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Moe J, Buxton JA, Wang YE, Chavez T, Feldman-Kiss D, Marr C, Purssell RA, Otterstatter M. Physiologic oxygen responses to smoking opioids: an observational study using continuous pulse oximetry at overdose prevention services in British Columbia, Canada. Harm Reduct J 2024; 21:89. [PMID: 38702702 PMCID: PMC11067188 DOI: 10.1186/s12954-024-01011-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND In British Columbia, Canada, smoking is the most common modality of drug use among people who die of opioid toxicity. We aimed to assess oxygen saturation (SpO2) while people smoked opioids during a pilot study that introduced continuous pulse oximetry at overdose prevention services (OPS) sites. METHODS This was an observational cohort study, using a participatory design. We implemented our monitoring protocol from March to August 2021 at four OPS. We included adults (≥ 18 years) presenting to smoke opioids. A sensor taped to participants' fingers transmitted real-time SpO2 readings to a remote monitor viewed by OPS staff. Peer researchers collected baseline data and observed the timing of participants' inhalations. We analyzed SpO2 on a per-event basis. In mixed-effects logistic regression models, drop in minimum SpO2 ≤ 90% in the current minute was our main outcome variable. Inhalation in that same minute was our main predictor. We also examined inhalation in the previous minute, cumulative inhalations, inhalation rate, demographics, co-morbidities, and substance use variables. RESULTS We recorded 599 smoking events; 72.8% (436/599) had analyzable SpO2 data. Participants' mean age was 38.6 years (SD 11.3 years) and 73.1% were male. SpO2 was highly variable within and between individuals. Drop in SpO2 ≤ 90% was not significantly associated with inhalation in that same minute (OR: 1.2 [0.8-1.78], p = 0.261) or inhalation rate (OR 0.47 [0.20-1.10], p = 0.082). There was an association of SpO2 drop with six cumulative inhalations (OR 3.38 [1.04-11.03], p = 0.043); this was not maintained ≥ 7 inhalations. Demographics, co-morbidities, and drug use variables were non-contributory. CONCLUSIONS Continuous pulse oximetry SpO2 monitoring is a safe adjunct to monitoring people who smoke opioids at OPS. Our data reflect challenges of real-world monitoring, indicating that greater supports are needed for frontline responders at OPS. Inconsistent association between inhalations and SpO2 suggests that complex factors (e.g., inhalation depth/duration, opioid tolerance, drug use setting) contribute to hypoxemia and overdose risk while people smoke opioids.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Jane A Buxton
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population of Public Health, University of British Columbia, 2206 East Mall, V6T 1Z8, Vancouver, BC, Canada
| | - Yueqiao Elle Wang
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Tamara Chavez
- CoVaRR-Net's Indigenous Engagement, Development, and Research Pillar 7, University of British Columbia, 103-1690 Nelson Street, Vancouver, BC, V6G 1M5, Canada
| | - Damian Feldman-Kiss
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Charotte Marr
- Portland Hotel Society, 9 East Hastings Street, Vancouver, BC, V6A 1M9, Canada
| | - Roy A Purssell
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Michael Otterstatter
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
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Cid A, Mahajan N, Wong WWL, Beazely M, Grindrod KA. An economic evaluation of community pharmacy-dispensed naloxone in Canada. Can Pharm J (Ott) 2024; 157:84-94. [PMID: 38463179 PMCID: PMC10924576 DOI: 10.1177/17151635241228241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 03/12/2024]
Abstract
Aims To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada. Methods We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted. Results Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone. Conclusion Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Ashley Cid
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Nikita Mahajan
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - William W L Wong
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Michael Beazely
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Kelly A Grindrod
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
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Bardwell G, Ivsins A, Wallace JR, Mansoor M, Kerr T. "The machine doesn't judge": Counternarratives on surveillance among people accessing a safer opioid supply via biometric machines. Soc Sci Med 2024; 345:116683. [PMID: 38364722 DOI: 10.1016/j.socscimed.2024.116683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/16/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs.
