Jane Buxton

Professor

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Great Supervisor Week Mentions

Each year graduate students are encouraged to give kudos to their supervisors through social media and our website as part of #GreatSupervisorWeek. Below are students who mentioned this supervisor since the initiative was started in 2017.

 

Lucky to have another @UBC #greatsupervisor in Dr. Jane Buxton (@ubcspph & @CDCofBC): a role model for empathy, compassion, and critical thought.

Stephanie Lake (2017)

 

Graduate Student Supervision

Doctoral Student Supervision (Jan 2008 - May 2021)
Cannabis use during an opioid-related public health crisis: implications for therapeutic advancements and harm reduction initiatives (2021)

Background: While opioid-related morbidity and mortality have risen in jurisdictions across North America, recent reforms to cannabis policy have sparked scientific inquiry into cannabinoid-based interventions to prevent or mitigate opioid-related harm. After systematically reviewing the literature on cannabis use during medication-based treatment of opioid use disorder (Chapter 2), this dissertation sought to: explore the role of cannabis in the relationship between methadone maintenance treatment (MMT) dose and treatment outcomes (Ch.3); characterize motivations for cannabis use (Ch.4); examine the association between cannabis use and illicit opioid use in the context of chronic pain (Ch.5); and document the impact of cumulative cannabis use on mortality (Ch.6) among marginalized people who use illicit drugs (PWUD). Methods: Data for Chapters 3-6 were derived from two community-based prospective cohort studies of PWUD in Vancouver, Canada. Regression analyses of longitudinal data were conducted, including generalized estimating equations (GEEs) and Cox frailty models for recurrent events (Ch.3); latent class analysis and GEEs (Ch.4); generalized linear mixed effects models (Ch.5); and time-varying Cox regression with weighted cumulative exposure measures modelled as restricted cubic splines (Ch.6). Results: In Chapter 3, frequent cannabis use significantly reduced the magnitude of the association between lower MMT dose and frequent illicit opioid use (n=1389), but not treatment retention (n=611). In Chapter 4, four latent classes of cannabis-using PWUD were identified, and links with socio-structural and health-related factors were observed, including poorer physical and mental health among therapeutic cannabis-using classes. In Chapter 5, high-frequency cannabis use was significantly negatively associated with high-frequency illicit opioid use among 1152 PWUD living with chronic pain. In Chapter 6, time to all-cause mortality was not impacted by increasing cumulative exposure to cannabis among 2211 PWUD. Conclusions: Certain motivations for cannabis use among PWUD are rooted in unmet healthcare needs and self-directed harm reduction. The findings of this dissertation signal the importance of conducting experimental research into cannabis for the management of opioid withdrawal and craving and as an opioid-sparing agent in the treatment of pain. In a newly legal environment, cannabis-based harm reduction efforts should be integrated alongside the provision of broader social and structural supports.

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Housing, building, and neighbourhood influences on the experience of home for long-term tenants of Vancouver's Downtown Eastside (2021)

Increasingly governments have turned to Housing First, a housing strategy where people are provided with housing that is not tied to treatment adherence or abstinence, to address urban poverty and homelessness. This thesis explores the question of “what next” by focusing on how “home” was experienced by long-term tenants living in Housing First buildings. Nineteen first interviews and eighteen second interviews were completed with tenants who had lived in their housing for at least three years and had a history of homelessness. A novel qualitative tool called the daily mapping calendar (DMC) was used to map daily activities and gain an understanding of how interrelationships between tenants (i.e. housed residents), DTES residents (i.e. both sheltered and unsheltered), and services providers shaped tenants' experiences of the spaces they frequented. Through situational analysis (a type of grounded theory), four social worlds were identified that shaped people’s service use: food security, health, income generation, and social connection. Further analysis identified housing, building and neighbourhood level influences on the experience of home. Factors central to the experience of home included: adequate and secure housing free of pests, where people experienced control and companionship; supportive relationships at the building level; and, tenants’ location in the DTES amid an on-going overdose crisis. These experiences were further embedded within an environment where gentrification and colonialism were interwoven. This research has important implications for where and how housing and services are provided. Priorities identified by tenants included protecting the inclusiveness and accessibility of the DTES, while also investing in housing and services outside of the DTES. The responsibilities of researchers and institutions to research participants were also explored, given the long history of intensive research in Vancouver’s Downtown Eastside. Drawing on the concepts of relational validity and morality, it is proposed that researchers have a responsibility to ensure that their findings make it back to research participants. The institutional responsibility to ensure open access (i.e., research is freely available online) to academic journal articles is also explored. Together these responsibilities provide insight into how research processes can be strengthened to ensure the continued trust and collaboration of research participants.

