UBC Faculty Research and Publications

Timing of Income Assistance Payment and Overdose Patterns at a Canadian Supervised Injection Facility Zlotorzynska, Maria; Milloy, M-J; Richardson, Lindsey; Nguyen, Paul; Montaner, Julio; Wood, Evan; Kerr, Thomas Apr 4, 2014

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
52383-Zlotorzynska_M_et_al_Timing_income_assistance.pdf [ 344.23kB ]
Metadata
JSON: 52383-1.0347306.json
JSON-LD: 52383-1.0347306-ld.json
RDF/XML (Pretty): 52383-1.0347306-rdf.xml
RDF/JSON: 52383-1.0347306-rdf.json
Turtle: 52383-1.0347306-turtle.txt
N-Triples: 52383-1.0347306-rdf-ntriples.txt
Original Record: 52383-1.0347306-source.json
Full Text
52383-1.0347306-fulltext.txt
Citation
52383-1.0347306.ris

Full Text

1    TIMING OF INCOME ASSISTANCE PAYMENT AND OVERDOSE PATTERNS AT A CANADIAN SUPERVISED INJECTION FACILITY   Maria Zlotorzynska PhD1, M.-J. S. Milloy PhD1,2, Lindsey Richardson PhD1,3, Paul Nguyen PhD1, Ju lio S Montaner MD1,3, Evan Wood MD PhD1,3 and Thomas Kerr PhD1,3  1. British Columbia Centre for Excellence in HIV/ AIDS, St. Paul’s Hospital,  608-1081 Burrard  Street, Vancouver, BC, CANADA, V6Z 1Y6 2. School of Population and  Public Health , University of British Columbia,  5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3 3. Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard  Street, Vancouver, BC, CANADA, V6Z 1Y6  Send correspondence to:   Thomas Kerr, PhD Director, Urban Health Research Initiative B.C. Centre for Excellence in HIV/ AIDS Associate Professor, Department of Medicine University of British Columbia St. Paul's Hospital 608-1081 Burrard  Street, Vancouver, B.C., V6Z 1Y6 Canada Tel: (604) 806-9116 Fax: (604) 806-9044 Email: uhri-tk@cfenet.ubc.ca     Word  Count: 2,199 Tables: 1 Figures: 0 Revised: February 25, 2014 Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  2 ABSTRACT   Background: Little is known about the relationship between timing of income assistance provision and  health behaviours among injection drug users (IDU). We therefore investigated  associations between income assistance provision and  overdose patterns among IDU utilizing Insite, a supervised  injection facility in Vancouver, Canada.  Methods: Using data collected  at Insite between March 2004 and  December 2010, we examined  trends in overdoses and  drugs injected . Data were stratified  by proximity to the most recent day of issue of income assistance cheques, based  on dates provided  by the province.  Results: After ad justment for frequency of use, the risk of overdose for those injecting at Insite on the three days starting with “cheque day” was higher than for those injecting on other days (Odds Ratio [OR]=2.06; 95% Confidence Interval [CI]: 1.80–2.36, p<0.001). These associations were also significant when drug-specific overdose rates were considered . The proportion of overdoses involving exclusive opioid  use was lower for events occurring around cheque day than on other days (OR=0.63; 95% CI: 0.47–0.84, p=0.002), though we observed  no significant association between the proportion of overdoses involving stimulants and  cheque timing (p=0.129).  Conclusions: The risk of overdose among IDU utilizing Insite was significantly higher on and  immediately after cheque day than during other days, and  may be associated with reduced  tolerance and  increases in binge drug use. Alternative models of income assistance administration should  be evaluated  to reduce overdoses around cheque day.   Word Count: 233 Keywords: Overdose; Illicit d rug use; Cheque effects; Supervised  injection facilities; Income assistance  Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  3 INTRODUCTION  Overdose is a significant health risk for people who use illicit d rugs, with injection drug users (IDU) experiencing a particularly high burden of overdose-attributed  mortality (Bargagli et al., 2006). Even when drug overdose does not result in death, the sequelae of non-fatal overdose among IDU are a significant source of morbid ity (Warner-Smith, Darke, & Day, 2002). Prevention of drug overdose is therefore a central component of efforts to reduce the harms associated  with injection drug use.  