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Affiliation(s)
- Geoff Bardwell
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada; British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - James R Wallace
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | - Manal Mansoor
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Moe J, Chavez T, Marr C, Cameron F, Feldman-Kiss D, Wang YE, Xavier JC, Mamdani Z, Purssell RA, Salmon A, Buxton JA. Feeling safer: effectiveness, feasibility, and acceptability of continuous pulse oximetry for people who smoke opioids at overdose prevention services in British Columbia, Canada. Harm Reduct J 2024; 21:45. [PMID: 38378610 PMCID: PMC10877878 DOI: 10.1186/s12954-024-00963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/12/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Smoking is the most common mode of unregulated opioid consumption overall and implicated in fatal overdoses in British Columbia (BC). In part, perception of decreased risk (e.g., fewer who smoke carry naloxone kits) and limited smoking-specific harm reduction services contribute to overdose deaths. Overdose prevention services (OPS) offer supervised settings for drug use. Continuous pulse oximetry, common in acute care, allows real-time, remote oxygen monitoring. We evaluated the effectiveness of a novel continuous pulse oximetry protocol aimed at allowing physical distancing (as required by COVID-19, secluded spaces, and to avoid staff exposure to vaporized opioids), its feasibility, and acceptability at OPS for people who smoke opioids. METHODS This was a mixed methods survey study. We developed a continuous pulse oximetry protocol in collaboration with clinical experts and people with lived/living experience of substance use. We implemented our protocol from March to August 2021 at four OPS in BC permitting smoking. We included adults (≥ 18 years) presenting to OPS to smoke opioids. Peer researchers collected demographic, health, and substance use information, and conducted structured observations. OPS clients participating in our study, OPS staff, and peer researchers completed post-monitoring surveys. We analyzed responses using a thematic inductive approach and validated themes with peer researchers. RESULTS We included 599 smoking events. OPS clients participating in our study had a mean age of 38.5 years; 73% were male. Most (98%) reported using "down", heroin, or fentanyl; 48% concurrently used other substances (32% of whom reported stimulants); 76% reported smoking alone in the last 3 days; and 36% reported an overdose while smoking. Respondents reported that the protocol facilitated physical distancing, was easy to use, high satisfaction, improved confidence, improved sense of safety, and that they would use it again. CONCLUSIONS Continuous pulse oximetry allowed safe physical distancing, was feasible, and acceptable in monitoring people who smoke opioids at OPS.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, Diamond Health Care Centre, University of British Columbia, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
- BC Centre for Disease Control, 655 West 12 Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Tamara Chavez
- CoVaRR-Net's Indigenous Engagement, Development, and Research Pillar 7, University of British Columbia, 103-1690 Nelson Street, Vancouver, BC, V6G 1M5, Canada
| | - Charotte Marr
- Portland Hotel Society, 9 East Hastings Street, Vancouver, BC, V6A 1M9, Canada
| | - Fred Cameron
- SOLID Outreach Society, 1056 North Park Street, Victoria, BC, V8T 1C6, Canada
| | - Damian Feldman-Kiss
- Department of Emergency Medicine, Diamond Health Care Centre, University of British Columbia, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Yueqiao Elle Wang
- Department of Emergency Medicine, Diamond Health Care Centre, University of British Columbia, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Jessica C Xavier
- BC Centre for Disease Control, 655 West 12 Avenue, Vancouver, BC, V5Z 4R4, Canada
- University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Zahra Mamdani
- BC Children's and Women's Hospital, 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Roy A Purssell
- Department of Emergency Medicine, Diamond Health Care Centre, University of British Columbia, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- BC Centre for Disease Control, 655 West 12 Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Amy Salmon
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 570-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- School of Population of Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z8, Canada
| | - Jane A Buxton
- BC Centre for Disease Control, 655 West 12 Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population of Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z8, Canada
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Karamouzian M, Cui Z, Hayashi K, DeBeck K, Reddon H, Buxton JA, Kerr T. Longitudinal polysubstance use patterns and non-fatal overdose: A repeated measures latent class analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024:104301. [PMID: 38182524 PMCID: PMC11222307 DOI: 10.1016/j.drugpo.2023.104301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 11/06/2023] [Accepted: 12/15/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Polysubstance use (PSU) is common among people who use opioids (PWUO) and has been associated with drug-related harms. We aimed to identify latent longitudinal PSU classes among a cohort of PWUO and characterize non-fatal overdose risks among different sub-classes over time. METHODS We used longitudinal data (2005-2018) from three ongoing prospective cohorts of people who use drugs in Vancouver, Canada. The primary outcome of interest was self-reported non-fatal overdose during the past six months. The primary exposure of interest was longitudinal PSU patterns among PWUO, obtained from repeated measures latent class analysis (RMLCA) of weekly substance use-related outcome indicators. Multivariable generalized estimating equations models were built to assess the association between latent PSU class membership and non-fatal overdose, adjusting for potential sociodemographic, behavioural, and structural confounders. RESULTS 2627 PWUO were included in the analysis, and 1094 (41.6 %) had experienced at least one non-fatal overdose during the study period. RMLCA revealed five distinct latent longitudinal PSU classes, including low/infrequent use (Class 1; 30 %), primarily opioid and methamphetamine use (Class 2; 22 %), primarily cannabis use (Class 3; 15 %), primarily opioid and crack use (Class 4; 29 %), and frequent PSU (Class 5; 4 %). In comparison with Class 1 (low), membership in all latent PSU classes except Class 3 (cannabis) was associated with increased odds of non-fatal overdose: Class 2 (opioids + meth) vs. Class 1 (Adjusted odds ratios [aOR] = 2.20, 95 % confidence intervals [CI]: 1.51-3.22), Class 4 (opioids + crack) vs. Class 1 (aOR = 1.06, 95 % CI: 0.85-1.33), and Class 5 (frequent) vs. Class 1 (aOR = 2.39, 95 % CI: 1.92-2.97). CONCLUSION Our findings highlighted the heterogeneous characteristics of PWUO in terms of patterns of PSU and non-fatal overdose risk. The diverse nature of PWUO and the potential additive or multiplicative impact of using several substances on overdoses should be reflected across the substance use treatment continuum and care provision.
