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“Getting out of downtown”: a longitudinal study of how street-entrenched youth attempt to exit an inner… Knight, Rod; Fast, Danya; DeBeck, Kora; Shoveller, Jean; Small, Will May 2, 2017

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RESEARCH ARTICLE Open Access“Getting out of downtown”: a longitudinalstudy of how street-entrenched youthattempt to exit an inner city drug sceneRod Knight1,2,3,6* , Danya Fast2,4,6, Kora DeBeck2,5,6, Jean Shoveller2,3 and Will Small1,2,6AbstractBackground: Urban drug “scenes” have been identified as important risk environments that shape the health ofstreet-entrenched youth. New knowledge is needed to inform policy and programing interventions to help reduceyouths’ drug scene involvement and related health risks. The aim of this study was to identify how young peopleenvisioned exiting a local, inner-city drug scene in Vancouver, Canada, as well as the individual, social and structuralfactors that shaped their experiences.Methods: Between 2008 and 2016, we draw on 150 semi-structured interviews with 75 street-entrenched youth. We alsodraw on data generated through ethnographic fieldwork conducted with a subgroup of 25 of these youth between.Results: Youth described that, in order to successfully exit Vancouver’s inner city drug scene, they would need to: (a)secure legitimate employment and/or obtain education or occupational training; (b) distance themselves – bothphysically and socially – from the urban drug scene; and (c) reduce their drug consumption. As youth attempted toleave the scene, most experienced substantial social and structural barriers (e.g., cycling in and out of jail, the need toaccess services that are centralized within a place that they are trying to avoid), in addition to managing complexindividual health issues (e.g., substance dependence). Factors that increased youth’s capacity to successfully exit thedrug scene included access to various forms of social and cultural capital operating outside of the scene, includingsupportive networks of friends and/or family, as well as engagement with addiction treatment services (e.g.,low-threshold access to methadone) to support cessation or reduction of harmful forms of drug consumption.Conclusions: Policies and programming interventions that can facilitate young people’s efforts to reduce engagementwith Vancouver’s inner-city drug scene are critically needed, including meaningful educational and/or occupational trainingopportunities, ‘low threshold’ addiction treatment services, as well as access to supportive housing outside of the scene.Keywords: Canada, Youth, Addiction, Drug scene, Street entrenchedBackgroundIntroductionUrban drug “scenes” – broadly defined as inner city areasfeaturing large drug-using populations and high levels ofstreet-based drug dealing (and often homelessness orunstable housing) – have been identified as important riskenvironments that shape the health of vulnerable popula-tions, including youth [1, 2]. Previous research indicatesthat young people (e.g., 30 years of age and under) whouse drugs in the context of drug scene entrenchment ex-perience elevated rates of infectious (e.g., HIV, HepatitisC) and chronic (e.g., diabetes, liver disease) diseases [3–6]amidst intersecting forms of social vulnerability [7–12].Moreover, young people entrenched in urban drug scenesfrequently experience extreme socioeconomic deprivation,homelessness, addiction, mental health issues and involve-ment in dangerous and criminalized income-generationactivities [1, 13–16]. Reducing youths’ drug scene involve-ment and related health risks is a critical priority for pub-lic health intervention.* Correspondence: rodney.knight@sfu.ca1Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, Canada2British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, 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.Knight et al. BMC Public Health  (2017) 17:376 DOI 10.1186/s12889-017-4313-9The investigation of young people’s transitions intohomelessness, as well as evolving forms of harmful druguse, has been an important focus for research and policyand programming interventions [17, 18]. For example, pre-vious research has identified risk factors associated withyouth’s transitions into homelessness, including family dys-function, experiences of abuse and trauma, various formsof exploitation, poverty, mental health crises, and a lack ofculturally appropriate social welfare services [17]. Researchfrom Vancouver, Canada, has identified how transitionsinto more harmful forms of illicit drug use among youthcan be powerfully shaped by geographical transitionsbetween neighbourhoods, and the social, structural andspatial processes that are embedded in particular places [1,15]. As young people become entrenched in these scenes/milieus across time, transitions into homelessness and moreharmful forms of drug use can come to seem increasinglyinevitable given the constraints of their everyday livedexperience. Indeed, in settings like Vancouver’s DowntownEastside and Downtown South neighbourhoods, decision-making and transitions related to drug use tend not to befocused so much on whether to take drugs or quit takingdrugs, but rather on shifting definitions of “desirable” ver-sus “undesirable” forms of drug use [13].While there is an established body of research investigat-ing young people’s transitions into various forms of druginvolvement (e.g., more or less harmful forms of illicit use),as well as various forms of precarious housing and home-lessness, far less research has explored how street-entrenched young people think about and enact transitionsaway from and out of urban drug scenes. Given the numer-ous harms and intersecting forms of disadvantage experi-enced by young people who are drug scene entrenched,new knowledge to inform policy and programming is critic-ally needed to better understand how young people canbest be supported to reduce or eliminate their involvementwith urban drug scenes. Drawing on a longitudinal studydesign and in-depth interviews with street-entrenchedyoung people in Vancouver, Canada, the aim of this studywas to identify how young people envision exiting a local,inner-city drug scene in Vancouver, as well as the individ-ual, social and structural factors that shape young people’strajectories as they attempt to exit this setting.MethodsStudy settingThis study is part of a larger program of ethnographic andqualitative research examining young people’s substanceuse and broader risk trajectories in the context of Vancou-ver’s inner city, street-based drug scene [1, 13, 19]. Thisdrug scene primarily consists of two distinctive