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Hospitalization among street-involved youth who use illicit drugs in Vancouver, Canada: a longitudinal… Chang, Derek C; Rieb, Launette; Nosova, Ekaterina; Liu, Yang; Kerr, Thomas; DeBeck, Kora Mar 20, 2018

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RESEARCH Open AccessHospitalization among street-involvedyouth who use illicit drugs in Vancouver,Canada: a longitudinal analysisDerek C. Chang1,2, Launette Rieb1,2, Ekaterina Nosova1, Yang Liu1, Thomas Kerr1,3 and Kora DeBeck1,4*AbstractBackground: Street-involved youth who use illicit drugs are at high risk for health-related harms; however, theprofile of youth at greatest risk of hospitalization has not been well described. We sought to characterizehospitalization among street-involved youth who use illicit drugs and identify the most frequent medicalreasons for hospitalization among this population.Methods: From January 2005 to May 2016, data were collected from the At-Risk Youth Study (ARYS), a prospectivecohort study of street-involved youth in Vancouver, Canada. Multivariable generalized estimating equation (GEE) wasused to identify factors associated with hospitalization.Results: Among 1216 participants, 373 (30.7%) individuals reported hospitalization in the previous 6 months at somepoint during the study period. The top three reported medical reasons for hospital admission were the following:mental illness (37.77%), physical trauma (12.77%), and drug-related issues (12.59%). Factors significantly associated withhospitalization were the following: past diagnosis of a mental illness (adjusted odds ratio [AOR] = 1.85; 95% confidenceinterval [95% CI] 1.47–2.33), frequent cocaine use (AOR = 2.15; 95% CI 1.37–3.37), non-fatal overdose (AOR = 1.76; 95% CI1.37–2.25), and homelessness (AOR = 1.40; 95% CI 1.16–1.68) (all p < 0.05).Conclusions: Findings suggest that mental illness is a key driver of hospitalization among our sample. Comprehensiveapproaches to mental health and substance use in addition to stable housing offer promising opportunitiesto decrease hospitalization among this vulnerable population.Keywords: Youth, Hospitalization, Mental illness, Drug overdose, Homeless, CocaineBackgroundYouth who are street-involved, defined as being homelessor using services for homeless youth, experience excessmorbidity and mortality relative to the general populationof adolescents and young adults [1, 2]. Many health con-cerns have been identified among this population, includ-ing sexually transmitted infections, mental illnesses,intentional and unintentional injuries, and substance use[3, 4]. Several health issues are directly related to substanceuse, including overdoses, infections, and psychologicaldistresses [4]. The experience of homelessness and mentalillnesses, such as conduct disorders, anxiety disorders, andmood disorders, which are prevalent among homelessyouth, may also contribute to or exacerbate health issuesamong this population [5]. Despite multiple health vulner-abilities, numerous barriers to accessing care exist, includ-ing inadequate transportation, cost, fear of judgment, andlack of trust [6, 7]. Consequently, street-involved youth areoften reluctant to engage with health services andfrequently delay seeking help until their health problemsdeteriorate, which increases the risk of hospitalization[6, 8]. This tendency also contributes to the economicburden of delaying care among this population [4, 9].Hospitalization among adult homeless populations hasbeen well studied, while there is a paucity of similarresearch among homeless youth populations [10–12]. In* Correspondence: uhri-kd@cfenet.ubc.ca1British Columbia Centre on Substance Use, British Columbia Centre forExcellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada4School of Public Policy, SFU Harbour Centre, Simon Fraser University, 515West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Chang et al. Harm Reduction Journal  (2018) 15:14 https://doi.org/10.1186/s12954-018-0223-0the USA, it has been documented that acute medicalconditions (primarily infections), mental illness, sub-stance use, and injuries are the most common reasonsfor hospitalization among homeless youth [10]. To ourbest knowledge, no study has longitudinally examinedhospital admissions among street-involved youth whouse drugs in a Canadian setting with universal healthcare. In the context of growing concerns of homeless-ness and its related