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Work experiences and conditions among people who use drugs engaged in peer work: a critical examination of peer work in British Columbia, Canada (2019)

Engaging with ‘peers’, or people with lived experience of illicit substance use (past or present) who use their experiential knowledge to inform their professional work in decision-making and service provision, has been increasingly recognized as best practice within mainstream health and ham reduction institutions across British Columbia, Canada, and elsewhere. Yet, the operationalization and structure of work in peer engagement contexts have not been studied in great depth. In this research, I generate a critical and in-depth understanding of peer work conditions, the organization of peer work, and the structural factors that shape equity, inequities, and constraints in the context of the everyday work experiences of peer workers. Grounded in critical theoretical perspectives and a qualitative research design informed by interpretive descriptive methods, I conducted fifteen interviews with people engaged in peer work in British Columbia. Data coding and analysis occurred concurrent to data collection and themes were generated inductively and recursively using constant comparison techniques. Study findings indicate that peer work was demanding, oppressive, and inequitable. The emotional demands of peer workers’ day-to-day working lives were illustrated by reports of trauma and structural harms. Expressions of oppression, including powerlessness, marginalization, and exploitation, were linked to a range of interlocking, interrelated systems that structurally shaped peer work conditions and perpetuated inequity. These findings illustrated how, despite peer workers’ efforts to engage in their work, systems of oppression and inequity that were structured into the organization of peer work may enable or constrain peer workers’ agency in these settings. Inequitable access to supports appeared to make it challenging for peer workers’ roles to be effectively utilized or recognized within institutions. Collectively, study findings suggest how equity, inequity, and oppression can be shaped through the organization and operationalization of peer work. While there may be good intentions to promote the inclusion of people who use drugs in health promotion and harm reduction organizations, I provide evidence that there are potential consequences to work that is misunderstood, poorly organized, and unsupported.

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Reasonable or unreasonable?: a patient-centred perspective of access to cannabis for medical purposes under different regulatory frameworks in Canada (2018)

The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.

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It's powerful to gather : a community-driven study of drug users' and illicit drinkers' priorities for harm reduction and health promotion in British Columbia, Canada (2017)

It is essential that the autonomy and dignity of people who use illicit substances be respected by meaningfully involving them in research into their needs and priorities. This dissertation reports on two projects in which substance users were involved in planning and conducting qualitative research in British Columbia, Canada. In the first phase of the research, a province-wide series of 17 workshops, facilitated by drug users, was held to identify health and harm reduction priorities for this population. I found that drug users in British Columbia identified clear priorities to improve their well-being: improving interactions with health professionals, promoting access to a range of housing options, improving treatment by police, ensuring harm reduction best practices are followed everywhere, improving social assistance, supporting drug users' organizations, and engaging new and existing allies. These were based on the values of collectivity, activity, freedom from surveillance, and accountability. An unexpected finding of this research was identifying a need and opportunity for drug users to collaborate with illicit drinkers (defined as people who consume non-beverage alcohol (e.g. mouthwash) and people who consume beverage alcohol in highly criminalized ways (e.g. homeless drinkers)) based on their shared priorities, values, and polysubstance use. In response to this conclusion, the second phase of this research involved a series of 14 town hall meetings with illicit drinkers in Vancouver’s Downtown Eastside to research their perceptions of the harms they face from illicit drinking, the strategies they currently use to reduce these harms, and their ideas for additional harm reduction initiatives. These meetings were planned and facilitated with a steering committee of drug users and illicit drinkers. I found that the harms illicit drinkers experience and some of the strategies they suggest (particularly safe spaces and managed alcohol programs) can usefully be interpreted as examples of structural, everyday, and symbolic violence. This work has led to several positive outcomes for drug users and illicit drinkers, including deeper involvement of substance users in planning provincial harm reduction services and the formation of an activist group for illicit drinkers.

