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1.  Harmful microinjecting practices among a cohort of injection drug users in Vancouver Canada 
Substance use & misuse  2010;45(9):1351-1366.
Objectives
We sought to identify factors associated with harmful microinjecting practices in a longitudinal cohort of IDU.
Methods
Using data from the Vancouver Injection Drug Users Study (VIDUS) between January 2004 and December 2005, generalized estimating equations (GEE) logistic regression was performed to examine sociodemographic and behavioral factors associated with four harmful microinjecting practices (frequent rushed injecting, frequent syringe borrowing, frequently injecting with a used water capsule, frequently injecting alone).
Results
In total, 620 participants were included in the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The median age was 31.9 (interquartile range: 23.4–39.3). GEE analyses found that each harmful microinjecting practice was associated with a unique profile of sociodemographic and behavioral factors.
Discussion
We observed high rates of harmful microinjecting practices among IDU. The present study describes the epidemiology of harmful microinjecting practices and points to the need for strategies that target higher risk individuals including the use of peer-driven programs and drug-specific approaches in an effort to promote safer injecting practices.
doi:10.3109/10826081003767643
PMCID: PMC3782079  PMID: 20509739
injection drug use; harmful; Vancouver; microinjecting practices
2.  Incarceration and drug use patterns among a cohort of injection drug users 
Addiction (Abingdon, England)  2009;104(1):69-76.
Aims
Drug law enforcement remains the dominant response to drug-related harm. However, the impact of incarceration on deterring drug use remains under-evaluated. We sought to explore the relationship between incarceration and patterns of drug use among people who inject drugs (IDU).
Design
Using generalized estimating equations (GEE), we examined the prevalence and correlates of injection cessation among participants in the Vancouver Injection Drug User Study followed over 9 years. In subanalyses, we used McNemar's tests and linear growth curve analyses to assess changes in drug use patterns before and after a period of incarceration among participants reporting incarceration and those not incarcerated.
Findings
Among 1603 IDU, 842 (53%) reported injection cessation for at least 6 months at some point during follow-up. In multivariate GEE analyses, recent incarceration was associated negatively with injection cessation [adjusted odds ratio (AOR) = 0.43, 95% confidence interval (CI) 0.37–0.50], whereas the use of methadone was associated positively with cessation (AOR = 1.38, 95% CI 1.22–1.56). In subanalyses assessing longitudinal patterns of drug use among incarcerated individuals and those not incarcerated over the study period, linear growth curve analyses indicated that there were no statistically significant differences in patterns of drug use between the two groups (all P > 0.05).
Conclusions
These observational data suggest that incarceration does not reduce drug use among IDU. Incarceration may inhibit access to mechanisms that promote injection cessation among IDU. In contrast, results indicate that methadone use is associated positively with injection cessation, independent of previous frequency of drug use.
doi:10.1111/j.1360-0443.2008.02387.x
PMCID: PMC3731940  PMID: 19133890
Addiction treatment; deterrence; drug law enforcement; drug policy; drug use patterns; incarceration; injection cessation; injection drug use
3.  The Burnaby treatment center for mental health and addiction, a novel integrated treatment program for patients with addiction and concurrent disorders: results from a program evaluation 
Background
Patients with addictions and concurrent disorders constitute the most underserved population in the system of care. There are numerous reasons why this population has so much difficulty accessing services, including behavioural issues, criminal engagement, and non-compliance with outpatient services. To improve services to this population which is marked by multiple morbidities, high mortality and insufficient access to health care, the government of British Columbia, Canada developed a program for people with both substance use disorder and one or more mental disorders who have not benefited from previous therapies.
Method
In July 2008, the Burnaby Treatment Centre for Mental Health and Addiction (BCMHA), a specialized and integrated tertiary care facility, was opened. The current article provides a description of the treatment program and a clinical profile of the population.
Results
The target population is being served, at intake clients present with high rates of psychopathology, childhood and adult trauma, and substance use.
Conclusion
While preliminary, these results indicate, that the novel approach of the Burnaby Centre may constitute a new path towards providing effective recovery for this population.
doi:10.1186/1472-6963-13-288
PMCID: PMC3733750  PMID: 23895592
Concurrent disorders; Integrated treatment; Marginalized populations
4.  Global landscape of HIV–human protein complexes 
Nature  2011;481(7381):365-370.
Human immunodeficiency virus (HIV) has a small genome and therefore relies heavily on the host cellular machinery to replicate. Identifying which host proteins and complexes come into physical contact with the viral proteins is crucial for a comprehensive understanding of how HIV rewires the host’s cellular machinery during the course of infection. Here we report the use of affinity tagging and purification mass spectrometry1-3 to determine systematically the physical interactions of all 18 HIV-1 proteins and polyproteins with host proteins in two different human cell lines (HEK293 and Jurkat). Using a quantitative scoring system that we call MiST, we identified with high confidence 497 HIV–human protein–protein interactions involving 435 individual human proteins, with ~40% of the interactions being identified in both cell types. We found that the host proteins hijacked by HIV, especially those found interacting in both cell types, are highly conserved across primates. We uncovered a number of host complexes targeted by viral proteins, including the finding that HIV protease cleaves eIF3d, a subunit of eukaryotic translation initiation factor 3. This host protein is one of eleven identified in this analysis that act to inhibit HIV replication. This data set facilitates a more comprehensive and detailed understanding of how the host machinery is manipulated during the course of HIV infection.
doi:10.1038/nature10719
PMCID: PMC3310911  PMID: 22190034
5.  Proteomics Analysis Reveals Post-Translational Mechanisms for Cold-Induced Metabolic Changes in Arabidopsis 
Molecular Plant  2011;4(2):361-374.
