Control and desire: The issue of identity in popular discourses of addiction

Abstract

Background: Binge drug use has been associated with increased risk of human immunodeficiency virus (HIV) infection and other serious health-related harms among adult drug user populations. This study sought to determine the prevalence and correlates of binge drug use among street-involved youth in a Canadian setting. Methods: From September 2005 to May 2012, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth aged 14–26 years who use illicit drugs. Multivariate generalized estimating equation (GEE) logistic regression was used to identify factors associated with binge drug use. Results: Of the 987 participants included in this analysis, 41.5% reported binge drug use at baseline and another 59.1% reported binge drug use at some point during the study. In multivariate GEE analyses, older age (adjusted odds ratio [AOR]?=?1.11), homelessness (AOR?=?1.67), drug injecting (AOR?=?1.63), non-fatal overdose (AOR?=?1.98), public injecting (AOR?=?1.42), being a victim of violence (AOR?=?1.38), sex work (AOR?=?2.51) and participation in drug dealing (AOR?=?2.04) were independently associated with binge drug use in the previous six months (all p?Discussion: The prevalence of reporting binge drug use among the youth was high in this setting and was independently associated with a range of high-risk activities and markers of vulnerability. Querying high-risk youth about binge drug use may help prioritize those in greatest need of addiction treatment strategies and public health interventions.     

High-Intensity Drug Use and Health Service Access Among Street-Involved Youth in a Canadian Setting

Background/Objectives: Addiction severity has been associated with numerous social- and health-related harms. This study sought to examine the prevalence and correlates of high-intensity drug use among street-involved youth in a Canadian setting with a focus on high-risk drug use practices and health service access.

Methods: Data were derived from the At-Risk Youth Study, a Vancouver-based prospective cohort of street-involved youth aged 14–26. We used generalized estimating equations to examine variables associated with high-intensity drug use, defined as daily use of crack cocaine, cocaine, heroin, or crystal methamphetamine. Results: From September 2005 to November 2012, of 1017 youth included in the analyses, 529 (52%) reported high-intensity drug use as defined above at least once during the study period. In a multivariate analysis, older age (Adjusted Odds Ratio [AOR] = 1.47); residing in the Downtown Eastside of Vancouver (AOR = 1.46); homelessness (AOR = 1.30); recent incarceration (AOR = 1.25); inability to access addiction treatment (AOR = 1.42); and crack pipe sharing and/or used syringe injecting (AOR = 2.64), were all positively and independently associated with high-intensity drug use (p < 0.05). The most common barrier to accessing addiction treatment reported by these youth was long waiting lists. Conclusions: High-intensity drug use among street-involved youth was prevalent and associated with structural and geographical disadvantages in addition to high-risk drug administration practices. Youth reporting more frequent drug use also reported barriers to accessing addiction treatment, highlighting the need to expand addiction services tailored to youth at greatest risk of harm from illicit drug use and street-involvement.     

Adults who misuse opioids: Substance abuse treatment use and perceived treatment need

Background: Opioid use disorder (OUD) and overdose deaths among the US population continue to increase. This study examined associations of OUD and other substance use disorders with substance abuse treatment use and perceived treatment need among US adults aged 18+ who misused opioids. Methods: The 2015–2016 National Survey on Drug Use and Health provided data (n?=?5100 respondents who misused opioids in the past year). We used multivariable logistic regression models to examine associations of opioid and other substance use disorders with treatment use and perceived treatment need, adjusting for sociodemographic and health statuses. Results: The data showed that 4.7% of adults misused opioids and 19.1% of those who misused had an OUD. Of those with an OUD, only 31.5% had received substance abuse treatment in the past year and 13.6% perceived the need for such treatment. Of those with an OUD, heroin use disorder (adjusted odds ratio [AOR]?=?2.59, 95% confidence interval [CI]?=?1.59–4.23) and having been arrested/booked (AOR?=?1.98, 95% CI?=?1.18–3.33) were associated with higher odds of receiving treatment, whereas lack of health insurance (AOR?=?0.49, 95% CI?=?0.25–0.94) was associated with lower odds. Heroin use disorder (AOR?=?2.16, 95% CI?=?1.23–3.83) and higher mental health impairment scores (AOR?=?1.05, 95% CI?=?1.01–1.09) were associated with higher odds of perceived treatment need. Conclusions: The overall low socioeconomic status and high rates of polysubstance use disorders among those with OUD indicate that they need financial and other help to access treatment and relapse prevention services. The very low rates of perceived treatment need also point to the need for strategies to increase individuals’ recognition of their need for treatment.     

