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Factors associated with inability to access addiction treatment among people who inject drugs in Vancouver,… Prangnell, Amy; Daly-Grafstein, Ben; Dong, Huiru; Nolan, Seonaid; Milloy, M-J; Wood, Evan; Kerr, Thomas; Hayashi, Kanna Feb 25, 2016

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RESEARCH Open AccessFactors associated with inability to accessaddiction treatment among people whoinject drugs in Vancouver, CanadaAmy Prangnell1, Ben Daly-Grafstein2, Huiru Dong1, Seonaid Nolan1,3, M-J Milloy1,3, Evan Wood1,3,Thomas Kerr1,3 and Kanna Hayashi1,3*AbstractBackground: Addiction treatment is an effective strategy used to reduce drug-related harm. In the wake of recentdevelopments in novel addiction treatment modalities, we conducted a longitudinal data analysis to examinefactors associated with inability to access addiction treatment among a prospective cohort of persons who injectdrugs (PWID).Methods: Data were derived from two prospective cohorts of PWID in Vancouver, Canada, between December2005 and November 2013. Using multivariate generalized estimating equations, we examined factors associatedwith reporting an inability to access addiction treatment.Results: In total, 1142 PWID who had not accessed any addiction treatment during the six months prior to interviewwere eligible for this study, including 364 women (31.9 %). Overall, 188 (16.5 %) reported having sought but wereultimately unsuccessful in accessing addiction treatment at least once during the study period. In multivariate analysis,factors independently and positively associated with reporting inability to access addiction treatment included: bingedrug use (Adjusted Odds Ratio [AOR] = 1.65), being a victim of violence (AOR = 1.77), homelessness (AOR = 1.99), andhaving ever accessed addiction treatment (AOR = 2.33); while length of time injecting was negatively andindependently associated (AOR = 0.98) (all p < 0.05).Conclusions: These findings suggest that sub-populations of PWID were more likely to report experiencing difficultyaccessing addiction treatment, including those who may be entrenched in severe drug addiction and vulnerable toviolence. It is imperative that additional resources go into ensuring treatment options are readily available whenrequested for these target populations.Keywords: Injection drug use, Addiction treatment, Homelessness, Drug or alcohol treatment, Binge drug use, ViolenceBackgroundInjecting illegal drugs remains a major public healthconcern with current estimates of 16 million usersworldwide [1]. People who inject drugs (PWID) have ahigher probability of contracting infectious diseases in-cluding HIV, bear an increased burden of morbidity andmortality, and may suffer from social isolation andstigma [1–3]. However, the risk of many of the negativeconsequences of injection drug use can be reduced byevidence-based addiction treatment [2], leading to a de-crease in drug use, HIV risk and criminal behavior aswell as increased likelihood of optimal HIV/AIDS treat-ment outcomes [4–6].Now more than ever, a range of novel evidence-basedaddiction treatment modalities have been developed, in-cluding the expanded availability of methadone and useof both buprenorphine and buprenorphine/naloxone foropiate addiction as well as residential treatment and out-patient treatment [7, 8]. In Vancouver, Canada, which ishome to Canada’s largest street-based drug scene [9],publically funded addiction treatment programs include* Correspondence: khayashi@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada3Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© 2016 Prangnell et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Prangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 DOI 10.1186/s13011-016-0053-6opiate agonist therapy, residential and outpatient treat-ment and inpatient and outpatient withdrawal manage-ment, and have recently been increasingly madeavailable [10, 11].In many settings, despite various addiction preventionand care initiatives in place, certain populations ofpeople who use drugs have previously been shown to ex-perience increased barriers to access addiction treat-ment, including Indigenous peoples and persons withdisabilities [12, 13]. Other barriers to treatment experi-enced