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Affiliation(s)
- Mohammad Karamouzian
- Centre on Drug Policy Evaluation, Saint Michael's Hospital, Toronto, ON M5B 1T8, Canada; British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada.
| | - Zishan Cui
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; School of Public Policy, Simon Fraser University, Burnaby, BC V6B 5K3, Canada
| | - Hudson Reddon
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, BC V6Z 1Y6, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, BC V6Z 1Y6, Canada
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Watson DP, Ray B, Phalen P, Duhart Clarke SE, Taylor L, Swartz J, Gastala N. Fentanyl Exposure and Detection Strategies Utilized by Clinical Trial Participants Seeking Linkage to Opioid Use Disorder Treatment at a Syringe Service Program. J Med Toxicol 2024; 20:13-21. [PMID: 38048033 PMCID: PMC10774457 DOI: 10.1007/s13181-023-00979-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/30/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023] Open
Abstract
INTRODUCTION The USA continues to face a fentanyl-driven overdose epidemic. Prior research has demonstrated users of illicit opioids are concerned about fentanyl exposure and overdose, but the strategies they report using to detect fentanyl's presence lack empirical support. This study compares self-report and biologically detected fentanyl use and investigates overdose risk and risk reduction behaviors among a sample of high-risk people who use opioids. METHODS Structured enrollment interviews conducted as part of a larger clinical trial assessed self-reported fentanyl exposure as well as strategies used to determine believed fentanyl exposure and prevent overdose among 240 participants enrolled at a Chicago, IL syringe service program. Urinalysis measured actual fentanyl exposure. RESULTS Most participants identified as African American (66.7%) and had considerable overdose experience (76.7% lifetime and 48% in the past year). Most also tested positive for fentanyl (93.75%) despite reporting no past year use of fentanyl or fentanyl-adulterated drugs (64.17%). The most utilized approaches reported for identifying fentanyl exposure were stronger effects of the drug (60.7%), sight or taste (46.9%), and being told by someone using the same drugs (34.2%). Few participants (14%) reported using fentanyl test strips. No significant associations were identified between self-report and urinalysis measures or urinalysis results and risk reduction strategies. CONCLUSION This study adds to prior fentanyl exposure risk research. The disconnect between participants' fentanyl detection methods and reported overdose experiences supports the need for more research to identify and understand factors driving access and use of overdose prevention resources and strategies.
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Affiliation(s)
- Dennis P Watson
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA.
