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Knowledge and possession of take-home naloxone kits among street-involved youth in a Canadian setting:… Goldman-Hasbun, Julia; DeBeck, Kora; Buxton, Jane A; Nosova, Ekaterina; Wood, Evan; Kerr, Thomas Dec 22, 2017

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RESEARCH Open AccessKnowledge and possession of take-homenaloxone kits among street-involved youthin a Canadian setting: a cohort studyJulia Goldman-Hasbun1, Kora DeBeck1,2, Jane A. Buxton3,4, Ekaterina Nosova1, Evan Wood1,5 and Thomas Kerr1,5*AbstractBackground: The distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdosefatalities among people who use drugs. However, little is known about the use of THN among youth whoare street-involved. The present study explores knowledge and possession of THN among street-involved youth in aCanadian setting.Methods: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age14–28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included itemsrelated to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors.Multivariable logistic regression models were used to identify factors independently associated with knowledge andpossession of THN.Results: Between December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%).While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/whiteethnicity was found to be positively associated with both knowledge and possession of THN (both p < 0.05). Publicinjection drug use in the last 6 months was found to be positively associated with knowledge of THN, while dailyheroin use and daily methamphetamine use were associated with possession of THN (all p < 0.05). Male gender wasnegatively associated with possession of THN (p < 0.05).Conclusions: These findings highlight important gaps between knowledge and possession of THN among youth andthe need to increase participation in THN programs among specific populations including non-white and male youth.Further research is needed to gain a better understanding of the barriers that may prevent certain youth from acquiringTHN kits.Keywords: Street youth, Urban context, Harm reduction, Opioid use, NaloxoneBackgroundNorth America is in the midst of an escalating overdoseepidemic. Increases in overdose deaths have been drivenby both prescription and non-prescription opioids in thepast two decades, with a 200% increase in the rate ofopioid-related overdose deaths reported in the UnitedStates (U.S.) since the year 2000 [1]. In British Columbia(B.C.), illicit drug overdose deaths increased by 49%from 2016 to September 2017, and many of these deathsinvolved opioids [2]. In addition, the rate of overdosedeaths involving synthetic opioids other than metha-done, such as fentanyl, increased by 80% from 2013 to2014 in the U.S. [1]. Fentanyl was detected in 68% ofillicit drug overdose deaths in 2016 in B.C., and theserates are increasing: preliminary data suggests that theproportion of illicit drug overdose deaths for which fen-tanyl was detected was 83% from January to September2017 [2]. Opioid use is also a concern among youth:while there is little national Canadian data on opioid useamong youth, one study using survey data from anationally representative sample of youth aged 10–18 in* Correspondence: drtk@cfenet.ubc.ca1British Columbia Centre on Substance Use, 608-1081 Burrard Street,Vancouver V6Z 1Y6, BC, Canada5Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver V6Z 1Y6, BC, 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.Goldman-Hasbun et al. Harm Reduction Journal  (2017) 14:79 DOI 10.1186/s12954-017-0206-6the U.S. found the 30-day prevalence of opioid use to be4.8% from 2008 to 2011 [3].Take-home naloxone (THN) programs, such as B.C.’sTake Home Naloxone program [4] and the OverdoseEducation and Nasal Naloxone Distribution program(OEND) in Massachusetts [5], have been important strat-egies in reducing overdose deaths among persons who usedrugs. Naloxone is an opioid antagonist used to