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Employment Among Users of a Medically Supervised Safer Injection Facility Richardson, Lindsey; Wood, Evan; Zhang, Ruth; Montaner, Julio; Tyndall, Mark; Kerr, Thomas Jul 7, 2009

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 EMPLOYMENT AMONG USERS OF A MEDICALLY SUPERVISED SAFER INJECTION FACILITY   Lindsey Richardson1, 3 Evan Wood1,2 Ruth Zhang1 Ju lio Montaner1,2 Mark Tyndall1,2 Thomas Kerr1,2     1. British Columbia Centre for Excellence in HIV/ AIDS, St. Paul's Hospital, 608-1081 Burrard  Street, Vancouver, BC, Canada, V6Z 1Y6 2. Department of Medicine, University of British Columbia  3. Department of Sociology, Oxford University, Manor Road Building, Manor Road, Oxford, UK, OX1 3UQ  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 Email: uhri@cfenet.ubc.ca  Word Count: 1,517 Tables: 1 Revised: February 4, 2007   Running head: Supervised  injection facility use and  employment  Key words:  employment; supervised  injection site; injection drug use  Page 1 ABSTRACT A supervised  injection facility (SIF), where individuals can inject drugs under medical supervision, opened in Vancouver in 2003. The scientific evaluation of the SIF has demonstrated  positive public health-related  outcomes. However, the influence of supervised  injection facilities on individual efforts to reintegrate into mainstream society has not been studied . We examined for a possible relationship between use of the SIF and  employment among a cohort of 1090 SIF users using generalised  estimating equations (GEE). In a multivariate analysis of factors associated  with employment, using the SIF for > 25% of injections (versus < 25% of injections) was not statistically significant (AOR = 1.05, 95% CI: 0.88-1.27). These findings suggest that the SIF is not having an adverse impact on efforts to seek employment.    Richardson et al. : Supervised injection facility use and employment   Page 2 INTRODUCTION The injection of illegal psychoactive drugs continues to be associated  with various harms, includ ing the spread  of blood-borne d isease (1) and  harm related  to public order and  public health (2-3). More than two dozen cities in Europe, Australia and  Canada have opened medically supervised  safer injection facilities (SIF) to address these harms. SIFs provide a place where individuals are able to inject previously acquired  illegal drugs under the supervision of medical staff. Known as Insite, the SIF in Vancouver, Canada is North America’s first government -supported , medically supervised  SIF. Insite opened in September of 2003 under a legal exemption by the Canadian government (4). The ongoing scientific evaluation of the Vancouver SIF has demonstrated  a number of positive outcomes, which have been summarized  elsewhere (5). Despite the demonstrated  benefits of Insite, critics suggest that it perpetuates drug use and interferes with efforts to achieve abstinence and  hence reintegration into mainstream society (6, 7). While there is abundant research demonstrating the effectiveness of harm reduction initiatives (8), the influence of Insite on injection drug users’ (IDU) reintegration warrants ongoing investigation.  One of the crucial components of reintegration into society for IDU is seeking and  hold ing regular employment (9), which can stabilize ind ividuals in structured  and  productive activity (10), provides a legal source of income and reduces social isolation (11). Employment is often considered  an important treatment outcome indicator (10, Richardson et al. : Supervised injection facility use and employment   Page 3 12), and  previous studies have found that employment is associated  with lowered health risk behaviour, decreased  criminal involvement and  increased  social integration (13-15). However, very few studies, if any, have examined the potential influence of a harm reduction-based  intervention on an individual’s willingness or ability to obtain or hold  a regular job. We sought to determine if use of the SIF has a negative impact on employment rates among a randomly selected  cohort of SIF users.   METHODS The Scientific Evaluation of Supervised  Injecting (SEOSI) cohort is a prospective study of users of Insite that has been p reviously described  in detail (4). Briefly, the sample consists of SIF users who were randomly recruited  from Insite for participation in this study and  who provided  informed consent. During study visits, blood samples for HIV and hepatitis C virus testing were drawn and a questionnaire was administered  to elicit demographic and  other information. The study has been approved by the University of British Columbia/ Providence Health Care Clinical Research Ethics Board .   