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Interest in low-threshold employment among people who inject illicit drugs : implications for street… DeBeck, Kora; Wood, Evan; Qi, Jiezhi; Fu, Eric; McArthur, Doug; Montaner, Julio; Kerr, Thomas Sep 30, 2011

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Interest in Low-Threshold Employment among People who InjectIllicit Drugs: Implications for Street DisorderKora DeBeck1, Evan Wood1,2, Jiezhi Qi1, Eric Fu1, Doug McArthur3, Julio Montaner1,2, andThomas Kerr1,21 British Columbia Centre for Excellence in HIV/AIDS2 Division of AIDS, Department of Medicine, University of British Columbia3 School of Public Policy, Simon Fraser UniversityAbstractBackground—Income generation opportunities available to people who use illicit drugs havebeen associated with street disorder. Among a cohort of injection drug users (IDU) we sought toexamine street-based income generation practices and willingness to forgo these sources ofincome if other low-threshold work opportunities were made available.Methods—Data were derived from a prospective community recruited cohort of IDU. Weassessed the prevalence of engaging in disorderly street-based income generation activities,including sex work, drug dealing, panhandling, and recycling/salvaging/vending. Usingmultivariate logistic regressions based on Akaike information criterion and the best subsetselection procedure, we identified factors associated with disorderly income generation activities,and assessed willingness to forgo these sources of income during the period of November 2008 toJuly 2009.Results—Among our sample of 874 IDU, 418 (48%) reported engaging in a disorderly incomegeneration activity in the previous six months. In multivariate analyses, engaging in disorderlyincome generation activities was independently associated with high intensity stimulant use, aswell as binge drug use, having encounters with police, being a victim of violence, sharing usedsyringes, and injecting in public areas. Among those engaged in disorderly income generation, 198(47%) reported a willingness to forgo these income sources if given opportunities for low-threshold employment, with sex workers being most willing to engage in alternative employment.Conclusion—Engagement in disorderly street-based income generation activities was associatedwith high intensity stimulant drug use and various markers of risk. We found that a highproportion of illicit drug users were willing to cease engagement in these activities if they hadoptions for causal low-threshold employment. These findings indicate that there is a high demand© 2011 Elsevier B.V. All rights reserved.Send correspondence to: Thomas Kerr, PhD, BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, B.C.,CANADA V6Z 1Y6, Tel: (604) 806-9116, uhri-tk@cfenet.ubc.ca.Competing Interests:Dr. Julio Montaner has received grants from, served as an ad hoc advisor to, or spoke at various events sponsored by; Abbott, ArgosTherapeutics, Bioject Inc, Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho,Merck Frosst, Pfizer, Schering, Serono Inc, TheraTechnologies, Tibotec, Trimeris.Authors declare no other competing interests.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptInt J Drug Policy. Author manuscript; available in PMC 2012 September 1.Published in final edited form as:Int J Drug Policy. 2011 September ; 22(5): 376–384. doi:10.1016/j.drugpo.2011.05.012.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfor low-threshold employment that may offer important opportunities to reduce drug-related streetdisorder and associated harms.Keywordsinjection drug use; income generation; low-threshold employment; sex work; drug dealing;panhandlingINTRODUCTIONThere are many established links between chronic illicit drug use and engagement in illegalincome generation activities (Ball, Shaffer, & Nurco, 1983; Bretteville-Jensen & Sutton,1996; Deschenes & Anglin, 1991; Fischier et al., 2001; Hammersley et al., 1989; Nurco,Cisin, & Ball, 1985; Silverman & Spruill, 1977). People who use illicit drugs and arestruggling with addiction are often unable to acquire and sustain formal employment, andyet the high costs associated with obtaining illicit drugs requires individuals to find means ofgenerating income (Bretteville-Jensen & Sutton, 1996; Cross et al., 2001; McCoy,Comerford, & Metsch, 2007; Platt, 1995; Richardson et al., 2008; Richardson et al., 2010).Given these constraints, the income generation opportunities available to illicit drug usersfrequently involve illegal activity and are often associated with street disorder (Bretteville-Jensen & Sutton, 1996; DeBeck et al., 2007). For example, common income generationstrategies include street-based sex work, drug dealing, panhandling and recycling/salvaging/vending which often take place on public streets and are generally considered to beundesirable activities from a community perspective (Bose & Hwang, 2002; Collins &Blomley, 2003; DeBeck et al., 2007; Kerr et al., 2008; Shannon et al., 2007a). In Vancouver,Canada these types of disorderly income generation activities are a well described feature ofthe city’s drug use epicentre known as the Downtown Eastside [DTES] (DeBeck et al.,2007; Kerr et al., 2008; Shannon et al., 2007a).To date, policy responses to address problems associated with illicit drug use, includingstreet