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Life History Calendar in a population of chronic opioid users: An evaluation of methodological utility and identifying patterns of drug use and addiction

treatment

Jill Fikowski, MPH CandidateSchool of Population & Public Health, University of British Columbia Canadian Public Health Association Conference Toronto, May 2014

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Overview• Background• Brief description of study and design• Methods • LHC Description• Findings

1. Factors impacting feasibility2. Challenges & Opportunities

• Recommendations

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Background• Vancouver’s Downtown Eastside has an

estimated population of 16,275 and is the home for about 4,700 injection drug users1, 2

• High prevalence of chronic and infectious disease including HIV/AIDS, hepatitis, tuberculosis, and syphilis3, 4

• 33% of the injection drug users in the Downtown Eastside are HIV positive4

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BackgroundPublic health concerns in this population:• Poverty & unhealthy physical environment • Social isolation • Drug dependency & mental illness• Non-legal activity• Low education levels • Limited access to addiction treatment

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Study DesignDescriptive cross-sectional pilot study with a mixed method design aimed at testing gender-specific patterns in drug use, victimization, access to care and physical and mental health among men and women with long-term opioid-dependence

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Study Inclusion criteria• 19 years of age or older • Reside in metropolitan Vancouver area• Minimum of 5 years of opioid use prior to participation• Used opioids regularly within the past 6 months• One or more episode[s] of methadone maintenance

treatment (MMT) or another form of opioid substitution treatment (e.g. Suboxone, Buprenorphine)

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Methods • Recruitment & Enrolment• Participants & Setting• Collection Methods

• Semi-structured questionnaires• Focus groups• Life History Calendar (LHC)

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Life History Calendar (LHC)• Calendar style instrument used to collect

time-linked retrospective data of events over a certain reference period5

Lifetime reference period • Identify life events that may have preceded or co-occurred

during the same time periods as illicit drug use• Time units broken down by month and year

,

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VariablesPatterns of

substance use Addiction treatment Major life events

– illicit substance use– periods of use,

abstinence, relapses – transitions

– type– duration

– children/pregnancy – incarceration – housing– non-legal activity– physical/mental

health, health care– victimization– intimate partner

relationships

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LHC-Layout

• Insert screen shot

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Procedures• Interviewer-coding manual used to guide data

collection • Participants positioned at the table beside the

interviewer with the study laptop open displaying the calendar

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Sample• 174 individuals participated in the GeMa study

(male=95; female=76; transgender=3)• 56 completed the LHC (male=33; female=22;

transgender=1)• Descriptive analysis revealed:

– Heroin primary illicit opioid injected for the first time (78.6%; mean age of first use=25 yrs.)

– MMT most frequently reported as the first drug treatment accessed (41.8%; M= 2.5 attempts)

Opioid_Licit

Heroin

Dilaudid

Morphine

Other Opioid

Speedballs

Illicit Stimulants

Stimulants

Marijuana

Tobacco

Alcohol

Incarcination

Housing

Physical

C

Anx

Dep

Schiz

Spiritual

Felt Love

Primary Care

Psych Diag

Psych Rx

MMTOSTWithdrawalCounsellingResidentialOther TxInsiteSt NurseNeedle ExMobile VanOther HR

0 5 10 15 20 25 30 35 40 45 50 55

1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Age Patient: 4001 ( M ) (1/3)

High use / Low useHigh intensity / Low intensityInjection / Smoke / Other

Regular / Sporadically

Unstable / Stable

Good / Fair / PoorYes / Somewhat

Physical (I=HIV, C=HCV)

Axis I / Axis II

Opioid_Licit

Heroin

Dilaudid

Morphine

Other Opioid

Speedballs

Illicit Stimulants

Stimulants

Marijuana

Tobacco

Alcohol

************************************************* *******************

|

Partner

Quality

Problem

Marriage

Cohabitation

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Child 9

Child 10

0 5 10 15 20 25 30 35 40 45 50 55

1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Age Patient: 4001 ( M ) (2/3)