neighbour-hoods: the Downtown Eastside and the Downtown South.Our long-term ethnographic research shows that streetentrenched young people in our setting frequently movebetween these two neighbourhoods, as they navigate elab-orate social spatial networks and the day-to-day realitiesof securing basic necessities. Although the DowntownEastside and the Downtown South are geographicallyadjacent (and within easy walking distance of each other),they are consistently differentiated according to theirhistory and a number of aspects of place. The DowntownEastside is widely conceived as Vancouver’s poorest andmost ‘run-down’ neighbourhood, and is the site of a largeconcentration of low-income, government-subsidizedhousing and numerous services that provide shelter,healthcare, food and harm reduction services to vulner-able populations (including large numbers of people whoinject drugs). The Downtown South is a residential andentertainment district characterized by both high- andsome low-income housing, as well as numerous entertain-ment venues (e.g., nightclubs) and other commercialenterprises (e.g., restaurants, shops). Both neighbourhoodsare characterized by shadow economies largely propelledby drug dealing, the exchange of stolen/s hand goods, andsex-work activities.The Downtown South and Downtown Eastside neigh-bourhoods are also differentiated by substance use pat-terns, although much overlap exists and it should also benoted that both neighbourhoods are inhabited by a largenumber of people who do not use illicit drugs. While theDowntown Eastside is generally identified with a trade incrack cocaine, cocaine, heroin and prescription opioidsbought and sold primarily by older individuals, the Down-town South is generally identified with high rates of crystalmethamphetamine sales and use primarily among youth[20]. Although various youth services are now situated inthe Downtown South (e.g., a large drop-in centre, ashelter, a community health clinic, a job search service,several outreach programs and mobile health vans), deci-sion makers and advocacy groups continue to struggle toaddress the “street youth problem” in this setting [14].Data collectionWe draw on over 150 audio-recorded and transcribedsemi-structured interviews with 75 street-entrenched youthconducted in four waves from 2008 to 2016 (see Table 1).These interview waves were embedded within an eight-yearprogram of ethnographic research conducted by the secondauthor (DF), which allows us to further contextualize thefindings that emerged from these interview series. Thislarger program of ethnographic research involved spendinghundreds of hours in the places where young people wereliving, working, sleeping, socializing, and accessing servicesand systems, documented through written field notes,audio-recordings, and photographs. All interview partici-pants were recruited by DF from the At-Risk Youth Study(ARYS), a prospective cohort of drug-using and street-involved youth in Vancouver. ARYS cohort members areKnight et al. BMC Public Health  (2017) 17:376 Page 2 of 11between the ages of 14 and 26 years and self-report the useof illicit drugs other than or in addition to marijuana in thepast thirty days, at the time of enrolment. See Wood et al.2006 for more details on the ARYS cohort [20]. Rather thanrandomly selecting participants to ensure their “representa-tiveness” of the broader street-entrenched population ofyouth in Vancouver, we purposefully sampled young peoplewho, by virtue of their lived experiences, had the capacityto reflect on the processes involved in exiting Vancouver’surban drug scene. This included selecting and recruitingyouth with various social identities (e.g., sexual identities;ethno-racial identities; gender identities) and lived experi-ences (e.g., experiences with: injection drug use; sex work;drug dealing).During interviews, youth reflected on the current na-ture of their drug scene involvement, and how their in-volvement had shifted across time as they attempted tonavigate drug use, multiple income generation strategies,unstable or undesirable housing, and social relationshipswith a wide range of actors including friends, romanticpartners, “business partners” (in the drug trade), serviceproviders and the police. All of the young people in oursample frequently spoke about their future aspirations,including their plans to reduce their involvement in thescene. Participants reflected on their attempts to enactparticular exits across multiple waves of data collection.All participants provided written informed consent toparticipate in in-depth interviews, and received a twentyto thirty dollar honorarium for each interview (theamount of the honorarium was increased in 2013). Thestudy was undertaken with ethical approval granted by theProvidence Healthcare/University of British ColumbiaResearch Ethics Board.Data analysisAudio-recorded interviews were transcribed verbatim,anonymized and checked for accuracy. ATLAS.TI soft-ware was used to manage the transcribed interview data.Data analysis was guided by three overarching analyticalquestions: (1) How do young people envision exiting theinner city drug scene?; (2) ‘What are the critical momentsthat influence youths’ experiences of “getting out” (e.g.,the individual, social, structural, and environmental fac-tors that shape these experiences over time)?’; and (3)‘How are young people’s transitions out of the inner-citydrug scene shaped by key periods (e.g., when do they ex-press a desire to “get out” or decrease their involvementwith the scene and/or reflect on a plan to do so)?’Co-authors DF and RK coded the interviews, wherebydata were highlighted and corresponding themes, labels,and notes about interpretations were made within theinterview transcripts. We used constant comparativeanalytical techniques [21], in which we evaluated ouremerging analyses in relation to previous research andall of our existing data in the current analysis. Specific-ally, the individual transcripts were compared andTable 1 Data collection processes from 2008 to 2016Wave 1 Wave 2 Wave 3 Wave 4Dates January 2008 to June 2008 July 2009 to April 2010 January 2011 to December 2012 January 2013–May 2016Data collectiontechniquesIn-depth interviews In-depth interviews Intensive ethnographic fieldworkdocumented through fieldnotes,audio recordingsIntensive ethnographicfieldwork documentedthrough fieldnotes, audiorecordingsResearchparticipants39 (18 men; 21 women) 28 (20 men; 8 women) 25 (16 men; 9 women) 15 (9 men; 5 women; 1transgender individual)Age range 16–26 (median age = 22) 14–25 (median age = 21) 20–30 (median = 26) 24–34 (median age = 28)Ethnicity 65% Caucasian, 25% ofIndigenous ancestry, 10%African