burdens, especially overdoses,among youth in North America [12], we sought to up-date the knowledge of the most common medicalreasons for hospital admission and characterizehospitalization among street-involved youth who usedrugs. We hope the findings can inform policy makersand healthcare workers to provide more effective inter-ventions to prevent more serious health conditions re-quiring hospitalization among this vulnerable populationand subsequently reduce the related economic burden.MethodsThe At-Risk Youth Study (ARYS) began in 2005 and is anongoing open prospective cohort study of street-involvedyouth in Vancouver, Canada. This study has beendescribed in detail previously [13]. In brief, snowball sam-pling and street-based outreach as well as self-referral areused to recruit participants into the study. Personsbetween 14 and 26 years of age who have used illicit drugsother than or in addition to cannabis in the past 30 daysand provide informed consent are eligible to participate.At baseline and semiannually thereafter, participantscomplete an interviewer-administered questionnaire. Thequestionnaire elicits sociodemographic data as well as in-formation regarding participants’ substance use and otherbehavioral and socioeconomic data such as housing andengagement with health and social services. All partici-pants receive a monetary stipend of $30 Canadian Dollarsafter each interview (in June 2016, the stipend amountwas increased to $40). The University of BritishColumbia/Providence Health Care Research Ethics Boardapproved the study.Data for this study was collected between January 2005and May 2016. The primary outcome was self-reportedhospitalization during the preceding 6 months. Specific-ally, participants were asked, “Have you been admitted tohospital in the last six months (yes vs. no)?” Participantswho responded affirmatively were then asked to reportthe reason for hospitalization. These descriptive data wereanalyzed and grouped to identify the most common rea-sons for hospitalization among this sample.To characterize hospitalization (which was self-reported and captured admissions to hospital), we con-sidered a range of variables potentially associated withhospitalization. These were all measured within the pre-ceding 6 months and included the following: anyinjection drug use, daily heroin use, daily non-medicalprescription opioid use, daily crystal methamphetamineuse, daily cocaine use, daily crack use, non-fatal over-doses, homelessness, living in the Downtown Eastside(DTES) neighborhood (Vancouver’s drug use epicenter),and incarceration (being in detention, prison, or jail).The following sociodemographic characteristics mea-sured at baseline were also considered: age, gender,ethnicity, self-identified as LGBT (lesbian, gay, bisexual,and transgender), and self-reported diagnosis of a mentalhealth illness. Covariates were selected based on reviewof the prior available literature [2, 3, 14].Since analyses of factors potentially associated withhospitalization included serial measures for each subject,we used generalized estimating equations (GEE) for bin-ary outcomes with logit link function for the analysis ofcorrelated data. These methods determine factors associ-ated with hospitalization throughout the greater than11-year follow-up period and provide standard errorsadjusted by multiple observations per person using anexchangeable correlation structure. Therefore, this ana-lysis considered data from every participant follow-upvisit. First, we used GEE bivariate analysis to determinefactors associated with hospitalization. To adjust forpotential confounding, all variables that were significantat p < 0.10 level in GEE bivariate analyses were consid-ered in a full model. Quasi-likelihood under the Inde-pendence model Criterion (QIC) statistic with abackward model selection procedure was used to screenall possible combinations of candidate variables andidentify the model with the best overall fit as indicatedby the lowest QIC value. Analyses were performed usingR version 3.2.4 (R Core Team (2016). R: A language andenvironment for statistical computing. R Foundation forStatistical Computing, Vienna, Austria). All p valueswere two-sided, and tests were considered significant atp < 0.05.ResultsOverall, 1216 individuals completed follow-up visitsincluding 380 (31%) female and 819 (67%) Caucasianyouth. The median age of participants at baseline was22 years (interquartile range [IQR] = 