High Risk Populations

This dataset contains information collected from surveys conducted in two BC sites (Vancouver and Victoria) designed to monitor patterns and trends in three specific illicit drug user populations: club/party attendees, street involved youth and street involved adults. These populations were selected because of elevated rates of illicit drug use within these populations and contexts, and the high levels of associated risks and harms. To date, eight waves of survey data collection (quantitative and qualitative) have been completed: 2008 (Wave 1 & 2), 2009 (Wave 1 & 2), 2010 (Wave 1 & 2), and 2011 (Wave 1 & 2). The first wave of data collection for 2012 is currently underway in both cities. The recruitment criteria for the street involved adult cohort were amended in late 2009. Previously, participants were required to be active injection drug users, but the criteria have been revised to include both injecting and non-injecting adults.

Most Widely Used Drugs

For wave 2 of 2011, in the month prior to being interviewed, the most widely used substances among street involved youth and club/recreational drug users in both cities were tobacco, marijuana and alcohol.  Ecstasy was also widely used in the last month by club drug users (65%). For street-involved adults, tobacco, crack and marijuana were the top three substances reported by this group.  In addition, a great number of substances including prescription drugs were used and available in Vancouver and Victoria. Some participants expressed concern about the purity of both street and party drugs cut with unknown substances including those not intended for human consumption.

Risky Combinations of Substances

The ‘substance use on recent occasion’ questions in the survey enabled the identification of risky combinations of substance use e.g., 15% simultaneous use of alcohol and cocaine and 44% of the club sample in both cities reported simultaneous use of both alcohol and marijuana on the previous weekend. Among the Adult Street Involved sample, a number of drug combinations were reported e.g., 3% combined alcohol and heroin, a potentially hazardous mix. For more detailed information please see the data tables.

Ease of Availability and Pricing of Drugs

The majority of drugs in all cohorts were reported to be “very easy” to obtain during late 2011. Prices reported ranged from $5 per tablet of ecstasy to $200 per gram for heroin. Cocaine powder and crack cocaine ranged around the $100 per gram.  Purity of drugs remained a concern in wave 2 of 2011 among all 3 cohorts. As one club drug user in Victoria noted, “cocaine is terribly impure and cut with speed and meth so you’re not really doing cocaine…so people do more and more because of the quick high from the meth…” Concerns about the purity of heroin were voiced by adult participants in both cities (e.g. “the heroin right now some is being laced/mixed with insulin…it could kill people”; “the purity of heroin [right now] is extremely high and therefore dangerous.”) While the use of levamisole (hog de-wormer) to bulk up powder cocaine remains a concern, it should be noted that fewer participants spoke about this in wave 2 of 2011 than in the past two waves.