Canadian72% Caucasian, 25% ofIndigenous ancestry, 3%African Canadian67% Caucasian, 25% of Indigenousancestry, 8% African Canadian60% Caucasian, 33% ofIndigenous ancestry, 7%African CanadianFollow-up fromprevious wavesN/A 12 from Wave 1 DF had contact with researchparticipants on at least a monthlybasis; in addition, 40 more formal,audio recorded semi-structured inter-views were conducted during thistimeDF had contact withresearch participants on atleast a monthly basis; inaddition, 56 more formal,audio recorded semi-structured interviews wereconducted during this timeRecruitmentprocessFacilitated by a youth peerresearch associateFacilitated by the staff atthe ARYS research office,and Fast’s ongoingrelationships with localyouthFacilitated by DF’s ongoingrelationships with local youthFacilitated by DF’s ongoingrelationships with localyouthPrimaryLocationThe ARYS research office inthe Downtown SouthThe ARYS research office inthe Downtown SouthThe places where youth were living,socializing and workingThe places where youthwere living, socializing andworkingKnight et al. BMC Public Health  (2017) 17:376 Page 3 of 11contrasted to identify patterns, as well as shared and di-vergent understandings identified. Discrepancies be-tween codes and emergent themes were resolvedthrough discussion and re-visiting the raw data duringteam meetings. Memos were kept by the lead author(RK) to document the analysis process as it developed,and these were discussed with the co-authors through-out the analysis of the data and writing of this article.We also used “verification” strategies to establish rigorin our approach to validating our decisions about theanalysis, including the emphasis of responsiveness andopenness of all authors to the data in adjusting or revis-ing the codes and presentation of each thematic to resultin a consensus-driven representation of our findings. Asthis process unfolded, we developed a set of codes toidentify the broad themes that emerged across the dataset (e.g., “exiting and physical and mental health”; “exit-ing and interpersonal relationships”; “the role of existingpolicies and programs”). As such, our analysis draws onboth a deductive approach, in which findings were com-pared and contrasted to existing theoretical and empir-ical literature, as well as an inductive approach, throughwhich we developed our coding schematic. Within ourpresentation of our analysis, we have sought to be highlycontextual and descriptive with regards to describing theextent to which changes have occurred over time witheach of our participants. To do so, we have offered anapproach to presenting our longitudinal data and ana-lysis in a way that allows us to present across- andwithin-person variations over time by providing both adata point (i.e., quote from an in-depth interview) alongwith a descriptive narrative to illustrate to the readerhow these changes have transpired over time.ResultsSample characteristicsOur sample of 75 participants frequented many of thesame service locations and had likely used drugs to-gether in the parks or alleyways of downtown Vancouverat one time or another. Yet, only a small number werenetworked in a more enduring sense, usually in the formof a romantic or crime-related partnership. Nevertheless,participants did share a number of common characteris-tics. The majority of youth grew up in low-income, ma-terially disadvantaged households; approximately three-fifths (n = 43) had experienced violence, abuse or neglectin their pasts and slightly less than half (n = 33) had ahistory of government (foster) care. Slightly less thanhalf of participants (n = 36) had a history of involvementin the juvenile justice system, and/or had served time ina provincial prison as an adult. Only 15 of 75 partici-pants had graduated from high school or later com-pleted their General Education Diploma. Approximatelythree-fifths of youth (n = 44) indicated that they hadbeen diagnosed with a mental illness by a health profes-sional, and a number of additional participants indicatedthat they suffered from a self-diagnosed mental healthissue.All but two participants reported being homeless dur-ing the course of the study (meaning that they weresleeping outside, “couch surfing” at friends’ or acquain-tances’ places, and/or staying at shelters – most often acombination thereof ). At some point during the studyperiod, all youth were engaged in drug use practices thatthey defined as problematic, using terms like “addiction,”“out-of-control” and “self-destructive.” Based on ourfieldwork and interview data, these terms consistentlyreferred to drug use which was resulting in physical, psy-chological and/or emotional problems, whether directlyas a result of the chemical properties of a particular sub-stance, or indirectly as a result of the violence and in-stability that often accompanies drug use in the contextof social, spatial and economic marginalization. For theyoung people who participated in this study, this in-cluded the daily use of heroin, crack and/or crystalmethamphetamine (meth). Fifty-five youth had usedmeth at least once in their lives; thirty-three had injectedmeth. Youth also engaged in varying forms of poly-substance use over time; for example, at any one time,up to half of those youth who reported using meth alsoreported using crack and/or heroin.Approximately three-quarters of participants (n = 54)received monthly social-assistance (welfare) payments,although this support was rarely enough to cover thecost of living in Vancouver. Most youth were thereforeinvolved in a range of illicit income-generation activities,including street-level drug dealing (n = 51), sex work(n = 14), and the exchange of stolen and purchasedgoods (n = 27). In sum, the majority of these youth wereor had at one time been significantly “entrenched” inVancouver’s street-based drug scene; they describedthemselves as being, or recently having been, largelyconsumed by a daily project of survival “on the streets”– a phrase that in our setting refers to numerous indoorand outdoor settings associated with the drug scene.FindingsDuring the interviews and fieldwork with young people,we asked participants to describe the futures they envi-sioned for themselves. While a minority of the partici-pants accepted a future in which they would remainentrenched in Vancouver’s inner-city drug scene as ‘inev-itable’, being addicted to drugs and dependent on the so-cial service infrastructure, the vast majority of youngpeople expressed a strong desire to exit the scene. Asparticipants described their future aspirations, many in-dicated that they wanted to exit the scene in order to re-connect with some aspect of their pasts, and theyKnight et al. BMC