disorder resulting from the income generation activities of illicit drug users, typicallyrely on law enforcement to deter and manage undesirable practices and behaviours (Boyum& Reuter, 2005; DeBeck et al., 2006;L. Maher, 2000; National Research Council, 2002).However, it has been documented that in many instances law enforcement initiatives seekingto reduce street disorder result in displacing disorderly activities to surroundingneighbourhoods (Aitken at al., 2002; Maher & Dixon, 1999; Wood et al., 2004). This hasbeen shown to negatively impact communities and separate vulnerable drug users fromfamiliar health and social services (Aitken at al., 2002; Cooper, Wypij, & Krieger, 2005;Maher & Dixon, 1999; Wood et al., 2004). Given these harms and the limited effectivenessof law enforcement in this area, alternative approaches to managing street disorder arerequired.A growing body of health research suggests that interventions, such as law enforcement, thatprimarily target the behaviour of individuals may be limited in their effectiveness andinadvertently produce harm because they fail to recognize and address the role that socialand structural factors play in shaping behaviour (Blankenship et al., 2006; Galea, Ahern, &Vlahov, 2003; Rhodes, 2002; Sumartojo, 2000). Rhodes’ Risk Environment Framework hasbeen used to illustrate the importance of considering factors exogenous to the individualwhen examining drug-related harm (Rhodes, 2002; Rhodes et al., 2005; Rhodes, 2009).According to this framework, social, structural, and environmental level factors create acontext that shapes individual behaviour and decision-making (Rhodes, 2002; Rhodes et al.,2003). From this perspective, risk is not only a product of individual behaviour, but isshaped and structured by laws, policies, and social relations that surround individuals.DeBeck et al. Page 2Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptTargets for policy intervention, therefore, involve altering social and structural environments(Blankenship, Bray, & Merson, 2000; Des Jarlais, 2000; Heimer et al., 2002). The problemof disorderly income generation is therefore not solely a matter of individuals choosing toengage in undesirable practices; rather, disorderly income generation is shaped byenvironmental, social and structural conditions. In turn, one potential approach to reducingstreet disorder is to change the structural environment surrounding individuals who usedrugs by creating sanctioned low-threshold employment opportunities.The concept of ‘low-threshold’ is to create programs that are easily accessible for activedrug users and a key component of low-threshold programs is that they do not requireabstinence from drug use. A recent longitudinal analysis among Vancouver based IDUrevealed low levels of regular employment among study participants and also demonstratedthat high intensity drug use was negatively associated with regular employment,highlighting the need for alternative employment strategies for this population (Richardsonet al., 2010). Initial research suggests that low-threshold programs can engage street-involved drug users and reduce their participation in some types of disorderly incomegeneration activities. An evaluation of a jewellery making economic empowerment programfor women who use illicit drugs demonstrated that the program was associated withreductions in sex work involvement (Sherman et al., 2000).In Vancouver, Canada there are a small number of existing low-threshold employmentopportunities available to individuals who actively use illicit drugs. For example, in theDTES of Vancouver a community café and catering social enterprise company provides anestimated nine low-threshold employment positions (Lougheed-Green, 2004; Potluckcatering), an organization that processes recyclable containers provides roughly 33 low-threshold positions (Dale & Newman, 2008; Lyotier, 2010), a local drug users groupprovides a small number of stipends for volunteer work undertaken by their members(Hayashi et al., 2010; Lloyd-Smith et al., 2010; VANDU, 2010) and a photo calendar projectinitiated by a social justice organization offers a program for residents of the DTES tobecome vendors and sell calendars and books (Grainger, November 30, 2008; Hope inShadows, 2010; Moore & Pell, 2010). Despite the existence of these opportunities, thenumber of low-threshold employment positions is limited and there is little informationavailable to determine whether there is a significant demand for this type of work amongindividuals who currently engage in disorderly income generation activities.Therefore, we sought to characterize the prevalence and correlates of engaging in disorderlyincome generation activities among a community recruited cohort of injection drug users(IDU) in Vancouver. We then sought to identify whether there was a demand for low-threshold employment among those who were engaged in disorderly income generation toidentify if this might be a suitable structural intervention to reduce one component of streetdisorder.METHODSData for this study was obtained from the Vancouver Injection Drug Users Study (VIDUS),which is an open prospective cohort that began enrolling IDU through street outreach andself-referral in May 1996. This study has been described in detail previously (Kerr et al.,2007; Wood et al., 2002). In brief, to be