Cold-induced changes of gene expression and metabolism are critical for plants to survive freezing. Largely by changing gene expression, exposure to a period of non-freezing low temperatures increases plant tolerance to freezing—a phenomenon known as cold acclimation. Cold also induces rapid metabolic changes, which provide instant protection before temperature drops below freezing point. The molecular mechanisms for such rapid metabolic responses to cold remain largely unknown. Here, we use two-dimensional difference gel electrophoresis (2-D DIGE) analysis of sub-cellular fractions of Arabidopsis thaliana proteome coupled with spot identification by tandem mass spectrometry to identify early cold-responsive proteins in Arabidopsis. These proteins include four enzymes involved in starch degradation, three HSP100 proteins, several proteins in the tricarboxylic acid cycle, and sucrose metabolism. Upon cold treatment, the Disproportionating Enzyme 2 (DPE2), a cytosolic transglucosidase metabolizing maltose to glucose, increased rapidly in the centrifugation pellet fraction and decreased in the soluble fraction. Consistent with cold-induced inactivation of DPE2 enzymatic activity, the dpe2 mutant showed increased freezing tolerance without affecting the C-repeat binding transcription factor (CBF) transcriptional pathway. These results support a model that cold-induced inactivation of DPE2 leads to rapid accumulation of maltose, which is a cold-induced compatible solute that protects cells from freezing damage. This study provides evidence for a key role of rapid post-translational regulation of carbohydrate metabolic enzymes in plant protection against sudden temperature drop.
doi:10.1093/mp/ssq078
PMCID: PMC3063518  PMID: 21242321
2-D DIGE; Arabidopsis; Cold response; freezing tolerance; heat shock protein; starch metabolism
6.  Access to Drug and Alcohol Treatment among a Cohort of Street-Involved Youth 
Drug and alcohol dependence  2008;101(1-2):1-7.
Background
A number of options for treatment are available to young drug users, but little is known about the youth who actually attempt to access such services. Here we identify characteristics of a cohort of street-involved youth and highlight commonly encountered barriers.
Methods
From September 2005 to July 2007, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of 529 drug users aged 14–26 living in Vancouver, Canada. Participants who attempted to access any addiction services in the six months prior to enrollment were compared in univariate analyses and multiple logistic regression modeling of sociodemographic and drug-related factors.
Results
Factors positively associated with attempting to access services included Aboriginal ethnicity (adjusted odds ratio [AOR] = 1.66 [1.05 – 2.62]), high school education (AOR = 1.66 [1.09 – 2.55]), mental illness (AOR = 2.25 [1.50 – 3.38]), non-injection crack use (AOR = 2.93 [1.76 – 4.89]), and spending >$50 on drugs per day (AOR = 2.13 [1.41 – 3.22]). Among those who experienced difficulty accessing services, the most commonly identified barrier was excessively long waiting lists. In a subgroup analysis comparing those who tried to access services but were unsuccessful to those who were successful, risk factors positively associated with failure included drug bingeing (odds ratio [OR] = 2.86 [1.22 – 6.76]) and homelessness (OR = 3.86 [1.11 – 13.4]).
Conclusions
In light of accumulating evidence that drug use among street youth is associated with risky health-related behaviors, improving access to treatment and other addiction services should remain an important public health priority.
doi:10.1016/j.drugalcdep.2008.10.012
PMCID: PMC2667152  PMID: 19081203
youth; street youth; adolescents; access; addiction services; methadone maintenance; drug treatment; alcohol treatment; detoxification; Aboriginal
7.  Assisted injection in outdoor venues: an observational study of risks and implications for service delivery and harm reduction programming 
Background
Assisted injection and public injection have both been associated with a variety of individual harms including an increased risk of HIV infection. As a means of informing local IDU-driven interventions that target or seek to address assisted injection, we examined the correlates of receiving assistance with injecting in outdoor settings among a cohort of persons who inject drugs (IDU).
Methods
Using data from the Vancouver Injection Drug Users Study (VIDUS), an observational cohort study of IDU, generalized estimating equations (GEE) were performed to examine socio-demographic and behavioural factors associated with reports of receiving assistance with injecting in outdoor settings.