Public Health  (2017) 17:376 Page 4 of 11frequently expressed a desire to do so independentlyand/or with limited supports. For others, an exit fromthe scene would represent a first step towards obtainingwhat they often referred to as a “normal life” in Vancou-ver. In order to successfully exit Vancouver’s inner citydrug scene, all of the youth articulated one or more be-liefs that they would need to: (a) secure legitimate em-ployment and/or obtain education or occupationaltraining; (b) distance themselves – both physically andsocially – from the urban drug scene; and (c) reducetheir drug consumption, including through the use ofaddiction treatment services. In the following sections,we describe the challenges that young people faced inexiting the drug scene and actualizing these visions of a“normal life” in Vancouver. We present quotes from ourinterview data to illustrate key aspects of our analysis,and provide context about the participants and their at-tempts to exit by drawing on data derived from both ourinterview and ethnographic data. All names appearingbelow are pseudonyms.Challenges finding legal employment and reducing relianceon illegal income generationParticipants described a deep desire to secure “legitim-ate,” legal employment that was partially or fully re-moved from the street-based drug scene. There wereoften dramatic differences between the kinds of jobs thatyouth envisioned securing and the kinds of employmentthat they were actually able to obtain in the context oflow levels of education (in almost all cases) and a lack ofthe social and symbolic capital required to obtain em-ployment. While many youth had at least some prior ex-perience working in a variety of labour and servicesector jobs, they often found themselves ill-equipped forthe job-hunting process, including being unable to an-swer conventional interview questions from prospectiveemployers. For example, Dave, a 23-year-old young Indi-genous man described how, even after securing an inter-view, he had not been offered the job because of “totallyblowing” the interview process:They asked me these hard questions that I couldn’t an-swer, and I totally blew it. Yeah, the simplest questionslike “What do you bring to the table?” What’s yourstrength?” And it’s like, “I thought you were just going toask me if I knew how to do the job.”As participants reflected on the practical actions thatwould be required to take in order to secure some formof legal employment, a number described a need to bothaddress the most unstable aspects of their everyday lives(e.g., the imperative to generate income in the context ofaddiction and unstable housing), and successfully navi-gate a number of other bureaucratic tasks (e.g., securingwelfare payments). As a result of the high level of chaosthat characterized their everyday lives on the streets,youth lamented “never seeming to be able to find thetime” to prepare resumes, do job searches and fill in jobapplications. Printed documents of this kind were also dif-ficult for many young people to carry around and store –whether in the context of street-based homelessness orresidence in a run down single room occupancy hotel(SRO). Living conditions on the streets and inside SROsalso made it difficult for youth to store and maintainclothing that would be appropriate for job interviews.In spite of the fact that an employment service infra-structure exists in the Downtown South in order to helpyouth with job searches and preparing job applicationsand resumes, it is worth noting that a large number ofyoung people insisted that these were tasks they plannedand wanted to accomplish on their own. Many of theyouth expressed a strong distrust towards “the system”and various aspects of the social service and health infra-structure due to previous experiences (e.g., negative ex-periences with foster care). However, as they attemptedto navigate the multiple steps required in order to enterthe legal job market, many young people became con-fused, in part because the majority of participants hadextremely limited computer literacy skills (e.g., did nothave the skills to fill out online applications). For ex-ample, Lee, a 27-year-old young Indigenous man de-scribed how he needed government identification beforehe could enrol in an alternative job training programthat he imagined would improve his chances of getting a“real” job. When asked about how he was going to goabout getting his ID, his response revealed some of hisconfusion in sorting through the logistics of multiple ap-plication processes with little support or guidance:I wanna go one step at a time. […] The ID would beprimary – first. And then look for a job. No, no! Look fora job first, right? ‘Cause then I could try to get my ID atthe same time. But I don’t know how that’s going to work,with working and getting it at the same time, it’s gonnabe… ‘Cause I’ll be working during the week, and, thehours will be gone. And I don’t know who would want todo that for me, or if I have to do it for myself.A number of young people described their attempts toenrol in various training and education programs. Manywere not able to do so successfully due to what they per-ceived to be complex admission requirements (e.g., theneed to provide transcripts of previous grades, the needto meet certain course prerequisites), as well as limitedopportunities for financial support. Others experiencedbarriers to completion of these programs upon enrol-ment. For example, even in the context of alternativeschool and training programs that are designed for “at-risk” youth, young people could quickly become over-whelmed by the content of lessons, leading some to“give up” and leave the program without approachingthe instructor or others for help. Again, many youngKnight et al. BMC Public Health  (2017) 17:376 Page 5 of 11people lacked the social capital needed to successfullycommunicate the challenges they were experiencingwith teachers and administrators (many of whom wouldlikely have been very receptive to requests for extrahelp). Moreover, some of the forms of social and sym-bolic capital that young people had accumulated on thestreets and across their lives (e.g., aggressive ways oftalking and interacting with others) could be at oddswith the kinds of social and symbolic capital that wouldhelp them to succeed in job interviews, training, andschool programs. Young people were highly cognizant ofthe mismatch between the kinds of traits (e.g., tough-ness, aggression, independence) they had cultivated inorder to survive and thrive in places like governmentcare homes, the streets of Vancouver, and prison, versusthose desired by potential employers and educators.Jordan, a 27-year-old