temporar-ily reverse the effects of an overdose [6]. Naloxone distri-bution programs provide participants with naloxone in apackaged kit and also provide training on how to recognizeand respond to an opioid-related overdose, includingadministration of naloxone [6]. In 2016, THN programswere operational in seven of Canada’s 13 provinces andterritories [6]. Similar programs have also been imple-mented in Asia, Australia, Europe, and the U.S. [7]. Arecent systematic review suggested that THN programsare effective in reducing overdose mortality rates in pro-gram participants and in the community [8], with little riskinvolved in its administration [9]. However, there isevidence that younger people who use drugs (PWUD) areless likely to access harm reduction services than olderPWUD [10–12], which raises concerns about the uptake ofTHN among youth.Previous studies have evaluated THN program imple-mentation in various settings [13–15]. One study examin-ing the perceptions of homeless and precariously housedyouth regarding the THN program in Vancouver, B.C.,found that participants reported positive experiences withTHN programs—such as increased sense of safety and im-proved self-esteem—and expressed the importance ofincreasing access to THN programs [16]. In addition, in a1999 study assessing the possible impact and acceptabilityof a THN program in South London, 89% of participantswho had witnessed an overdose fatality reported that theywould have administered naloxone if it had been available[17]. However, to our knowledge, there have been noquantitative reports of participation rates in THN pro-grams, or of the factors associated with participation,among youth who are street-involved.Drawing on a prospective cohort study of street-involved youth in a Canadian setting, we undertook thepresent study to identify sociodemographic and substanceuse-related factors associated with knowledge and posses-sion of THN among street-involved youth in Vancouver,B.C. Vancouver is home to one of Canada’s largest andlongest operational provincial THN programs: the pro-gram was launched in 2012 and has since distributedover 54,000 kits, with a significant increase in distribu-tion since 2016 (from 3394 kits in 2015 to 22,494 kits in2016) [4]. B.C.’s THN program targets people who are atrisk of an opioid overdose and people who are likely towitness and respond to an overdose (e.g., family orfriend of someone at risk) [4].MethodsThe At-Risk Youth Study (ARYS) is an open prospectivecohort study of street-involved youth who use illicitdrugs based in Vancouver, Canada. Youth aged 14–28who have used any illicit drug (other than or in additionto cannabis) in the preceding 30 days are eligible forstudy enrollment. Recruited youth are street-involved atbaseline, defined as having been without stable housingor having accessed street-based services in the preceding6 months [18–20]. Street-based outreach is used toenhance study recruitment both during daytime andnighttime hours in a range of neighborhoods throughoutVancouver where street youth are known to congregate.Snowball sampling is also used to maximize studyenrollment. After providing informed consent, partici-pants complete an interviewer-administered question-naire regarding sociodemographic and socioeconomicdetails, engagement with health and social services, sub-stance use patterns, and other behavioral data. All partici-pants are provided with monetary compensation for theirtime ($30 CAN). ARYS is approved by the University ofBritish Columbia and Providence Health Care ResearchEthics Board. The study has been described in more detailin previous publications [21].Questions regarding THN were added to the cohortquestionnaire in December 2014. The present analysisdraws on baseline data from all ARYS participants whocompleted a study visit between December 2014 andNovember 2016. Knowledge and possession of THNwere the main outcomes of interest and were ascertainedthrough the following questions: “Have