Results
From January 2004 to December 2005, a total of 620 participants were eligible for the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The proportion of participants who reported assisted injection outdoors ranged over time between 8% and 15%. Assisted injection outdoors was independently and positively associated with being female (Adjusted Odds Ratio (AOR) = 1.74, 95% Confidence Intervals (CI): 1.21-2.50), daily cocaine injection (AOR = 1.70, 95% CI: 1.29-2.24), and sex trade involvement (AOR = 1.44, 95% CI: 1.00-2.06) and was negatively associated with Aboriginal ethnicity (AOR = 0.58, 95% CI: 0.41-0.82).
Conclusions
Our findings indicate that a substantial proportion of local IDU engage in assisted injecting in outdoor settings and that the practice is associated with other markers of drug-related harm, including being female, daily cocaine injecting and sex trade involvement. These findings suggest that novel interventions are needed to address the needs of this subpopulation of IDU.
doi:10.1186/1477-7517-7-6
PMCID: PMC2856546  PMID: 20302638
8.  Incidence and determinants of initiation into cocaine injection and correlates of frequent cocaine injectors 
Drug and alcohol dependence  2008;99(1-3):176-182.
Purpose
To investigate the incidence and correlates of cocaine injection initiation and the impacts of daily cocaine injection among a cohort of injection drug users.
Methods
Among 1603 participants, from May 1996 and December 2005, risk factors for initiation of cocaine injection among baseline heroin users were determined by Cox proportional hazards regression and correlates of daily cocaine injection by generalized estimating equations.
Findings
Of the 238 individuals who had never injected cocaine, 200 (84%) had at least one follow-up visit and 121 (61%) consequently initiated into cocaine injection yielding an incidence density of initiation into cocaine injection of 21.9% (95% Confidence Interval (CI) 17.9 – 25.8) per 100 person years. In a multivariate model, Downtown Eastside (DTES) residence (Adjusted Hazard Ratio (AHR) = 2.46, 95% CI: 1.68-3.60), incarceration (AHR = 1.50, 95% CI: 1.01-2.24), requiring help injecting (AHR = 1.57, 95% CI: 0.99 – 2.49), and binge drug use (AHR = 1.82, 95% CI: 1.22 - 2.73) remained associated with initiation into cocaine injection. DTES residence (adjusted odds ratio (AOR) = 1.99, 95% CI: 1.62 – 2.46), incarceration (AOR = 1.29, 95% CI: 1.04 – 1.60), unstable housing (AOR = 1.28, 95% CI: 1.04 – 1.53), sex trade involvement (AOR = 1.46, 95% CI: 1.15 – 1.85), requiring help injecting (AOR = 2.11, 95% CI: 1.73 – 2.58]), borrowing syringes (AOR = 1.81, 95% CI: 1.35 – 2.43) and binge drug use (AOR = 2.16, 95% CI: 1.81 – 2.58) were independently associated with daily cocaine injection.
Conclusions
The baseline prevalence and subsequent incidence of initiation into cocaine injection was high. Daily cocaine injection was independently associated with a number of health and social harms including elevated HIV risk behavior.
doi:10.1016/j.drugalcdep.2008.07.003
PMCID: PMC2649881  PMID: 18805655
Cocaine; injection drug use; risk factors; HIV
9.  Smoking of crack cocaine as a risk factor for HIV infection among people who use injection drugs 
Background
Little is known about the possible role that smoking crack cocaine has on the incidence of HIV infection. Given the increasing use of crack cocaine, we sought to examine whether use of this illicit drug has become a risk factor for HIV infection.
Methods
We included data from people participating in the Vancouver Injection Drug Users Study who reported injecting illicit drugs at least once in the month before enrolment, lived in the greater Vancouver area, were HIV-negative at enrolment and completed at least 1 follow-up study visit. To determine whether the risk of HIV seroconversion among daily smokers of crack cocaine changed over time, we used Cox proportional hazards regression and divided the study into 3 periods: May 1, 1996–Nov. 30, 1999 (period 1), Dec. 1, 1999–Nov. 30, 2002 (period 2), and Dec. 1, 2002–Dec. 30, 2005 (period 3).
Results
Overall, 1048 eligible injection drug users were included in our study. Of these, 137 acquired HIV infection during follow-up. The mean proportion of participants who reported daily smoking of crack cocaine increased from 11.6% in period 1 to 39.7% in period 3. After adjusting for potential confounders, we found that the risk of HIV seroconversion among participants who were daily smokers of crack cocaine increased over time (period 1: hazard ratio [HR] 1.03, 95% confidence interval [CI] 0.57–1.85; period 2: HR 1.68, 95% CI 1.01–2.80; and period 3: HR 2.74, 95% CI 1.06–7.11).
Interpretation
Smoking of crack cocaine was found to be an independent risk factor for HIV seroconversion among people who were injection drug users. This finding points to the urgent need for evidence-based public health initiatives targeted at people who smoke crack cocaine.
doi:10.1503/cmaj.082054
PMCID: PMC2764753  PMID: 19841052
10.  Physical Violence Among a Prospective Cohort of Injection Drug Users: A Gender-Focused Approach 
Drug and alcohol dependence  2008;97(3):237-246.