Caucasian man described how hisprevious life experiences made him more comfortablewith the prospect of going to prison than university –despite his desire for a university education:My whole family’s been in and out of jail. […] I neverwent into a real school surrounding. But I did the corres-pondence [to get his General Educational Developmentwhile in jail]. I wish I could’ve went into a real schoolsurrounding. Probably still could. I’m thinking about go-ing to UBC [the University of British Columbia]. But I’dbe kind of intimidated of going to UBC. Cause there’snice people like yourself going there…I’d be more intimi-dated going to UBC [than jail]. I get really intimidatedwhen I get around normal crowds.While youth emphasized their desire to obtain someform of job or education training, it is striking to notethat, at the time of writing, none of the participantsfollowed throughout our study completed training andeducation programs except for those who did so while ina correctional facility.While relatively few youth managed to do so, securinglegal employment outside of the inner-city drug scenerepresented a critical moment in youth’s transitions outof the scene, as these moments profoundly influencedyoung people’s trajectories with “getting out” of theurban drug scene. However, the jobs that young peoplewere able to secure were most often low paid, low skilledand temporary. In comparison to more lucrative and fa-miliar (if also violent and dangerous) street-based formsof income generation such as drug dealing and the theftand exchange of stolen goods, these legal jobs could beexperienced as much less interesting and more monot-onous. In some cases, the effects of eventually losinglegal jobs could be disastrous for youth, and result in re-entrenchment in the inner city drug scene. Moreover, anumber of youth fell victim to “too-good-to-be-true”employment opportunities and scams that embroiledthem in serious legal trouble, or, more benignly, resultedin wasted time. With regards to the latter, one youngwoman spent several days distributing flyers on the un-derstanding that she would be paid by her ‘employer’once the task was completed. However, upon completingthe task she was unable to contact the employer and re-ceive payment. With regards to the former, Ryan, a 25-year-old Caucasian man, recounted how he was con-nected with an ‘employer’ through a legitimate jobagency, who nevertheless turned out to be a con artist.After working as a mover for two weeks, the young manattempted to cash his pay cheque, which was identifiedby the bank as a fraudulent cheque. After a criminal in-vestigation into his involvement in the scam, the youngman himself ended up being charged with fraud (by thatpoint the employer had disappeared). Despite his best ef-forts to prove that he had no knowledge that the busi-ness he was working for was actually operating illegally,he was sentenced to jail time. As Ryan described:I started getting my life together. I was working a legitjob. I was living a normal routine. I was startin’ to puton weight again. Everything was starting to go good. Iwas saving money. [pause] And then, I guess I was meantto be a homeless drug addict. Cause for some reason itjust… [pause] I go to work. And the guy that I’m workingfor is gone. Disappeared. The job didn’t exist anymore…Because I was a drug addict and had a previous crim-inal record they didn’t believe me. They didn’t care. Thejudge said, “We don’t believe you. People will do any-thing to get money for drugs.” I even presented the factthat I was clean. Had a sponsor and everything. It didn’tmatter. Like once a drug addict, in their eyes you’re al-ways a drug addict. […] I was gonna continue workingwith this legit job. If this didn’t happen and I didn’t go tojail, I probably would still be clean and I probably stillbe working.After serving his prison term, Ryan returned immedi-ately to the Downtown Eastside. With no money and noplace to stay, he once again found himself homeless, andquickly began using and selling drugs. At the time ofwriting, he continues to live in the Downtown Eastside,albeit in supportive housing.Challenges finding housing outside of Vancouver’s drugscenesYoung people also expressed a strong desire to findhousing that was outside of the city’s drug scenes. Overthe course of the study period, some youth managed todo so. While some of the housing that youth were ableto find outside of the scene was temporary and precar-ious (e.g., shelters, ‘couch surfing’ in the suburbs), partic-ipants consistently described how being physicallyremoved from Vancouver’s inner city and the associateddrug scenes was critical to reducing their drug scene in-volvement, including reducing their drug use. TheseKnight et al. BMC Public Health  (2017) 17:376 Page 6 of 11youth often described how being physically present inthe inner city could ‘trigger’ their desire to engage inbinge drug use, as it was more difficult to resist the urgeto use drugs when substances were highly visible andeasily accessible. For example, Jim, a 24-year-old Cauca-sian man described how securing a bed at a shelter out-side of the inner city had helped him transition awayfrom various facets of the scene, including using anddealing drugs:When I’m on the North Shore [a suburb of Vancouver]staying at the shelter, like, I just – I don’t know, I just don’tsee anything…If I was down here, like, I’d be getting’ thecravings, like, all day, like – you know? Just seeing some-body smoking their [crack or crystal methamphetamine]pipe, you know? Like, over there [on the North Shore] Idon’t have to worry about it. I don’t see anybody smokingtheir pipe or talking about it, you know?Participants’ attempts to find longer term and morepermanent housing outside of Vancouver’s inner citywere largely obstructed by meagre monthly social assist-ance (welfare) payments and the extremely high cost ofhousing in Greater Vancouver. Even among those whoreceived relatively higher rates of disability social assist-ance (those qualifying for different levels of disability as-sistance can receive additional financial support,1 beinga young person on welfare almost always automatically“marked” participants as undesirable tenants to pro-spective landlords. As Megan, a 22-year-old Indigenouswoman described:I don’t know who to ask [about getting better housing],or anything. Like who to go to, to help me get a place be-cause – I don’t know. It’s hard to get a place. Especially ifyou’re on welfare. You don’t get that much money on wel-fare. So it’s hard to find a place who, who will rent you[…] to younger people, because they don’t trust them.They think they’re gonna ruin the place and that they’regonna