by potential patients range from responsibility forchild care, having negative attitudes towards drug treat-ment staff, and experiencing financial constraints, to thefear and potential stigmatization of being labelled a druguser [14–16]. Of concern, those who were unable to ac-cess addiction treatment have been shown to havehigher rates of HIV risk behaviors and subsequent sero-conversion to HIV [17, 18]. For this reason, those PWIDwho are unable to access addiction treatment may beamong the most vulnerable populations.Given the well documented benefits of addiction treat-ment and the serious consequences arising when barriersto treatment exist, identifying drug-using populations thatexperience an inability to access treatment is important.Doing so will identify patients who may benefit from tar-geted interventions to increase access to addiction treat-ment and thus improve their overall health. In the wake ofrecent developments in novel addiction treatment modal-ities, we sought to identify factors independently associ-ated with an inability to access addiction treatmentamongst PWID in a Canadian setting.MethodsStudy proceduresThe Vancouver Injection Drug Users Study (VIDUS) andthe AIDS Care Cohort to evaluate Exposure to SurvivalServices (ACCESS) are ongoing open prospective cohortsof adult drug users recruited through self-referral andstreet outreach in Vancouver, Canada. These studies havebeen described in detail previously [19]. Briefly, VIDUSenrolls HIV-negative persons who reported injecting anillicit drug at least once in the month preceding enroll-ment; ACCESS enrolls HIV-infected individuals who re-port using an illicit drug other than marijuana in theprevious month. For both cohorts, other eligibility criteriaincluded being aged 18 years or older, residing in thegreater Vancouver region and providing written informedconsent. The questionnaire provided is in English only,however migrants or foreigners are able to participate,provided they spoke English and reside in the GreaterVancouver region. Any VIDUS participants who serocon-verted to HIV during follow-up were transferred to theACCESS cohort so that VIDUS includes HIV-negative in-dividuals only, and ACCESS includes HIV-positiveindividuals only. The study instruments and all otherfollow-up procedures for each study are essentially identi-cal to allow for combined analyses. At baseline and semi-annually thereafter, participants complete the sameinterviewer-administered questionnaire eliciting sociode-mographic data as well as information pertaining to druguse patterns, risk behaviors, and health care utilization.Nurses collect blood samples for HIV and Hepatitis Cvirus serology, provide basic medical care and arrange re-ferrals to appropriate health care services if required. Par-ticipants receive a $30 (CDN) honorarium for each studyvisit. The University of British Columbia/ProvidenceHealthcare Research Ethics Board provided ethical ap-proval for both studies.Study sample and primary outcome measureAll participants who were enrolled in the cohorts betweenDecember 1, 2005 and November 30, 2013, and who re-ported injecting drugs in the six months preceding base-line were included in the present analysis. Additionally, ateach follow up, the sample was restricted to individualswho did not report being enrolled in any addiction treat-ment in the previous six months. The primary outcome ofinterest was inability to access addiction treatment in theprevious six months. This was defined as responding “yes”to the question: “In the past 6 months, have you tried toaccess any treatment program but were unable?” Thesame question has been used in a previous study, showingits criterion validity and reliability [17]. In the same ques-tionnaire, participants were also asked about types of ad-diction treatment that they were unable to access, whichincluded inpatient and outpatient detoxification services;residential treatment and recovery houses; outpatient treat-ment through community clinics offering opioid agonisttreatment with methadone or buprenorophine/naloxoneand addiction counseling; and twelve-step programmes(i.e., Narcotics/Cocaine/Alcoholics Anonymous). Partici-pants were also asked to identify the reasons for why theywere unable to access addiction treatment in an open-ended question.Study