Although dramatically heightened rates of violence have been observed among injection drug users (IDU), little is known about the gender differences associated with violence among this population. Employing a risk environment framework, we performed an analysis of the factors associated with experiencing violence among participants enrolled in a prospective cohort study of IDU during the years 1996-2005 using generalized estimating equations (GEE). Among 1114 individuals, 291 (66%) of females and 470 (70%) of males reported experiencing violence during the study period. In multivariate analyses, mental illness, frequent alcohol use, frequent crack use, homelessness, Downtown Eastside residency, and requiring help injecting were positively associated with experiencing violence for both sexes (all p < 0.05). For females, binge drug use (AOR = 1.30) and drug dealing (AOR = 1.42) were positively associated with violence, while younger age (AOR = 1.02), frequent heroin injection (AOR = 1.24), and incarceration (AOR = 1.50) were significant for males. Women were more likely to be attacked by acquaintances, partners, and sex trade clients, while men were more likely to experience violence from strangers and the police. These findings indicate that susceptibility to violence among IDU is structured by environmental factors such as homelessness and drug-related factors such as frequent alcohol use and involvement in drug economies. Furthermore, important gender differences with respect to the predictors and characteristics of violent attacks do exist. These findings indicate an urgent need for the development of comprehensive programs and structural interventions that take a gender-focused approach to violence among IDU.
doi:10.1016/j.drugalcdep.2008.03.028
PMCID: PMC2570226  PMID: 18487025
Violence; Gender; Injection Drug Use; HIV; Canada
11.  EFFECTS OF POLICE CONFISCATION OF ILLICIT DRUGS AND SYRINGES AMONG INJECTION DRUG USERS IN VANCOUVER 
Background
Drug market policing has been associated with various harms among injection drug users (IDU). However, little is known about instances in which drugs and injecting equipment are confiscated from IDU in the absence of a formal arrest.
Methods
We examined factors associated with being stopped, searched, or detained by police among participants in the Vancouver Injection Drug Users Study (VIDUS) using logistic regression. We also examined actions taken by study participants immediately following instances in which drugs or syringes were confiscated by police.
Results
Among 465 active IDU, 130 (28.0%) reported being detained by police in the last six months without being arrested. In multivariate logistic regression analysis, factors associated with being stopped, searched or detained by police included homelessness (Adjusted Odds Ratio [AOR] = 3.96, 95%CI: 1.86 – 8.45), recent incarceration (AOR = 3.52, 95% CI: 1.75 – 7.10), frequent crack use (AOR = 2.24, 95% CI: 1.34 – 3.74), requiring help injecting (AOR = 5.20, 95% CI: 1.21 – 22.39), and lending syringes (AOR = 3.18, 95% CI: 1.09 – 9.30). Of those who reported being detained, 34% participants reported having had drugs confiscated, and 70% of these reported that they immediately acquired more drugs. 51% of participants who reported being detained also reported having had syringes confiscated, and of this group, 6% reported immediately borrowing used syringes.
Conclusions
Our study demonstrates that the IDU most affected by street-level policing tend to possess various characteristics, such as homeless, that place them at heightened risk for various adverse health outcomes. Our findings also suggest that the confiscation of drugs and/or needles and syringes through discretionary policing practices have potential to exacerbate drug market activity or prompt increased syringe borrowing. These findings indicate the need for ongoing evaluation of the public health impacts of discretionary policing approaches.
doi:10.1016/j.drugpo.2007.08.004
PMCID: PMC2529170  PMID: 17900888
12.  Unstable housing and hepatitis C incidence among injection drug users in a Canadian setting 
BMC Public Health  2009;9:270.
Background
There has emerged growing recognition of the link between housing and health. Since Vancouver, Canada has had increasing concerns with homelessness brought about by urban renewal in the lead-up to the 2010 Winter Olympic Games, we evaluated hepatitis C virus (HCV) incidence among injection drug users (IDU) with and without stable housing.
Methods
Data were derived from a collaboration between two prospective cohort studies of IDU in Vancouver, Canada. Using Cox Proportional Hazards regression, we compared HCV incidence among participants with and without stable housing, and determined independent predictors of HCV incidence.
Results
Overall, 3074 individuals were recruited between May 1996 and July 2007, among whom 2541 (82.7%) were baseline HCV-infected. Among the 533 (17.3%) individuals who were not HCV-infected at baseline, 147 tested HCV antibody-positive during follow-up, for an incidence density of 16.89 (95% confidence interval: 14.76 – 19.32) per 100 person-years. In a multivariate Cox regression model, unstable housing remained independently associated with HCV infection (relative hazard = 1.47 (1.02 – 2.13).
Conclusion
HCV prevalence and incidence are high in this setting and were associated with unstable housing. Efforts to protect existing low-income housing and improve access to housing may help to reduce HCV incidence.
doi:10.1186/1471-2458-9-270
PMCID: PMC2728719  PMID: 19640297
13.  Elevated HIV risk behaviour among recently incarcerated injection drug users in a Canadian setting: a longitudinal analysis 
BMC Public Health  2009;9:156.