you heard abouta take-home Narcan rescue kit that you can keep withyou for an opiate overdose?” and “Do you currently owna take-home Narcan rescue kit?” Individuals whoresponded “yes” versus “no” to these questions werecompared using logistic regression as described below.Explanatory variables of interest were chosen a prioribased on what we hypothesized might increase aware-ness and possession of THN. We examined the follow-ing explanatory variables: age (continuous, per yearolder), gender (male vs. female); residing in Vancouver’sDowntown Eastside (DTES) neighborhood in the last6 months [a district with an open drug market as well ashigh levels of substance use, poverty, and homelessness](yes vs. no); ever absolutely homeless (yes vs. no); educa-tion status (high school or greater vs. other); employ-ment in the last 6 months (yes vs. no); daily heroin usein the last 6 months (yes vs. no); daily methampheta-mine use in the last 6 months (yes vs. no); daily prescrip-tion opioid use in the last 6 months (yes vs. no); dailycocaine or crack use in the last 6 months (yes vs. no);public injection drug use in the last 6 months (yes vs.no); ever non-fatal overdosed [negative reaction fromusing too much drugs] (yes vs. no); incarceration in theGoldman-Hasbun et al. Harm Reduction Journal  (2017) 14:79 Page 2 of 7last 6 months, defined as being in detention, prison, orjail overnight or longer (yes vs. no); unable to accessaddiction treatment, defined as responding affirmativelyto the question: “In the past 6 months, have you tried toaccess any treatment program but were unable?” (yes vs.no); currently in methadone/methadose treatment (yesvs. no); and been in alcohol or drug treatment in last6 months (yes vs. no).Initially, we examined the descriptive characteristics,stratified by our two outcomes of interest (i.e., knowledgeand possession of THN) at the first study visit. Next, weexamined the bivariable associations between eachexplanatory variable and our two outcomes of interestusing logistic regression. As a last step, we fitted multivari-able models, considering all variables in bivariable analysesas the full model. All statistical analyses were performedusing R, version 3.2.4 (R Foundation for StatisticalComputing, Vienna, Austria). All p values were two-sided,and tests were considered significant at p < 0.05 level.ResultsBetween December 2014 and November 2016, a total of177 participants completed a baseline survey: 3 (1.7%)completed a survey in 2014, 60 (33.9%) completed a sur-vey in 2015, and 114 (64.4%) completed a survey in2016. Among this sample, 68 (38.4%) identified asfemale, 97 (54.8%) identified as Caucasian/white, and themedian age was 22.1 years (inter-quartile range [IQR] =20.2–23.4 years). Overdose was common in our studysample, with 81 (45.8%) participants having ever experi-enced a non-fatal overdose.Table 1 reports baseline characteristics of all partici-pants stratified by our two main outcomes of interest.As shown, 126 (71.2%) study participants reportedknowledge of THN, while 40 (22.6%) reported posses-sion of a THN kit. In addition, when stratified by year,34 participants (54%) reported knowledge of THN in2014 and 2015 (combined), while 92 participants (80.7%)reported knowledge of THN in 2016. Six participants(9.5%) reported possession of THN in 2014 and 2015(combined), while 34 participants (29.8%) reportedownership of THN in 2016.Table 2 shows the results of the bivariable and multi-variable analyses for knowledge of THN. In bivariableanalyses, factors positively associated with knowledge ofTHN included Caucasian/white ethnicity, ever homeless,daily heroin use, public injection drug use, recent en-gagement in drug or alcohol treatment, and inability toaccess addiction treatment. Daily cocaine or crack usewas negatively associated with knowledge of THN. Inmultivariable analyses, Caucasian/white ethnicity(adjusted odds ratio [AOR] = 2.36, 95% confidenceTable 1 Baseline characteristics of 177 street-involved