Parental Style and Its Association With Substance Use in Argentinean Youth

Background: In Europe and the United States, family relationships and parenting behavior can influence youth substance use, but less is known about their influence in Latin American countries. Objective: To explore whether parenting behavior is associated with substance use among Latin American youth. Methods: A cross-sectional, school-based survey of middle-school youth (n = 3172) in three Argentinian cities queried tobacco, alcohol, and drug use using items adapted from global youth surveys. Parenting behavior was assessed with previously validated items that tapped into demandingness and responsiveness, separately for mothers and fathers. Multilevel logistic regression models assessed associations between parenting behavior and substance use after adjusting for student characteristics, socioeconomic indicators, sensation seeking, and smoking amongst peers and family members. Results: Substance use prevalence was 10% for current smoking, 32% for current drinking alcohol, 17% for past 30-day binge drinking (≥5 drinks), and 8% for previous year illicit drug use (marijuana or cocaine). Greater maternal demandingness was independently associated with lower likelihood of current smoking (adjusted odds ratio [AOR] = 0.77; 95% confidence interval (CI): 0.64–0.92), current drinking (AOR = 0.81; 95% CI: 0.71–0.92), binge drinking (AOR = 0.77; 95% CI: 0.66–0.99, and drug use (AOR = 0.71; 95% CI: 0.61–0.83). No other parenting behavior were independently associated with substance use, except for paternal demandingness and binge drinking (AOR = 0.84; 95% CI: 0.74–0.97). For all outcomes, no interactions were found between parenting behavior and student gender. Conclusions: Among Argentine adolescents, maternal demandingness was the strongest and most consistent correlate of substance use, regardless of adolescent substance use behavior or gender.     

High Prevalence of Self-Reported Exposure to Adulterated Drugs Among People Who Experienced an Opioid Overdose in Canada: A Cohort Study

Background: In North America, rates of overdoses are increasing largely due to the adulteration of illicit drugs by illicit synthetic opioids. Objectives: We sought to examine the prevalence and correlates of self-reported exposure to adulterated drugs among people who experienced a non-fatal opioid overdose. Methods: Data were derived from three prospective cohort studies of people who use drugs in Vancouver, Canada between June and November 2016. Multivariable logistic regression analyses were used to examine the prevalence and correlates of self-reported exposure to adulterated drugs. Results: Among 117 participants who reported symptoms consistent with a non-fatal opioid overdose, 78 (66.7%) reported believing the drug was adulterated during their last overdose. Of those, 42 (53.8%) had not perceived adulteration prior to overdose. In the multivariable analysis, engagement in opioid agonist therapy (Adjusted Odds Ratio [AOR]?=?2.79, 95% Confidence Interval [CI]: 1.10, 7.45) was independently associated with having not perceived adulteration prior to overdose. Daily heroin use (AOR = 5.28; 95% CI: 1.92, 15.97) and reporting supervised injection site staff were present at most recent overdose (AOR = 6.16; 95% CI: 1.25, 47.27) were independently associated with having perceived adulteration prior to overdose. Conclusions/Importance: We found a high prevalence of believing adulterated drugs were present for the most recent overdose. Further, the high prevalence of unperceived adulteration prior to overdose supports the need to lower the risk of overdose by providing individuals with options to consume drugs in a safer manner, including supervised consumption sites.     

Correspondence between Oral Fluid Drug Test Results and Self-Reported Illicit Drug Use among Music Festival Attendees

Background: Use of illicit substances is often under-reported. Testing positive in oral fluid provides an objective confirmation of recent intake. Objectives: To examine the agreement between oral fluid test results and self-reported substance use among music festival attendees, and factors associated with reporting past 48?h drug use among users identified by drug testing. Methods: One thousand three hundred nine participants were recruited from six music festivals in Norway (June–August 2016). They completed a questionnaire and provided oral fluid samples analyzed for amphetamines, MDMA, tetrahydrocannabinol (cannabis), and cocaine. Additionally, their blood alcohol levels were measured. Results: Overall, 5.5% reported use of amphetamines, cannabis, cocaine, and/or MDMA during past 48?h in the questionnaire, whereas 10.8% tested positive in oral fluid. Only 16.7% of identified cocaine users and 31.1% of identified MDMA users reported past 48?h cocaine or MDMA use, respectively. Higher proportions of identified cannabis and amphetamine users reported past 48?h use (53.8% and 55.6%, respectively). Multivariable logistic regression analysis showed that among participants who tested positive, those reporting weekly illicit substance use (Adjusted Odds Ratio [AOR] 30.6; 95% Confidence Interval [CI] 6.3–147.9), and using such substances when younger than 18?years (AOR 5.0; 95% CI 1.9–13.4) were more likely to report past 48?h use. Conclusions/Importance: Oral fluid testing appears to be an important tool when studying illicit substance use among music festival attendees, as significant under-reporting was observed. Among those testing positive, regular, and experienced users were more likely to report recent use, compared to less regular and experienced users.     

