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Socioeconomic factors associated with cessation of injection drug use among street-involved youth Chang, Derek C; Hadland, Scott E; Nosova, Ekaterina; Wood, Evan; Kerr, Thomas; DeBeck, Kora Dec 7, 2017

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RESEARCH Open AccessSocioeconomic factors associated withcessation of injection drug use amongstreet-involved youthDerek C. Chang1,2, Scott E. Hadland3,4, Ekaterina Nosova1, Evan Wood1,5, Thomas Kerr1,5 and Kora DeBeck1,6*AbstractBackground: Although the initiation of injection drug use has been well characterized among at-risk youth, factorsthat support or impede cessation of injection drug use have received less attention. We sought to identifysocioeconomic factors associated with cessation of injection drug use among street-involved youth.Methods: From September 2005 to May 2015, data were collected from the At-Risk Youth Study (ARYS), aprospective cohort study of street-involved youth in Vancouver, Canada. Multivariate extended Cox regression wasutilized to identify socioeconomic factors associated with cessation of injection drug use for six months or longeramong youth who were actively injecting.Results: Among 383 participants, 171 (44.6%) youth reported having ceased injection (crude incidence density 22per 100 person-years; 95% confidence interval [CI], 19–26) at some point during study follow-up. Youth who hadrecently dealt drugs (adjusted hazard ration [AHR], 0.50; 95% CI, 0.29–0.87), engaged in prohibited street-basedincome generation (AHR, 0.41; 95% CI, 0.24–0.69), and engaged in illegal income generating activities (AHR, 0.19;95% CI, 0.06–0.61) were significantly less likely to report cessation of injection drug use.Conclusions: Our findings suggest that socioeconomic factors, in particular engagement in prohibited street-basedand illegal income generating activities, may pose barriers to ceasing injection drug use among this population.Effort to improve access to stable and secure income, as well as employment opportunities may assist youth intransitioning away from injection drug use.Trial registration: Our study is not a randomized controlled trial; thus the trial registration is not applicable.Keywords: Youth, Injection drug, Cessation, Prohibited street-based income generation, Illegal income generation,Drug dealingBackgroundYouth who are street-involved, defined as being homelessor using services for homeless youth, experience excessmorbidity and mortality relative to the general populationof adolescents and young adults [1, 2]. Although injectiondrug use is recognized as a risky activity by street-involvedyouth [2], it remains prevalent among this population andis associated with many harms, including infection withhuman immunodeficiency virus (HIV) and hepatitis Cvirus (HCV), as well as fatal overdose [1, 3, 4].Among adult populations of people who inject drugs,numerous factors have been associated with cessation ofinjection drug use including stable housing, use of super-vised injection facilities and engagement with addictiontreatment [5, 6]. Among youth populations, multiple stud-ies on drug use trajectories focus on the initiation of injec-tion drug use, and point to the role of unemployment,homelessness, and inability to access addiction treatmentas contributing factors to injection initiation [7–9]. Twolongitudinal studies drawing on data from 1995 to 2000and 2000–2008 respectively, found that homelessness,unemployment, and incarceration were associated with a* Correspondence: uhri-kd@cfenet.ubc.ca1British Columbia Centre on Substance Use, British Columbia Centre forExcellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada6Simon Fraser University, School of Public Policy, SFU Harbor Centre, 515West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 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.Chang et al. Substance Abuse Treatment, Prevention, and Policy  (2017) 12:50 DOI 10.1186/s13011-017-0136-zlower likelihood of ceasing injecting among youth [10,11]. Collectively, these findings suggest that economic vul-nerability plays a role in drug use trajectories and may in-fluence cessation of injection drug use. In an era of highrates of opioid overdose fatalities among young adults andadolescents who use drugs in North America [12, 13], up-dating the evidence base to better understand factors thatinfluence drug use trajectories, specifically injection cessa-tion, is particularly timely. Therefore, we sought to exam-ine the