variablesBased on the literature, we selected explanatory variablesthat we hypothesized might be associated with having dif-ficulty accessing addiction treatment [17, 20, 21]. Theseincluded sociodemographic data, including: age (per yearolder); gender (female vs. male); Caucasian (yes vs. no);homelessness in the previous six months (yes vs. no); em-ployment in the previous six months (any employment vs.none); involvement in drug dealing in the previous sixmonths (yes vs. no); involvement in sex work in the previ-ous six months (yes vs. no); education attainment (highschool completion or higher vs. less than high school).Drug-use variables referred to behaviours in the previousPrangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 Page 2 of 8six months, and included: ≥ daily injection cocaine use(yes vs. no); ≥ daily injection heroin use (yes vs. no); ≥daily injection crystal methamphetamine use (yes vs. no);≥ daily injection prescription opioid use (yes vs. no); ≥daily crack smoking (yes vs. no); ≥ daily alcohol use (yesvs. no); and binge drug use, defined as compulsive high-intensity injection drug use that exceeds normal patternsof consumption (yes vs. no) [22]. Other variables included:length of time since initiation of injection drug use (peryear longer); having ever enrolled in drug or alcohol treat-ment (yes vs. no); experiencing an overdose in the previ-ous six months (yes vs. no); being a victim of violence,defined as having been attacked, assaulted, or suffered vio-lence in the previous six months (yes vs. no); being HCVantibody positive (yes vs. no); HIV status (being HIV in-fected and not receiving ART in the previous six monthsvs. being HIV infected and receiving ART in the previoussix months vs. HIV negative); and incarceration in the pre-vious six months (yes vs. no). Since the only difference inthe eligibility criteria between the cohorts was the HIVserostatus, the HIV serostatus variable was included to ad-just for the cohort designation.Statistical analysisAs a first step, we examined the baseline sample charac-teristics stratified by reports of inability to access addic-tion treatment, using the Pearson’s Chi-squared test (forbinary variables) and Mann-Whitney test (for continu-ous variables). Fisher’s exact test was used when one ormore of the cells contained expected values less than orequal to five.Since analyses of factors potentially associated with in-ability to access addiction treatment included serial mea-sures for each participant, we used generalizedestimating equation (GEE) with logit link, which pro-vided standard errors adjusted by multiple observationsper person using an exchangeable correlation structure.Therefore, data from every participant follow-up visitwere considered in this analysis. As a first step, we usedbivariate GEE analyses to determine factors associatedwith inability to access addiction treatment. Next, be-cause our study aimed to identify the set of variablesthat best explain a higher odds of inability to access ad-diction treatment, we used an a priori-defined backwardmodel selection procedure based on examination of qua-silikelihood under the independence model criterionstatistic (QIC) to fit a multivariate model. In brief, wefirst included all explanatory variables that were associ-ated with inability to access addiction treatment at thelevel of p < 0.10 in bivariate analyses in a full model.After examining the QIC of the model, we removed thevariable with the largest p-value and built a reducedmodel. We continued this iterative process and selectedthe multivariate model with the lowest QIC value [23].In a sub-analysis, we used descriptive statistics to exam-ine specific addiction treatment modalities that partici-pants commonly reported being unable to access, andreasons why they were unable to access the treatment. Allp-values are two sided. All statistical analyses were per-formed using SAS software version 9.3 (SAS, Cary, NC).ResultsIn total, 1142 participants were eligible for the presentstudy. Among this sample, 364 (31.9 %) were women,644 (56.4 %) self-reported Caucasian ancestry and themedian age at baseline was 41.9 years (interquartilerange [IQR] = 34.9–48.0). Overall, the 1142 individualscontributed 5946 observations to the analysis and themedian number of follow-up