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UBC Theses and Dissertations

Socioeconomic marginalization and overdose : implications for upstream approaches for overdose prevention during a prolonged public health emergency Mitra, Sanjana


Background: Canada and the United States are in the midst of an escalating overdose crisis. While poverty and socioeconomic disadvantage are increasingly recognized as important contributors to drug-related harm, their precise role in overdose remains understudied. This dissertation sought to: synthesize evidence regarding the pathways and mechanisms linking socioeconomic elements to overdose outcomes; examine the relationship between a comprehensive range of socioeconomic indicators and non-fatal overdose; identify and characterize gender-stratified profiles of socioeconomic exposures in men and women who use drugs; and, finally, determine whether these gender-stratified profiles predict non-fatal overdose. Methods: Data from Chapter 2 came from a realist review of research published between 2004 and 2019. Data for Chapters 3-5 cover the time period between 2014 and 2018 and are from two community-recruited prospective cohort studies of people who use drugs (PWUD) in Vancouver, Canada. A range of longitudinal analytic techniques were used, including: generalized linear mixed-effect models, repeated measures latent class analyses, and generalized estimating equations. Results: Findings from the realist review identified eight overlapping socioeconomic dimensions with documented linkages to overdose outcomes through material, normative, and bio-psychosocial pathways. In Chapter 3, across the total sample of PWUD from Vancouver, homelessness, lower material security, and participation in informal and illegal income generating activities were independently and positively associated with non-fatal overdose. In Chapter 4, gender-stratified analyses revealed that men and women experienced mutually reinforcing and overlapping socioeconomic exposures characterized by variations in income, material and housing security, participation in informal or illegal income generation, criminal justice involvement, and police contact. Gendered profiles of increasing socioeconomic disadvantage aligned with high-intensity drug use patterns (e.g., opioids and stimulants) and a range of health-related outcomes (e.g., HCV). In Chapter 5, exposure to multiple increasing dimensions of socioeconomic disadvantage was found to be independently associated with greater likelihood of experiencing non-fatal overdose in both men and women. Conclusions: Socioeconomic determinants are key drivers of overdose risk. To address the socioeconomic production of overdose risk, findings point to the urgent need to expand upstream and multilevel programs and policies, including inclusive, gender-informed health and social welfare programming, and broader drug policy reform.

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