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Childhood sexual abuse and risk for initiating injection drug use : A prospective cohort study Hadland, Scott E.; Werb, Daniel; Kerr, Thomas; Fu, Eric; Wang, Hong; Montaner, Julio; Wood, Evan Nov 1, 2012

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Childhood Sexual Abuse and Risk for Initiating Injection DrugUse: A Prospective Cohort StudyScott E. Hadland, MD, MPH1,2, Dan Werb, MSc3,4, Thomas Kerr, PhD3,5, Eric Fu, MSc3,Hong Wang, MSc3, Julio S. Montaner, MD3,5, and Evan Wood, MD, PhD3,51Boston Medical Center, Department of Pediatrics, One Boston Medical Center Place, Boston,MA, USA, 021182Children's Hospital Boston, Department of Medicine, 300 Longwood Avenue, Boston, MA, USA,021153British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 BurrardStreet, Vancouver, BC, Canada, V6Z 1Y64University of British Columbia, School of Population and Public Health, Mather Building, 5804Fairview Avenue, Vancouver, BC, Canada, V6T 1Z35University of British Columbia, Faculty of Medicine, Vancouver, BC, Canada, V6T 1Z3AbstractObjective—This study examined whether childhood sexual abuse predicts initiation of injectiondrug use in a prospective cohort of youth.Method—From October 2005 to November 2010, data were collected from the At Risk YouthStudy (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada.Inclusion criteria were age 14-26 years, no lifetime drug injection, and non-injection drug use inthe month preceding enrollment. Participants were interviewed at baseline and semiannuallythereafter. Cox regression was employed to identify risk factors for initiating injection.Results—Among 395 injection-naïve youth, 81 (20.5%) reported childhood sexual abuse.During a median follow-up of 15.9 months (total follow-up 606.6 person-years), 45 (11.4%) youthinitiated injection drug use, resulting in an incidence density of 7.4 per 100 person-years. Inunivariate analyses, childhood sexual abuse was associated with increased risk of initiatinginjection (unadjusted hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.29–4.38; p=0.006),© 2012 Elsevier Inc. All rights reserved.Send correspondence to: Evan Wood, MD, PhD, BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 BurrardStreet, Vancouver, BC, Canada V6Z 1Y6, Phone: (604) 806-9116, Fax: (604) 806-9044, uhri-ew@cfenet.ubc.ca.Conflict of Interest Statement: Dr. Montaner has received educational grants from, served as an ad hoc advisor to or spoken atvarious events sponsored by Abbott Laboratories, Agouron Pharmaceuticals Inc., Boehringer Ingelheim Pharmaceuticals Inc., BoreanPharma AS, Bristol–Myers Squibb, DuPont Pharma, Gilead Sciences, GlaxoSmithKline, Hoffmann–La Roche, Immune ResponseCorporation, Incyte, Janssen–Ortho Inc., Kucera Pharmaceutical Company, Merck Frosst Laboratories, Pfizer Canada Inc., SanofiPasteur, Shire Biochem Inc., Tibotec Pharmaceuticals Ltd. and Trimeris Inc.Contributors: Drs. Hadland, Werb, Kerr, Montaner and Wood designed the study. Drs Hadland and Wood wrote the protocol. Dr.Hadland conducted the literature review and wrote the first draft of the manuscript. Mr. Fu and Ms. Wang undertook statisticalanalyses with additional input from Dr. Hadland. All authors contributed to and have approved the final manuscript.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 ManuscriptPrev Med. Author manuscript; available in PMC 2013 November 01.Published in final edited form as:Prev Med. 2012 November ; 55(5): 500–504. doi:10.1016/j.ypmed.2012.08.015.$watermark-text$watermark-text$watermark-textan effect that persisted in multivariate analysis despite adjustment for gender, age, Aboriginalancestry and recent non-injection drug use (adjusted HR, 2.71; 95% CI, 1.42–5.20; p=0.003).Conclusion—Childhood sexual abuse places drug users at risk for initiating injection. Addictiontreatment programs should incorporate services for survivors of childhood maltreatment.MeSH termschild abuse; sexual; drug abuse; adolescent; cohort studies1. IntroductionInjection drug use clearly places individuals at high risk of acquiring potentially fatal blood-borne pathogens such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV),and of experiencing other harms such as overdose (US Public Health Service, 1997; DesJarlais and Friedman, 1987). The risk for becoming infected is especially high