Background
While incarceration has consistently been associated with a higher risk of HIV infection for individuals who use injection drugs (IDU), the effect of incarceration on the post-release risk environment remains poorly described. We sought to assess the impact of incarceration on risk factors for HIV infection after release from prison in a sample of active IDU in Vancouver, Canada.
Methods
Using a prospective cohort of community-recruited IDU followed from May 1, 1996 to November 30, 2005, we examined contingency tables and performed linear growth curve analyses to assess changes in the prevalence of independent risk factors for HIV infection from before to after a period of incarceration among participants reporting incarceration and a matched control group.
Results
Of the 1603 participants followed-up over the study period, 147 (9.2%) were eligible for an analysis of post-incarceration risk behaviours and 742 (46.3%) were used as matched controls. Significant differences were found in one or both groups for the prevalence of frequent cocaine injection, requiring help injecting, binge drug use, residence in the HIV outbreak epicentre, sex-trade participation and syringe sharing (all p < 0.05) after incarceration. In linear growth curve adjusted for age, gender and ethnicity, syringe sharing was significantly more common in those recently released from prison (p = 0.03) than in the control group.
Conclusion
In a sample of Canadian IDU, we did not observe any effect of incarceration on the prevalence of several behaviours that are risk factors for HIV infection, including intensity of drug use or participation in the sex trade. However, those recently released from prison were more likely to report syringe sharing that those in a matched control group.
doi:10.1186/1471-2458-9-156
PMCID: PMC2695456  PMID: 19473508
14.  Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study 
Objective To examine the relation between plasma HIV-1 RNA concentrations in the community and HIV incidence among injecting drug users.
Design Prospective cohort study.
Setting Inner city community in Vancouver, Canada.
Participants Injecting drug users, with and without HIV, followed up every six months between 1 May 1996 and 30 June 2007.
Main outcome measures Estimated community plasma HIV-1 RNA in the six months before each HIV negative participant’s follow-up visit. Associated HIV incidence.
Results Among 622 injecting drug users with HIV, 12 435 measurements of plasma HIV-1 RNA were obtained. Among 1429 injecting drug users without HIV, there were 155 HIV seroconversions, resulting in an incidence density of 2.49 (95% confidence interval 2.09 to 2.88) per 100 person years. In a Cox model that adjusted for unsafe sexual behaviours and sharing used syringes, the estimated community plasma HIV-1 RNA concentration remained independently associated with the time to HIV seroconversion (hazard ratio 3.32 (1.82 to 6.08, P<0.001), per log10 increase). When the follow-up period was limited to observations after 1 January 1988 (when the median plasma HIV RNA concentration was <20 000 copies/ml), the median viral load was no longer statistically associated with HIV incidence (1.70 (0.79 to 3.67, P=0.175), per log10 increase).
Conclusions A longitudinal measure of community plasma HIV-1 RNA concentration was correlated with the community HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviours and sharing used syringes. If these findings are confirmed, they could help to inform both HIV prevention and treatment interventions.
doi:10.1136/bmj.b1649
PMCID: PMC2675696  PMID: 19406887
15.  High prevalence of HIV infection among homeless and street-involved Aboriginal youth in a Canadian setting 
Aboriginal people experience a disproportionate burden of HIV infection among the adult population in Canada; however, less is known regarding the prevalence and characteristics of HIV positivity among drug-using and street-involved Aboriginal youth. We examined HIV seroprevalence and risk factors among a cohort of 529 street-involved youth in Vancouver, Canada. At baseline, 15 (2.8%) were HIV positive, of whom 7 (46.7%) were Aboriginal. Aboriginal ethnicity was a significant correlate of HIV infection (odds ratio = 2.87, 95%CI: 1.02 – 8.09). Of the HIV positive participants, 2 (28.6%) Aboriginals and 6 (75.0%) non-Aboriginals reported injection drug use; furthermore, hepatitis C co-infection was significantly less common among Aboriginal participants (p = 0.041). These findings suggest that factors other than injection drug use may promote HIV transmission among street-involved Aboriginal youth, and provide further evidence that culturally appropriate and evidence-based interventions for HIV prevention among Aboriginal young people are urgently required.
doi:10.1186/1477-7517-5-35
PMCID: PMC2607257  PMID: 19019253
16.  A multidisciplinary bone metastases clinic at Toronto Sunnybrook Regional Cancer Centre – A review of the experience from 1999 to 2005 
Journal of pain research  2008;1:43-48.