eligible participants at recruitment must reside inthe Greater Vancouver Regional District, have injected illicit drugs in the previous month,and provide written informed consent. At enrolment and on bi-annual basis participantscomplete an interviewer-administered questionnaire and provide a blood sample forserologic testing. At each study visit participants are provided with a stipend ($20 CDN) fortheir time. The study has received ethics approval from St. Paul’s Hospital/University ofDeBeck et al. Page 3Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptBritish Columbia’s Research Ethics Board. The present analyses are restricted to thoseparticipants seen for study follow-up during the period of November 2008 to July 2009 asthe measure for our outcome of interest was available only for this period. If individualswere seen for multiple study follow-up visits during this study period, only data from theirfirst visit was used.All participants seen during our study period were asked to identify all their income sources(over the last six months) and to estimate the average number of hours per week they spentengaged in each income generation activity over the last 30 days. Categories of incomesources included recycling (includes salvaging recyclable materials and unsanctioned streetvending), panhandling, squeegeeing, sex trade work and drug dealing. Other categories ofincome sources included welfare (including disability, pensions and other forms ofgovernment transfers), family and friends, regular job, temporary work (including under thetable employment) and criminal activity (category encompasses a range of criminalactivities including theft, break and entry, robbery and fraud).To help determine whether low-threshold employment might have a positive effect onreducing street disorder, we began by evaluating factors associated with engaging indisorderly income generation. In this initial analysis the outcome of interest was engaging in‘disorderly income generation activities’ defined as reporting any of the following incomesources: recycling, squeegeeing, panhandling, selling drugs and exchanging sex for money.Although we were unable to confirm that all reported drug dealing and sex work activitiesoccurred in public settings, a previous study among VIDUS participants found that bothactivities are independently associated with spending time in Vancouver’s open drug scenesuggesting that these activities are largely street-based (DeBeck, 2011). Reports in the‘criminal activity’ category were not included in the ‘disorderly income generationactivities’ category because the focus of our analysis was on street-disorder and the linksbetween general criminal activities and street-disorder were unclear.To characterize factors associated with engagement in disorderly income generationactivities, we a priori selected a range of socio-demographic and behavioural variablesbased on previous literature on street disorder and income generation (DeBeck et al., 2011;DeBeck et al., 2007). We hypothesized that these variables would provide a profile ofindividuals engaged in disorderly income generation that could inform and direct policyinterventions in this area. Variables included: age (per year older); daily expenditure ondrugs (per additional $10); gender (female vs. male); Aboriginal ancestry (yes vs. no);unstable housing, defined as currently living in a single occupancy room in a hotel, atreatment or recovery house, jail, shelter or hostel, or having no fixed address for the last sixmonths (yes vs. no); high school education, defined as completing high school or obtainingequivalent diploma (yes vs. no); having regular employment, defined as having a regular ortemporary job (yes vs. no); daily cocaine injection (yes vs. no); daily heroin injection (yesvs. no); daily crack cocaine smoking (yes vs. no); non-fatal overdose (yes vs. no), bingedrug use, defined as a period of using drugs more often than usual (yes vs. no); encounterswith police in the last month, defined as being questioned, searched or stopped by police(yes vs. no); being a victim of violence (yes vs. no); syringe sharing, defined as borrowingor lending syringes already used by someone else to inject drugs (yes vs. no); using injectiondrugs in public locations, such as city streets, parks and alleys (yes vs. no); engaging in anyunprotected sex (yes vs. no); being recently incarcerated (yes vs. no); and current enrolmentin methadone treatment (yes vs. no). Unless otherwise stated, all drug use and behaviouralvariables refer to the previous six month period.In our primary analysis, we sought to assess whether a structural intervention in the form oflow-threshold employment might have an impact on street disorder. To do this we measuredDeBeck et al. Page 4Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptdemand for low-threshold employment and identified predictors of willingness to ceaseengagement in disorderly income generation activities if low-threshold employment wasavailable. Our measures were based on the questions: If you were offered casual work thatdid not interfere with your welfare, would you take it? and If yes, are there any incomesources in the last 30 days that you would eliminate? Participants were then asked toindicate which sources of income they would forgo. Variables of interest for this analysisincluded all variables