during theperiod immediately following the initiation of injection (Garfein et al., 1996; Roy et al.,2009). Survey-based studies of drug users have inquired retrospectively about individual andenvironmental factors associated with injection, revealing a number of factors morecommon among those who have ever injected compared to those who have not. Such factorsinclude parental substance use (Martinez et al., 1998), familial dysfunction (Martinez et al.,1998), early onset of drug use (Sherman et al., 2005) and other early misconduct (Fuller etal., 2002; Tomas et al., 1990), forced institutionalization (Martinez et al., 1998; Roy et al.,2003), prior use of non-injection crack/cocaine, heroin or methamphetamine (Fuller et al.,2001; Hadland et al., 2010; Irwin et al., 1996; Sherman et al., 2005; Wood et al., 2008),homelessness (Martinez et al., 1998), violent victimization (Fuller et al., 2002), survival sex(Martinez et al., 1998), and high-risk peer networks and neighborhoods (Fuller et al., 2001).With rare exception (Roy et al., 2003), however, these studies have tended to be limited bycross-sectional design, having recruited participants after they had already initiated injectiondrug use. Additionally, most of these studies recruited samples consisting predominantly ofadult injection drug users (IDU), rather than young people. Conducting large, prospectivecohort studies examining injection initiation among adolescents and young adults has provendifficult in many settings due to ethical concerns and difficulty locating and following at-risk youth populations, which in general are ‘hidden’ from traditional population-basedsampling methods due to homelessness and extensive street involvement (Farrow et al.,1992). As a result, risk factors for transitioning to injection drug use among young peopleremain poorly elucidated.One putative risk factor for initiating drug injection among youth is childhood sexual abuse,which is retrospectively reported by a large proportion of adult IDU (Ompad et al., 2005;Walton et al., 2011) and a well-established correlate of adult substance use in general(Molnar et al., 2001; Rounsaville et al., 1982). Cross-sectional studies of adult drug userssuggest an association between lifetime sexual abuse and injection drug use (Cheng et al.,2006), with perhaps greater likelihood of early transition to drug injection duringadolescence among those with a history of childhood sexual abuse (Holmes, 1997; Ompadet al., 2005). Prospective data of young adults following into middle adulthood demonstratethat those with a history of childhood maltreatment are more likely to use illicit drugs, toengage in polysubstance use, and to report substance use-related problems (Widom et al.,2006). Still, high quality studies drawing on prospective data from samples of youth arescarce (Roy et al., 2003), and the excess risk for initiating injection drug use conferred bychildhood sexual abuse, if any, remains poorly quantified.Hadland et al. Page 2Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textReported prevalence of childhood sexual abuse among drug-using adolescents and youngadults is high, with approximately one-third of youth disclosing prior abuse in severalsamples (Markowitz et al., 2011; Roy et al., 2004; Stoltz et al., 2007). The long-term mentalhealth consequences of childhood sexual abuse are diverse and include depression, anxiety,and post-traumatic stress disorder, some or all of which might in turn predispose to initiatingdrug injection (Browne and Finkelhor, 1986; Farrugia et al., 2011; Plotzker et al., 2007).Understanding which youth are at risk for transitioning to injection could help inform theallocation of already scarce public health efforts that seek to prevent the harms of injectiondrug use. In the present study, we hypothesize that history of childhood sexual abuseindependently predisposes to initiating injection drug use among youth.2. Methods2.1. SampleThe At Risk Youth Study (ARYS) followed a cohort of street-involved youth in Vancouver,Canada. Inclusion criteria for ARYS included: (1) aged 14 to 26 at the time of enrollment,and (2) use of an illicit drug other than or in addition to marijuana during the 30-day periodprior to enrollment. The ARYS cohort relied on snowball sampling, with recruitmentconducted in multiple neighborhoods in downtown Vancouver, including