| | - Bradley Ray
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Peter Phalen
- Department of Psychiatry, University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA
| | - Sarah E Duhart Clarke
- RTI International, 3040 Cornwallis Road, Research Triangle Park, Chapel Hill, NC, 27709, USA
| | - Lisa Taylor
- Chestnut Health Systems, Lighthouse Institute, 221 W Walton Street, Chicago, IL, 60610, USA
| | - James Swartz
- Jane Addams College of Social Work, The University of Illinois at Chicago, 1040 W Harrison Street, Chicago, IL, 60607, USA
| | - Nicole Gastala
- Department of Family Medicine, Mile Square Health Centers, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
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Tilhou AS, Zaborek J, Baltes A, Salisbury-Afshar E, Malicki J, Brown R. Association of Fentanyl Test Strip Use, Perceived Overdose Risk, and Naloxone Possession among People Who Use Drugs. Subst Use Misuse 2023; 59:254-257. [PMID: 37807227 DOI: 10.1080/10826084.2023.2267130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background: As opioid overdoses continue rising, interventions are needed to expand naloxone carriage, an opioid overdose reversal agent. Use of fentanyl test strips (FTS) might promote naloxone carriage. This study examines the relationship between FTS use, perceived overdose risk, and naloxone carriage in Wisconsin, United States. Methods: In a survey of people who use drugs (n = 341) in southern Wisconsin, respondents were asked about FTS use, perceived overdose risk, and how often they (1) have naloxone, (2) have more than one dose of naloxone, and (3) the number of naloxone doses possessed currently. Likert responses were mapped to an integer scale. Ordinal and linear multivariable regression examined the relationship between FTS use and study outcomes while adjusting for respondent characteristics. Results: Most respondents were male (59.6%), identified heroin as their drug of choice (70.7%) and reported intravenous use (87.9%). In unadjusted models, FTS use was associated with more often having naloxone (OR: 2.10; p = 0.005), more often having multiple naloxone doses (OR: 2.98; p < 0.001), and possessing a greater number of naloxone doses (dose count difference: 2.85; p = 0.001). In adjusted models, FTS use was associated with more often having multiple naloxone doses (OR: 2.29; p = 0.005) and possessing a greater number of naloxone doses (dose count difference: 2.25, p = 0.020). Conclusions: Individuals who use FTS more often carry multiple doses relative to individuals who do not use FTS. Given that naloxone carriage is critical for reducing opioid overdose risk, expanding FTS use may offer a strategy to reduce opioid overdose rates via improved naloxone carriage.
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Affiliation(s)
- Alyssa S Tilhou
- Department of Family Medicine, Boston University/Boston Medical Center, Boston, Massachusetts, USA
| | - Jen Zaborek
- Department of Biostatistics & Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Elizabeth Salisbury-Afshar
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Julia Malicki
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Randall Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Zinsli KA, Banta-Green CJ, Whiteside LK, Hood J, Kingston S, Tinsley J, Moreno C, Glick SN. Trends and correlates of naloxone possession and use among people who inject drugs in Seattle, Washington. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104272. [PMID: 38057247 DOI: 10.1016/j.drugpo.2023.104272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 10/27/2023] [Accepted: 11/16/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Naloxone distribution has been implemented as an essential opioid overdose prevention measure for people who inject drugs (PWID), and many jurisdictions in the United States have implemented policy change to increase naloxone access. This project describes temporal trends in and correlates of naloxone possession and use among PWID in the Seattle area of Washington State. METHODS Using a repeat cross-sectional design, we utilized two sets of serial cross-sectional surveys of PWID, which included biennial surveys of Seattle area syringe service program (SSP) clients and community-based National HIV Behavioral Surveillance surveys of PWID (NHBS-PWID) conducted from 2012-2019. Survey participant characteristics were descriptively compared between participants reporting naloxone possession to those not reporting naloxone possession. Multivariable Poisson regression was used to calculate prevalence ratios for naloxone possession comparing later to earlier survey years, adjusting for age, gender, race/ethnicity, primary drug, and experiencing and witnessing an overdose in the past 12 months. RESULTS Naloxone possession and use increased in both survey populations. The prevalence of possessing naloxone was 2.8 times greater [2019 vs. 2013= 95% CI: 2.40-3.33] among SSP participants and 2.8 times greater [2018 vs. 2012=95% CI: 2.41-3.16] among NHBS-PWID participants for the most recent time period. The prevalence of naloxone use was 1.3 times greater [2019 vs. 2017= 95% CI: 1.13-1.58] and 2.1 times greater [2015 vs. 2012=95% CI:1.62-2.73] among SSP and NHBS-PWID participants, respectively, for the most recent time period. CONCLUSION Naloxone possession and use increased in PWID in the Seattle area from 2012-2019, and is, at least in part, likely the result of numerous policy and programmatic efforts to facilitate easier naloxone accessibility in the wake of dramatic increases in overdose mortality. Further research on disparities in naloxone possession are needed to ensure equitable access.