from the primary analysis, in addition to engagement in specificdisorderly income generation activities, including recycling, panhandling, squeegeeing, drugdealing and sex work. As in the initial analysis, unless otherwise stated, all drug use andbehavioural variables refer to the previous six month period.For both our analyses, we used logistic regression to determine factors associated with ouroutcomes of interest. In univariate analysis categorical explanatory variables were analyzedusing Pearson’s chi-square test and continuous variables were analyzed using the Mann-Whitney test. Fisher’s exact test was used when one or more of the cell counts was less thanor equal to five. To evaluate factors independently associated with our outcomes of interest,we used Akaike information criterion (AIC) with the best subset selection procedure. Thisprovided a computationally efficient method to screen all possible combinations ofcandidate variables and identify the model with the best overall fit as indicated by the lowestAIC value (Shtatland et al., 2002). All statistical analyses were performed using SASsoftware version 9.1 (SAS, Cary, NC). All p-values are two sided.RESULTSDuring the study period a total of 874 participants completed follow-up visits, including 310(35%) women and 312 (36%) persons who identified as being of Aboriginal ancestry. Themedian age of participants was 45 years (interquartile range [IQR] = 39–51). Among oursample of 874 IDU surveyed between November 2008 and July 2009, a total of 418 (48%)reported engaging in disorderly income generation activities. The median number ofdisorderly activities that participants engaged in was 1 (IQR = 1–1). As displayed in Table 1,drug dealing (n=220, 25%) and recycling (n=165, 19%) were the most common types ofdisorderly income generation activity, and the median number of hours spent engaged indisorderly income generation activities each week was highest for drug dealing (20 hrs perweek, IQR = 6–40). The characteristics of the study sample stratified by engagement indisorderly income generation activities are presented in Table 2.Among individuals who reported engaging in disorderly income generation activities, 198(47%) indicated they would cease engaging in this activity if they had access to low-threshold employment. As shown in Table 1, among those who reported income from sextrade work, 51 (63%) indicated they would no longer engage in sex trade work if they hadaccess to low-threshold employment. Further, 97 (44%) respondents who reported incomefrom drug dealing, 21 (37%) respondents who reported engaging in panhandling and 48(29%) respondents who engaged in recycling reported that they would refrain from engagingin those disorderly income generation activities if they had access to causal employmentopportunities.The univariate and multivariate findings for our initial exploratory analyses of behavioraland socio-demographic variables associated with engaging in disorderly income generationactivities are also presented in Table 2. Factors that remained independently associated withdisorderly income generation activities included: regular employment (adjusted odds ratio[AOR] = 0.47, 95%CI: 0.32–0.69); daily cocaine injection (AOR = 2.11, 95%CI: 1.13–3.96); daily crack cocaine smoking (AOR = 3.29, 95%CI: 2.32–4.66); binge drug use (AOR= 1.57, 95%CI: 1.14–2.16); encounters with police (AOR = 2.49, 95%CI: 1.65–3.75); beingDeBeck et al. Page 5Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripta victim of violence (AOR = 1.69, 95%CI: 1.07–2.68); syringe sharing (AOR = 4.42,95%CI: 1.43–13.68); and public injecting (AOR = 2.27, 95%CI: 1.51–3.39).For our primary analysis, the univariate and multivariate results of factors associated withwillingness to cease engaging in disorderly income generation activities are presented inTable 3. Factors that remained independently associated with willingness to cease engagingin disorderly income generation included: sex work (AOR = 2.32, 95%CI: 1.35–3.96); drugdealing (AOR = 1. 91, 95%CI: 1.22–2.99); binge drug use (AOR = 1.55, 95%CI: 1.02–2.36); incarceration (AOR = 2.03, 95%CI: 1.11–3.73); and current enrolment in methadonetreatment (AOR = 1.68, 95%CI: 1.11–2.56).DISCUSSIONAmong our sample of 874 IDU, we found that 48% reported engaging in a disorderlyincome generation activity in the last six months. The most common activities reported weredrug dealing and recycling (which included salvaging and unsanctioned street vending). In amultivariate analysis people who reported engaging in disorderly income generationactivities were more likely to smoke crack cocaine on a daily basis and inject cocaine on adaily basis. This population was also more likely to engage in binge drug use, haveencounters with police, be a victim of violence, share used syringes and inject drugs inpublic areas. Conversely, individuals with regular employment were significantly less likelyto report engaging in disorderly income generation activities. We also found that amongindividuals who engaged in disorderly income generation activities, 47% reported that theywould be willing to stop engaging in these disorderly activities if they were offered otheropportunities for low-threshold employment. Individuals engaged in sex work, drug dealing,binge drug use, who were recently incarcerated or currently enrolled in methadone