Income level and drug related harm among people who use injection drugs in a Canadian setting

Abstract

Background Higher income is generally associated with better health outcomes; however, among people who inject drugs (IDU) income generation frequently involves activities, such as sex work and drug dealing, which pose significant health risks. Therefore, we sought to examine the relationship between level of income and specific drug use patterns and related health risks. Methods This study involved IDU participating in a prospective cohort study in Vancouver, Canada. Monthly income was categorized based on non-fixed quartiles at each follow-up with the lowest level serving as the reference category in generalized linear mixed-effects regression. Results Among our sample of 1,032 IDU, the median average monthly income over the study follow-up was $1050 [Interquartile range=785–2000]. In multivariate analysis, the highest income category was significantly associated with sex work (Adjusted Odds Ratio [AOR]=7.65), drug dealing (AOR=5.06), daily heroin injection (AOR=2.97), daily cocaine injection (AOR=1.65), daily crack smoking (AOR=2.48), binge drug use (AOR=1.57) and unstable housing (AOR=1.67). The high income category was negatively associated with being female (AOR=0.61) and accessing addiction treatment (AOR=0.64), (all p < 0.05). In addition, higher income was strongly associated with higher monthly expenditure on drugs (>$400) (OR=97.8). Conclusion Among IDU in Vancouver, average monthly income levels were low and higher total monthly income was linked to high-risk income generation strategies as well as a range of drug use patterns characteristic of higher intensity addiction and HIV risk. These findings underscore the need for interventions that provide economic empowerment and address high intensity addiction, especially for female IDU.

Initiation of drug dealing among a prospective cohort of street-involved youth

“…Stimulant use overall has long been associated with engagement in risky sex (including sex work), nonfatal overdose, and other markers of vulnerability, including syringe sharing, homelessness, and incarceration (25–29). Although the risk profiles of people who use stimulants might partially account for their increased odds of engaging in drug dealing, involvement in the drug trade has been linked to delayed stimulant-use cessation among adult injection drug users (30), suggesting that income from drug dealing may also encourage and perpetuate drug use (5,31). …”

Increased drug use and the timing of social assistance receipt among people who use illicit drugs

“…While this association may be explained in part by the need for individuals with higher intensity drug addiction to generate more income in order to meet their drug use needs (Bourgois, 1998; Deering et al, 2013; Maher, 1997), observational studies also suggest that some income generation strategies can contribute to higher intensity drug use or create additional barriers to decreasing drug use. Specifically, research from Vancouver, Canada (DeBeck et al, 2011; Kerr T et al, 2008; Long et al, 2014) and other settings (Bretteville-Jensen & Sutton, 1996; Fischer B, 1999; Grapendaal et al, 1995; Sherman & Latkin, 2002) suggest that people who self-report high intensity drug use are more likely to report income from street-based activities such as sex work and drug-dealing. Engagement in street-based activities may impede decreasing drug use (Ti L, 2014), directly when individuals are paid in drugs rather than money (Bretteville-Jensen & Sutton, 1996; Shannon K et al, 2008; Small et al, 2013) and indirectly as individuals may increase drug use in response to work stresses (Draus PJ, 2010; Erikson P, 2002).…”

Income generation and attitudes towards addiction treatment among people who use illicit drugs in a Canadian setting

“…These include, but are not limited to: prior criminal convictions (Pager 2003); drug testing, which is commonly a mandatory condition for job eligibility (Tunnell 2004); or the structural features of drug use scenes. For example, socioeconomic disadvantage and housing insecurity have been independently linked to job instability, and these social, structural and environmental influences may magnify challenges related to labour market participation (Long et al 2014, Sztramko et al 2014, Richardson et al 2013, Braine 2013, Sherman et al 2006). Further, drug policies that disproportionately focus on supply reduction may also impact patterns of income generation among PWUD: street-level policing aimed at disrupting drug market activity may inflate the prices of illicit drugs (Werb et al 2008, Wood et al 2003), which may in turn encourage or require PWUD to generate further income through illegal or prohibited activity (e.g.…”

“…For PWUD who acquire income through alternative income generating activities, the context of income generation may be linked to serious negative health outcomes (Long et al 2014). Sex work and drug dealing have been identified as relatively lucrative sources of income among PWUD (DeBeck et al 2007), yet PWUD involved in sex work are especially susceptible to harms such as heightened risk of blood-borne infections such as HIV (Arunachalam and Shah 2013, Deering et al 2011, Shannon et al 2007).…”