In the 1990s, Vancouver, Canada experienced  epidemics of drug overdoses and infectious d isease among the IDU population, especially in the impoverished  Downtown Eastside neighbourhood  (Fischer, Popova, Rehm, & Ivsins, 2006). In response, the city established  Insite, North America’s first government-sanctioned  supervised  injection facility (SIF) in 2003 (Wood, Kerr, Lloyd -Smith, et al., 2004). At Insite, clients can obtain sterile injection equipment and  inject pre-obtained  illicit substances under the supervision of health care professionals. The facility staff provides emergency response to overdoses, as well as primary health care and  referrals. To date, there have been no fatal overdoses reported at Insite. However, non -fatal overdose is a common occurrence at the facility (Kerr, Tyndall, Lai, Montaner, & Wood, 2006). In many North American jurisd ictions, including British Columbia (Li, Sun, Marsh, & Anis, 2007), monthly income assistance cheques are issued  to nearly all recipients on the same day. There is an emerging body of research investigating Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  4 associations between cheque issuance timing, and  substance use and  related  harms (Halpern & Mechem, 2001; Rosen, 2011). These so-called  “cheque effects” have been associated  with increases in psychiatric emergencies (Shaner et al., 1995), drug and  alcohol related  deaths (Verheul, Singer, & Christenson, 1997) and  admissions to a sobering unit for people who are publicly intoxicated  (Li et al., 2007). These spikes in health service utilization are troubling not only because of negative health consequences associated  with increased  substance use, but also due to the heavy burden placed  on healthcare systems around cheque day. It has been suggested  that a sudden increase in cash may act as a conditioned  cue for drug consumption (Epstein et al., 2009; O'Brien, Childress, McLellan, & Ehrman, 1992). This may be especially relevant in the Vancouver setting, as Insite is located  in a neighbourhood  with a high prevalence of injection drug use (Wood, Kerr, Small, et al., 2004), and  where a large number of residents receive income assistance (City of Vancouver, 2007). Thus, cheque issuance timing may be a strong environmental cue producing increased  drug use for many IDU who utilize Insite (Riddell & Riddell, 2006). Despite previous research on cheque effects and  substance use, little is known about how cheque timing affects injection drug use behaviour and  overdose patterns. One Vancouver-based  report found an increase in drug overdose hospital admissions around cheque day (Riddell & Riddell, 2006). However, a key limitation of this literature is the inability to standard ize for drug use rates as there were no data available on the total number of drug injection events during this period . Thus, it is unclear whether the higher occurrence of drug-related  harms observed  in this study Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  5 results from more people injecting drugs immediately after cheque issuance or whether these trends result from higher-risk drug use behaviour. To address this question, the present study investigates the effects of cheque issuance timing on overdose patterns among IDU who utilize the Vancouver SIF, using data on all injections performed at the facility during the study period . METHOD S Data on overdose events in the SIF were compiled  from the Insite facility’s comprehensive on-site surveillance database. This system was the source of data for earlier analyses of SIF overdose patterns and  has been previously described  in detail (Kerr et al., 2006; Wood, Kerr, Lloyd -Smith, et al., 2004). Briefly, all clients must register at the SIF using a pseudonymous identifier and  basic demographic information (i.e., gender and  age). Overdose events are clinically determined  by Insite nursing staff based  on observation of symptoms, including respiratory rate, level of consciousness and  skin colour. All activities in the SIF, including the type and  amount  of substances injected , the characteristics of overdose events and  emergency interventions, are entered  into the database and  associated  with the client’s identifier. The evaluation of Vancouver’s SIF has been reviewed and approved by the University of Br itish Columbia/ Providence Healthcare Research Ethics Board . For this cross-sectional analysis, we obtained  data on all injections in the facility between March 2004 and December 2010. Using monthly cheque d istribution dates provided by the BC Ministry of Social Development, we stratified  the data by the Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  6 number of days since the last income assistance cheque was issued . For further analyses, the data were categorized  into those events occurring on the three days starting with a cheque issue day and  events occurring on all other days. This served  as our primary outcome of interest, with overdoses occurring on all other days in the month serving as the comparison. We then calculated  the number of injections resulting in an overdose event and  d ivided  this number the total number of injections during each time period , to calculate overdose rates per 1,000 injections. Next, we calculated  overdose rates per 1,000 injections by drug type: opioids alone, defined  as heroin, morphine, methadone, hydromorphone or oxycodone; stimulants alone, defined  as cocaine, crack or crystal methamphetamine; and  both opioids and  stimulants. Each rate was calculated  by d ivid ing the number of drug-specific overdoses by the total number of injections involving that drug type. The median number of daily injections performed at the facility was also calculated  for both time periods. Finally, odds ratios were calculated  for the associations between the outcome and type of drugs used  prior to overdose events: opioids alone (yes vs. no); stimulants alone (yes vs. no); and  both opioids and  stimulants (yes vs. no).  