20–24). Participantscontributed 4956 observations during the study period.The median number of follow-up visits was 3 (IQR = 1–5),and the median number of months between study follow-up was 6 (IQR = 6–8). Participants who did not return for asubsequent follow-up visit after baseline were significantlyless likely to identify as LGBTQ and significantly morelikely to be HCV positive (both p <0.05), though no othersignificant differences were observed between the twogroups. Among our sample, 373 individuals (30.7%) re-ported being hospitalized at some point during the studyperiod. Over the study period, these 373 participantsChang et al. Harm Reduction Journal  (2018) 15:14 Page 2 of 6contributed a total of 564 (11.4%) study observations thatincluded a report of hospitalization. At baseline, 900 partic-ipants (74%) reported being homeless. At the most recentstudy visit during the study period, 111 of 272 participants(41%) reported being homeless (55% of the hospitalizedgroup and 45% of those who reported no hospitalizationduring the study period).Table 1 presents sociodemographic characteristics, druguse and socioeconomic factors at baseline, comparingthose who did and did not report hospitalization duringfollow-up. Table 2 displays unadjusted and adjusted oddsratios for hospitalization and variables of interest. The ad-justed multivariate model demonstrates that the youthwho had a past diagnosis of a mental illness (AOR, 1.85;95% CI, 1.47–2.33), used cocaine daily (AOR, 2.15; 95%CI, 1.37–3.37), experienced a non-fatal overdose (AOR,1.76; 95% CI, 1.37–2.25), or were homeless (AOR, 1.40;95% CI, 1.16–1.68) were significantly more likely to reportrecent hospitalization within the previous 6 months.Table 3 displays the top medical reasons forhospitalization. Mental illness (37.77%) was the mostcommon medical condition followed by physical trauma(12.77%) and drug-related conditions (12.59%).DiscussionBased on this prospective cohort of street-involvedyouth who use drugs, homelessness, past diagnosis of amental illness, frequent cocaine use, and non-fatal over-dose were significantly associated with hospitalization.Among the medical reasons for hospital admission,mental illnesses, physical trauma, and drug-related con-ditions were the most common reasons.Our finding that homelessness was significantly associ-ated with youth hospitalization is consistent with previ-ous literature indicating that homelessness and unstablehousing not only increase hospital use but also increasethe length of hospital stay [9, 14]. Conversely, the longertheir stay in the hospital, the more likely the youth couldlose their housing. Our results build on a significantbody of research highlighting the essential role of stablehousing in supporting the health and well-being ofvulnerable populations. Evidence also suggests that therelationship between mental illness and homelessnesscan be multidirectional. Homelessness is known to dir-ectly undermine mental health [15], and mental illnesscan directly contribute to becoming homeless [15].Regardless of the direction of the relationship, a multi-site randomized controlled study demonstrates that a“housing first” approach (combined with assertive com-munity treatment or intensive case management) im-proves housing stability among homeless youth withmental illnesses [16].Our study also shows that a history of mental illnesswas significantly associated with hospitalization amongstreet-involved youth, and mental illness was the numberone reason for hospital admission. While this correlationhas been established among adult homeless populations, ithas been less clear among homeless youth [17]. Previousliterature demonstrates that the prevalence of psychiatricdisorders is high (88%) among homeless youth, but onlyTable 1 Baseline characteristics (reported at time of study enrolment) of street-involved youth who report hospitalization duringstudy follow-up: At Risk Youth Study (ARYS), Vancouver, British Columbia, 2005–2016 (n = 1216)Characteristic HospitalizedYes (%) (n = 151) No (%) (n = 1065) p valueMedian age, years (IQR) 22 (20–23) 22 (20–24) 0.354Female gender 54 (35.8) 326 (30.6) 0.201Caucasian ethnicity 102 (67.5) 717 (67.3) 0.993Identified as LGBT 120 (79.5) 872 (81.9) 0.301Mental illness history 91 (60.3) 542 (50.9) 0.031*Any injection drug use‡ 54 (35.8) 348 (32.7) 0.460Daily heroin use‡ 24 (15.9) 112 (10.5) 0.046*Daily prescription opioid use‡ 6 (4.0) 36 (3.4) 0.694Daily crystal meth use‡ 25 (16.6) 137 (12.9) 0.223Daily cocaine use‡ 8 (5.3) 29 (2.7) 0.080Daily crack use‡ 29 (19.2) 157 (14.7) 0.166Non-fatal overdose‡ 31 (20.5) 139 (13.1) 0.015*Homeless‡ 122 (80.8) 778 (73.1) 0.052Living in the DTES‡ 48 (31.8) 303 (28.5) 0.397Incarcerated‡ 27 (17.9) 190 (17.8) 0.974*p < 0.05‡During the preceding 6 monthsChang et al. Harm Reduction Journal  (2018) 15:14 Page 3 of 631% had accessed any form of mental health services,including in community clinics, emergency rooms, oraddiction treatment [18]. Our findings therefore point tothe importance of improving access to mental health ser-vices in the community among street-involved youth.Substance use-related issues, specifically frequentcocaine use and non-fatal overdoses, were also associ-ated with youth hospitalization among our sample. Evi-dence has shown that illicit substance use is associatedwith increased risk of hospitalization [19]. Our studycontributes to the knowledge that cocaine in particularis associated with increased risk of hospitalization. Previ-ous literature also highlights other risks associated withstimulant use among homeless youth, particularly riskysexual behaviors and incarceration [20]. Given theseharms, it is particularly concerning that evidence-basedtreatment options for stimulant use disorder are limited;innovation in this area is needed.Moreover, non-fatal overdose was independently asso-ciated with hospitalization among street-involved youth.Drug-related overdoses continue to increase amongyoung adults and adolescents who use drugs, and opioidoverdoses have risen at an alarming rate in recent yearsin Vancouver [21–23]. Extensive morbidity is also associ-ated with non-fatal overdoses, including physical injury,falling, or personal assaults [24]. Overdose preventionand harm reduction programs, such as peer-based edu-cation and naloxone training, as well as expanding treat-ment options, can be expected to help decrease youthhospitalization [25, 26].In our study among street-involved youth engaged inillicit substance use, over 50% reported a history of men-tal illness at baseline indicating that the prevalence ofdual diagnosis among our sample is high. This is consist-ent with the literature that reports the prevalence of dualdiagnosis between 35 and 76% among homeless youth[4]. A recent study also found that precariously housedyouth were 48% more likely to be diagnosed with dualdiagnosis [27]. Given the prevalence of youth with dualdiagnosis, it is essential to integrate interventions suchas systematic screening for dual diagnosis and buildingmental health and addiction training into youth-servingorganizations [27]. Early diagnosis can also increase thelikelihood that youth will access care before the condi-tion progresses further and requires hospitalization.When trying to access healthcare, youth are known toface several barriers including financial (lack of freetransportation or health insurance), structure (unable toobtain birth certificate or ID), and personal (lack ofknowledge or fear of judgment from healthcare profes-sionals) [4, 6, 7]. Thus, it is critical to ensure that youthdo not face restrictive barriers when trying to access ser-vices, so youth can access early interventions to preventeventual hospitalizations.Table 2 Bivariable and multivariable GEE analyses of factorsassociated with hospitalization among street-involved youth:At-Risk Youth Study (ARYS), Vancouver, British Columbia, 2005–2016 (n = 1216)Characteristic Unadjusted OR(95% CI)Adjusted OR(95% CI)†p valueAge (per year older) 1.00(0.97–1.02)Female gender 0.90(0.72–1.13)Caucasian ethnicity 1.11(0.88–1.40)Identified as LGBT 0.89(0.68–1.18)Mental illness history 1.87(1.50–2.35)1.85 (1.47–2.33) < 0.001*Any injection drug use‡ 1.29(1.05–1.57)Daily heroin use‡ 1.11(0.87–1.41)Daily prescription opioiduse‡1.46(0.88–2.42)Daily crystal meth use‡ 1.13 (0.88–1.45)Daily cocaine use‡ 2.36(1.50–3.70)2.15 (1.37–3.37) 0.001*Daily crack use‡ 1.13(0.84–1.50)Non-fatal overdose‡ 1.98(1.55–2.51)1.76 (1.37–2.25) < 0.001*Homeless‡ 1.41(1.18–1.68)1.40 (1.16–1.68) < 0.001*Living in the DTES‡ 1.11(0.90–1.36)Incarceration‡ 1.11(0.87–1.43)*p < 0.05†Variables significant at p < 0.10 in bivariate models were eligible for possibleinclusion in the multivariable model; variables included in the finalmultivariable model were identified using a backward selection approach tominimize the Quasi-likelihood under the Independent model Criterion (QIC)‡During the preceding 6 monthsTable 