at night (Wood etal., 2006).Following informed consent, all participants completed an extensive baseline interviewer-administered questionnaire pertaining to sociodemographic data, drug use behaviors, andlifetime history of childhood sexual abuse. They were then surveyed and examined forstigmata of injection drug use semiannually thereafter, with youth reporting on drug usepatterns and other risk behaviors in the preceding six months. Participants were provided$20 CAN per visit as remuneration. ARYS was approved by the University of BritishColumbia/Providence Health Care Research Ethics Board.From October 2005 to November 2010, 984 participants were recruited into the ARYScohort, among whom 389 (39.5%) reported a prior history of injection. Those who hadpreviously injected were more likely to be older and to have experienced childhood sexualabuse (both p<0.05), but otherwise did not differ according to gender or Aboriginal ancestry.Of the 595 youth who had not previously injected drugs at baseline, 395 (66.4%) returnedfor ≥1 follow-up visit and are included in the incidence analysis of injection drug use.Among the 395 youth included in the incidence analysis, the mean age of participants was22.2 years (standard deviation [SD] = 2.7 years), and 269 (68.1%) youth were male and 105(26.6%) were of Aboriginal ancestry. 81 (20.5%) youth reported childhood sexual abuse.2.2. Dependent and independent variablesThe primary outcome, or dependent variable, was self-reported initiation of injection druguse in the preceding six months. Participants were asked, “In the last six months have youused a needle to chip, fix or muscle even once? (Yes / No)” The sample in the presentanalysis was limited to all participants with no prior history of injection drug use at the timeof enrollment. The primary independent variable of interest was self-reported history ofchildhood sexual abuse, based on earlier evidence from a study of street youth conductedelsewhere (Roy et al., 2003). At the baseline interview, participants were asked by a nurse ina separate, private interview in which confidentially was assured, “Before age 19, how manytimes were you sexually abused”, and participants were grouped into those with and withouta prior history of abuse. An array of covariates was also examined, including gender, age (asa continuous variable), Aboriginal ancestry, high school education, self-reported sexualorientation, lifetime homelessness, lifetime incarceration, non-injection drug use in theHadland et al. Page 3Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textpreceding six months (including heroin, cocaine, crack, and crystal methamphetamine use),and sex work in the preceding six months.2.3. Statistical analysesEach of the variables listed above was initially examined in a series of bivariate associationswith history of childhood sexual abuse. Next, applying Cox proportional hazards modeling,unadjusted hazard ratios for initiating injection drug use were computed for history ofchildhood sexual abuse and the other covariates. In addition, an interaction term examiningprior sexual abuse according to gender as a risk factor for initiating drug injection wastested, which was not significant (data not shown); therefore, subsequent analyses were notstratified by gender. The final multivariate Cox regression model adjusted for gender, age,Aboriginal ancestry and recent drug use (i.e., non-injection use of heroin, cocaine or crystalmethamphetamine in the preceding six months). Recent non-injection drug use wascombined into a single variable to ensure parsimony, and a sensitivity analysis wasconducted to determine whether this resulted in a different adjusted hazard ratio for thechildhood sexual abuse, and it did not. Covariates included in the multivariate model wereselected based on results of prior studies (Cheng et al., 2006; Fuller et al., 2001; Hadland etal., 2010; Irwin et al., 1996; Ompad et al., 2005; Sherman et al., 2005; Wood et al., 2008).We performed all statistical analyses using SAS version 9.1 (SAS Institute, Inc, Cary, NorthCarolina). Reported p values are two-sided and considered significant at p < 0.05.3. ResultsBaseline characteristics of the 395 youth included in the incidence analysis of injection druguse are reported in Table 1 and compared with regard to history of childhood sexual abuse.Those