Our objective in this study was to review the experience of a one-stop multidisciplinary bone metastases clinic (BMC) that offers a coordinated multidisciplinary approach to the care of cancer patients with bone metastases in a tertiary cancer centre. Patients with symptomatic bone metastases were referred to BMC and assessed by a team of specialists in various disciplines – interventional radiology, orthopedic surgery, palliative medicine, and radiation oncology. At initial consultation, patient demographics, reasons for referral, and case disposition were recorded. From January 1999 to February 2005, a total of 272 patients with bone metastases were referred to the BMC. The median age was 65 years (range 28–95) and median KPS score at consultation was 60 (range 30–90). The majority of patients came from home (74%), while others came from a nursing home or the hospital (9%). Almost a third (28%) of patients had 2 or more reasons of referral, yielding a total of 354 reasons. The most common reason for referral was bone pain (42%), bone metastases (21%), high risk for pathological fracture (12%), and pathological fracture (10%). Of the 272 patients who received consultation, 40% received palliative radiotherapy, 19% received interventional surgery, 7% were referred to other support services such as palliative care, physiotherapy, and 7% had further investigation or imaging. A multidisciplinary clinic is useful for co-coordinating the management of bone metastatic disease in symptomatic patients.
PMCID: PMC3004611  PMID: 21197287
bone metastases; multidisciplinary approach; experience
18.  Income Generating Activities of People Who Inject Drugs 
Drug and alcohol dependence  2007;91(1):50-56.
Background
Injection drug users (IDU) commonly generate income through prohibited activities, such as drug dealing and sex trade work, which carry significant risk. However, little is known about the IDU who engage in such activities and the role of active drug use in perpetuating this behavior.
Methods
We evaluated factors associated with prohibited income generation among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) using logistic and linear regression. We also examined which sources of income respondents would eliminate if they did not require money to pay for drugs.
Results
Among 275 IDU, 145 (53%) reported engaging in prohibited income generating activities in the past 30 days. Sex work and drug dealing accounted for the greatest amount of income generated. Non-aboriginal females were the group most likely to report prohibited income generation. Other variables independently associated with prohibited income generation include daily heroin injection (AOR = 2.3) and daily use of crack cocaine (AOR = 3.5). Among these individuals, 68 (47%) indicated they would forgo these earnings if they did not require money for illegal drugs, with those engaged in sex trade work (62%) being most willing to give up their illegal source of income.
Conclusion
These findings suggest that the costs associated with illicit drugs are compelling IDU, particularly those possessing markers of higher intensity addiction, to engage in prohibited income generating activities. These findings also point to an opportunity to explore interventions that relieve the financial pressure of purchasing illegal drugs and reduce engagement in such activities, such as low threshold employment and expansion of prescription and substitution therapies.
doi:10.1016/j.drugalcdep.2007.05.003
PMCID: PMC2047290  PMID: 17561355
IDU; Income Generation; Sex Trade Work; Drug Dealing
19.  Increasing use and Associated Harms of Crystal Methamphetamine Injection in a Canadian Setting 
Drug and alcohol dependence  2006;88(2-3):313-316.
Background
There is a growing concern surrounding crystal methamphetamine use in Canada despite surprisingly little empirical data to support such claims. We evaluated the trends in crystal methamphetamine injection and factors associated with injection of the drug among a cohort of injection drug users (IDU) in Vancouver.
Methods
We conducted a prospective analysis of factors associated with crystal methamphetamine injection among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with crystal methamphetamine injection were evaluated using generalized estimating equations (GEE) with logit link for binary outcomes.
Results
Overall, 1587 IDU were enrolled into the VIDUS cohort between May 1996 and December 2004. The proportion of IDU who reported injecting crystal methamphetamine during the last six months increased during the study period (Cochran-Armitage trend test, p < 0.001). In multivariate GEE analyses, crystal methamphetamine injection was independently associated with younger age (Adjusted Odds Ratio [AOR]: 4.77, 95% Confidence Interval [CI] = 3.40 - 6.70), Caucasian ethnicity (AOR = 2.21, 95% CI = 1.57 - 3.12), syringe borrowing (AOR = 1.62, 95% CI = 1.22 - 2.13), and syringe lending (AOR = 1.40, 95% CI = 1.02 - 1.86).
Interpretation
There was a significant trend towards increasing crystal methamphetamine injection in this setting and elevated HIV risk behavior and younger age were independently associated with crystal methamphetamine injection. Given that banning precursor chemicals has had a limited effect on reducing methamphetamine supply in other jurisdictions, pragmatic and effective interventions are needed to address the growing use of this drug.
doi:10.1016/j.drugalcdep.2006.10.019
PMCID: PMC1925049  PMID: 17141427
HIV transmission ; Injection drug use ; Crystal methamphetamine
20.  Rate of methadone use among Aboriginal opioid injection drug users 
Background
Previous studies have shown elevated rates of health-related harms among Aboriginal people who use injection drugs such as heroin. Methadone maintenance therapy is one of the most effective interventions to address the harms of heroin injection. We assessed the rate of methadone use in a cohort of opioid injection drug users in Vancouver and investigated whether methadone use was associated with Aboriginal ethnic background.
Methods
Using data collected as part of the Vancouver Injection Drug Users Study (May 1996–November 2005), we evaluated whether Aboriginal ethnic background was associated with methadone use using generalized estimating equations and Cox regression analysis. We compared methadone use among Aboriginal and non-Aboriginal injection drug users at the time of enrolment and during the follow-up period, and we evaluated the time to first methadone use among people not using methadone at enrolment.