youth, stratified by knowledge and possession of THNKnowledge of THN Possession of THNCharacteristic Yes (%)n = 126No (%)n = 51Yes (%)n = 40No (%)n = 137Sociodemographic characteristicsMedian age (Q1–Q3)a 22.2 (20.2–23.4) 21.9 (19.6–23.4) 22.1 (20.1–23.7) 22.1 (20.2–23.4)Male gender 73 (57.9) 36 (70.6) 15 (37.5) 94 (68.6)White ethnicity 78 (61.9) 19 (37.3) 29 (72.5) 68 (49.6)Downtown Eastside residenceb 33 (26.2) 14 (27.5) 8 (20.0) 39 (28.5)Ever absolutely homeless 116 (92.1) 41 (80.4) 36 (90.0) 121 (88.3)High school completion 58 (46.0) 26 (51.0) 20 (50.0) 64 (46.7)Employmentb 29 (23.0) 14 (27.5) 10 (25.0) 33 (24.1)Incarcerationb 22 (17.5) 4 (7.8) 6 (15.0) 20 (14.6)Substance use-related factorsDaily heroin useb 44 (34.9) 6 (11.8) 20 (50.0) 30 (21.9)Daily cocaine or crack useb 4 (3.2) 6 (11.8) 1 (2.5) 9 (6.6)Daily methamphetamine useb 37 (29.4) 12 (23.5) 17 (42.5) 32 (23.4)Daily use of prescription opioidsb 10 (7.9) 2 (3.9) 1 (2.5) 11 (8.0)Public injectingb 61 (48.4) 7 (13.7) 22 (55.0) 46 (33.6)Ever overdosed 61 (48.4) 20 (39.2) 20 (50.0) 61 (44.5)Drug or alcohol treatmentb 77 (61.1) 22 (43.1) 27 (67.5) 72 (52.6)Unable to access addiction treatmentb 28 (22.2) 4 (7.8) 7 (17.5) 25 (18.2)aQ1–Q3 = 25th–75th percentilesbIn the last 6 monthsGoldman-Hasbun et al. Harm Reduction Journal  (2017) 14:79 Page 3 of 7interval [CI] 1.02–5.61) and public injection drug use(AOR = 5.61, 95% CI 1.90–19.12) remained independ-ently positively associated with knowledge of THN. Dailycocaine or crack use (AOR = 0.09, 95% CI 0.01–0.59)remained independently negatively associated withknowledge of THN.Table 3 shows the results of the bivariable and multi-variable analyses for possession of THN. In bivariableanalyses, factors positively associated with possession ofTHN included: Caucasian/white ethnicity; daily heroinuse; daily methamphetamine use; and public injectiondrug use. Male gender was negatively associated withpossession of THN. In multivariable analyses,Caucasian/white ethnicity (AOR = 2.51, 95% CI1.02–6.51), daily heroin use (AOR= 3.08, 95% CI1.09–9.11), and daily methamphetamine use (AOR= 2.99,95% CI 1.13–8.13) remained independently positivelyassociated with possession of THN. Male gender (AOR =0.29, 95% CI 0.11–0.72) remained independently negativelyassociated with possession of THN.DiscussionIn the present study of street-involved youth, we ob-served an important gap between reported knowledge ofTHN programs and reported possession of THN kits.We also found an increase in the rates of both know-ledge and possession of THN that parallels the increasein THN distribution that occurred in 2016. Caucasian/white ethnicity was the only variable found to be inde-pendently positively associated with both knowledge andownership of THN. Public injection drug use was inde-pendently positively associated with THN knowledge,while daily cocaine or crack use was independently nega-tively associated with THN knowledge. In addition, dailyheroin and methamphetamine use were independentlypositively associated with THN ownership, while malegender was independently negatively associated withTHN ownership.Our findings build on a qualitative study conducted inVancouver, B.C., which found THN programs to begenerally well-received among street-involved youth,though the study did not assess rates of uptake in thispopulation [16]. Our findings also build on previous stud-ies that have examined knowledge of and participation inTHN programs among PWUD [8, 22]. One recent studyexamining THN participation among adult PWUD inVancouver, B.C., also identified an alarming gap betweenthe rates of knowledge and possession of THN [22]. Onelikely explanation for this gap is an underestimation ofoverdose risk (both personal and witnessed) amongPWUD. There is in fact evidence that PWUD are likely tounderestimate their own risk of opioid overdose [23],which has been identified as a major barrier to THN own-ership among adult PWUD [22]. Interestingly, one studyin the U.S. found