Predictors of Illicit Drug Use Among Prisoners

Background: The United States of America currently has the highest incarceration rate in the world, and approximately 80% of incarcerated individuals have a history of illicit drug use. Despite institutional prohibitions, drug use continues in prison, and is associated with a range of negative outcomes. Objectives: To assess the relationship between prison drug use, duration of incarceration, and a range of covariates. Results: Most participants self-reported a history of illicit drug use (77.5%). Seven percent reportedly used drugs during the previous six months of incarceration (n = 100). Participants who had been incarcerated for more than a year were less likely than those incarcerated for longer than a year to report using drugs (OR = 0.50; 95% CI = 0.26–0.98). Participants aged 37–89 were less likely than younger prisoners to use drugs (OR = 0.39; 95% CI = 0.19–0.80). Heroin users were twice as likely as nonheroin users to use drugs (OR = 2.28; 95% CI = 1.04–5.03); crack cocaine users were also twice as likely as participants with no history of crack cocaine usage to report drug use (OR = 2.53; 95% CI = 1.13–5.69). Conclusions: Correctional institutions should be used as a resource to offer evidence-based services to curb drug usage. Drug treatment programs for younger prisoners, heroin and crack cocaine users, and at the beginning of a prisoner's sentence should be considered for this population.     

Lifetime Doctor-Diagnosed Mental Health Conditions and Current Substance Use Among Gay and Bisexual Men Living in Vancouver,Canada

Background: Studies have found that gay, bisexual, and other men who have sex with men (GBM) have higher rates of mental health conditions and substance use than heterosexual men, but are limited by issues of representativeness. Objectives: To determine the prevalence and correlates of mental health disorders among GBM in Metro Vancouver, Canada. Methods: From 2012 to 2014, the Momentum Health Study recruited GBM (≥16 years) via respondent-driven sampling (RDS) to estimate population parameters. Computer-assisted self-interviews (CASI) collected demographic, psychosocial, and behavioral information, while nurse-administered structured interviews asked about mental health diagnoses and treatment. Multivariate logistic regression using manual backward selection was used to identify covariates for any lifetime doctor diagnosed: (1) alcohol/substance use disorder and (2) any other mental health disorder. Results: Of 719 participants, 17.4% reported a substance use disorder and 35.2% reported any other mental health disorder; 24.0% of all GBM were currently receiving treatment. A lifetime substance use disorder diagnosis was negatively associated with being a student (AOR = 0.52, 95% CI [confidence interval]: 0.27–0.99) and an annual income ≥$30,000 CAD (AOR = 0.38, 95% CI: 0.21–0.67) and positively associated with HIV-positive serostatus (AOR = 2.54, 95% CI: 1.63–3.96), recent crystal methamphetamine use (AOR = 2.73, 95% CI: 1.69–4.40) and recent heroin use (AOR = 5.59, 95% CI: 2.39–13.12). Any other lifetime mental health disorder diagnosis was negatively associated with self-identifying as Latin American (AOR = 0.25, 95% CI: 0.08–0.81), being a refugee or visa holder (AOR = 0.18, 95% CI: 0.05–0.65), and living outside Vancouver (AOR = 0.52, 95% CI: 0.33–0.82), and positively associated with abnormal anxiety symptomology scores (AOR = 3.05, 95% CI: 2.06–4.51). Conclusions: Mental health conditions and substance use, which have important implications for clinical and public health practice, were highly prevalent and co-occurring.     