3 Top five medical reasons for hospitalization amongstreet-involved youth: At-Risk Youth Study (ARYS), Vancouver,British Columbia, 2005–2016 (n=373 participants who contributed564 study observations)Medical condition N (%)Mental illness 213 (37.77)Physical trauma 72 (12.77)Drug related 71 (12.59)Infection related 48 (8.51)Pregnancy related 35 (6.21)Based on total number of reports of hospitalization, not number of participantsChang et al. Harm Reduction Journal  (2018) 15:14 Page 4 of 6There are several limitations to this study. First, theARYS cohort is not a random sample. Therefore, studyfindings may not generalize to other populations. Sec-ond, the results are based on self-reported data, whichmay be affected by recall bias and socially desirableresponding. Also, they may not accurately reflect themedical reasons for hospitalization. Third, as with allobservation studies, the independent associations thatwe found could have been influenced by other con-founding variables.ConclusionsOur study suggests that mental illnesses were a key driverof hospitalization among street-involved youth. Frequentcocaine use, non-fatal drug overdose, and homelessnesswere also significantly associated with hospitalization.Based on these findings, promising opportunities to pre-vent hospitalization may include ensuring stable housingin line with the “housing first” approach, increasing accessto youth-friendly mental health and addiction treatmentservices, providing overdose prevention education andharm reduction measures, and improving early identifica-tion of dual diagnosis and access to care.AcknowledgementsThe authors thank the study participants for their contribution to the research,as well as the current and past researchers and staff. We would specifically liketo thank Evan Wood, Carly Hoy, Jennifer Matthews, Deborah Graham, PeterVann, Steve Kain, Tricia Collingham, Marina Abramishvili, and Ana Prado for theirresearch and administrative assistance. We would also like to acknowledge ourfunding agencies, including Canadian Institutes of Health Research, MichaelSmith Foundation for Health Research, St. Paul’s-Providence Health Care, andUS National Institutes of Health.FundingThe study was supported by the US National Institutes of Health (U01DA038886)and the Canadian Institutes of Health Research (MOP–102742). Dr. Chang issupported by the Canadian Addiction Medicine Research Fellowship funded bythe US National Institutes of Health (R25DA037756). Dr. DeBeck is supported by aMSFHR/St. Paul’s Hospital Foundation – Providence Health Care Career ScholarAward and a Canadian Institutes of Health Research New Investigator Award.Availability of data and materialsThe datasets used and/or analyzed during the current study are availablefrom the corresponding author on a reasonable request.Authors’ contributionsDC, TK, and KD designed the study. DC conducted the literature review andwrote the first draft of the manuscript. DC and KD revised the subsequentdrafts of the manuscript with consultations from LR and TK. EN and YLundertook the data management and statistical analyses. All authors readand approved the final manuscript.Ethics approval and consent to participateThe University of British Columbia/Providence Health Care Research EthicsBoard approved the study, and consent to participate was obtained fromeach participant.Consent for publicationNot applicableCompeting interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1British Columbia Centre on Substance Use, British Columbia Centre forExcellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada. 2Department of Family Practice, St. Paul’sHospital, University of British Columbia, 608-1081 Burrard Street, Vancouver,BC V6Z 1Y6, Canada. 3Department of Medicine, St. Paul’s Hospital, Universityof British Columbia, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.4School of Public Policy, SFU Harbour Centre, Simon Fraser University, 515West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3, Canada.Received: 19 January 2018 Accepted: 13 March 2018References1. Boivin JF, Roy E, Haley N, Galbaud du Fort G. The health of street youth: aCanadian perspective. Can J Public Health. 2005;96:432–7.2. Small W, Fast D, Krusi A, Wood E, Kerr T. Social influences upon injectioninitiation among street-involved youth in Vancouver, Canada: a qualitativestudy. Subst Abuse Treat Prev Policy. 