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Improving hospital care for patients who use illicit drugs in Vancouver, Canada (2015)

Background: People who use illicit drugs (PWUD) experience a number of health-related harms that often lead to frequent hospitalizations. However, there exists little scientific evidence that has explored utilization and retention in hospital care, including leaving hospital against medical advice (AMA), among this population. The objective of this thesis is to provide evidence to improve hospital care for PWUD by first, identifying individual and contextual factors associated with leaving hospital AMA and other hospital-related experiences; and, second, to use these findings to develop and evaluate novel approaches to minimizing the risks and harms that PWUD experience in hospital settings. Methods: This dissertation draws on data collected from two open prospective cohort studies of HIV-positive and HIV-negative PWUD in Vancouver, Canada. These data were confidentially linked to a hospital discharge database as well as comprehensive records of HIV treatment and related clinical outcomes through a clinical monitoring laboratory. A variety of longitudinal and cross-sectional analytic techniques were used to examine the impact of intersecting individual and contextual factors on various hospital service outcomes. Results: This dissertation identified hospitals as a risk environment for PWUD, given the high prevalence of hospital discharge AMA and active illicit drug use in hospitals. The study findings highlighted various risk and protective factors for leaving hospital AMA, and discussed the negative consequences of being denied pain medication on illicit drug use in hospitals. The findings from this dissertation also point to novel strategies that may address these issues, including the implementation of an adult HIV/AIDS integrated health program operating in proximity to a hospital to minimize hospital discharge AMA among HIV-positive PWUD, as well as the potential for an in-hospital supervised injection facility (SIF) to reduce the harms associated with illicit drug use in hospital. Conclusion: Despite this setting of universal access to healthcare, there are individual- and contextual-level factors that play a pivotal role in shaping utilization and retention in hospital care among PWUD. The collective findings of this dissertation offer insights into how integrated harm reduction-based interventions may mitigate the risks associated with leaving hospital AMA and active illicit drug use in hospitals.

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A tool to assess capacity to consent for treatment among homeless populations with Problematic substance use (2014)

BACKGROUND: Individuals who misuse substances and who are homeless or unstably housed (IMSH) are at risk of acquiring communicable diseases such as HIV, sexually transmitted infections and blood-borne infections and have greater medical needs than the general population. However, obtaining informed consent for health care can be challenging as many IMSH have impaired cognition due to the effects of substances. This dissertation describes the development and validation process used to create a psychometric instrument that measures capacity to consent for health care (CTC-HC) among IMSH. METHODS: Forty-six qualitative interviews were conducted with 19 nurses who deliver care to IMSH and 27 IMSH to identify concepts that should be included in a capacity assessment instrument. A panel of experts reviewed possible items to obtain content and face validity. The instrument was administered to 302 IMSH. Construct and criterion validity were assessed by comparing the results of the new instrument to 1) a psychiatric assessment and 2) scores obtained from the MacArthur Competency Assessment Tool for Treatment. Item analysis was conducted to determine the reliability of the instrument and a confirmatory factor analysis was conducted. The areas under the receiver operating characteristic curves (ROC) were calculated to assess criterion validity. A diagnostic cut-off value was created using the corresponding points on the ROC. RESULTS: The final Capacity Assessment Instrument for People who misuse Substances (CAIPS) consists of items that address understanding, voluntariness, orientation, ability to communicate, sustained attention, distorted reality, appreciation, reasoning, expression of choice, decision making demands, and physical indication of substance use. These concepts were incorporated into an 11-item instrument that scores items on a four-point Likert scale. The CAIPS instrument demonstrated good internal reliability (Cronbach’s alpha: 0.861 – 0.893) and inter-observer reliability (weighted kappa statistic of 0.657). The factor analysis confirmed the unidimensionality assumption and the ROC analysis revealed that the CAIPS has a sensitivity of .75 - .81 and a specificity of .63 - .51.CONCLUSIONS: CAIPS is a reliable tool with moderate validity and is the first validated capacity assessment instrument available for clinicians to assess CTC-HC among IMSH.