party too much. Or that they’re gonna use drugsthere. […] People don’t like to, rent to younger peoplewho they can’t trust.Young people often found themselves in a situationwhere the only relatively stable housing they could ac-cess was low income, government subsidized housing inVancouver’s inner city designated for “hard to house”residents who use drugs.For those participants who did find jobs and housingoutside of Vancouver’s inner city, some described how thisgeographical shift in their day-to-day lives entailed leavingtheir existing friends and social networks behind. Formany, this process was viewed as essential to successfullyexiting the drug scene. For example, David, a 26-year-oldCaucasian man who moved out of downtown and into asuburb of Greater Vancouver described how this was apurposeful strategy to avoid the daily activities that ac-company drug use and drug scene involvement:I just moved to Surrey again, three days ago. A nicefour bedroom…in a quieter neighbourhood, I guess, thanI’m used to, but that’s okay. I’m getting older, less inclinedto want to be around drama and the people that causedrama [in downtown Vancouver]…I don’t really comedowntown much anymore. The environment here is kindof grimy. [There are people here] I don’t want to associ-ate with anymore. People that aren’t going anywhere. […]This whole little part of Vancouver here. With all of thehomeless and the addicts that I’ve known for years andyears and years and they’re still here and they’re notdoing nothing. I’m trying to do something with my lifeand trying to get somewhere. I can’t associate with themanymore.Challenges with addiction treatmentReducing problematic and binge drug use was viewed ascritical by youth in order to meaningfully exit the drugscene. Participants did describe services in the inner citywhere they could potentially get connected to drugtreatment programs and detox beds (e.g., Insite – Van-couver’s supervised injection site, community healthclinics). However, as with accessing service support infinding housing and employment, youth also expressed asense of “not knowing where to go to find help” and“needing to take care of things for themselves.” For ex-ample, Megan described:I don’t have any place where I can go to get help. Iknow I can go to Pender Clinic or Insite to ask where, like– if I really need something, where I can go to get that.But um, besides that, I don’t have any place where I –they can help me or anything.A number of the participants in this study simply didnot attempt to access treatment and detox services, evenwhen these were accessible. Instead, they oftenattempted to reduce their drug use using their ownstrategies. These strategies included attempts to quit“cold turkey” and “self detox,” as well as the use of othersubstances (e.g., marijuana, dextromethorphan fromcough syrup, crystal methamphetamine) to mediate thewithdrawal symptoms of “coming off of” crack cocaineand opiates [13]. Those youth who did access or attemptto access drug treatment experienced numerous barriers,including difficulties entering methadone maintenancetreatment (MMT) programs due to the cost of daily dis-pensing fees, long waiting lists for residential treatmentprograms, and aging out of State-provided youth ser-vices (which occurs at ages 21, 24 and in some cases 26in our setting, depending on the service). Emily, a 28-year-old Caucasian woman, described the difficulties sheexperienced in getting on MMT and welfare – steps thatshe viewed as crucial to fully exiting the scene and mov-ing to Quebec (a province in Eastern Canada) to livewith her mother. Her story revealed a complex set ofKnight et al. BMC Public Health  (2017) 17:376 Page 7 of 11actions that were required in order for her to accessMMT and welfare in the context of homelessness andaddiction. Namely, in order to have the dispensing feesfor methadone covered by the government (fees shecould not afford in the context of a severe addiction toopiates and homelessness), she needed to qualify for andreceive social assistance (welfare). In order to qualify forsocial assistance, she needed to provide a legal address,and demonstrate that she could not work as a result ofher addiction to heroin. Like many young people in oursetting, Emily was living and sleeping outside at thistime, rather than in a room in a run down and poten-tially dangerous single room occupancy hotel:I tried so many times to get on welfare, but I didn’thave an address, and I told them all, “Well, I’m home-less,” and they’d say, “Well, you’re healthy, so go get ajob.” And I’d be like, “Well, you know, I’m on drugs.”“Well, then go get clean.” “Well, that’s why I’m here. I’mtrying to get on methadone.” You know, and that waslike the Catch-22, like that – I’d have to be on metha-done [to qualify for welfare], and then that’s how I finallygot on welfare, ‘cause I got on methadone.Emily was ultimately able to get on social assistanceand methadone, largely as a result of the support of herfather who initially paid the dispensing fees for MMTand allowed her to use his address for the purposes ofsecuring welfare. He also eventually allowed her to stayat his house while she was transitioning off of heroinand onto methadone. At the time of an interview in2012, Emily had not used heroin for one year:I’m lucky because most of the people who live out here[on the streets], their parents don’t even live out here [inVancouver]. They have no connections with their parents… if it wasn’t for my dad, I still wouldn’t even be onmethadone because he paid 15 dollars a day [dispensingfees] for me to do so. Yeah, I mean he gave me a place tostay, so. I may not be clean without him – ‘cause then alot of people too, I know, would go to detox and getclean, and then come out and they don’t have a house,so they’re right back on the street with us, and it’s like,what are you going to do? Just sit there and not – every-one’s just like back in the same routine, right? Yeah, Iwas lucky I had my dad to go to.For Emily and a few other young people, having accessto social networks (e.g., family, friends) outside of thedrug scene was a critical factor in reducing their druguse, as well as finding housing and obtaining financialsupport. It should be noted, however, that for the vastmajority of participants these kinds of supports werenot an option – they did not feel that they couldappeal to family members for help (if they knew howto contact them at all), nor did they feel that theycould appeal to old friends and acquaintances fromoutside of the scene.DiscussionDespite expressing a desire and strong motivation to “getout”, almost all of the participants were unable to leave theinner-city drug scene for sustained