with a history of childhood sexual abuse were more likely to be female (58.0% werefemale among those with history of childhood sexual abuse vs. 25.2% were female amongthose without history of childhood sexual abuse; p < 0.001), to be of Aboriginal ancestry(37.0% vs. 23.9%; p = 0.017), to identify as gay/lesbian/bisexual (34.6% vs. 10.5%; p <0.001), and to have been recently involved in the sex trade (12.4% vs. 5.1%; p = 0.019). Ofnote, baseline rates of non-injection drug use did not differ between groups; the prevalenceof non-injection heroin use among those with and without a history of childhood sexualabuse were, respectively, 14.8% vs. 13.4% (p = 0.737); of cocaine, 34.6% vs. 36.6% (p =0.731); of crack, 48.2% vs. 45.5% (p = 0.675); and of crystal methamphetamine, 29.6% vs.29.3% (p = 0.954).During a median follow-up of 15.9 months per participant and a total study follow-up of606.6 person-years, 45 (11.4%) of the 395 youth initiated injection, resulting in an incidencedensity of 7.4 per 100 person-years. Table 2 demonstrates crude incidence rates andunadjusted hazard ratios (HR) for select variables with regard to initiation of drug use. Table3 demonstrates unadjusted and adjusted HR for these same variables, which were includedin the multivariate Cox proportional hazards regression model. Of note, the adjusted hazardratio for childhood sexual abuse was not substantially affected by the combining together ofrecent non-injection drug use into a single variable; in a sensitivity analysis, when drugswere included as separate variables, the adjusted hazard ratio for childhood sexual abusewas 2.65 (95% CI, 1.37– 5.11; p = 0.004).Figure 1 shows the cumulative incidence of initiating injection drug use according to historyof childhood sexual abuse during follow-up (log-rank test, p < 0.001).Hadland et al. Page 4Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-text4. DiscussionIn this large, prospective cohort of adolescents and young adults, we observed thatchildhood sexual abuse placed youth at two to three times greater risk of initiating injectiondrug use. Notably, history of childhood sexual abuse was highly prevalent in our sample,with more than one-fifth of all participants reporting having been abused. We did not,however, observe any difference in risk for initiating drug injection between males andfemales according to history of childhood sexual abuse, a finding consistent with priorevidence that abuse may have equally damaging long-term effects for both genders (Dube etal., 2005).Our results are consistent with prior cross-sectional data highlighting an association betweenprior sexual abuse and injection drug use among adults (Cheng et al., 2006). Indeed, adultIDU with a history of childhood sexual abuse frequently report transitioning to injectionearlier (including during adolescence) than those without such a history (Holmes, 1997;Ompad et al., 2005). However, one of the only other prospective studies of youth injectioninitiation to date did not demonstrate increased risk for injection drug use among survivorsof sexual abuse, although this study did not differentiate abuse during childhood from abuselater in life (Roy et al., 2003).The pathways leading from childhood sexual abuse to risky drug use behaviors are likely toinclude a complex series of intermediate and more proximal factors (Ompad et al., 2005).Indeed, the factors may even differ among youth subpopulations, with heavily street-involved youth like those sampled in this study initiating injection drug use within anenvironment of homelessness, poverty, heavy non-injection drug use, and other importantfactors that may differ substantially from the environment in which other youth initiateinjection drug use. Considered together, adverse childhood experiences – including sexualabuse, in addition to physical and emotional abuse/neglect, parental drug or alcohol abuse,parental incarceration, parental mental illness, domestic violence, or absence of one or bothparents – have been correlated with a number of negative long-term outcomes, includingsubsequent alcohol use (Dube et al., 2006), illicit drug use (Dube et al., 2003), teenpregnancy (Hillis et al., 2004), and attempted suicide (Dube et al., 2001; Hadland et al.,2011), with depressive symptoms mediating many of these relationships. It is thereforepossible that