesting that homeless youth are more likely to engagein riskier and more frequent substance use than housedyouth [5,14]. Specifically, prior findings indicate thatsome homeless youth may increase their drug use as asurvival strategy to suppress their appetite when food islimited and to stay alert to protect themselves and theirbelongings [15]. Problematic drug use and homelessnesshave been identified as accelerating entrenchment inillicit drug scenes [16], which is especially concerningsince high-intensity drug use was prevalent in our sam-ple and homeless youth have been found to be morelikely to have difficulty accessing drug and alcohol treat-ment services [17].Table 2 Bivariate and multivariate GEE analyses of factors associated with perceived increases in drug use (n = 511)Characteristic Odds ratio (95% CI) p value Adjusted odds ratio (95% CI) p valueAge(Per year older) 0.99 (0.95–1.04) 0.788Gender(Female vs. male) 0.90 (0.67–1.22) 0.503Caucasian ethnicity(Yes vs. no) 1.32 (0.99–1.77) 0.056 1.34 (0.99–1.82) 0.055Stable relationship (currently)(Yes vs. no) 0.98 (0.78–1.24) 0.882Homelessa(Homeless vs. not homeless) 2.64 (2.05–3.39) <0.001 2.45 (1.89–3.17) <0.001Employmenta(Yes vs. no) 0.78 (0.61–1.00) 0.051 0.77 (0.60–1.00) 0.047Sex worka(Yes vs. no) 1.64 (1.01–2.67) 0.045 1.65 (1.02–2.67) 0.041Drug dealinga(Yes vs. no) 1.98 (1.54–2.54) <0.001 1.79 (1.38–2.31) <0.001aRefers to activities in the past 6 months.Table 3 Bivariate GEE analyses of factors associated withperceived decreases in drug use (n = 468)Characteristic Odds ratio (95% CI) p valueAge(Per year older) 1.03 (0.98–1.08) 0.209Gender(Female vs. male) 0.93 (0.68–1.28) 0.657Caucasian ethnicity(Yes vs. no) 1.27 (0.93–1.74) 0.140Stable relationship (currently)(Yes vs. no) 1.20 (0.90–1.59) 0.213Homelessa(Homeless vs. not homeless) 1.60 (1.20–2.11) 0.001Employmenta(Yes vs. no) 1.08 (0.81–1.43) 0.618Sex worka(Yes vs. no) 1.09 (0.61–1.95) 0.776Drug dealinga(Yes vs. no) 1.20 (0.89–1.63) 0.228aRefers to activities in the past 6 months.Cheng et al. Harm Reduction Journal 2014, 11:12 Page 4 of 6http://www.harmreductionjournal.com/content/11/1/12Homelessness was also positively associated with per-ceived decreases in drug use in the bivariate analyses.One potential interpretation of this association is thathomeless youth have less stability and face greater chal-lenges generating income, which may make it harder topurchase drugs and could result in reduced drug con-sumption. Given that only homelessness was associatedwith reported decreasing drug use and a multivariateanalysis could not be constructed to address potentialconfounding factors, further investigation is needed tobetter contextualize the relationship between homeless-ness and reduced drug use.The relationship between perceived increased drug useto housing status and high-risk behaviours, such as sexwork and drug dealing, suggests that these youth aremore likely to be economically vulnerable. Contributingfactors to economic vulnerability include substance useand lower levels of education, which are themselvesassociated with engaging in the drug and sex trade[18-22]. As active involvement in the street economy islinked to substance abuse, disengagement with thelabour market is similarly associated with a range of psy-chological and health-related harms such as social exclu-sion and estrangement [23,24] and increased substanceuse [25]. Given that our findings and the research sug-gest that employment may play a protective role againstincreasing substance use, providing economic security tostreet-involved youth may mitigate some of the harmfulhealth-related effects of homelessness.There are several limitations to this study. First, thesedata are observational, and therefore, we are cautiousabout drawing causal inferences. Second, even thoughextensive street-based outreach was used, ARYS partici-pants were not systematically recruited, and therefore,the generalizability of this study may be limited. Thedemographics of the sample, however, are consistentwith other samples of street-involved youth in Vancou-ver [26,27]. Third, our measure for the main outcomesof interest is the perception of participants. Conse-quently, this may underestimate or overestimate the ef-fect of housing on drug use depending on whetheryouth are unaware of the impact of housing on theirsubstance use or if they over-attribute the role of hous-ing to their drug use. Finally, this study focused on thereported influence of housing status on drug use and didnot examine the potential effect of drug use on housingstatus. Drug use has been identified as a determinant ofhousing [3,4], and there is a need to better understandthe complex relationships affecting street-involvedyouth's housing and drug use.In summary, our study indicates that street-involvedyouth perceive their drug use to be affected by theirhousing status, and a range of social and structural fac-tors are associated with this relationship, includingeconomic vulnerability. These results suggest that effortsshould be made to reduce the social and structural bar-riers to meaningful employment for street-involvedyouth. Policy approaches focusing on appropriate hous-ing and reducing economic vulnerability show potentialfor addressing the trajectories of drug use among home-less and street-involved youth.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsTC took on a primary role in conceptualizing and designing the study,conducting the analysis and preparing the manuscript. PN assisted inconceptualizing the statistical analyses and performed all statistical analyses.PN also reviewed the final manuscript for statistical accuracy. EW and TKassisted with the interpretation of the data and revised the manuscript forimportant intellectual content. KD took on a senior role in conceptualizingand designing the study and reviewing drafts of the manuscript. All authorsreviewed and approved the final manuscript.AcknowledgementsThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff. We wouldspecifically like to thank Cody Callon, Deborah Graham, Peter Vann, SteveKain, Tricia Collingham and Carmen Rock for their research andadministrative assistance.FundingThe study was supported by the US National Institutes of Health (R01DA028532)and the Canadian Institutes of Health Research (MOP–102742). This researchwas undertaken, in part, thanks to funding from the Canada Research Chairsprogram, through a Tier 1 Canada Research Chair in Inner City Medicine whichsupports Dr. Evan Wood. Dr. Kora DeBeck is supported by a MSFHR/St. Paul'sHospital Foundation Providence Health Care Career Scholar Award. Fundingsources had no role in the study design; in the collection, analysis andinterpretation of data; in the writing of the report; or in the decision to submitthe paper for publication.Author details1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada. 2Faculty of Health Sciences, Simon Fraser University, Blusson Hall,Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6, Canada. 3Faculty ofMedicine, University of British Columbia, 317-2194 Health Sciences Mall,Vancouver, BC V6T 1Z3, Canada. 4School of Public Policy, Simon FraserUniversity, 515 West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3,Canada.Received: 25 September 2013 Accepted: 28 March 2014Published: 10 April 2014References1. Johnson G, Chamberlain C: Homelessness and substance abuse: whichcomes first? Aust Soc Work 2008, 61:342–356.2. 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