2009;4:8.3. Marshall BD, Grafstein E, Buxton JA, Qi J, Wood E, Shoveller JA, Kerr T.Frequent methamphetamine injection predicts emergency departmentutilization among street-involved youth. Public Health. 2012;126:47–53.4. Edidin JP, Ganim Z, Hunter SJ, Karnik NS. The mental and physicalhealth of homeless youth: a literature review. Child Psychiatry HumDev. 2012;43:354–75.5. Slesnick N, Prestopnik J. Dual and multiple diagnosis among substanceusing runaway youth. Am J Drug Alcohol Abuse. 2005;31:179–201.6. Chelvakumar G, Ford N, Kapa HM, Lange HLH, McRee AL, Bonny AE.Healthcare barriers and utilization among adolescents and young adultsaccessing services for homeless and runaway youth. J Community Health.2017;42:437–43.7. Ensign J, Bell M. Illness experiences of homeless youth. Qual Health Res.2004;14:1239–54.8. Ensign J, Gittelsohn J. Health and access to care: perspectives of homelessyouth in Baltimore City, U.S.A. Soc Sci Med. 1998;47:2087–99.9. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associatedwith homelessness in New York City. N Engl J Med. 1998;338:1734–40.10. Mackelprang JL, Qiu Q, Rivara FP. Predictors of emergency department visitsand inpatient admissions among homeless and unstably housedadolescents and young adults. Med Care. 2015;53:1010–7.11. Medlow S, Klineberg E, Steinbeck K. The health diagnoses of homelessadolescents: a systematic review of the literature. J Adolesc. 2014;37:531–42.12. Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions toimprove the health of the homeless: a systematic review. Am J Prev Med.2005;29:311–9.13. Wood E, Stoltz JA, Montaner JS, Kerr T. Evaluating methamphetamine useand risks of injection initiation among street youth: the ARYS study. HarmReduct J. 2006;3:18.14. Palepu A, Strathdee SA, Hogg RS, Anis AH, Rae S, Cornelisse PG, Patrick DM,O'Shaughnessy MV, Schechter MT. The social determinants of emergencydepartment and hospital use by injection drug users in Canada. J UrbanHealth. 1999;76:409–18.15. Hodgson KJ, Shelton KH, van den Bree MB, Los FJ. Psychopathology inyoung people experiencing homelessness: a systematic review. Am J PublicHealth. 2013;103:e24–37.16. Kozloff N, Adair CE, Lazgare LI, Poremski D, Cheung AH, Sandu R,Stergiopoulos V. “Housing first” for homeless youth with mental illness.Pediatrics. 2016;138(4):e20161514.17. Cheung A, Somers JM, Moniruzzaman A, Patterson M, Frankish CJ, Krausz M,Palepu A. Emergency department use and hospitalizations among homelessadults with substance dependence and mental disorders. Addict Sci ClinPract. 2015;10:17.18. Hodgson KJ, Shelton KH, van den Bree MB. Mental health problems in youngpeople with experiences of homelessness and the relationship with healthservice use: a follow-up study. Evid Based Ment Health. 2014;17:76–80.Chang et al. Harm Reduction Journal  (2018) 15:14 Page 5 of 619. Gryczynski J, Schwartz RP, O'Grady KE, Restivo L, Mitchell SG, Jaffe JH.Understanding patterns of high-cost health care use across differentsubstance user groups. Health Aff (Millwood). 2016;35:12–9.20. Nyamathi A, Hudson A, Greengold B, Leake B. Characteristics of homelessyouth who use cocaine and methamphetamine. Am J Addict. 2012;21:243–9.21. Riley ED, Evans JL, Hahn JA, Briceno A, Davidson PJ, Lum PJ, Page K. Alongitudinal study of multiple drug use and overdose among youngpeople who inject drugs. Am J Public Health. 2016;106:915–7.22. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involvedoverdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep.2016;65:1445–52.23. British Columbia Coroners Service. Illicit drug overdose deaths in BC, January 1,2007-March 31, 2017. Vancouver: British Columbia Coroners Service; 2017.http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf. Accessed 4 May 2017.24. Warner-Smith M, Darke S, Day C. Morbidity associated with non-fatal heroinoverdose. Addiction. 2002;97:963–7.25. Marshall BD, Green TC, Yedinak JL, Hadland SE. Harm reduction for youngpeople who use prescription opioids extra-medically: obstacles andopportunities. Int J Drug Policy. 2016;31:25–31.26. Mancini MA, Linhorst DM. Harm reduction in community mental healthsettings. J Soc Work Disabil Rehabil. 2010;9:130–47.27. Smith T, Hawke L, Chaim G, Henderson J. Housing instability and concurrentsubstance use and mental health concerns: an examination of Canadianyouth. J Can Acad Child Adolesc Psychiatry. 2017;26:214–23.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Chang et al. Harm Reduction Journal  (2018) 15:14 Page 6 of 6


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