Associations of categorical variables were assessed  using the Pearson’s chi-square test and  associations of continuous variables were assessed  using the Wilcoxon-Mann-Whitney test. All statistical analyses were performed using the SAS software version 9.3 (SAS Institute Inc., Cary NC, 2011). All p-values were two-sided . Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  7 RESULTS Between March 2004 and December 2010, there were a total of 1,338 overdose events at Insite, with a rate of 1.11 events per 1,000 injections (95% Confidence Interval [CI]: 1.05–1.17). No drug overdose fatalities occurred  at Insite during this time. The d istribution of overdose events per 1,000 injections was not uniform over time, with a peak occurring during the three days beginning with income assistance cheque issue day. As indicated  in Table 1, the risk of overdose for those injecting on the three days beginning with cheque day was significantly higher than  for those injecting on other days (Odds Ratio [OR]=2.06; 95% CI: 1.80–2.36, p<0.001). This association held  when drug-specific overdoses were examined. The risk of overdose on the three days beginning with cheque day was significantly higher for those injecting opioids alone (OR=2.16, 95% CI: 1.83–2.55, p<0.001), those injecting stimulants alone (OR=2.22, 95% CI: 1.55–3.18, p<0.001), and  those injecting both opioids and  stimulants (OR=1.74, 95% CI: 1.01–3.01, p=0.045). The daily number of injections at Insite was also significantly higher on the three days beginning with cheque day than on other days (median: 513 vs. 483, p<0.001).  Finally, we investigated  associations between types of drugs involved  in overdoses at Insite and  cheque issuance timing (Table 1). Exclusive opioid  use was reported  in 66% of overdoses that occurred  on the three days beginning with cheque day, while 75% of overdoses on other days involved  opioid  use (OR=0.63; 95% CI: 0.47–0.84, p=0.002). The proportion of overdoses involving only stimulants (15%) was slightly higher for events occurring on the three days beginning with cheque day as Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  8 compared  to events on other days (12%), though this association was not statistically significant (p=0.129). There was also no significant association between the proportion of overdoses involving both opioids and  stimulants, and  cheque issuance timing (p=0.269).  D ISCUSSION   In the present study, we observed  an overall overdose rate of 1.11 events per 1,000 injections (95% CI: 1.05–1.17) at Vancouver’s SIF between March 2004 and December 2010. This was a lower rate than one found in a previous study of drug overdose events at Insite conducted  between March 2004 and August 2005 (Kerr et al., 2006). We found a significant association between the rate of non-fatal overdose at Vancouver’s supervised  injection site and  the issuing of income assistance cheques. Specifically, the risk of injections resulting in overdose doubled  during the three days beginning with the issuing of income assistance cheques. This association was also significant when drug-specific overdose rates were considered . The corresponding median number of injections performed at Insite was also higher  around cheque day, consistent with previous studies that ind irectly observed  increased  substance use coincid ing with income assistance cheque timing (Halpern & Mechem, 2001; Maynard  & Cox, 2000).  Our findings are also consistent with a previous study that reported  an increase in the number of overdose admissions to a Vancouver hospital on the three days beginning with cheque day relative to other days in the month (Riddell & Riddell, Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  9 2006). In contrast to this previous work, the present analysis ad justed  the number of drug overdoses for the total number of daily injections performed at the facility . Thus, our study suggests that higher utilization of the facility alone cannot account for the higher incidence of overdoses at Insite around check day. Higher-risk drug behaviour, such as binge use, poly-drug use or higher drug doses may therefore be a contributing factor to elevated  risk of overdose around the provision of income assistance cheques. As many opioid  overdoses are related  to concurrent use of CNS system depressant drugs, such as alcohol or benzodiazepines (Jones, Mogali, & Comer, 2012), increased  consumption of CNS depressants with opioids following the issuance of cheques  is a possible explanation for the observed  findings. Further, it may be that ind ividual tolerance is lower when cheques are issued  as individuals may have exhausted  the funds they received  from their last cheque. Therefore, high-risk drug use combined  with low tolerance may plausibly explain the results observed  herein.  