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Inability to access addiction treatment predicts injection initiation among street-involved youth in… DeBeck, Kora; Kerr, Thomas; Nolan, Seonaid; Dong, Huiru; Montaner, Julio; Wood, Evan Jan 6, 2016

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SHORT REPORT Open AccessInability to access addiction treatmentpredicts injection initiation among street-involved youth in a Canadian settingKora DeBeck1,2*, Thomas Kerr1,3, Seonaid Nolan1,3, Huiru Dong1, Julio Montaner1,3 and Evan Wood1,3AbstractBackground: Preventing injection drug use among vulnerable youth is critical for reducing serious drug-relatedharms. Addiction treatment is one evidence-based intervention to decrease problematic substance use; however,youth frequently report being unable to access treatment services and the impact of this on drug use trajectoriesremains largely unexplored. This study examines the relationship between being unable to access addictiontreatment and injection initiation among street-involved youth.Methods: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth aged14–26 who use illicit drugs, from September 2005 to May 2014. An extended Cox model with time-dependent variableswas used to identify factors independently associated with injection initiation.Results: Among 462 participants who were injection naïve at baseline, 97 (21 %) initiated injection drug use over studyfollow-up and 129 (28 %) reported trying but being unable to access addiction treatment in the previous 6 months atsome point during the study period. The most frequently reported reason for being unable to access treatment wasbeing put on a wait list. In a multivariable Cox regression analysis, being unable to access addiction treatment remainedindependently associated with a more rapid rate of injection initiation (Adjusted Hazard Ratio =2.02; 95 % ConfidenceInterval: 1.12–3.62), after adjusting for potential confounders.Conclusion: Inability to access addiction treatment was common among our sample and associated with injectioninitiation. Findings highlight the need for easily accessible, evidence-based addiction treatment for high-risk youth asa means to prevent injection initiation and subsequent serious drug-related harms.Keywords: Injection initiation, At-risk youth, Addiction treatment, Injection preventionFindingsPreventing vulnerable youth from initiating injectiondrug use is critical for reducing drug-related morbidityand mortality [1–4]. There are a number of features ofyoung drug injectors that highlight the urgency of inter-vening early in their drug use trajectories to prevent thetransition to injection drug use [5]. For instance, priorresearch among street-involved youth indicates that onceyouth initiate injection drug use, the majority rapidlybecome established injectors [6]. Young new injectioninitiators are also more prone to engage in risky druguse practices that put them at higher risk of drug over-dose and infectious disease transmission [3, 4, 7–9].Structural level influences, such as homelessness andunemployment [10–12], alongside individual level fac-tors including childhood trauma, and specific drug usepatterns [13, 14], have been recognized as factors that fa-cilitate transitions into injection drug use among vulner-able youth. While these findings suggest that injectionprevention efforts should be directed to the areas ofhousing, employment, and childhood trauma preventionand recovery, addiction treatment may provide add-itional opportunities to reduce injection initiation. It haslong been established that addiction treatment is one ofthe most cost-effective interventions to reduce problem-atic substance use [15, 16]. However, prior studies* Correspondence: urhi-kd@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada2School of Public Policy, Simon Fraser University, Vancouver, CanadaFull list of author information is available at the end of the article© 2016 DeBeck 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.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:1 DOI 10.1186/s13011-015-0046-xindicate that many vulnerable individuals are unable toaccess addiction treatment [17–20]. To determine therole that barriers to accessing addiction treatment mayplay in influencing drug use trajectories, we examinedwhether inability to access addiction treatment was asso-ciated with injection initiation among a cohort of street-involved youth.MethodsData for this study was obtained from the At-RiskYouth Study (ARYS), which is an open prospectivecohort of street-involved youth in Vancouver, Canadathat has been described in detail previously [21]. Inbrief, study recruitment is open and undertakenusing snowball sampling and extensive street-basedoutreach methods. To be eligible, participants at re-cruitment must be age 14–26 years, have used illicitdrugs in the past 30 days, and provide writteninformed consent. At baseline and on a semi-annualbasis, participants complete an interviewer-administeredquestionnaire that elicits information related