Differences in substances used by city, gender, age and cohort type, 2011 Wave 2

• Vancouver versus Victoria: Prevalence of past 30 day Cocaine (OR=0.38, 95% CI=0.23-0.61), crack (OR=0.38, 95% CI=0.23-0.61), ecstasy (OR=0.38, 95% CI=0.23-0.61) and LSD (OR=0.38, 95% CI=0.23-0.61) use among Victoria participants was less likely than among Vancouver participants.
• Gender: No significant gender differences were found for cocaine/crack, crystal meth, heroin, ecstasy, LSD, and mushroom use in the past 30 days for participants in wave 2 of 2011.
• Age: For ecstasy, those aged 35 and older were 7.8 times less likely to have reported using this substance in the past month than those aged 15-24 (OR=0.13, 95% CI=0.04-0.43). In addition, participants aged 25 to 34 were 2.7 times more likely than 15-24 year olds to have reported mushroom use in the past month (OR=2.72. 95% CI=1.11-6.65). 
• High-risk cohorts: The club cohort was significantly less likely to have reported crack (OR=0.04, 95% CI=0.01-0.10), crystal meth (OR=0.30, 95% CI=0.11-0.79) and heroin (OR=0.04, 95% CI=0.01-0.16) use than the street-involved adults in the most recent wave.  In addition, the street-involved youth were also 7.1 times less likely than the street-involved adults to have reported crack use in the past 30 days (OR=0.14, 95% CI=0.03-0.60).  Alternatively, ecstasy, LSD and mushrooms were all significantly more likely to have been reported by street involved youth and club participants than the street involved adult cohort.  This shows a distinct difference regarding the groups that use “party” drugs versus harder street substances such as heroin and crack cocaine.
• Time period: Participants interviewed in the second wave of 2011 were statistically less likely to have reported crack use in the past month compared to participants surveyed one year prior in the second wave of 2010 (OR=0.65, 95% CI=0.43-1.00). Ecstasy also was significantly less likely in the second wave of 2011 compared to the same point in 2010 (OR=0.62, 95% CI=0.42-0.91). By contrast, participants in the most recent 2011 wave were more likely to have reported crystal meth use (OR=1.83, 95% CI=1.22-2.76) in the past 30 days.   
• There was no statistical difference between needle sharing in adult injection drug users for Vancouver vs. Victoria in the second wave of 2011. Looking across the entire sample since 2008, Victoria had significantly higher reports of needle sharing than Vancouver.

Notes

1. Demographic differences in terms of drug use were tested using multivariate logistic regression models.

The target high-risk populations which were considered of primary interest for this monitoring exercise included ‘club and party drug scenes’ as well as both adolescent and adult injection drug users. Drawing from international high-risk monitoring systems including those implemented in Australia and the European Union, research in both Vancouver and Victoria featured the administration of a lengthy monitoring instrument. This instrument was administered face-to-face in an interview format with trained research assistants running through each item and then recording responses on the survey instrument. This method was selected over a more traditional “self-complete” approach in order to maintain the fidelity of the survey design and to reduce the number of “missing data”. This approach also permitted the inclusion of more complex items.

Recruitment criteria reflecting methodological conventions in other international high-risk monitoring systems (see Shand et al 2003), specific recruitment criteria were devised for each population of interest to ensure the collection of timely and useful research data. Given the strong interest in local drug markets and drug use cultures, participants for each of the three cohorts of interest were required to have lived in the research site for at least six months. Similarly, for each cohort participants were required to have used drugs other than alcohol and tobacco at least once per month in each of the last six months. For the adult injection drug use cohort, participants were required to have injected a drug at least once per month in each of the past six months. For the two “adult” cohorts (groups 1 and 2 noted above) eligible participants included individuals aged 19 years and older; for the adolescent cohort, participants were required to be aged between 15 and 24 years of age. With respect to each of these recruitment criteria, screening instruments were developed to test for these criteria at intake and prior to the completion of all information and participant consent protocols.

Sampling

The sampling of these populations relied on targeted participant selection in order to achieve representation for this group, yet was cross-sectional over time (i.e., no cohort methods). Various efforts were made to recruit a diverse sentinel population from a range of settings in each cohort in each of the two study sites. This was achieved through the combined use of convenience, purposive and snowball sampling methods. To enhance the cross-sectional nature of these samples, it was determined in each instance that no more than 50% of the entire sample ought to be recruited through snowballing methods. In turn, a minimum of five “start points” for this snowballing was deemed appropriate, though no more than three individuals were recruited through each snowballing “point” or contact. This approach was designed in order to enhance the diversity of the sample recruited through snowballing methods and remains consistent with established methodological guidelines (see Biernacki and Waldorf 1981).

In addition to snowballing techniques, specific fixed site recruitment strategies were designed for each completed cohort. Recruitment sites were selected on the basis of their representativeness of different sectors or elements of the target population. For example, for the “club drugs” cohort, five distinct nightclub and/or bar sites were identified at which outreach recruitment took place. These venues were deemed to be representative or indicative of different sub-cultures within the local “night-time economy” on the basis of advice from local key experts and other stakeholders. Similarly, two sites were selected for recruitment for the adult IDU cohort. The advantage with such fixed site recruitment is that it enables more consistent comparisons to be made over time as individuals are recruited at regular intervals from the same sites (see also Strauss and Corbin 1998).