Further analysis examined the drug types involved  in overdose events at Insite in relation to cheque issuance timing. Interestingly, the proportion of overdoses involving only opioids declined  on the three days beginning with cheque day relative to other times. Small increases in the proportion of overdose events involving stimulants alone, and  those involving both opioids and  stimulants around cheque day were also observed , but these findings were not statistically significant. However, regard less of timing, opioid  use accounted  for the overwhelming majority of overdose events in this study, consistent with previous findings in this setting (Kerr et al., 2006). Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  10 This study has notable limitations. First, the population of IDU injecting at Insite is not a random sample drawn from all local IDU. Indeed , previous studies have found that the facility attracts a population particularly at risk  for blood-borne infections and  overdose (Wood et al., 2005). Thus, the results of the present study may not be generalizable to other settings. Second, The Insite database does not collect information on non-injection drug use or substances consumed by users outside the SIF. While Insite staff request information about drugs that are being injected  upon entry into the injecting room, collecting additional information from individuals post -overdose may provide further insight into the dynamics reported  herein. Finally , the SIF database does not collect information on the income sources of clients and  we have no data on the prevalence of income assistance receipt among those who experienced  overdose after injecting drugs at Insite. While previous research on Vancouver IDU has found that social assistance constitutes the majority of monthly income for a high proportion of IDU, many IDU supplement this income with other sources (DeBeck et al., 2007).Therefore conclusions regard ing a possible causal relationship between cheque issuance and  drug overdose should  be made with caution. Our findings have important policy implications. Under the current model of monthly income assistance cheque issuance, both the number of injections and  the demand for emergency overdose interventions at Insite is highest on the three days beginning with cheque day. Thus staffing and  resource allocation decisions should  be made accordingly. More importantly, these associations also suggest that there may be an opportunity for structural interventions to reduce the incidence of drug overdose. It Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  11 is important to note that many IDU may experience a number of barriers to maintaining employment, including physical and  mental comorbid ities, and  unstable housing (Gresenz, Watkins, & Podus, 1998). Discontinuing assistance is unlikely to eliminate substance use, and  could  exacerbate health  and  social problems related  to poverty in this population. Thus, more research is needed to characterize the determinants of overdose in order to inform interventions for those on social assistance. The ideal timing and  quantity of income assistance cheques has not been examined in detail. Alternative models of income assistance cheque issuance include issuing payments via smaller and  more frequent cheques. While it is possible that such policy changes may alter the timing of overdose events without a reduction in overall incidence, a wider d istribution of the demand for overdose-associated  health services may still be beneficial. An alternative approach of assigning a payee representative to administer funds on behalf of the recipient has also been proposed  (Rosen, McMahon, & Rosenheck, 2007). However, this can be perceived  as coercive (Elbogen, Swanson, & Swartz, 2003) and  has not been found to decrease substance use when used  in the absence of addiction treatment interventions (Rosen et al., 2007; Rosenheck, Lam, & Randolph, 1997), and  thus may not be appropriate or desirable. There is therefore a need  to further research harm reduction and income management interventions for IDU receiving income assistance to decrease high-risk drug behaviour while preserving recipient autonomy. In conclusion, we found a twofold  increase in the risk of overdose for those injecting drugs at a supervised  injection facility on the three days beginning with the Zlotorzynska et al., Timing of income assistance payment and overdose patterns at a Canadian supervised injection facility  12 issuing of income assistance cheques relative to those injecting at the facility on other days. Our findings suggest that alternative models of income assistance cheque issuance may be warranted  to decrease the morbid ity associated  with drug overdose and  to ease the burden on health systems following cheque day.  