The primary endpoint for this analysis was self-reported  status of having a job with a regular salary or temporary work in the six months prior to interview. Potential explanatory variables of interest included  gender (male vs. female), age, Aboriginal ethnicity, education (less than high school vs. high school or more), unstable housing, daily heroin injection, daily cocaine injection, daily crack cocaine smoking, binge drug use, sex trade involvement, resid ing in the Downtown Eastside (i.e., Vancouver’s drug use and  HIV epicenter), and  regular SIF use. Consistent with previous studies (16, 17), we defined  ”binge drug use” as self-reported  periods when drugs were injected  more Richardson et al. : Supervised injection facility use and employment   Page 4 frequently than usual, “unstable housing” as living in hotels, hostels, jail or prison, or being homeless, and  “regular SIF use” as performing at least 25% of injections (versus a control group of  less than 25% of injections) at the SIF. Since analyses of factors potentially associated  with employment during follow -up included  serial measures for each subject, we used  generalised  estimating equations (GEE) for binary outcomes with logit link for the analysis of correlated  data to determine which factors were independently associated  with employment in the prior six months. These methods provided  standard  errors ad justed  by multiple observations per person using an exchangeable correlation structure. Data from every participant follow-up visit was therefore considered  in this analysis. This approach has been used  successfully in previous stu dies examining correlates of drug treatment access in prospective cohort studies of IDU (18).   As a first step, we examined associations between employment and  predictors of interest using univariate GEE. We also fit a multivariate logistic GEE model to ad just for potential confounding and  included those variables that were statistically significant at the p < 0.05 in univariate analyses. Regular SIF use was also included in the final model as a key variable of interest. All statistical analyses were perfo rmed using SAS software version 9.1 (SAS, Cary, NC). All p -values are two sided . RESULTS  Between December 2003 and December 2005, 1090 individuals were enrolled  in SEOSI and  all of these were included  in the current analysis. Of these, 889 (82%) had  at Richardson et al. : Supervised injection facility use and employment   Page 5 least one additional follow-up visit and  731 (67%) were seen at the most recent follow -up. Overall, these participants contributed  to 3083 observations during the follow -up period . Among these individuals, the median age was 38.4 (interquartile range [IQR] 32.7 - 44.3), 211 (19.4%) were of Aboriginal ethnicity, and  317 (29%) were female. Of the 1090 eligible participants for this analysis, 396 (36.3%) reported having had  a regular job at some point during the six months prior to semi-annual follow-up interviews. The univariate GEE analyses assessing associations between employment and  variables of interest are shown in Table 1. Only binge drug use (odds ratio [OR] = 1.19, 95% confidence interval [CI]: 1.01-1.41) was positively associated  with employment. Factors negatively associated  with employment included  female gender (OR = 0.23, 95%CI: 0.17-0.31), Aboriginal ethnicity (OR = 0.44, 95%CI:  0.31-0.61), lower education level (OR = 0.54, 95%CI: 0.42-0.68), unstable housing (OR = 0.56, 95%CI: 0.47-0.67), Downtown Eastside residency (OR = 0.66, 95%CI: 0.54-0.80), sex trade involvement (OR = 0.49, 95%CI: 0.36-0.65), and  daily heroin injection (OR = 0.80, 95%CI: 0.66-0.97). Associations between employment and  daily cocaine use and  employment and  daily crack use do not reach statistical significance. Regular SIF use (OR = 1.06, 95%CI: 0.90-1.25) was not associated  with employment.   In the multivariate GEE analysis also shown in Table 1, binge drug use remained  positively associated  with employment (ad justed  odds ratio [AOR] = 1.27, 95%CI: 1.06-1.52). Factors negatively associated  with employment were female gender (AOR = 0.26, 95%CI: 0.18-0.37), Aboriginal ethnicity (AOR = 0.56, 95%CI: 0.40-0.80), lower education level (AOR = 0.63, 95%CI: 0.50-0.81), unstable housing (AOR = 0.58, 95%CI 0.47-0.71), Richardson et al. : Supervised injection facility use and employment   Page 6 and  daily heroin use (AOR = 0.81, 95%CI: 0.66-0.99). Downtown Eastside residency and  sex trade involvement d id  not retain significance. DISCUSSION  In the present study we found low rates of employment among SIF users but no statistically detectable relationship between regular use of the SIF and  employment  as opposed  to non-regular SIF use. These data therefore suggest that regular use of the SIF neither interferes with nor promotes facility users’ willingness or capacity to seek out and  retain formal employment.    