visits was 3 (IQR: 1–8). Ofthe 1142 individuals, 188 (16.5 %) reported a total of 250reports of inability to access addiction treatment givingan incidence density of 5.1 reports (95 % confidenceinterval [CI]: 4.3–6.1) per 100 person-years. The baselinecharacteristics of all participants stratified by reportedinability to access treatment are presented in Table 1.Also at baseline, compared to ACCESS, VIDUS partic-ipants were more likely to be young, be Caucasian, injectheroin or prescription opioids at least daily, have a his-tory of drug or alcohol treatment, have employment, en-gage in drug dealing, experience violence, while theywere less likely to engage in binge drug use and beHCV-positive (all p < 0.05). There were 1988 observa-tions from ACCESS and 3958 observations from theVIDUS cohort. Among ACCESS observations, 72 (3.6 %)involved a report of inability to access addiction treat-ment, while there were 178 (4.5 %) reports in VIDUS.There was no significant difference in these reports be-tween the two cohorts (Chi-square test p-value = 0.113).The results of the bivariate and multivariate GEE ana-lyses of factors associated with reporting being unable toaccess addiction treatment are presented in Table 2. Asshown, in the final multivariate model, factors thatremained independently associated with inability to ac-cess addiction treatment included: homelessness (ad-justed odds ratio [AOR] = 1.99, 95 % CI: 1.47–2.69), timesince initiating injecting drug use (AOR = 0.98, 95 % CI:0.97–1.00), having ever accessed drug or alcohol treat-ment (AOR = 2.33, 95 % CI: 1.47–3.68), binge drug use(AOR = 1.65, 95 % CI: 1.26–2.16), and being a victim ofviolence (AOR = 1.77, 95 % CI: 1.29–2.42).In the sub-analysis, the top three treatment modalitiesthat participants were seeking but unable to access in-cluded inpatient detoxification services (66.4 %), in-patient treatment centres (14.8 %), and recovery houses(13.2 %), as shown in Table 3. Table 4 presents self-reported reasons for being unable to access addictiontreatment. Being placed on a waitlist (58.4 %) was theprimary reason participants gave for being unable toPrangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 Page 3 of 8access addiction treatment, followed by the program notaccepting couples (8.0 %) and being turned down by thetreatment program (7.6 %).DiscussionWe found that a substantial proportion of our study sam-ple of PWID in Vancouver, Canada who were not enrolledin addiction treatment were unable to access addictiontreatment despite motivated to do so. In the multivariateanalysis, unsuccessful attempts to engage in addictiontreatment were independently and positively associatedwith periods of homelessness, having ever been in drug oralcohol treatment, binge drug use, and reporting being avictim of violence, and were independently and negativelyassociated with length of time since initiating injectingdrug use. The most common addiction treatment modal-ities reported to be inaccessible included inpatientdetoxification, inpatient treatment centres, and place-ment at a recovery house. Though a variety of reasonswere cited for inability to access addiction treatment,being placed on a waitlist, programs not accepting cou-ples, and being turned down by program were the mostcommon.Our finding that PWID with longer injecting careers wereless likely to experience inability to access addiction treat-ment has not been reported in previous studies, although aprevious Australian study did find that long term drugusers were more commonly in treatment [24]. These find-ings collectively demonstrate the need to ensure those indi-viduals with shorter drug injecting histories have increasedaccess to treatment in order to minimize future conse-quences of long term drug use, including declining healthand increasing risk of death [25]. Additional studies under-standing the differences in needs between individuals withTable 1 Baseline sample characteristics, stratified by reporting inability to access addiction treatment in the past six months amongPWID in Vancouver, Canada (n = 1142)Characteristic Inability to access addiction treatmenta Odds ratio(95 % CI)p - valueYesn (%) 68 (6.0)Non (%) 1074 (94.0)Age (median, IQR) 39 (32–44) 42 (35–48) 0.008Female gender 24 (35.3) 340 (31.7) 1.18 (0.70–1.97) 