This study found a significantly increased risk of ED utilization among street-involved youth who reported frequent MA injection. Within 1 year of enrolment into the ARYS cohort, the cumulative incidence of ED utilization among frequent MA injectors was approximately 70%, compared with only 35% among occasional MA injectors and non-MA injectors. Furthermore, in a confirmatory subanalysis, a dose–response relationship was found to exist between the mean number of annual ED visits and the frequency of MA injection. The most common ED presentations among frequent users of MA were those related to substance dependence, misuse or overdose, followed by psychiatric disorder diagnoses. These findings support recent research indicating that substance-related conditions, including those related to MA use, are significant contributors of ED utilization in North America, and that acute injuries, overdose and psychiatric problems are the most common presentations among substance users.18,19
This study may inform public health interventions that more effectively reduce the negative health consequences of frequent MA use, and improve access to appropriate health services for street-involved youth who require care.
The finding that frequent MA injectors are more likely to visit the ED for substance-related disorders has important implications for interventions that seek to improve the health of this population. The utilization of emergent care for substance dependence and misuse may indicate that youth are unable to access other forms of treatment modalities; an absence of treatment programmes for MA-dependent youth has been observed previously in the study setting.20
A scale-up of residential and outpatient programmes that meet the needs of this patient population is urgently required. While some studies have demonstrated that mechanisms which formally link addiction treatment services with direct access to primary medical care are effective in some emergency settings,21
to the authors’ knowledge, no studies have evaluated similar programmes for MA-using youth. Although integrated service models may be as effective for young people as for adults, providers must address multiple barriers that street-involved youth experience while attempting to access traditional health services. These include, but are not limited to, confusion over issues regarding confidentiality and consent, transportation problems, and lack of respect and perceived judgmentalism from service providers.6,22
Further examples of structural barriers include services that are perceived as being too rigid (e.g. by appointment only), inflexible (e.g. require ID) or inaccessible (i.e. inconvenient hours of operation).23
The finding that 11% of visits resulted in discharge without service suggests a need to enhance the capacity of the ED to provide prompt, accessible and low-barrier health services for this population.
Although the long-term health and social consequences of chronic MA use among adult populations have been well described,24,25
there is little evidence to inform effective interventions to address health issues experienced by MA-using youth.26
The results of this study suggest that street-involved youth who inject MA, particularly those who do so frequently, may require a comprehensive set of interventions to address and reduce MA-related comorbidities. While behavioural counselling remains the standard of practice in treating MA dependence, few have been evaluated rigorously and their effectiveness in younger populations remains to be fully determined.27
Peer educator interventions that seek to reduce MA use among youth and their social and drug-using networks have shown some success, particularly for young people who are disenfranchised, homeless or disconnected from the school system.28,29
Finally, environmental–structural interventions, including the provision of low threshold supportive housing services and reforms to punitive enforcement practices that adversely impact street youths’ access to health and social services, are thought to have potential to reduce underlying vulnerability to the harmful effects of substance use and thus are in need of evaluation.30
In the USA, lack of insurance has been found to be a primary barrier experienced by street youth who attempt to access care.22
Although health care in Canada is publicly funded and thus all patients have universal access to hospital and primary care services, disparities in health service utilization, particularly among the most disadvantaged, continue to exist.31
This study characterized the ED utilization patterns of a population of youth who are among the most marginalized, and thus probably experience some of the greatest disparities in access to care. While clinics and services designed specifically for street-involved young people may help to reduce health inequities and over-reliance on acute services, some studies have shown that many programmes are heavily underutilized by youth in greatest need of care.6
For these reasons, interventions that aim to reduce MA-related harms and connect MA-using street youth with appropriate primary care should seek not only to provide youth-friendly services but also commit to the meaningful engagement of young people in the development, implementation and evaluation of these programmes. Furthermore, the vast majority of ED visits were found to occur outside of standard clinic operating hours. This finding suggests that expanding the range of services for young patients presenting with substance use problems within the ED setting may be more cost-effective, and address this population’s health concerns more appropriately than the provision of additional youth-friendly ambulatory clinics.
This study has several limitations. Firstly, ED utilization was probably underestimated as participants may have received care at other settings not evaluated in this analysis. Secondly, although there is no reason to believe that individuals receiving care at other hospitals would differ with respect to MA use from those who accessed the ED under study, it is possible that the SPH ED may be preferred by certain types of patients and for certain types of health complaints. Therefore, the diagnoses observed in this study are probably not representative of the true disease burden in the population. Thirdly, the authors were unable to determine the number of participants who moved outside of Vancouver after enrolment. Fourthly, although ED utilization was determined with certainty through a confidential linkage to ED records, all other variables were self-reported. Fifthly, the authors were unable to determine what proportion of ED visits observed in this sample were suitable uses of emergent care, or whether the health concern may have been more appropriately treated in a primary care setting. For example, the authors were unable to disaggregate ‘psychiatric disorders’ into acute psychotic episodes and those related to chronic conditions. Finally, the small sample size (particularly with regard to the subgroups of occasional and frequent MA injectors) may have limited the study’s power to detect significant associations. The small sample size and relatively short follow-up period also explains why no HIV seroconversions or deaths were observed among study participants when other studies have demonstrated a high incidence of both outcomes in street youth populations.32,33
In summary, street-involved youth who report frequent injection of MA were found to be at an increased risk of ED utilization. Effective interventions to reduce the adverse health consequences of MA use and improve access to subacute and ambulatory settings will require not only the integration of services to address underlying health concerns experienced by this population, but also the meaningful engagement of youth to lessen barriers to care.