mental illness may indeed be a crucial intermediate in the pathway leadingfrom childhood sexual abuse to later initiation of injection drug use. Complicating matters,childhood sexual abuse is often experienced as part of a ‘cluster’ of adverse childhoodexperiences, such as physical or emotional abuse/neglect, witnessing domestic violence,parental marital discord, or having a parent who is substance abusing, mentally ill, orcriminally involved (Dong et al., 2003), all of which may have various contributions to risk.Future studies should therefore carefully examine the contribution of these various factors toinitiating drug injection.There are some limitations to the present study. First, our study recruitment employedextensive street-based outreach with snowball sampling. This method does not produce atruly random sample (Wood et al., 2006). However, the characteristics of our cohort aresimilar to those of other at-risk youth in western Canada (Miller et al., 2006; Ochnio et al.,2001). Also, because the sample was street-involved, they may not be fully representative ofthe general adolescent population at large. Second, our study relied heavily on self-report.Given that questions probed highly sensitive personal data, our results may have beenaffected by social desirability bias despite efforts to assure confidentiality (Briere, 1992).Recall bias may have also affected our results, particularly if those with heavier drug usepatterns were more likely to recall a history of childhood sexual abuse (Widom et al., 1999).Finally, as outlined earlier, although our results show a strong relationship betweenHadland et al. Page 5Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textchildhood sexual abuse and initiating drug injection, our findings do not indicate whichfactors might be intermediates in this pathway.5. ConclusionIn summary, we conclude that childhood sexual abuse is associated with substantiallyincreased risk of initiating injection drug use among at-risk youth. These results highlightthe dual need for programs that seek to prevent childhood maltreatment as well as those thatmitigate the downstream consequences of sexual abuse during adolescence and youngadulthood (Kerr et al., 2009). Indeed, adverse childhood experiences such as sexual abuseare likely to predispose to a range of risk behaviors and adverse health outcomes inadolescence and early adulthood that extend well beyond injection drug use (Anda et al.,2008; Chapman et al., 2004; Dube et al., 2005; Dube et al., 2003), and survivors ofchildhood abuse should remain a focus of research, policy and advocacy. A small body ofevidence shows promise for home visit programs as well as population-level parentingeducation for preventing childhood abuse and neglect, while a reduction in adverse mentalhealth outcomes has been demonstrated for sexually abused children with symptoms of post-traumatic stress disorder (MacMillan et al., 2009). Further developing these programs andensuring wider implementation among at-risk youth may serve an important role in reducinginjection drug use and its associated harms.AcknowledgmentsWe thank the At Risk Youth Study (ARYS) participants for their willingness to be included in the study, as well ascurrent and past ARYS investigators and staff. We also acknowledge Deborah Graham, Tricia Collingham, LeslieRae, Caitlin Johnston and Steve Kain for their assistance in research and administration. The corresponding authoraffirms that all who contributed significantly to the work are acknowledged here.Role of Funding Source: This study was supported by the US National Institutes of Health (RO1 DA011591) andthe Canadian Institutes of Health Research (HHP-67262). Dr. Kerr is additionally supported by the Michael SmithFoundation for Health Research (MSFHR). This research was undertaken, in part, thanks to funding from theCanada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supportsDr Evan Wood. None of the aforementioned organizations had any further role in study design, the collection,analysis or interpretation of data, in the writing of the report, or the decision to submit the work for publication.ReferencesAnda RF, Brown DW, Felitti VJ, Dube SR, Giles WH. Adverse childhood experiences andprescription drug use in a cohort study of adult HMO patients. BMC Public Health. 2008; 8:198.