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Affiliation(s)
- Kaitlin A Zinsli
- Department of Epidemiology, University of Washington, Seattle WA, USA.
| | - Caleb J Banta-Green
- Addictions, Drug and Alcohol Institute, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lauren K Whiteside
- School of Medicine, Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Julia Hood
- HIV/STD Program, Public Health - Seattle and King County, Seattle, WA, USA
| | - Susan Kingston
- Addictions, Drug and Alcohol Institute, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Joe Tinsley
- HIV/STD Program, Public Health - Seattle and King County, Seattle, WA, USA
| | - Courtney Moreno
- HIV/STD Program, Public Health - Seattle and King County, Seattle, WA, USA
| | - Sara N Glick
- HIV/STD Program, Public Health - Seattle and King County, Seattle, WA, USA; Division of Allergy and Infectious Disease, School of Medicine, University of Washington, Seattle, WA, USA
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Kamal A, Ferguson M, Xavier JC, Liu L, Graham B, Lock K, Buxton JA. Smoking identified as preferred mode of opioid safe supply use; investigating correlates of smoking preference through a 2021 cross-sectional study in British Columbia. Subst Abuse Treat Prev Policy 2023; 18:27. [PMID: 37194018 DOI: 10.1186/s13011-023-00515-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/04/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND The increasing number of illicit drug toxicity deaths in British Columbia (BC) has led to calls for a regulated (pharmaceutical grade) supply of substances ("safe supply"). In order to inform safe supply recommendations, we aimed to identify why people currently smoke opioids and assess the preferred mode of consumption if people who use opioids were provided with opioid safe supply. METHODS The BC Harm Reduction Client Survey (HRCS) is an annual survey that gathers information about people who use drugs' (PWUD) substance use characteristic with the goal of contributing to evidence-based policy. This study utilized data from the 2021 HRCS. The outcome variable was "prefer smoking opioid safe supply" ('yes/no'). Explanatory variables included participants' demographics, drug use, and overdose characteristics. Bivariate and hierarchical multivariable logistic regressions were conducted to identify factors associated with the outcome. RESULTS Of 282 total participants who indicated a preference for a mode of consumption for opioid safe supply, 62.4% preferred a smokable option and 19.9% preferred to inject if provided with opioid safe supply. Variables significantly associated with the outcome (preferred smoking) included: being 19-29 years old (AOR=5.95, CI =1.93 - 18.31) compared to >50 years old, having witnessed an overdose in the last 6 months (AOR=2.26, CI=1.20 - 4.28), having smoked opioids in the last 3 days (AOR=6.35, CI=2.98 - 13.53) and having a preference to smoke stimulants safe supply (AOR=5.04, CI=2.53 - 10.07). CONCLUSION We found that over half of participants prefer smokable options when accessing opioid safe supply. Currently in BC, there are limited smokable opioid safe supply options as alternatives to the toxic street supply. To reduce overdose deaths, safe supply options should be expanded to accommodate PWUD that prefer smoking opioids.
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Affiliation(s)
- Ariba Kamal
- Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jessica C Xavier
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Lisa Liu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
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Intention to seek emergency medical services during community overdose events in British Columbia, Canada: a cross-sectional survey. Subst Abuse Treat Prev Policy 2022; 17:56. [PMID: 35883186 PMCID: PMC9315848 DOI: 10.1186/s13011-022-00484-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Canada and the United States continue to experience increasing overdose deaths attributed to highly toxic illicit substances, driven by fentanyl and its analogues. Many bystanders report being hesitant to call 9-1-1 at an overdose due to fears around police presence and arrests. In Canada, a federal law was enacted in 2017, the Good Samaritan Drug Overdose Act (GSDOA), to provide protection from simple drug possession and related charges when 9-1-1 is called to an overdose. There is limited evidence, however, that the GSDOA has improved rates of intention to call 9-1-1 at overdose events. We therefore sought to examine intent to call 9-1-1 among persons who received GSDOA education and were at risk of witnessing an overdose. Methods A cross-sectional survey was conducted with people at risk of witnessing an overdose recruited at 19 Take Home Naloxone (THN) program sites across British Columbia as well as online through Foundry from October 2020 to April 2021. Descriptive statistics were used to examine intention to call 9-1-1 at future overdoses. Multivariable logistic regression models were built in hierarchical fashion to examine factors associated with intention to call 9-1-1. Results Overall, 89.6% (n = 404) of the eligible sample reported intention to call 9-1-1. In the multivariable model, factors positively associated with intention to call 9-1-1 included identifying as a cisgender woman (adjusted odds ratio [AOR]: 3.37; 95% CI: 1.19–9.50) and having previous GSDOA awareness ([AOR]: 4.16; 95% CI: 1.62–10.70). Having experienced a stimulant overdose in the past 6 months was negatively associated with intention to call 9-1-1 ([AOR]: 0.24; 95% CI: 0.09–0.65). Conclusion A small proportion of the respondents reported that, despite the enactment of GSDOA, they did not intend to call 9-1-1 and those who were aware of the act were more likely to report an intention to call at future overdose events. Increasing GSDOA awareness and/or additional interventions to support the aims of the GSDOA could address ongoing reluctance to seek emergency medical care by people who use drugs. Supplementary Information The online version contains supplementary material available at 10.1186/s13011-022-00484-0.