potential relationship between socioeconomicfactors and cessation of injection drug use among street-involved youth in Vancouver, Canada.MethodsThe At-Risk Youth Study (ARYS) is an ongoing prospect-ive cohort study of street-involved youth in Vancouver,Canada. This study has been described in detail previously[14]. In brief, snowball sampling and street-based outreachas well as self-referral were used to recruit participantsinto the study. Persons between 14 and 26 years of agewho had used illicit drugs other than or in addition tocannabis in the past 30 days and provided informed con-sent were eligible to participate. At baseline and semian-nually thereafter, participants complete an interviewer-administered questionnaire. The questionnaire elicitssociodemographic data as well as information regardingparticipants’ substance use and other behavioral and so-cioeconomic data such as housing, income sources, incar-ceration, and engagement with health and social services.All participants receive a monetary stipend of $30 (Canad-ian Dollar) after each interview. The University of BritishColumbia/Providence Health Care Research Ethics Boardapproved the study.All participants who completed a baseline survey andwere seen for study follow-up between September 2005and May 2015 were eligible for the study. The presentanalysis was restricted to participants who reported ac-tive injection (i.e., those who reported any drug injectionduring the preceding six months, either at their baselinevisit or at any follow-up visit) and who returned for atleast one additional follow-up visit to assess for cessationof injection drug use. The primary outcome of interestwas self-reported cessation of injection drug use duringthe preceding six months at any follow-up visit. Specific-ally, participants were asked, “In the last six months,have you used a needle to chip, fix, or muscle even once(yes vs. no)?”Socioeconomic factors that we hypothesized might be as-sociated with cessation of injection drug use included:homelessness; living with family; eviction from housing; liv-ing in the Downtown Eastside neighborhood (Vancouver’sdrug use epicenter); employment (having a regular, tempor-ary, or self-employed work); loss of income assistance (be-ing cut off or denied income assistance); health care access(having been to a health care facility); incarceration (beingin detention, prison or jail); sex work involvement (exchan-ging sex for money, gifts, or drugs); drug dealing; engagingin prohibited street-based income generating activities(panhandling, recycling, squeegeeing); and engaging in il-legal income generating activities (theft, robbing, fraud,other illegal actives excluding sex work and drug dealing).All socioeconomic factors were time-updated measuresbased on activities or situations in the preceding six monthstime period. To protect against reverse causation wherebyreported socioeconomic factors were a consequence of in-jection cessation, measures were taken from the studyfollow-up visit that preceded the visit at which a participantreported cessation of injection.The following mental health related factors which wehypothesized might influence socioeconomic status werealso considered: self-reported history of mental illness(defined as reporting having ever been diagnosed with amental illness at study baseline); childhood physical orsexual abuse (defined as affirmative answers at studybaseline to the question: “Have you ever been physically/sexually abused?”); and depression at study baseline(based on the Center for Epidemiologic Studies Depres-sion Scale >22). Mental health related measures werenot time-updated.We also considered sociodemographic and drug-use re-lated factors that we hypothesized, based on a review ofthe prior available literature, might potentially confoundthe relationship between socioeconomic factors and injec-tion cessation [10, 11]. These factors included: age (peryear older); gender (female vs. male); ethnicity (Caucasianvs. non-Caucasian); high school completion; any heroinuse; any prescription opioid use; any crystal meth use; anycocaine use and any crack use. As with the time-updatedsocioeconomic factors, measures for the drug-use vari-ables were also lagged to the prior study visit. This allowedus to account for behaviors during the six months preced-ing injection cessation to avoid issues related to reversecausation whereby measures were a consequence of injec-tion cessation and not predictors of cessation.As a first step, we compared sociodemographic charac-teristics