periods of time. Amongthose who successfully transitioned their housing orincome-generation activities outside of the inner-city drugscene, as well as those who reduced their drug use, theirtransitions were usually partial and temporary. For ex-ample, while a small sub-set of our participants managed tomove home, stay with family or friends, reduce their druguse and/or find what they considered to be “legitimate”forms of employment, it became clear that many otherfacets of their daily lives remained firmly established and in-terconnected within Vancouver’s inner-city drug scene. Asa result, it was extremely difficult for young people to enactlong-term change without multiple forms of support acrossthe various facets of their lives that were entrenched in thescene, including their income-generation activities, socialnetworks and housing. For example, as youth sought outaddiction treatment services (e.g., methadone) to supportcessation or reduction of harmful forms of drug consump-tion, participants reported both administrative and financialbarriers to engaging with these services in ways that couldalso concurrently or successively facilitate the reduction oftheir involvement with other facets of the scene, includingsafe housing and employment or training opportunities thatexist outside of the scene.Some, but very few, managed to “get out and stay out”of the inner-city drug scene. Finding housing and/or em-ployment, and reducing problematic drug use via drugtreatment or other means were all critical moments inyouths’ exiting trajectories. For example, a small subset ofyouth managed to move away from the inner city, usuallyinto one of the suburbs of Greater Vancouver where hous-ing is more affordable. Nonetheless, as we learned abouthow their experiences with exiting the scene actually un-folded over time it became increasingly clear that theyfaced a synergistic set of barriers in their efforts to both“get out” of the scene and “get into” a new life free frominvolvement with the social and physical features associ-ated with the urban drug scene. For instance, as youthattempted to “get into” new lives out of the scene (e.g.,physically and socially), accessing housing, employment orother forms of assistance (e.g., income assistance, drugtreatment) were often complicated by a dearth of social(e.g., friends, family) or cultural (e.g., education, skills, ap-pearance) capital that could provide them with support innavigating highly complex bureaucratic health and socialservice systems that were situated in so-called “main-stream society”. For example, due to the limited exposurestreet-entrenched youth often have with so-called “main-stream society”, many are unable to identify what mightconstitute a “too-good-to-be-true” employment orincome-generation opportunity (e.g., scams).Knight et al. BMC Public Health  (2017) 17:376 Page 8 of 11These findings highlight the limitations of conven-tional social and health services available to supportyouth with reducing their involvement with Vancouver’sinner-city drug scene, despite expressing a strong desireand engaging in their best efforts to do so. In fact, veryfew youth reported engaging with support services inways that either helped them find housing or get a joboutside of the scene, or to reduce harmful forms of drugconsumption – and, none of the youth reported receiv-ing assistance that could provide holistic support (i.e.,support that addresses the interconnected facets of ayoung person’s involvement in the scene) in addressingtheir aims either concurrently or consecutively. Indeed,while some services are available to support youth withincome assistance or finding a job in Vancouver’s innercity, most of our participants were either entirely un-aware of the existing support services available to themin Vancouver’s inner city or expressed a strong reluc-tance to engaging with support due to a mistrust of “thesystem”. Almost all of our participants also insisted thesteps they needed to take to exit the scene needed to bedone on their own. As such, our findings align with pre-vious research examining young people’s experienceswith ‘moving out’ of homelessness [22] in which youngpeople attempting to exit the inner-city drug sceneexpressed favour towards ‘independent’ exits fromhomelessness (e.g., transition into private housing with-out the support of formal social services) over those thatwere characterized as ‘dependent’ exits (e.g., transitionalsteps towards exiting, including staying with family orfriends) from homelessness.Optimizing the best strategies for youth entrenched ininner-city drug scenes at the appropriate time in the lifecourse is integral to improving young people’s opportun-ities to exit the scene. Our findings underscore the needto enhance the provision of holistic programs and ser-vices that support youth entrenched in inner-city drugscenes while concurrently transitioning multiple and in-terconnected facets of their lives into a new routine andlife that is no longer firmly established within the inner-city scene. This approach to intervention requires a dy-namic process of information exchange, policy develop-ment, and program-planning activities that adapt andrespond to key transitional periods (e.g., contemplation),as well as critical moments in which young people areactively seeking out ways to transition out of the scene.There are examples of promising interventions in thisarea that may leverage opportunities to provide moreholistic and/or low-threshold services. For example, pro-viding support opportunities to combine and enhanceexisting approaches to acquiring income assistance, edu-cational and/or occupational and other life skills trainingopportunities and support (e.g., Street Health’s ID Safe –safe storage services of important ID for homeless orunder-housed people), ‘low threshold’ addiction treat-ment services (e.g., Vancouver’s Portland Hotel Society’sOnSite Detox & Transitional Housing Program), andsupportive housing outside of the scene (e.g.,Vancouver’s MPA Society’s programs and services thataim to offer residents full participation in society inneighbourhoods throughout Metro Vancouver) repre-sents promising opportunities to influence youths’ exit-ing trajectories. Moreover, in the Province of BC, newevidence-based regulatory policies and clinical reformsare opening up novel opportunities to address problem-atic substance use, including innovative pharmacothera-peutic approaches, new and revised clinical practiceguidelines, dedicated detox and treatment beds foryoung people, as well as the integration of addictionsmedicine and care into other areas of the health servicedelivery system (e.g., community-based