therapy,were most interested in ceasing their engagement in disorderly income generation activities.These findings support the conclusions of previous studies indicating that disorderly incomegeneration activities are common among illicit drug users (Bretteville-Jensen & Sutton,1996; Cross et al., 2001; Deschenes & Anglin, 1991; Nurco et al., 1985). The significantassociations between engaging in disorderly income generation activities and daily crackcocaine smoking and daily cocaine injecting are consistent with a growing number of studieslinking frequent cocaine use with a greater likelihood of engaging in risky behaviours(Booth, Kwiatkowski, & Chitwood, 2000; Buchanan et al., 2006; Edlin et al., 1994) andillegal activities (Cross et al., 2001; DeBeck et al., 2007). These associations suggest that thecompulsive drug acquisition behaviours associated with cocaine addiction may perpetuatethe need to generate income through prohibited means. In particularly the relatively shorthalf-life of cocaine compared with opioids or methamphetamine may contribute to anincreased frequency of drug use and pressure to purchase larger quantities of drugs (Jeffcoatet al., 1989). In addition, the negative psychiatric effects of high intensity cocaine use mayhave destabilizing influences that present barriers to engaging in formal employment (Crosset al., 2001). Indeed, previous research found that frequent crack cocaine smoking wasnegatively associated with attaining formal employment among IDU in our study setting(Richardson et al., 2010).Our findings further indicate that individuals who engage in disorderly income generationactivities are a vulnerable population at risk for multiple negative health and socialoutcomes. Many of the behaviours associated with disorderly income generation activitiesincluding daily cocaine injection, daily crack cocaine smoking, binge drug use and syringesharing, have all been independently linked with increased risk of HIV infection in thissetting (DeBeck et al., 2009; Miller et al., 2006; Tyndall et al., 2003). Although many ofthese findings have been reported previously, they underscore the importance of identifyingDeBeck et al. Page 6Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptinterventions to reduce engagement in disorderly income generation activities. Therefore, itis of particular importance that our primary analyses found a high demand for low-thresholdemployment among street-involved IDU and considerable willingness among thispopulation to cease engaging in disorderly activities if they were provided withopportunities for casual low-threshold employment. Previously mentioned findingsdocumenting low levels of regular employment among IDU support the need for alternativeincome generation interventions (Richardson et al., 2010). The potential for low-thresholdemployment to reduce engagement in disorderly income generation has already beendemonstrated to be successful among women involved in sex work (Sherman et al., 2006).Our findings are also consistent with current literature in the drug use field that emphasizesthe importance that structural factors, such as employment opportunities, play in shapingrisk behaviour (Blankenship et al., 2000; Des Jarlais, 2000; Heimer et al., 2002).The association between current enrolment in methadone treatment and willingness to giveup disorderly income generation is consistent with the well-documented positive effect ofmethadone treatment on reducing illegal income generation (Ball & Alan, 1991; Dole et al.,1969). This finding also suggests that substitution therapies may have an even greaterbeneficial role if more low-threshold opportunities were made available.It is noteworthy that in our study participation in sex work was the strongest independentpredictor of willingness to take low-threshold employment. Given the physical dangers andhealth risks associated with sex work, it is understandable that participants engaged in sexwork were most likely to be willing to cease engaging in this behaviour if given otheroptions to earn income (Shannon et al., 2007a; Shannon, et al., 2007b). In addition to theinherent risks associated with sex work, numerous studies have also linked prohibitive sex-work legislation with increasing the vulnerability of sex workers and undermining theirability to protect their health and physical security (Maher, 2000; Maher & Dixon, 1999;Shannon et al., 2008; Shannon et al., 2009). Although the intention of prohibitive sex-worklegislation is to deter engagement in the activity, it appears that the laws that areimplemented to reduce the harms of sex work are actually increasing risks. The strongdemand for low-threshold employment found in the current study among individualsengaged in sex works suggests that there are important opportunities to reduce theprevalence of this activity through means that do not criminalize sex workers and carry theunanticipated negative consequences of criminal justice interventions. It is important to note,however, that the income earned through sex work is often much greater than through otherincome generation opportunities. Despite the potential for sex workers to reduce theirengagement in sex work if alternative low-threshold employment opportunities were madeavailable, it is likely that the income will not be sufficient for some sex workers. In additionto supporting