to drug useand contact with health and social services. At each studyvisit participants are provided with a stipend ($30Canadian currency) for their time. The study hasbeen approved by the University of British Columbia’sResearch Ethics Board.The study period for this analysis was September 2005to May 2014. To examine the potential relationship be-tween initiation into injection drug use and inability toaccess addiction treatment, all participants who hadnever injected drugs at baseline and had completed atleast one follow-up visit during the study period were in-cluded in the present analysis. The primary outcome ofinterest was injection initiation which was defined as themidpoint between the last report of remaining injectionnaïve and the first report of having used a needle tochip, fix or muscle drugs. For descriptive purposes wealso assessed the median number of years between initi-ation of non-injection “hard” drug use (defined as use ofheroin, cocaine, crack, or crystal methamphetamine) andinitiation of injection drug use. These estimates werebased on the reported age of first non-injection “hard”drug use, and age of participants at the midpoint be-tween the last report of remaining injection naïve andthe first report of having used a needle to chip, fix, ormuscle drugs. The primary explanatory variable of inter-est was being unable to access addiction treatment de-fined as responding affirmatively to the question: "In thepast 6 months, have you tried to access any treatmentprogram but were unable?" Participants were also askedto specify the types of addiction treatment they had diffi-culty accessing (e.g., detox, recovery house, treatmentcenter, counselor, other), as well as the main reason theywere unable to access the program (waiting lists,behavioral issues, rejection from program, logistics suchas hours of optional, location, paperwork etc.).To determine whether there was a significant relation-ship between our outcome of interest and our primaryexplanatory variable we a priori selected a range of sec-ondary explanatory variables we hypothesized might beassociated with both injection initiation and being un-able to access addiction treatment. Secondary explana-tory factors included: number of years since initiated“hard” drug use defined as use of cocaine, crack, heroin,or crystal methamphetamine (per additional year); gen-der (female vs. male); ethnicity (Caucasian vs. other);non-injection cocaine use (yes vs. no); crack smoking(yes vs. no); non-injection crystal methamphetamine use(yes vs. no); and non-injection heroin use (yes vs. no).All drug use variables including being unable to accessaddiction treatment refer to circumstances and behav-iors over the previous 6 months and were treated astime-updated covariates on the basis of semi annualfollow-up data. In addition, to protect against reversecausation whereby reported behaviors were a conse-quence of drug injecting, all drug use variables includingbeing unable to access addiction treatment were laggedto the previous available observation [10, 11].To assess the relationship between being unable to ac-cess addiction treatment and injection initiation, as afirst step we calculated the incidence density of injectioninitiation using a Poisson model. Then, using an ex-tended Cox model with time-dependent variables, we es-timated the unadjusted relative hazards and 95 %confidence intervals for factors associated with injectioninitiation [22]. To fit our multivariable Cox model, weran a fixed multivariable model where all variables ofinterest were included into a single model. All statisticalanalyses were performed using SAS software version 9.3(SAS, Cary, NC, USA). All tests of significance weretwo-sided.ResultsOverall, 1157 street-involved youth were recruited intothe ARYS cohort during the study period. At enrolment659 (57 %) youth had never injected drugs. Among thisgroup, during the study period, the average yearly loss tofollow-up rate was 3.15 %. At the time the analysis wasconducted, 462 (70 %) participants completed at leastone study follow-up to assess for injection initiation andwere therefore included in the analysis. There were nosignificant differences with respect to gender (Chi-squarep-value =0.943; degrees of freedom [df] =1) or ethnicity(Chi-square p-value =0.117; df =1) between the 462 youthwho represented the eligible study population and the 197injecting naïve youth who were ineligible because they ei-ther did not have a follow up visit at the time the analysisDeBeck et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:1 Page 2 of 5was conducted or were not enrolled in the cohort longenough to be due for a study follow-up.Among the sample of 462 youth included in the study,142 (31 %) were female and the median age was21.5 years (interquartile range [IQR] = 19.6–23.2). Themedian number of study visits was 4 (IQR = 2–6), themedian time between study visits was 6.2 (IQR: 5.7–8.1)months, and the median follow up time per participantwas 22.4 (IQR = 11.9–43.2) months. Baseline characteris-tics