Perception of High Alcohol Use of Peers Is Associated With High Personal Alcohol Use in First-Year University Students in Three Central and Eastern European Countries

Objectives: The objectives of this study were to assess discrepancies between estimated peer and personal drinking behavior and to determine associations between perceptions of peer and personal drinking behavior among university students from Hungary (HU), Lithuania (LT), and the Slovak Republic (SK). Methods: 2,554 freshman university students completed an online questionnaire on the frequency of their personal alcohol use, the number of heavy drinking occasions and on their perception concerning the corresponding drinking behavior of a typical student. Associations between perceived peer and personal use were analyzed by means of logistic regression, adjusting for sex. Results: The majority of students across all countries thought their peers drink more frequently and are more often involved in heavy drinking occasions than themselves. Students who perceived the frequency of peer alcohol use to be higher were more likely to drink alcohol twice a week or more often (SR: OR = 3.81, 95% CI = 2.51–5.79; LT: OR = 3.16, 95% CI = 2.11–4.75; HU: OR = 2.10, 95% CI = 1.53–2.87) compared with students who drink alcohol monthly or less. Those who perceived the number of peer heavy drinking occasions as high were more likely to report heavy drinking weekly or more often (SR: OR = 3.16, 95% CI = 1.92–5.20; LT:OR = 3.56, 95% CI = 2.14–5.94; HU:OR = 1.41, 95% CI = 0.79–2.51) compared with students who report heavy drinking less than monthly. Conclusions/Importance: University students perceived peer alcohol use to be higher than their personal use. Given the association between perceptions and personal alcohol use, future research should investigate if targeting perceptions in the surveyed countries may have an impact on alcohol use.     

Prevalence and Correlates of Any and Frequent Synthetic Cannabinoid Use in a Representative Sample of High School Students

Background: There is increasing evidence that Synthetic Cannabinoid (SC) use is associated with adverse health effects, but little is known about the prevalence of SC use and risk and protective factors for SC use among adolescents. Objectives: To determine the prevalence and correlates of any and frequent SC use in a representative sample of high school students. Methods: The 2013 Youth Risk Behavior Survey was administered to 3,928 high school students in Nevada. A state-added question assessed any and frequent SC use (10 or more times). Weighted logistic regression identified factors for both outcomes. Results: 17.3% of students reported SC use and 4.3% used SCs frequently. As expected, there were strong associations between SC use and other substance use. After controlling for substance use, any SC use was associated with being Hispanic (AOR = 1.74; 95% CI = 1.27, 2.38) and living in a rural county (AOR = 1.68; 95% CI = 1.26, 2.23). Frequent SC use was higher among students who were male (AOR = 2.14; 95% CI = 1.19, 3.84), 18 years of age (AOR = 2.34; 95% CI = 1.18, 4.67), lived in a rural county (AOR = 1.84; 95% CI = 1.11, 3.04), and were offered, sold, or given illegal drugs on school property (AOR = 2.40; 95% CI = 1.53, 3.79). Protective factors for frequent SC use included high parental monitoring (AOR = 0.54; 95% CI = 0.31, 0.93) and sports team participation (AOR = 0.61; 95% CI = 0.37, 0.99). Conclusions/Importance: SC prevention policies and programs should focus on adolescents who live in rural settings and engage in substance use. Initiatives to address drug availability as school and promote parent involvement are also warranted.     

Patterns of Mood and Personality Factors and Associations With STI/HIV-Related Drug and Sex Risk Among African American Male Inmates

Background: Research on the association between antisocial personality disorder (ASPD) with comorbid mental disorders and sexually transmitted infection (STI)/HIV risk among inmates is scant despite the high prevalence of psychopathology and of STI/HIV in this population. Methods: We used baseline data from Project DISRUPT, a cohort study conducted among incarcerated African American men (n = 207), to measure associations between ASPD and STI/HIV risk. We also conducted latent class analyses (LCAs) to identify subgroups defined by ASPD with comorbid stress, depression, and borderline personality disorder symptoms and measured associations between latent class membership and STI/HIV risk. Results: Approximately 15% had ASPD and 39% reported depression. Controlling for sociodemographics, stress, and depression, ASPD was independently associated with illicit [AOR = 3.23, 95% confidence interval (CI): 1.18–8.87] and injection drug use (AOR: 5.49, 95% CI: 1.23–24.42) but not with sexual risk. LCAs suggested that those at high risk of ASPD were likely to experience co-morbid mental disorders. ASPD comorbid with these disorders was linked to drug and sex risk. Conclusions: STI/HIV prevention for inmates should incorporate diagnosis and treatment of ASPD and comorbid disorders, and interventions to address ASPD-related factors (e.g., impulsivity) that drive STI/HIV risk.     