the development of low-threshold employment opportunities, amending lawsthat limit the ability of sex workers to protect their health and physical safety should besimultaneously considered and pursued.IDU who engaged in drug dealing were also significantly more willing to cease this incomegeneration activity if they were given alternative opportunities for low-thresholdemployment. Former studies of drug distribution networks suggest that many street-leveldrug dealers do not receive significant compensation for their work (Levitt & Venkatesh,2000). These works support our findings suggesting that this group may respond well tolow-threshold employment opportunities. This should be of particular interest to policy-makers given the high costs of drug law enforcement which attempt to deter illicit drugproduction and distribution with the threat of incarceration and legal penalties which, todate, have been limited in their ability to prevent engagement in drug dealing among IDUand other segments of the general population (Bewley-Taylor, Trace, & Stevens, 2005;National Research Council, 2002; Rehm et al., 2006).DeBeck et al. Page 7Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptIt is clear from the high rates of engagement in disorderly income generation activitiesreported in our study that current direct and indirect prohibitions against practices such asdrug dealing and sex work are not successfully deterring or preventing engagement in theseactivities. However, it is interesting to note that sex work and drug dealing, as well as recentincarceration, were all significantly associated with willingness to cease engagement indisorderly income generation activities. This may suggest that the deterrent influence ofprohibitions against drug dealing and sex work could be successful in situations where IDUwere given opportunities to choose other less risk income generation opportunities.Unfortunately, it currently appears that the less risky generation opportunities available tomost IDU remain limited (McCoy et al., 2007; Richardson et al., 2008; Richardson et al.,2010).A key implication of this study is that creating low-threshold employment opportunities andsupporting existing initiatives that currently provide these positions has potential to reduceboth street disorder and health risks currently faced by individuals who engage in disorderlyincome generation activities. Models of low-threshold employment for active illicit drugusers already exist in our study setting and elsewhere (Hope in Shadows, 2010; Lougheed-Green, 2004; Lyotier, 2010; Potluck catering, 2010; VANDU, 2010); however, our studysuggests that there is a high demand for this type of work and increasing their capacity andavailability has potential to reduce both individual- and community-level harms.There are a number of limitations with this study. Firstly, VIDUS is not a random sample ofIDU and therefore these findings may not generalize to other drug using populations.However, the association between crack cocaine smoking and street-based incomegeneration suggests that our findings are likely not specific to injection as the sole mode ofcocaine use and may be relevant for crack cocaine smokers that do not have a history ofinjecting. It should also be noted that the median age of participants in VIDUS is 45 years,which is likely higher than the general population of IDU in Vancouver. This could beexpected to result in an under-estimation of risks as younger drug users tend to be morelikely to engage in riskier behaviours and practices (Kral et al., 2000). Secondly, there arelimitations with combining different street-based disorderly income generation activities intoone category as each of these activities is unique and likely attracts different populations. Itis evident from our primary analysis that there are unique characteristics among each group.Although it is crude to combine these very different activities, from a policy perspective it ismeaningful to provide a picture of the net factors associated with these activities, as well asdirection as to whether a potential policy intervention will likely have an overall beneficialimpact despite the differences among activities. While it would have been ideal tosupplement our primary analysis with additional models that considered each individualincome generation activity separately, low event counts precluded these additionalcomparisons. An additional limitation with our variable definition is our overly broaddefinition of ‘recycling’. Recycling can constitute a public good when it involves removinglitter from public areas; however, it could alternatively constitute a public harm if it involvesdestructively removing materials from buildings or structures, such as copper piping. Weanticipate that the demand for low-threshold employment may be higher for those involvedin destructive forms of recycling given the threat of legal repercussions. Unfortunately oursurvey instrument did not differentiate between these different forms of recycling and thusour results are limited in this regard. We believe the distinctions between different forms ofrecycling are important and warrant further investigation. A third limitation in our study isthat many of our measures relied on self-reported information concerning practices andbehaviours that are illegal and/or stigmatized, such as