Results
During the study period, 1603 injection drug users (435 Aboriginal, 1168 non-Aboriginal) were recruited. At enrolment, 54 (12.4%) Aboriginal participants used methadone compared with 247 (21.2%) non-Aboriginal participants (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.38–0.73, p < 0.001). Among the 1351 (84.3%) participants who used heroin, Aboriginal people were less likely to use methadone throughout the follow-up period (adjusted OR 0.60, 95% CI 0.45–0.81, p < 0.001). Among people using heroin but who were not taking methadone at enrolment, Aboriginal ethnic background was associated with increased time to first methadone use (adjusted relative hazard 0.60, 95% CI 0.49–0.74, p < 0.001).
Interpretation
Methadone use was lower among Aboriginal than among non-Aboriginal injection drug users. Culturally appropriate interventions with full participation of the affected community are required to address this disparity.
doi:10.1503/cmaj.070105
PMCID: PMC1896027  PMID: 17606937
21.  Factors associated with premature mortality among young injection drug users in Vancouver 
Background
Young injection drug users (IDUs) may be at increased risk of premature mortality due to the health risks associated with injection drug use including overdoses and infections. However, there has been little research conducted on mortality causes, rates and associations among this population. We undertook this study to investigate patterns of premature mortality, prior to age 30 years, among young IDUs.
Methods
Since 1996, 572 young (≤29 years) IDUs have been enrolled in the Vancouver Injection Drug Users Study (VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and hepatitis C (HCV). Mortality data have been continually updated through linkages with the Provincial Coroner's Office. Crude and age-specific mortality rates, standardized mortality ratios, and life expectancy measures were calculated using person-time methods. Predictors of mortality were identified using Cox regression analyses.
Findings
Twenty-two participants died prior to age 30 years during the follow-up period for an overall crude mortality rate of 1,368 per 100,000 person-years. Overall, young IDUs were 16.4 times (95% confidence interval [CI]; 9.1–27.1) more likely to die; young women IDUs were 54.1 times (95%CI; 29.6–90.8) and young men IDUs were 12.9 times (95%CI; 5.5, 25.3) more likely to die when compared to the Canadian non-IDU population of the same age. The leading observed cause of death among females was: homicide (N = 9); and among males: suicide (N = 3) and overdose (N = 3). In Cox regression analyses, factors associated with mortality were, HIV infection (Hazard Ratio [HR]: 4.55; CI: 1.92–10.80) and sex work (HR: 2.76; CI: 1.16–6.56).
Interpretation
Premature mortality was 13 and 54 times higher among young men and women who use injection drugs in Vancouver than among the general population in Canada. The majority of deaths among the women were attributable to homicide, suggesting that interventions should occur not only through harm reduction services but also through structural interventions at the legal and policy level.
doi:10.1186/1477-7517-4-1
PMCID: PMC1769365  PMID: 17201933
22.  The prevalence and incidence of sexually transmitted infections in a prospective cohort of injection drug users in Vancouver, British Columbia 
BACKGROUND:
While several studies have reported on sexual risk behaviours and the prevalence of sexually transmitted infections (STIs) among injection drug users (IDUs), there are fewer prospective studies that have been able to examine populations of IDUs with no history of STIs. Therefore, the authors examined prevalence, correlates and factors associated with time to first STI infection in a prospective cohort of IDUs in Vancouver, British Columbia.
METHODS:
The authors examined the prevalence and correlates of STIs among IDUs at the time of recruitment into a prospective cohort study. The authors also evaluated the cumulative rate of time to first STI among IDUs with no history of STIs at baseline using the Kaplan-Meier method, and modelled factors independently associated with first STI using Cox regression.
RESULTS:
Between May 1996 and November 2003, 1560 individuals were recruited into the cohort; of these individuals, 745 reported a history of STI at baseline. Among the 815 who did not report an STI at baseline, 671 (82%) had at least one follow-up visit and were eligible for the analysis of time to first STI. After 36 months of follow-up, the cumulative rate of first STI was 8.2% for men and 15.9% for women (log-rank P<0.001), whereas the cumulative rate of first STI was 8.0% for IDUs who did not report sex trade involvement versus 19.8% for IDUs who reported sex trade involvement (log-rank P<0.001). In multivariate analyses, the risk of first STI remained independently associated with unprotected sex with regular partners (relative hazard=2.04, 95% CI 1.29 to 3.23; P=0.001) and unprotected sex with sex trade clients (relative hazard=2.36, 95% CI 1.46 to 3.82; P=0.005).
CONCLUSIONS:
In the present study, the authors found that STIs were associated with both regular sex partnerships and sex trade involvement. These findings are of particular concern because both unprotected sex with regular partners and sex trade involvement is common among IDUs. Interventions to encourage condom use among IDUs, particularly those with regular sex partners and those involved in the sex trade, should be further developed.