of the study sample are presented in Table 1. Overstudy follow-up, 97 (21 %) injection initiation eventswere observed for an incidence density of 8.6 cases per100 person years [95 % Confidence Interval (CI): 7.0–10.6]. The median time to injection initiation from studyenrolment was 11.2 months (IQR: 3.9–23.9), and themedian number of years between initiation of non-injection “hard” drug use (defined as use of heroin,cocaine, crack, or crystal methamphetamine) and initi-ation of injection drug use was 7.1 (IQR = 4.6–9.5).At some point during the study period 129 (28 %)youth reported being unable to access addiction treat-ment. In total, 183 study observations included a reportof being unable to access addiction treatment. Amongthese study observations, the most common type of ad-diction treatment that participants reported being unableto access was detox services (n = 76, 41 %), followed bytreatment centers (n = 65, 35 %), recovery houses (n =20, 10 %), and counselors (n = 8, 4 %). The main reasonparticipants reported being unable to access additiontreatment was waiting lists (n = 118, 66 %), followed bylogistical issues such as hours of optional, location, re-quired paperwork etc. (n = 32, 18 %). Being rejected fromthe program for an unspecified reason (n = 16, 9 %), andhaving behavioral issues (n = 10, 6 %) were two otherTable 1 Baseline characteristics and Cox regression analysis for factors associated with injection initiation among street-involvedyouth (n = 462)Characteristic Baseline Characteristics Bivariable and Multivariable Cox Regression AnalysisInjection Initiation Unadjusted HRa p-value Adjusted HR(95 % CI)p-valuefYes (n = 97) n (%) No (n = 365) n (%) (95 % CI)bUnable to access addiction treatment d,eYes 15 (15.5) 33 (9.0) 2.19 (1.27–3.78) 0.005 2.02 (1.12–3.62) 0.019No 80 (82.5) 324 (88.8)Years since initiated hard drug use (HR per additional year)Median 5.4 5.4 1.00 (0.94–1.07) 0.893 0.99 (0.92–1.06) 0.714IQR (3.7–7.8) (3.1–7.9)Caucasian EthnicityYes 68 (70.1) 219 (60.0) 1.50 (0.97–2.31) 0.069 1.40 (0.88–2.21) 0.152No 29 (29.9) 146 (40.0)Female GenderYes 28 (28.9) 114 (31.2) 0.96 (0.62–1.50) 0.872 1.06 (0.68–1.65) 0.805No 69 (71.1) 251 (68.8)Heroin Usec,d,eYes 24 (24.7) 52 (14.2) 2.12 (1.34–3.36) 0.001 1.48 (0.86–2.55) 0.157No 70 (72.2) 307 (84.1)Cocaine Usec,d,eYes 43 (44.3) 186 (51.0) 1.17 (0.77–1.78) 0.449 1.06 (0.69–1.64) 0.782No 52 (53.6) 176 (48.2)Crack Smokingd,eYes 68 (70.1) 190 (52.1) 1.71 (1.11–2.63) 0.015 1.23 (0.76–1.97) 0.402No 27 (27.8) 171 (46.8)Crystal Meth Usec,d,eYes 51 (52.6) 122 (33.4) 2.31 (1.53–3.47) <0.001 2.00 (1.32–3.04) 0.001No 43 (44.3) 238 (65.2)Not all cells add up to 462 as participants may choose not to answer sensitive questionsaHR hazard ratio; bCI confidence intervalcdenotes non-injection use; ddenotes activities in the 6 months prior to follow-up interview; erefers to the activities lagged to the pervious available study follow-up;fp-values based on Wald testDeBeck et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:1 Page 3 of 5common barriers. Note, out of the 183 observations thatincluded a report of being unable to access addictiontreatment, 10 observations did not specify the type oftreatment that the participant was unable to access, 162observations indicated one type of treatment, and 11 ob-servations indicated 2 types of treatment. Similarly, 11observations did not specify a reason the participant wasunable to access treatment, 164 observations indicatedone reason, and 8 observations indicated 2 reasons.Table 1 shows the unadjusted and adjusted relativehazards of injection initiation. Being unable to accessaddiction treatment was significantly associated withinjection initiation in both bivariable [hazard ratio =2.19,95 % CI: 1.27–3.78] and multivariable Cox regression ana-lyses [adjusted hazard ratio =2.02, 95 % CI: 1.12–3.62].DiscussionAmong our sample of youth, 28 % sought but were un-able to access addiction treatment at some point duringthe study period. Youth who were unable to access ad-diction treatment were over two times more likely tosubsequently initiate injection drug use, highlighting acritical missed opportunity to intervene to prevent injec-tion initiation among high-risk youth. These findings areconsistent with prior studies indicating that inability toaccess and engage with key health and social services,such as addiction treatment, housing, and employmentnegatively influences drug use behaviors and trajectoriesamong vulnerable populations [10–12, 19, 23]. Priorcross-sectional analyses also found that contact withaddiction treatment significantly delayed injection initi-ation among heroin users in the United States, highlight-ing the protective benefits of addiction treatment [24].Given the importance of intervening early in youths’drug use trajectories to prevent injection initiation, ourfindings indicate that addressing deficiencies in youthaddiction treatment, particularly with respect to waitinglists and logistical issues, should be a top priority. Numer-ous barriers to accessing addiction