that people who use opioids reportedtheir desire to help an overdosing peer to be a biggermotivation for THN enrollment than a fear of personalTable 2 Bivariate and multivariate logistic regression analyses of factors associated with knowledge of THNCharacteristics Unadjusted AdjustedOdds ratio(95% CI)p value Odds ratio(95% CI)p valueAge (per year younger) 1.06 (0.94–1.20) 0.352 1.05 (0.88–1.26) 0.587Gender (male vs. female) 0.57 (0.28–1.14) 0.119 0.61 (0.24–1.49) 0.283White ethnicity (yes vs. no) 2.74 (1.41–5.43) 0.003 2.36 (1.02–5.61) 0.047Downtown Eastside residencea (yes vs. no) 0.94 (0.46–1.99) 0.863 0.43 (0.15–1.19) 0.108Ever homeless (yes vs. no) 2.83 (1.09–7.38) 0.031 1.99 (0.54–7.34) 0.297High school completion (yes vs. no) 0.82 (0.43–1.57) 0.551 0.94 (0.40–2.20) 0.883Employmenta (yes vs. no) 0.79 (0.38–1.69) 0.534 0.91 (0.36–2.37) 0.842Incarcerationa (yes vs. no) 2.43 (0.87–8.67) 0.120 1.84 (0.50–8.08) 0.380Daily heroin usea (yes vs. no) 4.02 (1.70–11.17) 0.003 2.37 (0.73–9.03) 1.171Daily cocaine or crack usea (yes vs. no) 0.25 (0.06–0.90) 0.036 0.09 (0.01–0.59) 0.016Daily methamphetamine usea (yes vs. no) 1.35 (0.65–2.95) 0.433 0.70 (0.26–1.90) 0.477Daily use of prescription opioidsa (yes vs. no) 2.11 (0.53–14.07) 0.346 1.38 (0.17–18.75) 0.784Public injectinga (yes vs. no) 6.09 (2.69–15.72) < 0.001 5.61 (1.90–19.12) 0.003Ever overdosed (yes vs. no) 1.41 (0.73–2.77) 0.314 0.76 (0.32–1.76) 0.522Unable to access addiction treatmenta (yes vs. no) 3.29 (1.20–11.58) 0.035 3.41 (1.02-14.10) 0.062Drug or alcohol treatmenta (yes vs. no) 2.00 (1.03–3.91) 0.041 1.71 (0.71–4.19) 0.235CI confidence intervalaIn the last 6 monthsGoldman-Hasbun et al. Harm Reduction Journal  (2017) 14:79 Page 4 of 7overdose [24], further suggesting that PWUD tend tounderestimate their risk of personal overdose and mayalso be underestimating their risk of witnessing an over-dose. It is also possible that some youth did not participatein the THN program due to perceived ineligibility (at thetime of data collection only individuals considered high-risk for witnessing or experiencing an overdose receivedfree kit following administration training), though this isunlikely due to the high-risk study population, as well asthe high rates of non-fatal overdose among this sample ofyouth. Nolan et al.’s [22] study of adult PWUD identifiedeven lower rates of THN possession (13%) than those re-ported in our sample of young PWUD (22.5%). This maypartially be explained by the fact that naloxone distribu-tion increased significantly in 2016; Nolan et al.’s [22]study used data from 2014 to 2015 only, while the currentstudy included data from participants who completed aquestionnaire in 2016. However, it is also worth notingthat Vancouver’s THN program targeted youth throughthe distribution of THN in emergency departments aswell as youth-centered promotional activities [25], whichmay have contributed to higher rates of uptake amongyouth.Public injection, heroin use, and methamphetamineuse have all been associated with non-fatal overdose[26, 27] and were also associated with THN knowledgeor possession in the present study. This may suggest thatcertain forms of high-intensity drug use can prompt THNparticipation. The present study also found that cocaineor crack use was negatively associated with THN know-ledge, which could be explained by a lower perceived riskof opioid-related overdose among people who use crackor cocaine when compared to people who use opioids. Be-cause naloxone only reverses the effects of opioid-relatedoverdoses (and not overdoses caused by cocaine or crack),naloxone kit acquisition may seem irrelevant to youth whodo not use opioids daily. However, all street-involved youthare at risk of witnessing an overdose due to the high ratesof daily opioid use and non-fatal overdose in their environ-ment [28], and one study of youth who inject drugs foundthat “speedball” (a mixture of heroin and cocaine) use wasassociated with an increased risk of