How changing income assistance payment schedules impact drug use and related harm

A study published this week in The Lancet Public Health examines how we can use our income assistance systems to address drug use and drug-related harm.

The study, led by University of British Columbia (UBC) medical sociologist Dr. Lindsey Richardson and conducted at the British Columbia Centre on Substance Use (BCCSU), tests whether varying the timing and frequency of income assistance payments can mitigate drug-related harms linked to the existing once-monthly payment schedule that is common across North America and Europe. Monthly synchronized income assistance payments have long been linked to considerable and costly increases in drug use and resulting harm, including overdose, hospital admission, treatment interruption and emergency service calls.

The study finds that varying when people who use drugs receive their income assistance payments reduces escalations in drug use around government payment days as well as individual payment days outside the week of the standard government schedule. However, changes also have unintended consequences that may increase individual drug-related harm, specifically exposure to violence. The study confirms preliminary results reported at multiple scientific meetings.

“As drug use and drug-related harm continue to be a defining public health challenge that has only been exacerbated by the COVID-19 pandemic, innovative thinking about how social and preventive approaches can help mitigate these harms is critical,” says Dr. Richardson, research scientist at BCCSU, associate professor at UBC and principal investigator of the study. “These complex findings signal the potential for the income assistance system to address both the consequences of poverty as well as the severe drug-related harm seen each month around payments.”

Researchers at the BCCSU followed 194 participants in Vancouver, British Columbia for six-month periods between 2015 and 2019 to evaluate the impact of alternative payment schedules. In British Columbia, income assistance is distributed on the last Wednesday of each month.

Two interventions were evaluated in comparison with the standard monthly cheque distribution: a staggered schedule where participants receive payments monthly on a day that does not fall during the week of synchronized government disbursement; and a split and staggered schedule, where participants receive semi-monthly payments two weeks apart on days that do not fall during the week of synchronized government disbursement.

The study found:

• Intervention participants were about one-third as likely to increase their drug use on government payment days when they received their payments either desynchronized from government payments or desynchronized and in smaller increments, particularly in terms of the frequency of use and quantity of substances used.
• Intervention participants were about one-half as likely to increase their drug use on their individual payment days when they received their payments.
• Study analyses also identified that participants in the staggered study group may be more likely to be exposed to violence.

While conducted locally, the study’s findings have important applications for contexts that see drug-related harm concentrate around income support payments. The study illustrates the importance of experimental research in anticipating the intended and unintended effects of social and other policy reforms. It also points to the importance of preventive, in addition to reactive responses such as naloxone administration to the ongoing crisis of drug use, drug toxicity and overdose.

There have been longstanding calls for upstream interventions to address the inequitable distribution of drug-related harm among disadvantaged populations. This study responds with an innovative experimental study specifically focusing on a known social determinant of health, applying sociological knowledge about the social drivers of drug use to a long-identified challenge for individuals, service providers and first responders.

Importantly, the findings of the study do not justify the drug testing of benefit recipients nor the retrenchment or withdrawal of benefits for people who use drugs, practices that are largely deemed unfair, immoral and objectionable.

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