Neighborhood of residence and risk of initiation into injection drug use among street-involved youth in a Canadian setting

Background

While research has suggested that exposure to environments where drug use is prevalent may be a key determinant of drug-related risk, little is known regarding the impact of such exposure on the initiation of illicit injection drug use. We assessed whether neighborhood of residence predicted rates of injecting initiation among a cohort of street-involved youth in Vancouver, British Columbia.

Methods

We followed street-involved injecting naïve youth aged 14–26 and compared rates of injecting initiation between youth residing in Vancouver's Downtown Eastside (DTES) neighborhood (the site of a large street-based illicit drug market) to those living in other parts of the city. Univariate and multivariate Cox regression analyses were employed to determine whether residence in the DTES was independently associated with increased risk of initiation of injection drug use.

Results

Between September, 2005 and November, 2011, 422 injection-naïve individuals were followed, among whom 77 initiated injecting for an incidence density of injecting of 10.3 (95% confidence interval [CI] 5.0–18.8) per 100 person years. In a multivariate model, residence in the DTES was independently associated with initiating injection drug use (adjusted hazard ratio [AHR] = 2.16, 95% CI: 1.33–3.52, p = 0.002).

Conclusions

These results suggest neighborhood of residence affects the risk of initiation into injection drug use among street-involved youth. The development of prevention interventions should target high-risk neighborhoods where risk of initiating into injecting drug use may be greatest.     

Health care engagement behaviors of men who use performance- and image-enhancing drugs in Australia

Abstract

Background: Although people who inject performance- and image-enhancing drugs (PIEDs) report fewer unsafe injecting practices, stigma and discrimination may negatively impact their access to help and information. Engagement with health care services, compared with social networks (friends, relatives, and gym associates) and the Internet and media (steroid user forums, information sites, and magazines), may be important for harm minimization. Methods: A cross-sectional Internet or in-person survey of men who use PIEDs in Australia in 2014–2015 examined differences in sources for PIEDs, injecting equipment, and anabolic-androgenic steroids (AAS) information and factors associated with having periodical medical checks related to PIEDs issues using multivariate logistic regression. Results: In total, 267 men (mean age: 25?years, SD: 8.7?years; 246 of 267 [92%] reported recent AAS injection) were recruited. Most participants sourced injecting equipment from health professionals, PIEDs from their social networks, and AAS information from the Internet and media. Self-reported AAS knowledge was high and frequent. Higher income (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.03, 4.00), ≥2 different PIEDs used in addition to AAS (AOR: 1.94, 95% CI: 1.08, 3.49), and sourcing AAS information from health care professionals (AOR: 3.14, 95% CI: 1.81, 5.46) were independently associated with periodical medical checks. Participants nominated preference for improved health services through needle-syringe programs, primary care services, and peer educator support groups. Conclusion: Men who use PIEDs in Australia consider themselves well informed but tend to use Internet and media sources, providing potentially misleading or inaccurate information. Increasing trust between men who use PIEDs and health care providers may enable delivery of PIEDs-specific information to those at greatest need.     

Introductory editorial

Syringe sharing continues to play an integral part in HIV epidemics involving injection drug users around the world. We examined the prevalence of syringe sharing among Canadian street youth enrolled in a prospective cohort study known as the At-Risk Youth Study (ARYS), and used logistic regression to examine factors associated with syringe sharing. Among 509 participants, 154 (30%) had injected drugs in the last 6 months and of those 44 (29%) injectors had shared a syringe in the previous 6 months. In logistic regression, being female (adjusted odds ratio [AOR] = 2.31, [95%CI: 1.01–5.28]), binge drug use (AOR = 2.11 [95%CI: 0.99–4.51]) and injection cocaine use (AOR = 2.43 [95%CI: 1.05–5.60]) remained associated with syringe sharing. These data indicate that, in order to reduce the potential for an explosive HIV epidemic among this population, further interventions are urgently needed to address the high level of syringe sharing among street-involved youth.     