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Steinberg A, Mehta A, Papamihali K, Lukac CD, Young S, Graham B, Lock K, Fleury M, Buxton JA. Motivations for concurrent use of uppers and downers among people who access harm reduction services in British Columbia, Canada: findings from the 2019 Harm Reduction Client Survey. BMJ Open 2022; 12:e060447. [PMID: 35501101 PMCID: PMC9062822 DOI: 10.1136/bmjopen-2021-060447] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION An increase in crystal methamphetamine (methamphetamine) use during the overdose epidemic is being observed in British Columbia (BC), Canada, and across North America. Concurrent use (ie, using uppers and downers one after the other or together) can increase the risk of fatal and non-fatal opioid overdose. OBJECTIVES We investigated motivations for concurrent use of uppers and downers, specifically how (eg, in what order) and why people use concurrently, to identify potential interventions to prevent overdose and other harms. SETTING AND PARTICIPANTS The 2019 Harm Reduction Client Survey was administered across 22 harm reduction supply distribution sites in BC (n=621). This thematic analysis examined 307 responses by people who affirmed concurrent use to classify order and reasons for using uppers and downers concurrently. RESULTS Of the 307 people who responded 'yes' to concurrent use, 179 (58.3%) used downers then uppers, 76 (24.8%) used uppers then downers and 184 (59.9%) mixed uppers and downers together. Four main reasons for concurrent use emerged: self-medication, availability and preference, drug effects/properties, and financial and life situation. People who mixed drugs together predominantly wanted to achieve desired drug effects/properties, such as a specific high or balancing stimulating and sedating effects. CONCLUSIONS The ongoing rise in overdoses in BC is multifactorial, and the recent parallel increases in methamphetamine use and concurrent use with opioids may contribute. Qualitative interviews may further elucidate reasons for concurrent use. Addressing reasons for concurrent use identified in this study through harm reduction strategies and education may affect the rates of overdose morbidity and mortality.
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Affiliation(s)
- Abigail Steinberg
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amiti Mehta
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Christine D Lukac
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sara Young
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mathew Fleury
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
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12
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Lukac CD, Steinberg A, Papamihali K, Mehta A, Lock K, Buxton JA. Correlates of concurrent use of stimulants and opioids among people who access harm reduction services in British Columbia, Canada: Findings from the 2019 Harm Reduction Client Survey. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 102:103602. [DOI: 10.1016/j.drugpo.2022.103602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
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13
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Ferguson M, Parmar A, Papamihali K, Weng A, Lock K, Buxton JA. Investigating opioid preference to inform safe supply services: A cross sectional study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 101:103574. [PMID: 35007878 DOI: 10.1016/j.drugpo.2021.103574] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The drug toxicity crisis continues to be a significant cause of death. Over 24,600 people died from opioid toxicity in Canada over the last 5 years. Safe supply programs are required now more than ever to address the high rate of drug toxicity overdose deaths caused by illicit fentanyl and its analogues. This study aims to identify opioid preferences and associated variables to inform further phases of safe supply program implementation. METHODS The Harm Reduction Client Survey, an annual cross-sectional survey of people who use drugs (PWUD), was administered at harm reduction supply distribution sites in BC in October-December 2019. The survey collects information on substance use patterns, associated harms, stigma, and utilization of harm reduction services. Eligibility criteria for survey participation included aged 19 years or older; self-reported substance use of any illicit substance in the past six months, and ability to provide verbal informed consent. We conducted multivariate logistic regression to investigate associations with opioid preference. We used the dichotomized preference for either heroin or fentanyl as an outcome variable. Explanatory variables of interest included: geographic region, urbanicity, gender, age category, Indigenous identity, housing, employment, witnessing or experiencing an overdose, using drugs alone, using drugs at an observed consumption site, injection as preferred mode of use, injecting any drug, frequency of use, and drugs used in last 3 days. RESULTS Of the 621 survey participants, 405 reported a preferred opioid; of these 57.8% preferred heroin, 32.8% preferred fentanyl and 9.4% preferred prescription opioids. The proportion of participants who preferred heroin over fentanyl significantly increased with age. The adjusted odds of a participant 50 or older preferring heroin was 6.76 (95% CI: 2.78-16.41, p-value: < 0.01) times the odds of an individual 29 or under. The adjusted odds of an Indigenous participant reporting a preference for heroin compared to fentanyl was 1.75 (95% CI: 1.03-2.98, p-value: 0.04) the odds of a non-Indigenous participant reporting the same. Adjusted odds of heroin preference also differed between geographic regions within British Columbia, Canada. CONCLUSION Opioid preference differs by age, geographic area, and Indigenous identity. To create effective safe supply programs, we need to engage PWUD about their drugs of choice.