[PubMed: 18533034]Briere J. Methodological issues in the study of sexual abuse effects. Journal of consulting and clinicalpsychology. 1992; 60:196–203. [PubMed: 1592948]Browne A, Finkelhor D. Impact of child sexual abuse: a review of the research. Psychol Bull. 1986;99:66–77. [PubMed: 3704036]Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. 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Circumstances of first crystalmethamphetamine use and initiation of injection drug use among high-risk youth. Drug AlcoholRev. 2008; 27:270–6. [PubMed: 18368608]Hadland et al. Page 9Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textHighlights• We examine whether childhood sexual abuse predicts injection drug use• We follow a prospective cohort of youth in Vancouver, Canada• More than one-fifth of youth report childhood sexual abuse• Abuse independently predicts risk for initiation of injection drug use• Addiction treatment should incorporate services for survivors of childhoodabuseHadland et al. Page 10Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textFigure 1.Cumulative incidence of initiation of injection drug among youth in Vancouver, Canada,2005-2010 (n = 395).Hadland et al. Page 11Prev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-text$watermark-text$watermark-text$watermark-textHadland et al. Page 12Table 1Baseline characteristics of injection-naïve youth according to history of childhood sexual abuse in Vancouver,Canada, 2005-2010 (n = 395).Childhood Sexual AbuseCharacteristic Total (%) (n = 395) No (%) (n = 314) Yes (%) (n = 81) p ValueSociodemographic factors Female gender 126 (31.9) 79 (25.2) 47 (58.0) <0.001 Mean age (SD) 22.2 (2.7) 22.2 (2.8) 22.4 (2.8) 0.415 Aboriginal ancestry 105 (26.6) 75 (23.9) 30 (37.0) 0.017 High school educationa 194 (49.1) 160 (51.0) 34 (42.0) 0.150 Gay/lesbian/bisexual 61 (15.4) 33 (10.5) 28 (34.6) <0.001 Ever homeless 231 (58.5) 179 (57.0) 52 (64.2) 0.242 Ever incarcerated 295 (74.7) 241 (76.6) 54 (66.7) 0.063Drug use-related behaviors Non-injection heroin useb 54 (13.7) 42 (13.4) 12 (14.8) 0.737 Non-injection cocaine useb 143 (36.2) 115 (36.6) 28 (34.6) 0.731 Non-injection crack useb 182 (46.1) 143 (45.5) 39 (48.2) 0.675 Non-injection crystal methamphetamine useb 116 (29.4) 92 (29.3) 24 (29.6) 0.954 Mean age first drug use (SD) 14.3 (2.6) 14.4 (2.4) 13.9 (3.3) 0.898Sexual abuse history Sex workb 26 (6.6) 16 (5.1) 10 (12.4) 0.019aPrior completion of or current enrollment in high schoolbDenotes behavior in the preceding six monthsPrev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textHadland et al. Page 13Table 2Crude incidence densities and unadjusted hazard ratios (HR) for factors related to initiation of injection druguse among youth in Vancouver, Canada, 2005-2010 (n = 395).Characteristic Number of new injectors Rate, per 100 person-years HR (95% CI) p ValueGender Female 14 2.4 1.03 (0.55 – 1.92) 0.930 Male 31 2.4 ReferenceAgea < 22 years 24 5.9 1.96 (1.09 – 3.52) 0.025 ≥ 22 years 21 3.0 ReferenceAboriginal ancestry Yes 14 2.9 1.16 (0.62 – 2.19) 0.637 No 31 2.3 ReferenceRecent non-injection drug useb Yes 41 6.2 2.63 (0.92 – 7.47) 0.023 No 4 2.3 ReferenceChildhood sexual abuse Yes 16 4.4 2.38 (1.29 – 4.38) 0.006 No 29 1.9 ReferenceaIncluded as dichotomous variable with median split for ease of interpretation (though treated as continuous variable in final multivariate model)bDenotes non-injection use of heroin, cocaine or crystal methamphetamine in the preceding six monthsPrev Med. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textHadland et al. Page 14Table 3Unadjusted and adjusted hazard ratios (HR) for factors related to initiation of injection drug use among youthin Vancouver, Canada, 2005-2010 (n = 395).Characteristic Unadjusted HR (95% CI) p Value Adjusted HR (95% CI) p ValueFemale gender 1.03 (0.55 – 1.92) 0.764 0.66 (0.32 – 1.35) 0.256Age (per year younger) 1.14 (1.03 – 1.26) 0.010 1.11 (0.98 – 1.25) 0.088Aboriginal ancestry 1.16 (0.62 – 2.19) 0.382 1.32 (0.67 – 2.59) 0.424Recent non-injection drug usea 2.63 (0.92 – 7.47) 0.070 2.67 (0.92 – 7.70) 0.070Childhood sexual abuse 2.38 (1.29 – 4.38) 0.006 2.71 (1.42 – 5.20) 0.003aDenotes non-injection use of heroin, cocaine or crystal methamphetamine in the preceding six monthsPrev Med. Author manuscript; available in PMC 2013 November 01.


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