and socioeconomic factors between those who didand did not cease injection drug use at any time duringfollow-up using Pearson’s chi-squared test and Fisher’sexact test (for cell counts under 5) for categorical variablesand the Wilcoxon test for continuous variables. Participantswere right-censored at the time of their first cessation event(i.e., no further person-time at risk was contributed by thatparticipant), but if they reported resuming injection druguse at a later visit, they reentered the cohort of individualsat risk; participants who did not report any cessation wereright-censored at the time of their last follow-up visit. Wealso used an extended Cox proportional hazards regressionmodel with time-updated variables to examine bivariateChang et al. Substance Abuse Treatment, Prevention, and Policy  (2017) 12:50 Page 2 of 7associations between each of the sociodemographic and so-cioeconomic factors, and time to cessation of injection druguse. The extended Cox model has been validated [15] andwidely used in previous studies [7, 16, 17]. The inclusion oftime-updated covariates in an extended Cox model negatesthe requirement of the proportional hazards assumption[15]. Variables significant at p < 0.10 in bivariate analyseswere eligible for inclusion in the final multivariate model,which used backward selection to identify the model withthe best fit based on minimizing the Akaike InformationCriterion (AIC). To help determine if our results were ro-bust, we also ran a fixed multivariate model where all vari-ables of interest were forced into a single model. Inaddition, multicollinearity was assessed in two ways. First,we assessed for multicollinearity at baseline using “everceased using drugs” as an outcome. We then appliedvariance inflation factors directly to the multivariable Coxmodel and used “injection drug use cessation” as an out-come. Analyses were performed using R version 3.2.4 (RFoundation for Statistical Computing, Vienna, Austria). Allp values were two-sided and tests were considered signifi-cant at p < 0.05.ResultsOverall, among 383 actively drug-injecting youth whoreturned for follow-up, the median age was 22 (inter-quartile range [IQR] 21–24) year, 248 (64.8%) were maleand 276 (72.1%) were white. An additional 151 youth re-ported injection drug use at study enrollment but didnot return or were not yet eligible to return for a studyvisit due to the nature of an open cohort study. The 383youth who completed a study follow-up visit were simi-lar to the 151 who did not with regard to all study vari-ables at baseline (p > 0.05 for all), with the exceptionthat individuals who did not complete a study follow-upvisit were more likely to have begun using drugs at ayounger age and inject cocaine. Participants contributed765 person-years of total follow-up with a median of19 months (IQR, 10–31) of follow-up per participantand a median of 3 (IQR, 2–5) study visits per partici-pant. Based on the follow-up data, 171 (44.6%) youth re-ported cessation of injection drug use, resulting in acrude incidence density of 22 per 100 person-years (95%confidence interval [CI], 19–26 per 100 person-years).Table 1 lists sociodemographic characteristics, drug use,mental health, and socioeconomic factors at baseline,stratified by injection cessation at any point during studyfollow-up. Youth did not differ according to sociodemo-graphic and mental health characteristics at baseline.However, those who ceased injection over study follow-upwere significantly more likely to have recently used heroin,prescription opioids, and accessed health care at baseline.Table 2 displays unadjusted and adjusted hazard ratiosfor cessation of injection drug use and variables of interest.Adjusted models demonstrate that youth who had recentlydealt drugs (AHR, 0.50; 95% CI, 0.29–0.87), engaged in pro-hibited street-based income generation (AHR, 0.41; 95% CI,0.24–0.69), engaged in illegal income generating activities(AHR, 0.19; 95% CI, 0.06–0.61), or used heroin (AHR, 0.55;95% CI, 0.34–0.87), were significantly less likely to reportcessation of injection drug use. The results of the fixedmultivariate model were all similar (data not shown) andno multicollinearity was detected based on aforementionedassessment.DiscussionIn this prospective cohort of street-involved youth whoinject drugs, 44 % of the participants reported havingceased injection drug use at some point during the studyperiod. We found that recent engagement in drug deal-ing, prohibited street-based, and other illegal incomegenerating activities