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Injection career trajectories among illicit drug users in Vancouver, Canada (2013)

Background: Though vast resources have been allocated toward the prevention of illicit drug use, the prevalence of injection drug use remains high globally. This thesis therefore sought to identify factors that influence the natural history of injection drug use by: systematically reviewing the epidemiologic literature on the prevention of injecting initiation; identifying the role of drug-related and personality-based risk factors in increasing the risk of injecting initiation; and evaluating the role of harm reduction interventions in potentially modifying the likelihood of injecting cessation among injection drug users (IDU). Methods: Street-involved youth and IDU participating in ongoing prospective observational cohorts in Vancouver, Canada, completed semi-annual interviewer-administered questionnaires. Longitudinal epidemiologic methods were applied to assess the association between selected drug-related, personality-based (e.g., sensation seeking level), and structural factors on the outcomes of interest, while controlling for a variety of potential sociodemographic and behavioural confounders.Results: The systematic review found that a limited set of interventions to prevent injecting has been scientifically evaluated and implemented. A longitudinal analysis of injecting initiation found that non-injection crystal methamphetamine use was significantly associated with injecting initiation among street-involved youth. The adaptation of a sensation seeking scale for use in a related longitudinal analysis found that higher sensation seeking was associated with injecting and risk factors for injection initiation. Finally, in a longitudinal analysis conducted over a span of 15 years, rates of injecting cessation among a cohort of IDU increased significantly despite a substantial expansion in needle and syringe program (NSP) implementation.Conclusions: This thesis identified gaps in current responses to preventing injection drug use. A set of drug-related and personality-based factors associated with increased risk of injecting initiation among street-involved youth was also identified, including non-injection crystal methamphetamine use and higher sensation seeking. Further, an increase in the rate of injecting cessation among IDU occurred during a period of substantial expansion of NSP sites in Vancouver. These results suggest that resources should be allocated towards the development of interventions to prevent injection initiation, and that harm reduction interventions should be considered complementary to broader efforts to reduce both injection drug use and related harms.

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Policing and public health: Experiences of people who inject drugs in Bangkok, Thailand (2013)

Background: In recent years, Thailand has intensified policing efforts as a strategy to address a continuing epidemic of illicit drug use. Thailand’s “war on drugs” campaign of 2003 received international criticism due to extensive human rights violations. However, few studies have since investigated the impacts of drug policing on people who inject drugs (IDU) in this setting. Drawing on the Risk Environment Framework, this dissertation sought to: explore IDUs’ lived experiences with police; identify the prevalence and correlates of experiencing beatings and drug testing by police; examine the relationship between exposures to policing and syringe sharing; and assess changes in the availability of illicit drugs among IDU in Bangkok, Thailand.Methods: Between June 2009 and June 2012, a community-recruited sample of IDU in Bangkok participated in a serial cross-­sectional mixed-­methods study and completed interviewer-­administered questionnaires and semi-structured in-­depth interviews. Audio-­recorded interviews were transcribed verbatim and a thematic analysis was conducted to document the character of IDUs’ encounters with police. A variety of multivariate regression techniques were used to estimate independent relationships between exposures to specific policing tactics and indicators of drug-­related harm, as well as to examine a temporal trend of street-­level availability of illicit drugs.Results: Respondents’ narratives indicated that drug policing involved numerous forms of human rights infringements and negatively influenced healthcare access among IDU in Bangkok. Reports of beatings and drug testing by police were common (38% and 67%, respectively) and were independently associated with various indicators of drug-­related harm, including syringe sharing and barriers to healthcare. Street-­level availability of illicit drugs increased significantly between 2009 and 2011.Conclusions: The findings indicate that the over-reliance on repressive drugpolicing is not suppressing the illegal drug market and is instead contributing to police-­perpetrated abuses, the perpetuation of risky injection behaviour, and an impediment to healthcare among IDU in Bangkok. These findings raise concern about the ongoing policing practices and point to the need for providing greater police oversight, as well as a shift toward more balanced approaches to drug control in this setting.

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Social and structural barriers to effective antiretroviral therapy for HIV infection among injection drug users (2012)