ACKN OWLED GEMENTS The authors thank the study participants, current and  past study staff, the staff of Insite, the Portland  Hotel Society, and  Vancouver Coastal Health. 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 has been supported  by Vancouver Coastal Health and  Canadian Institutes of Health Research (MOP–111039). This research was undertaken, in part, thanks to funding  from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports Dr. Evan Wood.   13  REFERENCES Bargagli, A. M., Hickman, M., Davoli, M., Perucci, C. A., Schifano, P., Buster, M., et al. (2006). Drug-related mortality and its impact on adult mortality in eight European countries. European Journal of Public Health, 16(2), 198-202. DeBeck, K., Shannon, K., Wood, E., Li, K., Montaner, J., & Kerr, T. (2007). Income generating activities of people who inject drugs. Drug and Alcohol Dependence, 91(1), 50-56. Elbogen, E. B., Swanson, J. W., & Swartz, M. S. (2003). Effects of legal mechanisms on perceived coercion and treatment adherence among persons with severe mental illness. Journal of Nervous and Mental Disease, 191(10), 629-637. Epstein, D. H., Willner-Reid, J., Vahabzadeh, M., Mezghanni, M., Lin, J. L., & Preston, K. L. (2009). Real-time electronic diary reports of cue exposure and mood in the hours before cocaine and heroin craving and use. Archives of General Psychiatry, 66(1), 88-94. Fischer, B., Popova, S., Rehm, J., & Ivsins, A. (2006). Drug-related overdose deaths in British Columbia and Ontario, 1992-2004. Canadian Journal of Public Health, 97(5), 384-387. Gresenz, C. R., Watkins, K., & Podus, D. (1998). Supplemental Security Income (SSI), Disability Insurance (DI), and Substance Abusers. Community Mental Health Journal, 34(4), 337-350.   14 Halpern, S., & Mechem, C. (2001). Declining rate of substance abuse throughout the month. American Journal of Medicine, 110, 347–351. Jones, J. D., Mogali, S., & Comer, S. D. (2012). Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend, 125(1-2), 8-18. Kerr, T., Tyndall, M. W., Lai, C., Montaner, J. S. G., & Wood, E. (2006). Drug-related overdoses within a medically supervised safer injection facility. International Journal of Drug Policy, 17(5), 436–441. Li, X., Sun, H., Marsh, D., & Anis, A. (2007). Impact of welfare cheque issue days on a service for those intoxicated in public. Harm Reduction Journal, 4(1), 12. Maynard, C., & Cox, G. B. (2000). Association between week of the month and hospitalization for substance abuse. Psychiatric Services, 51(1), 31. O'Brien, C. P., Childress, A. R., McLellan, A. T., & Ehrman, R. (1992). Classical Conditioning in Drug-Dependent Humansa. Annals of the New York Academy of Sciences, 654(1), 400–415. Riddell, C., & Riddell, R. (2006). Welfare Checks, Drug Consumption, and Health: Evidence from Vancouver Injection Drug Users. Journal of Human Resources, 41(1), 138–161. Rosen, M. I. (2011). The 'check effect' reconsidered. Addiction, 106(6), 1071-1077. Rosen, M. I., McMahon, T. J., & Rosenheck, R. (2007). Does assigning a representative payee reduce substance abuse? Drug and Alcohol Dependence, 86(2-3), 115-122.   15 Rosenheck, R., Lam, J., & Randolph, F. (1997). Impact of representative payees on substance use by homeless persons with serious mental illness. Psychiatric Services, 48(6), 800-806. Shaner, A., Eckman, T. A., Roberts, L. J., Wilkins, J. N., Tucker, D. E., Tsuang, J. W., et al. (1995). Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door? New England Journal of Medicine, 333(12), 777–783. Verheul, G., Singer, S., & Christenson, J. (1997). Mortality and morbidity associated with the distribution of monthly welfare payments. Academic Emergency Medicine, 4(2), 118–123. Warner-Smith, M., Darke, S., & Day, C. (2002). Morbidity associated with non-fatal heroin overdose. Addiction, 97(8), 963–967. Wood, E., Kerr, T., Lloyd-Smith, E., Buchner, C., Marsh, D. C., Montaner, J. S., et al. (2004). Methodology for evaluating Insite: Canada's first medically supervised safer injection facility for injection drug users. Harm Reduction Journal, 1(1), 9. Wood, E., Kerr, T., Small, W., Li, K., Marsh, D. C., Montaner, J. S., et al. (2004). Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ, 171(7), 731-734.   16 Wood, E., Tyndall, M. W., Li, K., Lloyd-Smith, E., Small, W., Montaner, J. S., et al. (2005). Do supervised injecting facilities attract higher-risk injection drug users? American Journal of Preventive Medicine, 29(2), 126-130. City of Vancouver (2007). 2005/2006 Downtown Eastside Community Monitoring Report, 10th Ed.      

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.52383.1-0347306/manifest

Comment

Related Items