may pose barriers to injection cessa-tion among youth in our setting.Our findings build on two previous studies of cessa-tion of injection drug use among street-involved youthconducted by Steensma et al. in Montreal between 1995and 2000 [10] and Evan et al. in San Francisco between2000 and 2008 [11]. Similar to our study, both drew ondata from a prospective cohort of young people who useillicit drugs. These studies found that homelessness, em-ployment, and history of incarceration were negativelyassociated with cessation of injection drug use amongstreet-involved youth. Although these specific variableswere not found to be associated with injection cessationamong our study sample, we did find that other markersof economic vulnerability, namely that generating in-come through unstable risky income sources correlatednegatively with injection drug cessation.Previous studies have demonstrated that street-involvedyouth are economically vulnerable and often resort torisky income generating activities including drug dealing(58%) and other prohibited and illegal street-based incomesources (82%) [18, 19]. Youth who engaged in risky in-come generating activities are known to be at increasedrisk for homelessness, high intensity drug use, encounterwith police, and violence [18]. Engaging in drug dealing isalso known to be associated with markers of economicand social vulnerability including homelessness, crack co-caine use, and police violence [19].Our study contributes to the understanding that stableand safe income sources are critical for the health andwell-being of street-involved youth [18, 20, 21]. In par-ticular, our findings suggest that stable income supportcould facilitate cessation of injection drug use in thispopulation. This is consistent with the concept of “re-covery capital” [22], which highlights the importance ofinternal and external resources to achieve and sustaincessation from risky substance use. Similarly, integratingChang et al. Substance Abuse Treatment, Prevention, and Policy  (2017) 12:50 Page 3 of 7youth into their communities is important for increasingtheir social capital and prospects for economic security[23]. Nonetheless, lack of meaningful employment andlabor market exclusion still exist as barriers to employ-ment for this population [18]. Previous studies haveTable 1 Baseline characteristicsa of street youth who injectdrugs stratified by whether they ceased injection at any pointduring study follow-up: At Risk Youth Study (ARYS), Vancouver,British Columbia, 2005–2015 (n = 383)Ceased Injection Drug UsebYes (%)(n = 171)No (%)(n = 212)p ValueSociodemographic characteristicsMedian age, years (IQR) 22 (20–24) 22 (21–24) 0.769GenderMale 103 (60.2) 144 (67.9) 0.118Female 68 (39.8) 68 (32.1)EthnicityCaucasian 126 (73.7) 150 (70.8) 0.573Non-Caucasian 45 (26.3) 61 (28.8)High school educationcYes 59 (34.5) 62 (29.3) 0.281No 111 (64.9) 148 (69.8)Drug use related factorsAny heroin useYes 114 (66.7) 175 (82.5) <0.001No 57 (33.3) 37 (17.5)Any prescription opioid useYes 55 (32.2) 97 (45.8) 0.007No 116 (67.8) 115 (54.2)Any crystal meth useYes 116 (67.8) 162 (76.4) 0.061No 55 (32.2) 50 (23.6)Any cocaine useYes 78 (45.6) 97 (45.8) 0.978No 93 (54.4) 115 (54.2)Any crack useYes 113 (66.1) 131 (61.8) 0.385No 58 (33.9) 81 (38.2)Mental health related factorsMental illness historyYes 104 (60.8) 138 (65.1) 0.388No 67 (39.2) 74 (34.9)Childhood physical or sexual abuseYes 116 (67.8) 142 (67.0) 0.933No 45 (26.3) 54 (25.5)DepressionYes 75 (43.9) 105 (49.5) 0.057No 53 (31) 46 (21.7)Socioeconomic factorsHomelessYes 121 (70.8) 160 (75.5) 0.305No 49 (28.7) 51 (24.1)Table 1 Baseline characteristicsa of street youth who injectdrugs stratified by whether they ceased injection at any pointduring study follow-up: At Risk Youth Study (ARYS), Vancouver,British Columbia, 2005–2015 (n = 383) (Continued)Ceased Injection Drug UsebYes (%)(n = 171)No (%)(n = 212)p ValueLiving with familyYes 20 (11.7) 26 (12.3) 0.865No 151 (88.3) 186 (87.7)EvictedYes 18 (10.5) 25 (11.8) 0.664No 82 (48.0) 132 (62.3)Living in the Downtown EastsideYes 64 (37.4) 82 (38.7) 0.802No 107 (62.6) 130 (61.3)EmployedYes 62 (36.3) 93 (43.9) 0.131No 109 (63.7) 119 (56.1)Loss of income assistanceYes 13 (7.6) 18 (8.5) 0.899No 108 (63.2) 157 (74.1)Accessed health careYes 133 (77.8) 166 (78.3) 0.045No 38 (22.2) 46 (21.7)IncarceratedYes 35 (20.5) 46 (21.7) 0.792No 135 (78.9) 166 (78.3)Sex workYes 27 (15.8) 31 (14.6) 0.751No 144 (84.2) 181 (85.4)Dealt drugsYes 86 (50.3) 108 (50.9) 0.899No 85 (49.7) 104 (49.1)Prohibited street-based