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Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Amrit Parmar
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Anita Weng
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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14
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Adverse events related to bystander naloxone administration in cases of suspected opioid overdose in British Columbia: An observational study. PLoS One 2021; 16:e0259126. [PMID: 34714854 PMCID: PMC8555799 DOI: 10.1371/journal.pone.0259126] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Take-Home Naloxone programs have been introduced across North America in response to rising opioid overdose deaths. There is currently limited real-world data on bystander naloxone administration, overdose outcomes, and evidence related to adverse events following bystander naloxone administration. Methods The research team used descriptive statistics from Take-Home Naloxone administration forms. We explored reported demographic variables and adverse events among people who received by-stander administered naloxone in a suspected opioid overdose event between August 31, 2012 and December 31, 2018 in British Columbia. We examined and contextualized differences across years given policy, program and drug toxicity changes. We used multivariate logistic regression to examine whether an association exists between number of ampoules of naloxone administered and the odds that the recipient will experience withdrawal symptoms. Results A large majority (98.1%) of individuals who were administered naloxone survived their overdose and 69.2% had no or only mild withdrawal symptoms. Receiving three (Adjusted Odds Ratio (AOR) 1.64 (95% Confidence Interval (CI): 1.08–2.48)) or four or more (AOR 2.19 (95% CI: 1.32–3.62)) ampoules of naloxone was significantly associated with odds of moderate or severe withdrawal compared to receiving one ampoule of naloxone. Conclusions This study provides evidence from thousands of bystander reversed opioid overdoses using Take-Home Naloxone kits in British Columbia, and suggests bystander-administered naloxone is safe and effective for opioid overdose reversal. Data suggests an emphasis on titration during bystander naloxone training in situations where the person experiencing overdose can be adequately ventilated may help avoid severe withdrawal symptoms. We identified a decreasing trend in the likelihood of moderate or severe withdrawal over the study period.
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Parent S, Papamihali K, Graham B, Buxton JA. Examining prevalence and correlates of smoking opioids in British Columbia: opioids are more often smoked than injected. Subst Abuse Treat Prev Policy 2021; 16:79. [PMID: 34663374 PMCID: PMC8522853 DOI: 10.1186/s13011-021-00414-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND British Columbia (BC) is in the midst of an opioid overdose crisis. Since 2017, smoking illicit drugs has been the leading mode of drug administration causing overdose death. Yet, little is known about people who smoke opioids, and factors underlying choice of mode of administration. The study objectives are to identify the prevalence and correlates associated with smoking opioids. METHODS The Harm Reduction Client Survey is a monitoring tool used by the BC Centre for Disease Control since 2012. This survey is disseminated to harm reduction sites across BC to understand drug use trends and drug-related harms. We examined data from the survey administered October-December 2019 and performed descriptive, univariate, and multivariate analyses to better understand factors associated with smoking opioids. RESULTS A total of 369 people who used opioids in the past 3 days were included, of whom 251 (68.0%) reported smoking opioids. A total of 109 (29.5%) respondents experienced an overdose in the past 6 months; of these 79 (72.5%) smoked opioids. Factors significantly associated with smoking opioids were: living in a small community (AOR =2.41, CI =1.27-4.58), being a woman (AOR = 1.84, CI = 1.03-3.30), age under 30 (AOR = 5.41, CI = 2.19-13.40) or 30-39 (AOR = 2.77, CI = 1.33-5.78) compared to age ≥ 50, using drugs alone (AOR = 2.98, CI = 1.30-6.83), and owning a take-home naloxone kit (AOR = 2.01, CI = 1.08-3.72). Reported use of methamphetamines within the past 3 days was strongly associated with smoking opioids (AOR = 6.48, CI = 3.51-11.96). CONCLUSIONS Our findings highlight important correlates associated with smoking opioids, particularly the recent use of methamphetamines. These findings identify actions to better respond to the overdose crisis, such as targeted harm reduction approaches, educating on safer smoking, advocating for consumption sites where people can smoke drugs, and providing a regulated supply of opioids that can be smoked.