Male / Female / TGGood / Fair / Poor

F / J / V / T / O

RC / SC / NC / DK

High use / Low useHigh intensity / Low intensityInjection / Smoke / Other

(DP, AP) / DP / AP

Opioid_Licit

Heroin

Dilaudid

Morphine

Other Opioid

Speedballs

Illicit Stimulants

Stimulants

Marijuana

Tobacco

Alcohol

Employment

Insurance

Welfare

Sex Work

Drug Dealing

Property Theft

Neglect.P

Neglect.E

Abuse.E

Abuse.E.IPV

Abuse.P

Abuse.P.IPV

Abuse.S

Abuse.S.IPV

Self Harm

Social Support

0 5 10 15 20 25 30 35 40 45 50 55

1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013

Age Patient: 4001 ( M ) (3/3)

FT / PT / C

Very Often / Often / Sometimes / Rarely

Ym / Yl

Good / Fair / Poor

Severe / Moderate / Minimum

High use / Low useHigh intensity / Low intensityInjection / Smoke / Other

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Factors affecting feasibilityInterviewer Training

1. Familiarity with the demographic of population2. Collection of data and layout of instrument3. Subjectivity of ‘significant’ life events4. Prompting vs. anchoring

Interviewer Techniques• Events reported in semi-structured questionnaires

used to anchor during interview

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Factors affecting feasibilityCharacteristics of the Interviewer

1. Recognizing belief system surrounding drug use and marginalized populations 2. Ability to detect the emotional and physical state of the participant

Characteristics of the Population1. High prevalence of victimization2. Cognitive/physical factors affecting memory recall

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Would we recommend the use of the LHC again in this population?

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Opportunities for Improvement

• Shorten the reference period• Reduce the number of variables • Administer as a complimentary method to

semi-structured questionnaires• Useful way of visually examining the

relationship between patterns of drug use and major life events

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Limitations• Retrospective memory recall• Psychometric evaluation

– Intra & Inter-rater reliability – Objective measures to validate responses

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Thank-youQuestions?

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References1. Tyndall M, Craib K, Currie S, et al. Impact of HIV infection on mortality in a cohort

of injection drug users. AIDS. 2007. 2. Vancouver/Richmond Health Board. Report on the health of the population of

Vancouver/Richmond. Vancouver;1999:22. 3. Schecter M, O’Shaughnessy M. Distribution of injection drug users in the Lower

Mainland. A brief report for the Vancouver/Richmond Health Board. Vancouver;1999:6.

4. Strathdee S, Archibald C, Ofner, M, et al. Determinants of HIV seroconversion in injection drug users during a period of rising prevalence in Vancouver. Vancouver Injection Drug Use Survey. VIDUS Project, May 1997. Int J AIDS and Sex Transm Dis 1997;8:427-435.

5. Freedman D, Thornton A, Camburn D, Alwin D, Young-demarco L. The life history calendar: a technique for collecting retrospective data. Sociological methodology 1988;18:37-68.

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References6. Anglin M, Hser Y, Chou C. Reliability and Validity of Retrospective Behavioral Self-

Report By Narcotics Addicts. Evaluation Review 1993; 17(91).7. Glasner T, van der Vaart W. Applications of calendar instruments in social surveys:

a review. Quality & Quantity 2009;43(3):333-349.8. Nelson IA. From Quantitative to Qualitative: Adapting the Life History Calendar

Method. Field Methods 2010;22(4):413-428.9. Yoshihama M, Gillespie B, Hammock AC, Belli RE, Tolman RM. Does the Life History

Calendar method facilitate the recall of intimate partner violence? Comparison of two methods of data collection. Social Work Research 2005;29(3):151-163.

10. Yoshihama M, Bybee D. The Life History Calendar Method and Multilevel Modeling: Application to Research on Intimate Partner Violence. Violence against Women 2011;17(3):295-308.

11. Bailey J, Hill KG, Hawkins JD, Catalano RF, Abbott RD. Men's and women's patterns of substance use around pregnancy. Birth-Issues in Perinatal Care 2008;35(1):50-59.

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Acknowledgements

• Participants of the Gender Matters Study• Daphne Guh-Senior Statistician• Centre for Health Evaluation and Outcomes Sciences

(CHEOS)• University of British Columbia -School of Population

& Public Health• Canadian Institutes of Health Research (CIHR)