income generating activitiesdYes 54 (31.6) 82 (38.7) 0.149No 117 (68.4) 130 (61.3)Illegal income generating activitieseYes 40 (23.4) 54 (25.5) 0.638No 131 (76.6) 158 (74.5)aCharacteristics reported at time of study enrollmentbCells do not uniformly add up to column total due to missing valuescPrior completion of or current enrollment in high schooldProhibited street-based income generating activities included panhandling,recycling, and squeegeeingeIllegal income generating activities included theft, robbing, fraud, and otherillegal actives excluding sex work and drug dealingChang et al. Substance Abuse Treatment, Prevention, and Policy  (2017) 12:50 Page 4 of 7pointed to the need for targeted interventions to in-crease income security among street-involved youth.Proposed interventions include restructuring incomeassistance, providing low-threshold employment, and re-ducing barriers to traditional employment by addressingstigma and other harms of criminalization [18, 20, 24,25]. The potential for these types of interventions tosupport injection cessation warrants further exploration.There are several limitations to this study. First, theARYS cohort is not a random sample. Our snowball sam-pling methods may have reduced heterogeneity and valid-ity of the findings, although it is noteworthy that thecharacteristics of the ARYS sample are similar to thosefrom other cohorts of street-involved youth [10, 11]. An-other potential limitation of our sample is that partici-pants who were lost to follow-up were more likely to haveTable 2 Unadjusted and adjusted hazard ratios (HR) for factors associated with cessation of injection drug use among street youthwho inject drugs: At-Risk Youth Study (ARYS), Vancouver, British Columbia, 2005–2015 (n = 383)Unadjusted HR (95% CI) Adjusted HR (95% CI)a p ValueeSociodemographic characteristicsAge (per year older) 1.00 (0.99–1.01)Female Gender 1.01 (0.73–1.40)Caucasian Ethnicity 1.09 (0.75–1.60)High school educationb 1.10 (0.79–1.54)Drug use related factorsAny heroin usec 0.58 (0.42–0.81) 0.55 (0.34–0.87) 0.010Any prescription opioid usec 0.75 (0.56–1.02)Any crystal meth usec 0.64 (0.47–0.88) 0.65 (0.42–1.01) 0.054Any cocaine usec 1.16 (0.86–1.56)Any crack usec 1.08 (0.79–1.47)Mental health related factorsMental illness history 1.07 (0.76–1.54)Childhood physical or sexual abused 0.82 (0.56–1.18)Depressiond 0.64 (0.43–0.93) 0.64 (0.41–1.01) 0.053Socioeconomic factorsHomelessd 0.68 (0.51–0.90) 1.25 (0.86–1.83) 0.246Living with familyd 1.76 (1.22–2.55) 1.21 (0.73–2.02) 0.459Evictedd 0.44 (0.22–0.89) 0.59 (0.29–1.21) 0.152Living in the Downtown Eastsided 0.58 (0.42–0.82) 0.67 (0.42–1.06) 0.085Employedd 1.49 (1.11–2.01)Loss of income assistanced 0.54 (0.25–1.16)Accessed health cared 1.11 (0.81–1.54)Incarceratedd 0.57 (0.37–0.88) 0.83 (0.46–1.51) 0.546Sex workd 0.40 (0.23–0.72) 0.62 (0.29–1.33) 0.221Dealt drugsd 0.37 (0.25–0.56) 0.50 (0.29–0.87) 0.015Prohibited street-based income generating activitiesd,f 0.50 (0.34–0.72) 0.41 (0.24–0.69) 0.001Illegal income generatingactivitiesd,g0.25 (0.13–0.50) 0.19 (0.06–0.61) 0.005aVariables significant at p < 0.10 in bivariate models were eligible for possible inclusion in the multivariate model (extended Cox proportional hazards regressionmodel); variables included in the final multivariate model were identified using a backward selection approach to minimize the Akaike Information Criterion (AIC)bDenotes completion of or current enrollment in high schoolcIncludes both non-injection and injection use; drug use behaviors were lagged by one visit in order to assess behaviors during the 6 months when participantswho ceased were still injectingdReported for the 6 months prior to the last follow-up visit at which a participant was still injectingeP-values refer to adjusted HRfProhibited street-based income generating activities included panhandling, recycling, and squeegeeinggIllegal income generating activities included theft, robbing, fraud, and other illegal actives excluding sex work and drug dealingChang et al. Substance Abuse Treatment, Prevention, and Policy  (2017) 12:50 Page 5 of 7begun using drugs at an earlier age and more likely to re-port injecting cocaine. Both these characteristics are asso-ciated with higher risk activities [26] and therefore ourstudy may overestimate the true occurrence of injectioncessation among street-involved youth. Other potentiallimitations relate to the reliance on self-report for keymeasures of interest. Self-report may be affected by so-cially desirable responding and