To facilitate both convenience as well as snowball sampling methods advertisements for each research cohort were placed in bars, clubs and cafes, at needle exchanges and community health centres across the study sites. Additionally, many participants found out about the survey through word of mouth from other participants who had completed the survey.  About 11% of IDU participants were secondary referrals (i.e. from snowball sampling methods) compared to about 17% for the club drugs sample. Participants for the club drug study were recruited through diverse methods including advertisements on local club and rave internet sites, word of mouth and local personal networks. All participants received compensation for their time and any travel expenses they may have accrued in the form of a $20 cash honorarium.

Survey Instruments and Procedures

For the club drugs sample, a standardized quantitative and qualitative protocol was administered in each primary target population in each of the two study sites (Vancouver and Victoria). Nine in-depth drug categories were covered: ecstasy cocaine, crack, crystal meth, LSD, heroin, mushrooms, GHB, and ketamine. Each protocol included items on drug use and related risk behaviors; drug markets, price, availability, perceptions of quality in these markets and trends over time; perceptions of risks and harmful effects of drug use; health and socio-economic indicators. Interviews took approximately 60 to 90 minutes to complete.

The IDU sample followed a similar protocol with both quantitative and qualitative items included. Items pertaining to recent drug use behaviours (yesterday and last weekend) were assessed as well as items looking at local drug markets for cocaine, crack, crystal meth and heroin. The two survey instruments were each designed with the broader national study model in mind. In particular, efforts were made to design a standardized survey that could be implemented across various sites and provinces throughout Canada. To this end, local and/or idiosyncratic drug references and questions were omitted in preference for more generic and inclusive terms, references and item wording. This was primarily achieved through a careful cross-referencing of each survey instrument with comparable national and provincial survey instruments. Wherever possible, standardized items were selected to improve the relevance and utility of each instrument. A training manual for interviewers was also developed which will aid the standardization of these instruments.

Instruments

Canadian Recreational Drug Use Survey–BC CRDUS Survey (last updated 2 May 2011).

Canadian Adult Sentinel Survey of Intravenous Drug Use–BC CASSIDU Survey (last updated 2 May 2011).

Canadian Youth Sentinel Survey of Intravenous Drug Use–BC CYSSIDU Survey (last updated 2 May 2011).

John Carsley, MD, CM, MSc, CCFP, FCFP, FRCPC
Medical Health Officer, Vancouver Coastal Health Authority
Medical consultant, Infant, Child & Youth Program in Vancouver
School Medical Officer, BC School District 39

A Community Medicine Specialist, Dr. Carsley is a graduate of Yale University and the McGill University Faculty of Medicine, where he received his medical degree and a Master's degree in Epidemiology and Biostatistics. He has worked in primary care organization, immunization programming and evaluation, communicable disease prevention and control, and environmental health, spending the last ten years in Montreal as head of the health protection sector. He has been involved in the investigation of, and response to, many significant outbreaks of communicable disease at the local, regional and national levels and has served on a wide variety of regional, provincial and national expert committees on communicable disease prevention and public health program development, practice and policy.

Dr. David Marsh, MD, CCSAM
Associate Dean, Postgraduate Education

Dr. Marsh graduated in Medicine from Memorial University of Newfoundland in 1992, following prior training in neuroscience and pharmacology. In July 2010, Dr. Marsh joined the Northern Ontario School of Medicine (NOSM) as Associate Dean, Community Engagement. He brings skills and experience with health care administration, strategic planning, community-based research and social accountability as well as a personal background of Aboriginal ancestry to this role.