drug dealing, sex work and syringesharing and are therefore vulnerable to social desirable responding. In this present study, thiscould have resulted in an under-reporting of engagement in disorderly income generationactivities and associated risks resulting in conservative estimates of the prevalence of theseDeBeck et al. Page 8Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptactivities and risks. There are other limitations with our measures of street-based incomegeneration activities. Specifically, the amount of money earned through street-baseddisorderly income generation activities does not account for ‘in-kind’ transactions or non-monetary contributions (i.e., exchanging sex for drugs, being paid in drugs rather thanmoney for drug dealing, or receiving food when panhandling). This could have also led to anunder-reporting of engagement in street-based disorderly income generation. Lastly, ourstudy relied on willingness responses that do not represent actual changes in incomegeneration practices. There are potentially a host of external factors that might influenceincome generation practices, some of which may involve complex social networks andpower relations. Therefore, the provision of low-threshold employment can not be expectedto automatically translate into a reduction of street-based income generation among allparticipants who indicated a willingness to change their income generation practices.However, it is important to note that previous analyses evaluating the validity of reportingwillingness to use a supervised injection facility on subsequent rates of use among illicitinjection drug users found that willingness measures were reasonably accurate predictors oflater behaviour among IDU (DeBeck, 2010).In summary, we found that 48% of our sample of IDU recently engaged in disorderlyincome generation activities, and these practices were associated with high intensitystimulant drug use and various markers of risk. However, we also found that a highpercentage of IDU reported being willing to cease engagement in disorderly incomegeneration activities if they had options for causal low-threshold employment. Thesefindings indicate that there is a high demand for low-threshold employment which may offerimportant opportunities to reduce drug-related street disorder and associated harms.AcknowledgmentsThe authors thank the study participants for their contribution to the research, as well as current and pastresearchers and staff. We would specifically like to thank Deborah Graham, Tricia Collingham, Carmen Rock,Peter Vann, Caitlin Johnston, Steve Kain, and Calvin Lai for their research and administrative assistance. We alsothank the anonymous peer reviewers for their constructive comments and suggestions that helped improve themanuscript. The study was supported by the US National Institutes of Health (R01DA011591) and(R01DA021525) and the Canadian Institutes of Health Research (MOP–79297, RAA–79918). Thomas Kerr issupported by the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research.Kora DeBeck is supported by a Michael Smith Foundation for Health Research Senior Graduate Trainee Award anda Canadian Institutes of Health Research Doctoral Research Award. Julio Montaner has received an Avant-Gardeaward (DP1DA026182) from the National Institute of Drug Abuse, US National Institutes of Health.ReferencesAitken C, Moore D, Higgs P, Kelsall J, Kerger M. The impact of a police crackdown on a street drugscene: Evidence from the street. International Journal of Drug Policy. 2002; 13:189–198.Ball, John C.; Ross, Alan. The effectiveness of methadone maintenance treatment: Patients, programs,services, and outcome. New York, NY, US: Springer-Verlag Publishing; 1991.Ball J, Shaffer J, Nurco D. The day to-day criminality of heroin addicts in Baltimore -- A study in thecontinuity of offence rates. Drug and Alcohol Dependence. 1983; 12(2):119–142. 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Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 13Table 1Participation in disorderly income generation activities among injection drug users (last six months) (n=874)Income Source N (%) reporting activityMedian hrs per week engaged in activity*(IQR) N (%) would cease to engage in activity**Recycling 165 (19) 14 (8–30) 48 (29)Panhandling 57 (7) 14 (4.5–40) 21 (37)Squeegeeing 5 (1) 5 (2–10) 0 (0)Drug Dealing 220 (25) 20 (6–40) 97 (44)Sex Work 81 (9) 9 (3–21) 51 (63)*Refers to number of hours spent doing the activity in the average week over the last 30 days;**Indicates participants that would cease to engage in the activity if they had other opportunities for low-threshold employment.Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 14Table 2Univariate and multivariate analyses of factors associated with engaging in disorderly income generation activities among injection drug users (n=874)CharacteristicDisorderly income generation aYesNoORb  (95% CI)p-valueAORb  (95% CI)p-valuen= 418, n (%)n= 456, n (%)Age Per year older43 (38–50) c46 (41–51) c0.97 (0.95 – 0.98)<0.001Daily Expenditure on Drugs Per additional $1050 (30–100) c30 (10–60) c1.05 (1.03 – 1.07)<0.0011.02 (1.00 – 1.03)0.066Female Gender Yes165 (39)145 (32)1.40 (1.06 – 1.85)0.018 No253 (61)311 (68)Aboriginal Ancestry Yes152 (36)160 (35)1.06 (0.80 – 1.39)0.694 No266 (64)296 (65)Unstable Housing (current) Yes110 (26)58 (13)2.45 (1.73 – 3.48)<0.001 No308 (74)398 (87)High School Education Yes199 (48)248 (54)0.76 (0.58 – 0.99)0.045 No219 (52)208 (46)Regular Employment d Yes55 (13)137 (30)0.35 (0.25 – 0.50)<0.0010.47 (0.32 – 0.69)<0.001 No363 (87)319 (70)Daily Cocaine Injection d Yes49 (12)18 (4)3.23 (1.85 – 5.64)<0.0012.11 (1.13 – 3.96)0.020 No369 (88)438 (96)Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 15CharacteristicDisorderly income generation aYesNoORb  (95% CI)p-valueAORb  (95% CI)p-valuen= 418, n (%)n= 456, n (%)Daily Heroin Injection d Yes110 (26)43 (9)3.43 (2.34 – 5.03)< 0.001 No308 (74)413 (91)Daily Crack Smoking d Yes213 (51)74 (16)5.36 (3.92 – 7.34)< 0.0013.29 (2.32 – 4.66)< 0.001 No205 (49)382 (84)Overdose (non-fatal) d Yes20 (5)7 (2)3.22 (1.35 – 7.70)0.006 No398 (95)449 (98)Binge Drug Used Yes230 (55)150 (33)2.50 (1.90 – 3.28)< 0.0011.57 (1.14 – 2.16)0.006 No188 (45)306 (67)Encounters with Police d Yes129 (31)50 (11)3.62 (2.53 – 5.19)< 0.0012.49 (1.65 – 3.75)< 0.001 No289 (69)406 (89)Victim of Violence d Yes84 (20)42 (9)2.48 (1.66 – 3.69)< 0.0011.69 (1.07 – 2.68)0.025 No334 (80)414 (91)Syringe Sharing d Yes28 (7)4 (1)8.11 (2.82 – 23.33)< 0.0014.42 (1.43 – 13.68)0.010 No390 (93)452 (99)Public Injecting d Yes148 (35)52 (11)4.26 (3.00 – 6.05)< 0.0012.27 (1.51 –3.39)< 0.001 No270 (65)404 (89)Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 16CharacteristicDisorderly income generation aYesNoORb  (95% CI)p-valueAORb  (95% CI)p-valuen= 418, n (%)n= 456, n (%)Unprotected Sex d Yes113 (27)98 (21)1.35 (0.99 – 1.85)0.056 No305 (73)358 (79)Recent Incarceration d Yes65 (16)30 (7)2.61 (1.66 – 4.12)< 0.001 No353 (84)426 (93)Methadone Treatment (current) Yes188 (45)218 (48)0.89 (0.68 – 1.16)0.402 No230 (55)238 (52)Note:a Disorderly income generation includes: recycling, squeegeeing, panhandling, selling drugs, and engaging in sex work measured in the last six months;b OR = Odds Ratio, CI = Confidence Interval, AOR = Adjusted Odds Ratio;c Median and Interquartile Range;d Denotes activities or situations referring to previous 6 months.Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 17Table 3Univariate and multivariate analyses of factors associated with willingness to cease engaging in disorderly income generation activities among injectiondrug users (n=418)CharacteristicWilling to cease engaging in disorderly income generation aYesNoOR b (95% CI)p-valueAORb  (95% CI)p-valuen= 198, n (%)n= 220, n (%)Age Per year older43 (37–49)44 (38–51)0.98 (0.96 – 1.00)0.006Daily Expenditure on Drugs Per additional $1060 (30–100) c50 (20–100) c1.01 (1.00 – 1.03)0.073Female Gender Yes88 (44)77 (35)1.49 (1.00 – 2.20)0.049 No110 (56)143 (65)Aboriginal Ancestry Yes81 (41)71 (32)1.45 (0.97 – 2.17)0.0671.52 (0.99 – 2. 35)0.058 No117 (59)149 (68)Unstable Housing (current) Yes63 (32)47 (21)0.73 (0.49 – 1.07)0.1051.50 (0.92 – 2.43)0.103 No135 (68)173 (79)High School Education Yes86 (43)113 (51)0.76 (0.58 – 0.99)0.0450.73 (0.48 – 1.10)0.136 No112 (57)107 (49)Regular Employment d Yes23 (12)39 (18)0.61 (0.35 – 1.06)0.079 No175 (88)181 (82)Sex Work d Yes52 (26)29 (13)2.34 (1.42 – 3.88)<0.0012.32 (1.35 – 3.96)0.002Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 18CharacteristicWilling to cease engaging in disorderly income generation aYesNoOR b (95% CI)p-valueAORb  (95% CI)p-valuen= 198, n (%)n= 220, n (%) No146 (74)191 (87)Drug Dealing d Yes122 (62)98 (45)2.00 (1.35 – 2.95)<0.0011.91 (1.22 – 2.99)0.005 No76 (38)122 (55)Recycling d Yes67 (34)98 (45)0.64 (0.43 – 0.95)0.025 No131 (66)122 (55)Panhandling d Yes27 (14)30 (14)1.00 (0.57 – 1.75)1.0001.66 (0.89 – 3.13)0.114 No171 (86)190 (86)Daily Cocaine Injection d Yes24 (12)25 (11)1.08 (0.59 – 1.95)0.810 No174 (88)195 (89)Daily Heroin Injection d Yes61 (31)49 (22)1.55 (1.00 – 2.41)0.048 No137 (69)171 (78)Daily Crack Smoking d Yes108 (55)105 (48)1.31 (0.89 – 1.93)0.164 No90 (45)115 (52)Overdose (non-fatal) d Yes11 (6)9 (4)1.38 (0.56 – 3.40)0.484 No187 (94)221 (96)Binge Drug Used Yes125 (63)105 (48)1.88 (1.27 – 2.77)0.0021.55 (1.02 – 2.36)0.041Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 19CharacteristicWilling to cease engaging in disorderly income generation aYesNoOR b (95% CI)p-valueAORb  (95% CI)p-valuen= 198, n (%)n= 220, n (%) No73 (37)115 (52)Encounters with Police d Yes69 (35)60 (27)1.43 (0.94 – 2.16)0.094 No129 (65)160 (73)Victim of Violence d Yes42 (21)42 (19)1.14 (0.71 – 1.84)0.589 No156 (79)178 (81)Syringe Sharing d Yes14 (7)14 (6)1.12 (0.52 – 2.41)0.773 No184 (93)206 (94)Public Injecting d Yes81 (41)67 (30)1.58 (1.06 – 2.37)0.026 No117 (59)153 (70)Unprotected Sex d Yes59 (30)54 (25)1.30 (0.85 – 2.01)0.227 No139 (70)166 (75)Recent Incarceration d Yes43 (22)22 (10)2.50 (1.43 – 4.35)0.0012.03 (1.11 – 3.73)0.022 No155 (78)198 (90)Methadone Treatment (current) Yes103 (52)95 (43)1.43 (0.97 – 2.10)0.0711.68 (1.11 – 2.56)0.015 No95 (48)125 (57)Note:a Disorderly income generation includes: recycling, squeegeeing, panhandling, selling drugs, and engaging in sex work measured in the last six months;Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDeBeck et al. Page 20b OR = Odds Ratio, CI = Confidence Interval, AOR = Adjusted Odds Ratio;c Median and Interquartile Range;d Denotes activities or situations referring to previous 6 months.Int J Drug Policy. Author manuscript; available in PMC 2012 September 1.


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