care). For ex-ample, in response to the current fentanyl and opioidoverdose crisis in Vancouver, along with the growingbody of evidence supporting the effectiveness of Subox-one®, the Vancouver Coastal Health Authority (VCH) is-sued new clinical addiction treatment guidelines in 2015that make Suboxone® a recommended first-line pharma-cotherapy for opioid use disorder among young people.While our data do not have the capacity to distil the ex-tent to which these new and emerging ‘low-threshold’pharmacotherapies will influence young people’s exitingtrajectories over time, these policy changes may repre-sent a critical ‘next step’ for improving young people’sopportunities to access care and exit the scene.Significant challenges remain, however, as these find-ings also reveal youth’s affinity for exiting independently– i.e., accomplishing many of their transitions out of thescene on their own and without the support of formalservices. Indeed, these findings underscore the need forintervention planners to adapt approaches that can ac-count for these complexities, including multi-faceted“upstream” policy responses that reunite “harm reduc-tion” with direct adaptation of the larger systems ofpower and political economy that create harm, and tak-ing seriously the need for larger scale structural changethat prevent youth from “entering” urban drug scenes inthe first place [23–26]. Indeed, socially just approachesto reduce human suffering among young peopleentrenched in Vancouver’s urban drug scene will requireinter-sectoral approaches and sustained commitmentfrom a variety of stakeholders (e.g., political, publichealth, law enforcement).Strengths and limitationsThis study has several strengths and limitations. First,while the composition of our sample is meant to reflectthe diversity of experiences and backgrounds of youth in-volved within Vancouver’s urban drug scene, the youth inKnight et al. BMC Public Health  (2017) 17:376 Page 9 of 11our sample includes many of the ‘higher’ risk youthinvolved with Vancouver’s urban drug scene – particularly,a group of young people who are deeply entrenchedwithin Vancouver’s inner-city drug scene [13]. As such, weacknowledge that our sample is not representative of allyouth in the inner-city drug scene. Second, while many ofthese findings may have implications for youth living inurban drug scenes elsewhere, due to the unique social andspatial features of Vancouver’s urban drug scene (e.g.,features of the social service infrastructure, socio-legalcontext), there are some findings that may not begeneralizable elsewhere. Nevertheless, by drawing onlongitudinal ethnographic techniques, our study was ableto identify how young people plan to “exit” an urban drugscene, as well as how their “exiting” trajectories actuallyunfold over time.ConclusionWhile young people entrenched in Vancouver’s inner-citydrug scene express a strong desire to – often independently– exit the scene, they face a set of key challenges and bar-riers, including securing legitimate employment or training,distancing themselves (both physically and socially) fromthe urban drug scene, and reducing their drug consump-tion. Taken as a whole, these findings highlight a set ofsocial and structural barriers that impede young people’scapacity to meaningfully distance themselves fromVancouver’s urban drug scene, as well as the limitations ofconventional social and health services available to supportyouth to reduce their engagement with inner-city risk envi-ronments. Integrated policies and programing interventionsthat can facilitate young people’s efforts to prevent and/orreduce engagement with urban drug scenes are criticallyneeded, including a holistic and adaptive approach towardseducational and/or occupational training opportunities, ‘lowthreshold’ addiction treatment services, as well as access tosupportive housing outside of the scene.Endnotes1In British Columbia, youth who receive Disability 2assistance or meet the Persons with Persistent MultipleBarriers (PPMB) criteria are entitled to an additionalamount of approximately five and three hundred dollarsrespectively. Both support levels also provide individualswith an additional fixed monthly rent of CAD$375 forrooms in Single Room Occupancy Hotels or supportivehousing buildings which is deducted directly from socialassistance payments.AbbreviationsARYS: At-Risk Youth Study; ID: Identification; Meth: crystal methamphetamine;MMT: methadone maintenance treatment; SRO: single room occupancy hotelAcknowledgementsWe are thankful to the youth who took part in this study.FundingThis study was supported by the US National Institutes of Health (R01DA033147,R01DA028532, U01DA038886). RK and DF are supported by Post-DoctoralFellowships from CIHR and MSFHR. WS is supported by a Career Scholar Awardfrom MSFHR. KD is supported by a MSFHR / St. Paul’s Hospital Foundation–-Providence Health Care Career Scholar Award and a CIHR New Investigator Award.Availability of data and materialsAll relevant data are presented within the paper and are fully sufficient toreplicate the study findings.Authors’ contributionsDF conducted the ethnographic fieldwork and many of the interviews. RKdrafted the first version of the manuscript with subsequent contributionsfrom all co-authors. All authors read and approved the final manuscript.Competing interestsNone to declare.Consent for publicationNot applicable.Ethics approval and consent to participateAll participants provided informed consent, and the study was undertakenwith ethical approval granted by the Providence Healthcare/University ofBritish Columbia Research Ethics Board.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, Canada. 2British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 3School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver V6T 1Z3, Canada. 4Department of Medicine, University of BritishColumbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9, Canada.5School of Public Policy, Simon Fraser University at Harbour Centre, 515 WestHastings Street, Vancouver, BC V6B 5K3, Canada. 6British Columbia Centre onSubstance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’sHospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.Received: 25 October 2016 Accepted: 26 April 2017References1. 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Soc Sci Med.2005 Sep 30;61(5):1026–44.26. Rhodes T. The ‘risk environment’: a framework for understanding andreducing drug-related harm. International journal of drug policy. 2002 Jun30;13(2):85–94.•  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:Knight et al. BMC Public Health  (2017) 17:376 Page 11 of 11


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