treatment have beenidentified in the literature and include: limited availabilityand insufficient use of evidence-based medication-assistedtherapies; long wait times; lack of adequately trained pro-viders; age restrictions; limited hours of operation; dis-crimination; and stigma, among others [18, 19, 25–31].Our study has limitations. First, as with other studiesof street-involved youth, the ARYS cohort is not a ran-dom sample and therefore these findings may notgeneralize to other populations. Second, this study isbased on self-reported information and is susceptible torecall bias and socially desirable responding. We antici-pate that any response bias would likely underestimatethe prevalence of risk behaviors and therefore bias ourresults towards the null.In summary, we found that inability to access addic-tion treatment predicted injection initiation amongstreet-involved youth. Facilitating engagement with ad-diction treatment by reducing wait lists and increasingthe availability of low-threshold evidence-based treat-ments offer important opportunities to engage withvulnerable youth and potentially prevent them fromtransitioning to injection drug use.AbbreviationsARYS: At-Risk Youth Study; IQR: Interquartile range; CI: Confidence Interval;HR: Hazard ratio.Competing interestsJM has received limited unrestricted funding, paid to his institution, fromAbbvie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and ViiVHealthcare. All other authors declare that they have no conflicts of interest.Authors’ contributionsKD, TK, and EW designed the study and wrote the protocol, KD managedthe literature search and prepared the first draft of the analysis; HDconducted the statistical analyses with input from KD and EW; all authorsmade a substantive intellectual contribution to the main content of thestudy, provided critical comments on the final draft, and approved the finalmanuscript.AcknowledgementsThe authors thank the ARYS study participants for their contribution to theresearch, as well as current and past researchers and staff. We wouldspecifically like to thank Cody Callon, Jennifer Matthews, Deborah Graham,Peter Vann, Steve Kain, Tricia Collingham, Kristie Starr and Carmen Rock fortheir research and administrative assistance. The study was supported bythe US National Institutes of Health (U01DA038886). KD is supported by aMSFHR/St. Paul’s Hospital‐Providence Health Care Career Scholar Awardand a Canadian Institutes of Health Research New Investigator Award.This research was undertaken, in part, thanks to funding from the CanadaResearch Chairs program through a Tier 1 Canada Research Chair in InnerCity Medicine, which supports EW. JM is supported with grants paid to hisinstitution by the British Columbia Ministry of Health and by the US NationalInstitutes of Health (R01DA036307). Funding sources had no role in the:design and conduct of the study; collection, management, analysis, andinterpretation of the data; and preparation, review, or approval of themanuscript; and decision to submit the manuscript for publication.Author details1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.2School of Public Policy, Simon Fraser University, Vancouver, Canada.3Division of AIDS, Department of Medicine, University of British Columbia,Vancouver, Canada.Received: 2 October 2015 Accepted: 23 December 2015References1. Miller CL, Kerr T, Strathdee SA, Li K, Wood E. Factors associated withpremature mortality among young injection drug users in Vancouver.Harm Reduct J. 2007;4:1.2. Miller CL, Wood E, Spittal PM, Li K, Frankish JC, Braitstein P, et al. The futureface of coinfection: prevalence and incidence of HIV and hepatitis C viruscoinfection among young injection drug users. J Acquir Immune DeficSyndr. 2004;36(2):743–9.3. Roy E, Haley N, Leclerc P, Sochanski B, Boudreau JF, Boivin JF. Mortality in acohort of street youth in Montreal. Jama. 2004;292(5):569–74.4. Werb D, Kerr T, Lai C, Montaner J, Wood E. Nonfatal overdose among acohort of street-involved youth. J Adolesc Health. 2008;42(3):303–6.5. Fuller CM, Vlahov D, Ompad DC, Shah N, Arria A, Strathdee SA. High-riskbehaviors associated with transition from illicit non-injection to injectiondrug use among adolescent and young adult drug users: a case–controlstudy. Drug Alcohol Depend. 2002;66(2):189–98.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:1 Page 4 of 56. 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(2):468–72.7. Baldwin P, Shrestha R, Potrepka J, Copenhaver M. 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Pharmacologicallyassisted treatment of opioid-dependent youth. Paediatric drugs. 2013;15(6):449–58.31. Woody GE, Poole SA, Subramaniam G, Dugosh K, Bogenschutz M, Abbott P,et al. Extended vs short-term buprenorphine-naloxone for treatment ofopioid-addicted youth: a randomized trial. JAMA. 2008;300(17):2003–11.•  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:DeBeck et al. Substance Abuse Treatment, Prevention, and Policy  (2016) 11:1 Page 5 of 5

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