PMCID: PMC2095031  PMID: 18159549
IDU; Prospective cohort; STI
23.  Potential uptake and correlates of willingness to use a supervised smoking facility for noninjection illicit drug use 
Many cities are experiencing infectious disease epidemics and substantial community harms as a result of illicit drug use. Although medically supervised smoking facilities (SSFs) remain untested in North America, local health officials in Vancouver are considering to prepare a submission to Health Canada for an exemption to open Canada’s first SSF for evaluation. Reluctance of health policymakers to initiate a pilot study of SSFs may be due in part to outstanding questions regarding the potential uptake and community impacts of the intervention. This study was conducted to evaluate the prevalence and correlates of willingness to use an SSF among illicit drug smokers who are enrolled in the Vancouver Injection Drug Users Study. Participants who reported actively smoking cocaine, heroin, or methamphetamine who returned for follow-up between June 2002 and December 2002 were eligible for these analyses. Those who reported willingness to use an SSF were compared with those who were unwilling to use an SSF by using logistic regression analyses. Four hundred and forty-three participants were eligible for this study. Among respondents, 124 (27,99%) expressed willingness to attend an SSF. Variables that were independently associated with willingness to attend an SSF in multivariate analyses included sex-trade work (adjusted odds ratio [AOR]=1.85), crack pipe sharing (AOR=2.24), and residing in the city’s HIV epicentre (AOR=1.64). We found that participants who demonstrated a willingness to attend an SSF were more likely to be involved in the sex trade and share crack pipes. Although the impact of SSFs in North America can only be quantified by scientific evaluation, these data indicate a potential for public health and community benefits if SSFs were to become available.
doi:10.1093/jurban/jti051
PMCID: PMC3456572  PMID: 15872188
Harm reduction; HCV; HIV; Supervised smoking facilitics
24.  Elevated rates of HIV infection among young Aboriginal injection drug users in a Canadian setting 
Objectives
Recent reports have suggested that Aboriginal and American Indian people are at elevated risk of HIV infection. We undertook the present study to compare socio-demographic and risk variables between Aboriginal and non-Aboriginal young (aged 13 – 24 years) injection drug users (IDUs) and characterize the burden of HIV infection among young Aboriginal IDUs.
Methods
We compared socio-demographic and risk variables between Aboriginal and non-Aboriginal young IDUs. Data were collected through the Vancouver Injection Drug Users Study (VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and Hepatitis C (HCV).
Results
To date over 1500 Vancouver IDU have been enrolled and followed, among whom 291 were aged 24 years and younger. Of the 291 young injectors, 80 (27%) were Aboriginal. In comparison to non-Aboriginal youth, Aboriginal youth were more likely to test seropositive for either HIV (20% vs 7%, p=< 0.001) or Hepatitis C virus (HCV) (66% vs 38%, p =< 0.001), be involved in sex work and live in the city's IDU epi-centre at baseline. After 48 months of follow-up, Aboriginal youth experienced significantly higher HIV seroconversion rates than non-Aboriginal youth, 27.8 per ppy (95% CI: 13.4–42.2) vs. 7.0 per ppy (95% CI: 2.3–11.8) respectively (log-rank p = 0.005) and the incidence density over the entire follow-up period was 12.6 per 100 pyrs (CI: 6.49–21.96) and 3.9 per 100 pyrs (CI: 1.8–7.3) respectively.
Interpretation
These findings demonstrate that culturally relevant, evidence based prevention programs are urgently required to prevent HIV infection among Aboriginal youth.
doi:10.1186/1477-7517-3-9
PMCID: PMC1431516  PMID: 16524484
25.  Recent incarceration independently associated with syringe sharing by injection drug users. 
Public Health Reports  2005;120(2):150-156.
OBJECTIVES: Few prospective studies are available on the relationship between incarceration and HIV risk among injection drug users (IDUs). The authors evaluated self-reported rates of syringe sharing and incarceration among a cohort of IDUs. METHODS: This study analyzed syringe lending by HIV-infected IDUs and syringe borrowing by HIV-negative IDUs among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with each outcome (syringe lending and borrowing) were evaluated using generalized estimating equations for binary outcomes. RESULTS: The study sample consisted of 1,475 IDUs who were enrolled into the VIDUS cohort from May 1996 through May 2002. At baseline, 1,123 (76%) reported a history of incarceration since they first began injecting drugs. Of these individuals, 351 (31%) reported at baseline that they had injected drugs while incarcerated. Among 318 baseline HIV-infected IDUs, having been incarcerated in the six months prior to each interview remained independently associated with syringe lending during the same period (adjusted odds ratio [OR]=1.33; 95% confidence interval [CI] 1.06, 1.69; p=0.015). Similarly, among the 1,157 baseline HIV-negative IDUs, having been incarcerated in the six months prior to each interview remained independently associated with reporting syringe borrowing during the same period (adjusted OR=1.26; 95% CI 1.12, 1.44; p<0.001). CONCLUSIONS: Incarceration was independently associated with risky needle sharing for HIV-infected and HIV-negative IDUs. This evidence of HIV risk behavior should reinforce public health concerns about the high rates of incarceration among IDUs.
PMCID: PMC1497693  PMID: 15842116

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