0.533Caucasian 40 (58.8) 604 (56.2) 1.11 (0.68–1.83) 0.677Homelessnessa 45 (66.2) 392 (36.5) 3.73 (2.19–6.35) <0.001Daily injection cocaine usea 11 (16.2) 101 (9.4) 1.85 (0.94–3.64) 0.071Daily injection heroin usea 32 (47.1) 361 (33.6) 1.75 (1.07–2.86) 0.025Daily injection meth usea 1 (1.5) 56 (5.2) 0.27 (0.04–1.98) 0.200Daily injection prescription opioid usea 27 (39.7) 310 (28.9) 1.62 (0.98–2.67) 0.059Daily crack smokinga 29 (42.7) 422 (39.3) 1.15 (0.70–1.89) 0.583Daily alcohol usea 6 (8.8) 87 (8.1) 1.11 (0.47–2.65) 0.806Years since first injection drug use (median, IQR) 17 (11–22) 19 (11–28) 0.084Drug or alcohol treatment Ever 59 (86.8) 804 (74.9) 2.20 (1.08–4.50) 0.027Employmenta 21 (30.9) 258 (24.0) 1.41 (0.83–2.41) 0.202Drug dealinga 36 (52.9) 335 (31.2) 2.48 (1.51–4.06) <0.001Sex worka 7 (10.3) 150 (14.0) 0.72 (0.32–1.60) 0.413High school degree 40 (58.8) 500 (46.6) 1.64 (0.99–2.72) 0.051Overdosea 6 (8.8) 66 (6.2) 1.48 (0.62–3.54) 0.372Binge drug usea,b 35 (51.5) 400 (37.2) 1.77 (1.08–2.90) 0.021A victim of violencea 26 (38.2) 230 (21.4) 2.25 (1.35–3.74) 0.002HCV positive 58 (85.3) 941 (87.6) 0.78 (0.39–1.57) 0.490HIV+ and not on ARTa 10 (14.7) 164 (15.3) 0.88 (0.44–1.77) 0.720HIV+ and on ARTa 9 (13.2) 203 (18.9) 0.64 (0.31–1.32) 0.225Incarcerationa 20 (29.4) 187 (17.4) 1.97 (1.14–3.39) 0.013Note: The p-value for variable age was obtained from Mann-Whitney test; exact mid p-values for daily injection meth use and overdose were obtained fromFisher’s exact test; and for other binary variables p-values were obtained from Chi-square test with degree of freedom = 1PWID people who inject drugs, CI confidence interval, IQR interquartile rangeaDenotes activities in the previous six monthsbRefers to any route of consumption (i.e., sniffing, snorting, smoking or injecting)Prangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 Page 4 of 8Table 2 Bivariate and multivariate GEE analyses of factors associated with inability to access addiction treatment among PWID inVancouver, Canada (n = 1142)Characteristic Unadjusted AdjustedOdds ratio (95 % CI) p - value Odds ratio (95 % CI) p - valueAge(per year older) 0.97 (0.96–0.98) <0.001Gender(female vs. male) 1.42 (1.03–1.95) 0.033 1.37 (0.98–1.92) 0.062Ethnicity(Caucasian vs. other) 0.82 (0.60–1.12) 0.205Homelessnessa(yes vs. no) 2.53 (1.92–3.33) <0.001 1.99 (1.47–2.69) <0.001Daily injection cocaine usea(yes vs. no) 1.58 (1.04–2.41) 0.032Daily injection heroin usea(yes vs. no) 1.69 (1.24–2.31) <0.001Daily injection meth usea(yes vs. no) 1.15 (0.61–2.15) 0.669Daily injection prescription opioid usea(yes vs. no) 1.51 (1.11–2.07) 0.010Daily crack smokinga(yes vs. no) 1.30 (0.98–1.74) 0.073Daily alcohol usea(yes vs. no) 1.37 (0.90–2.11) 0.144Length of time injecting drugs(per year longer) 0.98 (0.97–0.99) <0.001 0.98 (0.97–1.00) 0.045Drug or alcohol treatment ever(yes vs. no) 2.36 (1.51–3.68) <0.001 2.33 (1.47–3.68) <0.001Any employment (reg, temp, self) a(yes vs. no) 1.02 (0.74–1.42) 0.888Drug dealinga(yes vs. no) 1.90 (1.42–2.55) <0.001 1.32 (0.96–1.83) 0.090Sex worka(yes vs. no) 1.04 (0.67–1.61) 0.861High school degree or higher(yes vs. no) 1.15 (0.84–1.58) 0.379Overdosea(yes vs. no) 1.45 (0.85–2.49) 0.175Binge drug usea,b(yes vs. no) 1.76 (1.37–2.25) <0.001 1.65 (1.26–2.16) <0.001A victim of violencea(yes vs. no) 2.19 (1.62–2.97) <0.001 1.77 (1.29–2.42) <0.001HCV positive(yes vs. no) 0.97 (0.59–1.61) 0.916Prangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 Page 5 of 8variations in their length of injecting history may aid in ad-dressing the barriers specific to newer users.We identified a positive and independent associationbetween an inability to access addiction treatment andbinge drug use. This is particularly alarming as bingedrug use has been identified as an independent risk fac-tor of HIV seroconversion [22]. Somewhat surprisingwas our finding of an association between having everbeen in drug or alcohol treatment and being unable toaccess addiction treatment, as this result has not beenpreviously demonstrated. A negative association waspreviously identified between exposure to addictiontreatment and attaining stable housing, suggesting that ahistory of addiction treatment may be a marker of severedrug addiction [26]. A recent Swiss study utilized an ad-vanced statistical method to assess