overdose [29]. Inaddition, fentanyl-detected deaths in B.C. often involve theuse of other illicit drugs [2], though it remains unclear whatproportion of these deaths can be attributed to fentanylcontamination and polysubstance use. As such, all street-involved youth who use illicit drugs would be importantTHN owners, and youth who use cocaine or crack maybenefit from targeted educational and marketing efforts toincrease THN participation.A recent meta-analysis found male gender to be one ofthe factors most strongly associated with drug overdosedeath [30], and in B.C., males accounted for 83% of allillicit drug overdose deaths from January to September2017 [2]. However, male gender was negatively associatedwith THN ownership in the current study. This highlightsthe need to target male youth in THN programs, whomay face sociocultural barriers to accessing THNTable 3 Bivariate and multivariate logistic regression analyses of factors associated with ownership of THNCharacteristics Unadjusted AdjustedOdds ratio(95% CI)p value Odds ratio(95% CI)p valueAge (per year younger) 1.04 (0.90–1.20) 0.610 1.05 (0.88–1.25) 0.627Gender (male vs. female) 0.27 (0.13–0.57) 0.001 0.29 (0.11–0.72) 0.008White ethnicity (yes vs. no) 2.68 (1.27–5.99) 0.012 2.51 (1.02–6.51) 0.049Downtown Eastside residencea (yes vs. no) 0.63 (0.25–1.43) 0.289 0.38 (0.11–1.14) 0.097Ever homeless (yes vs. no) 1.19 (0.41–4.35) 0.768 1.25 (0.31–6.00) 0.767High school completion (yes vs. no) 1.14 (0.56–2.32) 0.714 1.37 (0.54–3.54) 0.508Employmenta (yes vs. no) 1.05 (0.45–2.32) 0.906 1.23 (0.44–3.31) 0.685Incarcerationa (yes vs. no) 1.02 (0.35–2.62) 0.963 0.80 (1.19–2.96) 0.748Daily heroin usea (yes vs. no) 3.57 (1.70–7.54) 0.001 3.08 (1.09–9.11) 0.036Daily cocaine or crack usea (yes vs. no) 0.36 (0.02–2.03) 0.346 0.25 (0.01–2.43) 0.295Daily methamphetamine usea (yes vs. no) 2.43 (1.15–5.09) 0.019 2.99 (1.13–8.13) 0.028Daily use of prescription opioidsa (yes vs. no) 0.29 (0.02–1.58) 0.248 0.20 (0.01–1.36) 0.161Public injectinga (yes vs. no) 2.53 (1.23–5.29) 0.012 1.55 (0.55–4.32) 0.403Ever overdosed (yes vs. no) 1.23 (0.61–2.50) 0.566 0.63 (0.24–1.58) 0.336Unable to access addiction treatmenta (yes vs. no) 0.94 (0.35–2.28) 0.899 0.77 (0.22–2.47) 0.671Drug or alcohol treatmenta (yes vs. no) 1.85 (0.89–3.98) 0.106 1.47 (0.58–3.82) 0.419CI confidence intervalaIn the last 6 monthsGoldman-Hasbun et al. Harm Reduction Journal  (2017) 14:79 Page 5 of 7programs not experienced by male adult PWUD. There isin fact evidence that male adolescents and young adultsare less likely than their female counterparts to accesshealth services due to stigma, as well as gender, social, andcultural norms [31, 32]. The same meta-analysis alsofound Caucasian/white ethnicity to be positively associ-ated with drug overdose death [30]. In the present study,Caucasian/white ethnicity was positively associated withboth knowledge and possession of THN, which is consist-ent with what has been found in the literature of adultPWUD [22]. However, in B.C., First Nations individualsare at increased risk of fatal overdose compared to thegeneral population [33]. First Nations individuals, andother non-white individuals who may be more vulnerableto overdose, may then also benefit from targeted strategiesto improve their access to THN.There are limitations to this study. First, because thisis a cross-sectional study, we are unable to infer caus-ation. Second, because there are no registries of streetyouth to draw upon, our sample was not randomlyselected and therefore may not be representative of allstreet youth in Vancouver. However, we note that thecharacteristics of the ARYS sample are similar to thosefrom other studies of high-risk youth [34–36]. Third, werelied on self-report, which may have been subject toresponse biases, including recall bias and socially desir-able responding, though we know of no reason why thiswould explain the associations we identified in thisstudy. Fourth, due to our smaller sample