These find ings indicate that the previously observed  benefits of the SIF, including increased  use of addiction treatment and  reductions in HIV risk behavior (19, 20) have not been undermined by an adverse effect of regular SIF use on employment. One presently unexplored  opportunity, which should  be the subject of future research, would  be to evaluate the impact of incorporating employment services into the range of community resource referrals offered  to SIF users. Specialized  employment programs designed  for substance users have been shown elsewhere to have positive impacts on treatment enrollment, retention and  effectiveness (15, 21).    Our results also show that there are barriers to employment among users of Insite for females, ind ividuals of Aboriginal ethnicity, those who do not finish high school and  those with unstable housing. The effect of socio-demographic characteristics on the vocational activity of IDU is an important result that warrants further examination.  Richardson et al. : Supervised injection facility use and employment   Page 7  It is worth noting the drug use patterns of respondents reporting employment. While daily heroin use is marginally and  negatively associated  with employment, binge drug use is positively associated  with employment. This suggests that SIF users who  hold  regular jobs may concentrate their drug use, which may have implications for the health risks associated  with binge drug use, such as increased  syringe sharing (20, 22), HIV sero-conversion (23), and  non-fatal overdose (24). Our study is limited  by SEOSI’s observational nature and  reliance on self-report, which may introduce both recall and  socially desirable reporting biases. Further, while the SEOSI participants have been shown to be statistically similar to the over all cohort of users of Insite (4), it is not possible to generalise the current findings, derived  from a specific sample population, to IDU populations more broadly. Lastly, the employment variable used  for this analysis is loosely defined  as having a regular or temporary job in the six months prior to interview. As such, it is not possible to identify more precise employment patterns among SEOSI participants, which may range from full-time employment or intermittent work to persistent unemployment.  In sum, we found no relationship between SIF use and  employment, suggesting that SIF use does not interfere with employment, an activity that is strongly associated  with addiction recovery. This find ing challenges claims that the SIF impedes reintegration into society, supports previous findings that the SIF has not produced any community or health-related  harms (5), and  suggests that the well-documented  benefits of the SIF have not been undermined  by adverse effects of SIF use on employment rates. Richardson et al. : Supervised injection facility use and employment   Page 8 Given the small proportion of employed SEOSI participants, these findings further suggest that there may be opportunities to incorporate employment service -related referrals into the resources available at Insite.   Richardson et al. : Supervised injection facility use and employment   Page 9 Acknowledgments The authors wish to thank the participants in SEOSI and  the staff of Insite, the Portland  Hotel Society, and  Vancouver Coastal Health (Chris Buchner, David  Marsh, and Heather Hay.) We also thank the current and  past SEOSI staff. We would  specifically like to thank Deborah Graham, Tricia Collingham, Caitlin Johnston, Steve Ka in, and Calvin Lai for their research and  administrative assistance. The evaluation of the supervised  injecting facility was originally made possible through a financial contribution from Health Canada, although the views expressed  herein do not represent the official policies of Health Canada. The evaluation is currently supported by the Canadian Institutes of Health Research and  Vancouver Coastal Health. Lindsey Richardson is supported  by the Clarendon Fund, Oxford  University Press. Mark Tyndall is supported  by a Michael Smith Foundation for Health Research Senior Scholar Award . Thomas Kerr is supported  by a Michael Smith Foundation for Health Research Scholar Award  and  a Canadian Institutes of Health Research New Investigator Award .Richardson et al. : Supervised injection facility use and employment   Page 10 REFERENCES 1. Aceijas C, Stimson GV, Hickman M, Rhodes T, United Nations Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS 2004 Nov 19;18(17):2295-303. 2. Kimber J, Dolan K, van Beek I, Hedrich D, Zurhold H. Drug consumption facilities: An update since 2000. Drug and Alcohol Review 2003; 22(2):227-33. 3. Wright NM, Tompkins CN. Supervised injecting centres. BMJ 2004; 328(7431):100-2. 4. Wood E, Kerr T, Lloyd-Smith E, Buchner C, Marsh DC, Montaner JS, et al. Methodology for evaluating Insite: Canada's first medically supervised safer injection facility for injection drug users. Harm Reduct J 2004; 1(1):9. 5. Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. CMAJ 2006; 175(11):1399-404. 6. Mangham C. A critique of Canada's INSITE injection site and its parent philosophy: Implications and recommendations for policy planning. J Global Drug Pol and Pract; 1(2):August 7, 2007. 7. CBC News. Police group takes aim at Vancouver safe injection site. CBC News. Sept 1 2006. 8. Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug and Alcohol Review. 2006 [cited August 14, 2007]; 25(6):611. Available from: http://www.informaworld.com/10.1080/09595230600944529. Richardson et al. : Supervised injection facility use and employment   Page 11 9. Platt JJ. Vocational rehabilitation of drug abusers. Psychol Bull 1995; 117(3):416-33. 10. Vaillant GE. What can long-term follow-up teach us about relapse and prevention of relapse in addiction? Br J Addict 1988; 83(10):1147-57. 11. Hills J, Le Grand J, Piachaud D. Understanding social exclusion. Oxford: Oxford University Press, 2002. 12. Magura S, Staines GL, Blankertz L, Madison EM. The effectiveness of vocational services for substance users in treatment. Subst Use Misuse 2004; 39(13-14):2165-213. 13. March JC, Oviedo-Joekes E, Romero M. Drugs and social exclusion in ten European cities. Eur Addict Res 2006; 12(1):33-41. 14. Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Arch Gen Psych 2001; 58(5):503-8. 15. Lundgren LM, Schilling RF, Ferguson F, Davis K, Amodeo M. Examining drug treatment program entry of injection drug users: Human capital and institutional disaffiliation. Eval Program Planning 2003; 26(2):123-32. 16. Wood E, Tyndall MW, Spittal PM, Li K, Kerr T, Hogg RS, et al. Unsafe injection practices in a cohort of injection drug users in Vancouver: Could safer injecting rooms help? CMAJ 2001; 165(4):405-10. 17. Stoltz JA, Wood E, Small W, Li K, Tyndall M, Montaner J, et al. Changes in injecting practices associated with the use of a medically supervised safer injection facility. J Public Health 2007; 29(1):35-9. Richardson et al. : Supervised injection facility use and employment   Page 12 18. Shah NG, Celentano DD, Vlahov D, Stambolis V, Johnson L, Nelson KE, et al. Correlates of enrollment in methadone maintenance treatment programs differ by HIV-serostatus. AIDS 2000; 14(13):2035-43. 19. Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction 2007; 102(6):916-9. 20. Kerr T, Tyndall M, Li K, Montaner J, Wood E. Safer injection facility use and syringe sharing in injection drug users. Lancet 2005; 366(9482):316-8. 21. Reif S, Horgan CM, Ritter GA, Tompkins CP. The impact of employment counseling on substance user treatment participation and outcomes. Subs Use Misuse 2004; 39(13):2391.  22. Fairbairn N, Wood E, Small W, Stoltz JA, Li K, Kerr T. Risk profile of individuals who provide assistance with illicit drug injections. Drug Alcohol Depend 2006; 82(1):41-6. 23. Miller CL, Kerr T, Frankish JC, Spittal PM, Li K, Schechter MT, et al. Binge drug use independently predicts HIV seroconversion among injection drug users: Implications for public health strategies. Subst Use Misuse 2006; 41(2):199-210. 24. Kerr T, Fairbairn N, Tyndall M, Marsh D, Li K, Montaner J, et al. Predictors of non-fatal overdose among a cohort of polysubstance-using injection drug users. Drug Alcohol Depend. 2007; 87(1):39-45.  Richardson et al. : Supervised injection facility use and employment   Page 13  Table 1 - Bivariate and multivariate GEE* analysis of factors associated with employment during follow -up (n = 1090) Characteristic Unadjusted Odds Ratio (95% CI‡) p-value Adjusted Odds Ratio (95% CI‡) p- value Gender     (female vs. male) 0.23 (0.17-0.31) <0.001 0.26 (0.18-0.37) <0.001 Aboriginal ethnicity     (yes vs. no) 0.44 (0.31-0.61) <0.001 0.56 (0.40-0.80) 0.001 Education level     (< h.s. § vs. h.s. or more) 0.54 (0.42-0.68) <0.001 0.63 (0.50-0.81) <0.001 Unstable housing      (yes vs. no) 0.56 (0.47-0.67) <0.001 0.58 (0.47-0.71) <0.001 DTES†† residency      (yes vs. no) 0.66 (0.54-0.80) <0.001 0.82 (0.66-1.01) 0.068 Sex trade involvement     (yes vs. no) 0.49 (0.36-0.65) <0.001 0.93 (0.65-1.33) 0.707 Daily heroin use†     (yes vs. no) 0.80 (0.66-0.97) 0.026 0.81 (0.66-0.99) 0.041 Daily cocaine use†     (yes vs. no) 0.88 (0.73-1.05) 0.152 - - Daily crack use†     (yes vs. no) 1.22 (0.92-1.62) 0.164 - - Binge drug use†     (yes vs. no) 1.19 (1.01-1.41) 0.034 1.27 (1.06-1.52) 0.008 SIF use†     (<25% vs. >25% of injections) 1.06 (0.90-1.25 0.465 1.05 (0.88-1.27) 0.568 Note: * GEE = Generalised  Estimating Equation; ‡ CI = Confidence Interval;  § h.s. = high school; † Denotes activities/ events in the 6-month period preceding interview; †† DTES = Downtown Eastside; all variables shown in univariate GEE analysis were included in the multivariate GEE analysis.     

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