opioid agonist ther-apy utilization patterns and found that the time untilreadmission shortened as the number of treatment epi-sodes increased [27]––a finding that somewhat contra-dicts our result. As cycling in and out of treatment iscommon among people with any substance use disor-ders, future research could apply such method to investi-gate patterns of participation in other treatmentmodalities, including detoxification services, and extendour finding. Regardless, it is essential that individualswho wish to enter treatment have the opportunity re-gardless of previous attempts.We also identified a positive and independent associ-ation between being a victim of violence and reportingan inability to access addiction treatment. As previouslyreported, PWID are subjected to elevated levels of vio-lence compared to the general population, commonlydue to inextricable involvement in unpredictable drugmarket situations and informal activities, such as drugdealing, sex work and theft [28–30]. Individuals en-gaging in prohibited income generating activities alsoshow more intense drug use patterns [31]. As a result ofthe violence experienced, many individuals will increasetheir drug use, experience physical injuries, and displayan increase in mental health symptoms, all of which mayhave long term impacts on their health [32, 33]. Further,women who experience partner based violence oftenalso have a lack of social support to actively pursue ad-diction treatment [34]. It is particularly concerning thatthose experiencing violence have difficulty accessingtreatment, as this vicious cycle could be stopped by en-gaging PWID in addiction treatment to avoid partakingin risky drug use environments.We also found that inpatient detoxification was themost common addiction treatment modality that par-ticipants were unable to access, with waitlists beingthe primary reason for this inaccessibility. This isconsistent with previous studies showing that amongreferrals to a Vancouver-based in-patient detoxifica-tion, 35 % of clients dropped off the waitlist prior tocommencing treatment [35]. Being placed on a wait-list has also been shown to decrease retention whenin receipt of treatment, a problem which has beendemonstrated not only in this setting, but other set-tings as well [35–37]. However, the criteria for requir-ing inpatient detoxification are evolving with stand-alone detoxification (without longer term outpatienttreatment) being no longer advised in most cases ofopioid addiction and in some cases of alcohol addic-tion [38, 39]. However, our findings do diverge from ourpast work that found disparities in access to addictiontreatment based on ethnicity/ancestry [12], and is encour-aging that we no longer find that people of non-CaucasianTable 2 Bivariate and multivariate GEE analyses of factors associated with inability to access addiction treatment among PWID inVancouver, Canada (n = 1142) (Continued)HIV and treatment statusa(HIV+ and not on ART vs HIV−) 0.93 (0.59–1.46) 0.748(HIV+ and on ART vs HIV_HIV−) 0.76 (0.50–1.14) 0.186Incarcerationa(yes vs. no) 1.68 (1.17–2.42) 0.005GEE generalized estimating equations, PWID people who inject drugs, CI confidence intervalaDenotes activities in the previous six monthsbRefers to any route of consumption (i.e., sniffing, snorting, smoking or injecting)Table 3 Treatment modalities participants were unable toaccess among PWID in Vancouver, Canada (n = 250)Treatment modality Number of reports % of reportsDetox/youth detox 139 55.6Treatment centre 38 15.2Recovery House 33 13.2Methadone or Suboxone 18 7.2Counsellor 11 4.4Daytox 6 2.4Twelve-step programmes 3 1.2Residential community 2 0.8Out-patient treatment 2 0.8Cocaine treatment program 0 0.0Drug treatment court 0 0.0PWID people who inject drugsPrangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 Page 6 of 8ancestry were more likely to experience difficulty obtain-ing addiction treatment, suggesting that recent efforts toscale-up access to treatment options, may be demonstrat-ing positive results [10, 12]. In this particular setting inVancouver, Canada, low threshold access to opioidagonist treatment is widely available through the uni-versal no-cost medical insurance plan with the co-operation of community physicians and pharmacies.As a result of this integration