Conduct Disorder Symptoms and Illicit Drug Use in Juvenile Justice Involved Youth: The Reciprocal Relationship Between Positive Illicit Drug-Use Attitudes and Illicit Drug Use

Conduct disorder (CD) symptoms cooccur at high rates with illicit drug use in juvenile justice involved youth, which results in poorer outcomes; however, research has not identified where best to intervene in this relationship, limiting the identification of modifiable risk factors to reduce negative effects of CD symptoms. Two mediation models were examined to investigate the potential for CD symptoms to influence a reciprocal relationship between illicit drug use and positive drug attitudes, controlling for age, gender, and race. Data were examined for 245 juvenile justice involved youth (mean age = 15.46, SD = 1.30, range 12–18, 64.9% Black, 80.4% male) who completed court-ordered psychological assessments. Findings indicate: (1) Positive attitudes toward illicit drug use significantly mediated the relationship between CD symptoms and illicit drug use (β = 0.16, CI 0.09–0.27; test for indirect effect z = 4.17, p < .001) and (2) illicit drug use significantly mediated the relationship between CD symptoms and positive attitudes toward illicit drug use (β = 0.20, CI 0.12–0.32; test for indirect effect z = 4.87, p < .001). Overall, the present study suggests that CD symptoms impart risk for illicit drug use both indirectly, through more positive attitudes toward illicit drug use, and directly, which further strengthens positive attitudes toward illicit drug use.     

Short-term injection drug use changes following hepatitis C virus (HCV) assessment and treatment among persons who inject drugs with acute HCV infection

BackgroundIt is unclear whether treatment and care for hepatitis C virus (HCV) infection can help people who inject drugs (PWID) modify their injection drug use behaviours. This study examined changes in injection drug use among PWID with acute HCV systematically referred for HCV clinical assessment and treatment and offered targeted health care services, over the course of one year.MethodsThe study sample included PWID with documented acute HCV infection recruited and followed-up semi-annually at least twice in IMPACT (2007–2015), a longitudinal community-based prospective study in Montréal, Canada. Following enrolment, participants with contra-indications to treatment due to severe co-morbidity were offered targeted health care services. Pegylated interferon-alpha (12–24 weeks) was offered to all other participants who did not spontaneously resolve their infection. At each study visit, data were collected on socio-demographic factors and drug use patterns. Logistic regression was used to assess changes in injection drug use at one-year follow-up.ResultsOf the 87 eligible participants (mean age: 35.6; 78.2% male), 21.8% received treatment [(RT), Sustained virological response: 84.2%], 25.3% spontaneously resolved their infection (SR), 14.9% had contra-indication(s) (CI) and 37.9% chose not to engage in HCV care post-diagnosis (NE). In multivariate analyses adjusting for age, gender and injection drug use at baseline, the RT [Adjusted odds ratio (AOR): 0.18; 95% Confidence interval (CI): 0.04–0.76], SR (AOR: 0.34; 95% CI: 0.08–1.40), and CI (AOR: 0.24; 95% CI: 0.05–1.22) groups were less likely to report injection drug use at follow-up relative to the NE group.ConclusionPWID who received treatment, spontaneously resolved their infection or presented with treatment contra-indication(s) reported reduced injection drug use at one-year follow-up relative to those who did not engage in therapy. Findings suggest that the benefits of HCV assessment and treatment may extent to helping PWID modify their injection drug use patterns.     

Offer of financial incentives for unprotected sex in the context of sex work

Introduction and Aims. Commercial sex workers (CSW) are often portrayed as vectors of disease transmission. However, the role clients play in sexual risk taking and related decision making has not been thoroughly characterised. Design and Methods. Participants were drawn from the Vancouver Injection Drug Users Study, a longitudinal cohort. Analyses were restricted to those who reported selling sex between June 2001 and December 2005. Using multivariate generalised estimating equation, we evaluated the prevalence of and factors associated with being offered money for sex without a condom. Results. A total of 232 CSW were included in the analyses, with 73.7% reporting being offered more money for condom non‐use, and 30.6% of these CSW accepting. Variables independently associated with being offered money for sex without a condom included daily speedball use [adjusted odds ratio (AOR) = 1.21, 95% confidence interval (CI): 0.23–0.62], daily crack smoking (AOR = 1.51, 95% CI: 1.04–2.19), daily heroin injection (AOR = 1.76, 95% CI: 1.27–2.43) and drug use with clients (AOR = 3.22, 95% CI: 2.37–4.37). Human immunodeficiency virus seropositivity was not significant (AOR = 0.98, 95% CI: 0.67–1.44). Discussion and Conclusions. Findings highlight the role clients play in contributing to unprotected sex through economic influence and exploitation of CSW drug use. HIV serostatus has no bearing on whether more money is offered for sex without a condom. Novel interventions should target both CSW and clients. [Johnston CL, Callon C, Li K, Wood E, Kerr T. Offer of financial incentives for unprotected sex in the context of sex work. Drug Alcohol Rev 2009]