Background: Despite the development of antiretroviral therapy (ART), injection drug users (IDU) continue to have high levels of HIV-related morbidity and mortality. This thesis sought to apply the risk environment conceptual framework on patterns of HIV treatment outcomes by: Systematically reviewing the epidemiologic literature on HIV disease progression among illicit drug users; examining the incidence of viral rebound among IDU on ART; evaluating the role of homelessness on the suppression of plasma HIV RNA viral load; and assessing the role of incarceration on the likelihood of non-adherence to ART.Methods: HIV-seropositive IDU participating in an ongoing prospective observational cohort completed biannual interviewer-administered questionnaires. This data was confidentially linked to comprehensive records on HIV treatment and related clinical outcomes held by a clinical monitoring laboratory and antiretroviral dispensary. A variety of longitudinal analytic techniques were used to estimate the independent relationships between selected social- and structural-level exposures and the outcomes of interest while controlling for relevant sociodemographic, clinical and behavioural factors.Results: The systematic review found that only a minority of studies included social- and structural-level measures in analyses of disease progression and treatment outcomes. Longitudinal analysis of viral rebound found that incarceration and sex trade involvement were significantly associated with higher rates. Among individuals initiating ART, homelessness was a significant structural barrier to suppression. Among individuals prescribed ART, we observed a dose-dependent relationship between non-adherence and the number of incarceration episodes. Conclusions: In this setting of free and universal access to HIV care and ART, sub-optimal treatment outcomes were common among IDU. Consistent with an application of the HIV risk environment, a number of prevalent social- and structural-level exposures were associated with higher risks of non-adherence to treatment and poorer treatment outcomes, including homelessness, sex trade involvement and incarceration. Interventions to reduce elevated levels of preventable HIV-related morbidity and mortality among IDU should consider the role played by modifiable aspects of the HIV risk environment.

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Master's Student Supervision (2010 - 2020)
Classifying people living with hepatitis C virus using a population-level latent class analysis to understand association with treatment uptake and optimize integration of health services (2020)

BackgroundHepatitis C virus (HCV) infection affects diverse populations such as people who inject drugs (PWID), 'baby boomers' (BB’s), gay, bisexual, and other men who have sex with men (gbMSM), and immigrants from HCV endemic regions. Assessing patterns of shared characteristics, the burden of syndemics, and the likelihood of treatment uptake among subpopulations may facilitate targeted program planning.MethodsThe BC Hepatitis Testers Cohort includes all HCV cases identified in BC from 1990 to 2015 followed up to 2018 and linked with data on medical visits, emergency department visits, hospitalizations, cancers, prescription drugs, and deaths. Latent Class Analysis was used to group people diagnosed with HCV according to shared characteristics previously shown to be related to HCV acquisition, transmission, retention in care and/or treatment uptake. Models were fitted step-wise, with the best fitting model chosen based on fit statistics, epidemiological meaningfulness, and maximisation of posterior probability for class assignment. Latent class groups were named based on defining characteristics and analysed for their association with treatment uptake (based on first treatment course).ResultsThe best fitting latent class model had six groups, with names and characteristics as follows: Younger PWID (n=11,563): people born >1974, mental illness, material deprivation, recent injection drug use (IDU). Older PWID (n=15,266): past IDU, HIV, HBV, TB coinfections, alcohol misuse. gbMSM (n=12,698): gbMSM, material privilege, no liver disease. People of Asian Backgrounds (n=4,718): East/South Asians, people born
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Illicit prescription opioid injection: prevalence, characteristics, and health outcomes among people who inject drugs in Vancouver, Canada (2015)

Background: The use of prescription opioid (PO) painkillers has increased substantially in Canada and the United States over the previous two decades, bringing widespread public health concern related to non-medical PO use and overdose. Meanwhile, the injection of POs has become common among illicit drug-using populations. This thesis sought to outline the health outcomes associated with injecting POs; evaluate the impact of PO injection on non-fatal overdose; and identify the characteristics associated with PO injection among HIV-positive individuals who use injection drugs (IDU). Methods: A systematic search was undertaken to identify studies that assessed associations between PO injection and various health outcomes. Data-driven studies used longitudinal measures from the Vancouver Injection Drug User Study (VIDUS) or the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS). Generalized estimating equations (GEEs) were used to estimate the effect of PO injection (with and without concurrent heroin use) on non-fatal overdose (study 1) and to identify exposures and clinical characteristics independently associated with PO injection among HIV-positive IDU (study 2). Results: Among 31 articles included in a systematic review, several health outcomes were identified in relation to PO injection. Between December 2005 and May 2014, study 1 followed 1660 IDU, of whom a median of 24.5% reported recent PO injection. In a multivariable GEE analysis, injecting heroin or both POs and heroin, but not PO alone, significantly increased the odds of overdosing compared to injecting non-opioids. Between December 2005 and November 2013, study 2 followed 634 HIV-positive IDU. In a multivariable GEE analysis, periods of PO injection were positively associated with Caucasian ethnicity, heroin injection and drug dealing, and negatively associated with older age and methadone maintenance treatment. Conclusions: Findings of this research highlight a constellation of social and drug-related vulnerabilities associated with injecting POs, emphasizing the importance of considering PO injection in current harm reduction strategies. These results further strengthen the rationale for expanding several harm reduction-based interventions (e.g., supervised injection sites, take-home naloxone, methadone maintenance treatment and alternatives), and integrating them into current health care treatment for IDU.