recall bias. The potentialimpacts could result to an over or under estimation of ouroutcome of interest though, overall, we expect the impactsto bias the results towards the null. Lastly, as with all ob-servation studies, despite extensive adjustment for poten-tial confounding, the independent associations that weobserved could be influenced by other factors that we areunable to adjust for.ConclusionsIn sum, our study suggests that economic vulnerabilitycharacterized by resorting to risky income generationstrategies including drug dealing, prohibited street-basedand other illegal activities, may pose barriers for street-involved youth to cease injection drug use. These find-ings underscore the potential for social interventionsthat provide stable and secured income sources to influ-ence drug use trajectories and reduce drug related harm.Further study in this area is warranted.AcknowledgementsThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff. We wouldspecifically like to thank Carly Hoy, Jennifer Matthews, Deborah Graham,Peter Vann, Steve Kain, Tricia Collingham, Marina Abramishvili, and AnaPrado for their research and administrative assistance.FundingThe study was supported by the US National Institutes of Health(U01DA038886) and the Canadian Institutes of Health Research (MOP–102742). Dr. Chang is supported by Canadian Addiction Medicine ResearchFellowship funded by the US National Institutes of Health (R25DA037756). Dr.Hadland was supported by the Loan Repayment Program Award L40DA042434 (NIH/NIDA). This research was undertaken, in part, thanks tofunding from the Canada Research Chairs program through a Tier 1 CanadaResearch Chair in Inner City Medicine which supports Dr. Wood. Dr. DeBeckis supported by a MSFHR / St. Paul’s Hospital Foundation– Providence HealthCare Career Scholar Award and a Canadian Institutes of Health Research NewInvestigator Award.Availability of data and materialsThe datasets used and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.Authors’ contributionsSH, EW, TK and KD designed the study. DC conducted the literature reviewand wrote the first draft of the manuscript. DC and KD revised thesubsequent drafts of the manuscript with consultations from SH, EW, and TK.KN undertook data management and statistical analyses. All authors readand approved the final manuscript.Ethics approval and consent to participateThe University of British Columbia/Providence Health Care Research EthicsBoard approved the study and consent to participate was obtained fromeach participant.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1British Columbia Centre on Substance Use, British Columbia Centre forExcellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada. 2Department of Family Medicine, Universityof British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver,BC V6Z 1Y6, Canada. 3Grayken Center for Addiction / Department ofPediatrics, Boston Medical Center, One Boston Medical Center Place, Boston,MA 02118, USA. 4Division of General Pediatrics, Department of Pediatrics,Boston University School of Medicine, 88 East Newton St., Vose Hall, Room322, Boston, MA 02118, USA. 5Department of Medicine, University of BritishColumbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada. 6Simon Fraser University, School of Public Policy, SFU Harbor Centre,515 West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3, Canada.Received: 10 July 2017 Accepted: 28 November 2017References1. 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Conceptualizing recovery capital: expansion of atheoretical construct. Subst Use Misuse. 2008;43:1971–86.23. Barman-Adhikari A, Rice E. Social networks as the context for understandingemployment services utilization among homeless youth. Eval ProgramPlann. 2014;45:90–101.24. Debeck K, Wood E, Qi J, Fu E, McArthur D, Montaner J, Kerr T. Interest inlow-threshold employment among people who inject illicit drugs:implications for street disorder. Int J Drug Policy. 2011;22:376–84.25. Richardson L, Wood E, Li K, Kerr T. Factors associated with employmentamong a cohort of injection drug users. Drug Alcohol Rev. 2010;29:293–300.26. Debeck K, Kerr T, Marshall BD, Simo A, Montaner J, Wood E. Risk factors forprogression to regular injection drug use among street-involved youth in aCanadian setting. Drug Alcohol Depend. 2013;133:468–72.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Chang et al. Substance Abuse Treatment, Prevention, and Policy  (2017) 12:50 Page 7 of 7


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