size, we werenot able to include data related to witnessed overdoseand naloxone administration, which may have influencedthe results of our multivariate analyses. We also did notask youth about their reasons for not owning kits, orwhether those who reported THN possession carried thekits with them. Lastly, our study included pre-2016 data,after which THN distribution increased significantly.Our results demonstrate an increase in THN uptake thatparallels the program’s expansion; however, current ratesof THN uptake may be continuing to rise.ConclusionsTo our knowledge, this is the first study to examinesociodemographic characteristics and substance use-related factors of street-involved youth who are familiarwith and have acquired THN kits and the first to evalu-ate the rates of knowledge and possession of THN inthis population. The findings of the present study high-light the need to increase knowledge of and access toTHN among all street-involved youth who use illicitdrugs, particularly among local populations found tobe among the highest risk of fatal overdose. Specifically,these findings suggest that males, people who do notidentify as “Caucasian/white,” and people who usecrack or cocaine would benefit from targetedapproaches to improve their access to THN programs.Future research should focus on examining interven-tions that aim to address barriers to THN acquisitionamong those currently underrepresented in THNprograms.AbbreviationsAOR: Adjusted odds ratio; ARYS: At-Risk Youth Study; B.C.: British Columbia;CI: Confidence interval; DTES: Downtown Eastside; OEND: OverdoseEducation and Nasal Naloxone Distribution program; OR: Odds ratio;PWUD: People who use drugs; THN: Take-home naloxone; U.S.: United StatesAcknowledgementsThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff.FundingThe study was supported by the US National Institutes of Health(U01DA038886) and the Canadian Institutes of Health Research(MOP–102742). Dr. Kora DeBeck is supported by a MSFHR/St. Paul’s HospitalFoundation–Providence Health Care Career Scholar Award and a CanadianInstitutes of Health Research New Investigator Award. This research wasundertaken, in part, thanks to funding from the Canada Research Chairsprogram through a Tier 1 Canada Research Chair in Inner City Medicinewhich supports Dr. Evan Wood.Availability of data and materialsThe data used for this study is not publicly available. For further informationon the data and materials used in this study, please contact thecorresponding author.Authors’ contributionsJGH, KD, and TK conceptualized the study design. EN performed thestatistical analyses, and JGH and TK interpreted the results. JGH drafted theinitial manuscript. TK, KD, JB, and EW provided substantial revisions of themanuscript and guidance throughout the writing. All authors have read andapproved the final manuscript.Ethics approval and consent to participateThe At-Risk Youth Study has been approved by the Providence Health Care/University of British Columbia’s Ethics Board. All participants providedinformed consent prior to participating in this study.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, 608-1081 Burrard Street,Vancouver V6Z 1Y6, BC, Canada. 2School of Public Policy, Simon FraserUniversity, 515 West Hastings Street, Vancouver V6B 5K3, BC, Canada. 3Schoolof Population and Public Health, University of British Columbia, 2206 EastMall, Vancouver V6T 1Z3, BC, Canada. 4British Columbia Centre for DiseaseControl, 655 West 12th Avenue, Vancouver V5Z 4R4, BC, Canada.5Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver V6Z 1Y6, BC, Canada.Goldman-Hasbun et al. 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Steensma C, Boivin JF, Blais L, Roy E. Cessation of injecting drug use amongstreet-based youth. J Urban Health. 2005;82:622–37.•  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:Goldman-Hasbun et al. Harm Reduction Journal  (2017) 14:79 Page 7 of 7

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