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Association between chronic rhinosinusitis and health-related quality of life in adults with cystic fibrosis (2014)

Objectives: In the past four decades, the median age of survival has nearly doubled for individuals with cystic fibrosis (CF), where over half the population is now adults. The prevalence of chronic diseases such as chronic rhinosinusitis (CRS) has increased with older age. In the non-CF population, CRS is associated with reduced health-related quality of life (HRQoL). Our objectives were to determine the prevalence of CRS among adults with CF and evaluate its impact on their HRQoL. Methods:One hundred sixty individuals from an academic teaching hospital in Vancouver, Canada were eligible to participate in this cross-sectional study. Included subjects were above the age of 18 years, had a confirmed diagnosis of CF and attended the CF clinic between September 2013 and April 2014. Participants completed a CF-specific HRQoL questionnaire (i.e. CFQ-R 14+), and underwent symptom and endoscopic assessment to diagnose CRS. Medical charts were reviewed for potential confounders that included socio-demographic (age, gender and body-mass index) and clinical factors (age of CF diagnosis, type of CF mutation, lung function and chronic Pseudomonas aeruginosa infection). Multivariable linear regression was used to model the relationship between CRS and HRQoL, adjusted for potential confounders. Results:One hundred twenty-one individuals were contacted prior to clinic visits of which, 113 (93.4%) consented to participate. The prevalence of CRS was found to be 64.2%. Socio-demographic and clinical factors were similarly distributed between CRS-positive and negative groups, except age of CF diagnosis. CRS-positive individuals were diagnosed with CF at younger age than non-CRS counterparts, although this finding was not significant (mean difference: 6.5 years, p=0.13). In unadjusted analysis, those with CRS reported worse HRQoL on 10 of 12 domains of the CFQ-R 14+. These findings remained despite adjustment for potential confounders. Individuals with CRS reported significantly worse HRQoL on Respiratory symptoms (adjusted regression coefficient: -13.33, p=0.001) and Digestion (adjusted regression coefficient: -8.71, p=0.03) domains, than non-CRS counterparts.Conclusion:The majority of adults with CF suffer from concomitant CRS. CRS is associated with worse HRQoL based on multiple domains of the CFQ-R 14+. CRS should be diagnosed and managed to optimize the HRQoL for adults with CF.

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Initiation of Illicit Drug Use Among Youth: Determinants and Responses (2010)

Background: Many youth initiate illicit drugs at a high level. Further, despite the application of preventive interventions to reduce this phenomenon and related harms, there is little evidence that current efforts to prevent illicit drug use and problematic drug use are effective. This research project was therefore undertaken to investigate determinants of, and popular responses to, the initiation of illicit drug use among youth.Methods: Meta-analytic techniques were used to quantify the evidence on the effectiveness of anti-illicit drug public service announcements. Further, data from the At-Risk Youth Study (ARYS), a prospective cohort of homeless and street-involved youth between the ages of 14 and 26, were analyzed using linear regression analysis to determine factors associated with residing in Vancouver’s downtown eastside (DTES), the location of a large open air illicit drug market, and in the downtown south (DTS), an adjacent neighbourhood. Specifically, between September 2005 and December 2007, participants completed a baseline questionnaire which elicted information on income sources, drug use behaviours, sexual behaviours, and the initiation of illicit drugs. Results: We identified 7 randomized trials (n = 5,428) and 4 observational trials (n = 17,404). A meta-analysis of eligible randomized trials demonstrated no significant effect, while observational studies showed evidence of both harmful and beneficial effects. Further, among 222 youth participants, having a primary illicit income source and injection heroin use were significantly associated with residing in the DTES in multivariate analysis. No significant differences in risk of drug trade and sex trade involvement, crack use, injection cocaine use, and injection crystal methamphetamine use were found between youth residing in each neighbourhood. Conclusions: Our findings suggest that current approaches to the prevention of the initiation of illicit drug use among youth may be limited. Further, the results of our linear regression analysis suggest that a consideration of social and structural factors may increase the effectiveness of current preventive interventions. As such, policymakers should consider reorienting current approaches to illicit drug prevention among youth.

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