Prior to moving to NOSM, David served as the Physician Leader, Addiction Medicine with Vancouver Coastal Health and Providence Health Care and Clinical Associate Professor in the School of Population and Public Health, Faculty of Medicine at the University of British Columbia from 2004-2010. Previously, he held leadership roles at the Addiction Research Foundation and the Centre for Addiction and Mental Health in Toronto from 1996-2003. Author of over 40 peer-reviewed papers, book chapters and government reports, Dr. Marsh’s research interests focus primarily on withdrawal management, methadone maintenance, heroin-assisted treatment, harm reduction interventions such as supervised injection. In 2004 Dr. Marsh received the Nyswander-Dole Award from the American Association for the Treatment of Opioid Dependence in recognition of his contribution to this field.

Dr. Tim Stockwell
Director, Centre for Addictions Research of BC
Professor, Department of Psychology, University of Victoria

Dr. Stockwell directs the Centre for Addictions Research of BC (CARBC), a multi-site and multi-campus network dedicated to research, knowledge exchange and the advancement of public policy on substance use issues. He also holds a position as Professor in the Department of Psychology at the University of Victoria, and is Co-Leader of the BC Mental Health and Addictions Research Network. Dr. Stockwell has published over 200 research papers, book chapters and monographs, plus several books on prevention and treatment issues. Dr. Stockwell is a qualified clinical psychologist who accomplished both clinical and research work in the UK before spending 16 years with Australia’s National Drug Research Institute as Deputy Director and then Director. Dr. Stockwell studied Psychology and Philosophy at Oxford University and obtained a PhD at the Institute of Psychiatry, University of London, in 1980. He is currently President of the international Kettil Bruun Society for Social and Epidemiological Research on Alcohol.

Mr. Clifton Chow
Research Lead, Youth Addiction Services, Vancouver Coastal Health

Clifton Chow is the research coordinator for Youth Addictions at Vancouver Coastal Health. His role in the BC Monitoring Project involves the administration and analysis of the high-risk population surveys component. He has a Masters in Family Studies from UBC (2005) with a focus on parent-child interactions. His experience working with drug users includes administering the Vancouver Youth Drug Reporting System (YDRS) to several hundred youth aged 16 to 24. His research interests include youth drug use practices, and the cultural differences in youth drug attitudes.

Mr. Andrew Ivsins
Research Assistant, Centre for Addictions Research of BC

Mr. Ivsins is responsible for the coordination and administration of the high-risk population component in Victoria. He is currently an M.A. candidate in Sociology at the University of Victoria. Prior to joining CARBC, Andrew worked at the Centre for Addiction and Mental Health in Toronto, where he was involved in various research projects related to illicit substance use and public health. His research interests and experience include street-involved adults and youth, marginalized populations, injection and other illicit substance use and public health.

Dr. Cameron Duff
Monash Fellow, Social Sciences and Health Research Unit, Monash University, Australia

Dr. Duff was the Manager of Research and Prevention Services for the Vancouver Coastal Health Authority and a Clinical Assistant Professor in the School of Population and Public Health at the University of British Columbia, Canada. Prior to moving to Vancouver in 2005, Dr. Duff was the Director of the Centre for Youth Drug Studies at the Australian Drug Foundation in Melbourne. Dr. Duff was awarded his PhD in Political Theory from the University of Queensland in 2002.

Mr. Warren Michelow
PhD Candidate, Department of Health Care and Epidemiology, UBC

Warren Michelow has a Master of Arts in Liberal Studies from Simon Fraser University and is a graduate student at University of British Columbia in the Department of Health Care and Epidemiology where he commenced the PhD program in September 2007. He currently works for CARBC on a number of drug-related surveillance projects. In his previous job he worked for University of British Columbia Department of Psychiatry on a Methamphetamine and Psychosis Study. He has worked with street involved youth, drug using youth and adults, and injecting drug users for over six years. He also has extensive experience working with HIV and Hepatitis C infected youth and adults.

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