participants would typ-ically not have as much difficulty accessing opioidagonist treatment compared to other treatmentmodalities.This study has several limitations. First, the VIDUSand ACCESS cohorts are not random samples andtherefore may not generalize to other populations ofPWID. Second, data collection was based on self-report and thus could be subject to reporting bias, in-cluding socially desirable responses which may haveresulted in under-reporting of illicit drug use andother stigmatized behaviours. As a result, the preva-lence of some risk behaviours may have been under-estimated in the present study. However, self-reportedrisk behaviour has been shown to be largely accurateamong adult drug-using populations [40]. Third, therewere no variables representing family and social net-working, which may have been important factors toanalyze and should be included in future research.Lastly, as with any observational research, unmeas-ured confounders may exist that were not accountedfor in our analyses and contributed to the overallresults.ConclusionIn summary, despite the recent increasing support foraddiction treatment in Vancouver [10], our findings indi-cate that some sub-populations of PWID are more likelyto be marginalized from accessing addiction treatmentservices, including those who are homeless, those withshorter injecting careers, those who report binge druguse, those with previous alcohol or drug treatment ex-perience, and those who report experiencing violence.Given that the primary reason we identified for inabilityto obtain addiction treatment was waitlists, it is impera-tive that additional resources go into ensuring treatmentoptions are readily available when requested. Addition-ally, this study identified the need for targeted interven-tions for patient populations suffering severe negativeconsequences of their addiction as they are often theones having a difficult time accessing treatment.AbbreviationsPWID: People who inject drugs; HIV: Human immunodeficiency virus.Competing interestsThe authors report no conflicts of interest. The authors alone are responsiblefor the content and writing of this paper.Authors’ contributionsTK, EW, MJM and KH designed and managed the cohorts. AP, BDG, and KHdesigned the study. HD conducted the statistical analyses. AP drafted themanuscript, and incorporated suggestions from all co-authors. All authors madesignificant contributions to the conception of the analyses, interpretation of thedata, and drafting of the manuscript. All authors read and approved the finalmanuscript.Table 4 Reasons for being unable to access addition treatment among PWID in Vancouver, Canada (n = 250)Reasons Number of reports % of reportsWaiting list 146 58.4Don’t take couples 20 8.0Turned down by program 19 7.6Personal reasons/issues 13 5.2Communication issues with the program 11 4.4Behaviour problems 9 3.6Missed appointments 9 3.6Program is full 8 3.2Don’t know of any program 7 2.8Don’t have type of program I want or need 7 2.8Can’t afford the fees 7 2.8Failed too many times 2 0.8No treatment program nearby 1 0.4Methadone restrictions within the program 1 0.4Other (in jail, no pets policy, medical issues, too many rules) 39 15.6PWID people who inject drugsPrangnell et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:9 Page 7 of 8AcknowledgementsThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff. The study wassupported by the US National Institutes of Health (U01DA038886,R01DA021525). This research was undertaken, in part, thanks to funding fromthe Canada Research Chairs program through a Tier 1 Canada Research Chairin Inner City Medicine which supports Dr. Evan Wood. Dr. Kanna Hayashi issupported by the Canadian Institutes of Health Research New InvestigatorAward (MSH-141971). Dr. Milloy is supported in part by the United StatesNational Institutes of Health (R01DA021525).Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2Human BiologyProgram, University of Toronto, Wetmore Hall, Room 105, 300 Huron Street,Toronto, ON M5S 3J6, Canada. 3Department of Medicine, University of BritishColumbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada.Received: 26 October 2015 Accepted: 18 February 2016References1. Mathers BM, Degenhardt L, Phillips B, et al. 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