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Affiliation(s)
- Stephanie Parent
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kristi Papamihali
- Harm Reduction Services, BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Brittany Graham
- Harm Reduction Services, BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jane A Buxton
- Harm Reduction Services, BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
- School of Population and Public Health, University of British Columbia, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
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Biggar E, Papamihali K, Leclerc P, Hyshka E, Graham B, Taylor M, Payer D, Maloney-Hall B, Buxton JA. Towards cross-Canada monitoring of the unregulated street drug supply. BMC Public Health 2021; 21:1678. [PMID: 34525994 PMCID: PMC8441944 DOI: 10.1186/s12889-021-11757-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions. Methods The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018–March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use. Results The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal. Conclusions This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.
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Affiliation(s)
- Emily Biggar
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada.
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Pascale Leclerc
- Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal, 1301 rue Sherbrooke est, Montreal, QC, H2L 1M3, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, 3-300 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Marliss Taylor
- Streetworks, Boyle Street Community Services, 10116-105 Ave, Edmonton, Alberta, T5H 0K2, Canada
| | - Doris Payer
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Bridget Maloney-Hall
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
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17
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Burton G, McAuley A, Schofield J, Yeung A, Matheson C, Parkes T. A systematic review and meta-analysis of the prevalence of take-home naloxone (THN) ownership and carriage. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103298. [PMID: 34078563 DOI: 10.1016/j.drugpo.2021.103298] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Drug-related deaths globally are increasing year on year, with the largest proportion of these being opioid-related. The opioid antagonist naloxone distributed for take-home use ('Take-Home Naloxone (THN)') has been championed as one method of tackling this public health crisis, however to be effective it must be available at an opioid overdose. Ownership and carriage are therefore fundamental to THN success. This study aimed to assess the prevalence of ownership and carriage of THN internationally among people who use drugs (PWUD). METHODS NHS Scotland Journals, AMED, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL Complete, PubMed, Cochrane Library, PROSPERO and grey literature were searched for articles which measured prevalence of THN ownership or carriage between 1996 and 2020. Ownership was defined as report of a personal supply of THN. Carriage was defined as the participant carrying THN on their person at time of data collection or reporting a frequency of how often they carry THN. Risk of bias was evaluated using the Joanna Briggs Checklist for Prevalence Studies. RESULTS Systematic search yielded 6363 papers, with ten eligible papers identified. Eight articles were included in ownership prevalence and five articles included for carriage prevalence, with an overlap of three studies between both measures. Pooled prevalence indicated moderate ownership levels (57%, CI 47-67%) but lower carriage levels (20%, CI 12-31%). Analysis was complicated by the limited number of available studies and lack of standardised terminology and measurement. CONCLUSION Understanding naloxone ownership and carriage globally is hampered by limited evidence and heterogeneity across studies. From the available data, prevalence of THN carriage overall appears low, despite moderate ownership. Given the variation across studies, future research should seek to utilise more standardised terminology and methods of measurement. Furthermore, services distributing THN must ensure the importance of regular carriage of naloxone is consistently emphasised.
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Affiliation(s)
- Gillian Burton
- University of Stirling, Salvation Army Centre for Addiction Services and Research, Colin Bell Building, Stirling, FK9 4LA, Scotland
| | - Andrew McAuley
- Glasgow Caledonian University, 70 Cowcaddens Road, Glasgow, G4 0BA, Scotland.
| | - Joe Schofield
- University of Stirling, Salvation Army Centre for Addiction Services and Research, Colin Bell Building, Stirling, FK9 4LA, Scotland
| | - Alan Yeung
- Glasgow Caledonian University, 70 Cowcaddens Road, Glasgow, G4 0BA, Scotland
| | - Catriona Matheson
- University of Stirling, Salvation Army Centre for Addiction Services and Research, Colin Bell Building, Stirling, FK9 4LA, Scotland
| | - Tessa Parkes
- University of Stirling, Salvation Army Centre for Addiction Services and Research, Colin Bell Building, Stirling, FK9 4LA, Scotland
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Papamihali K, Collins D, Karamouzian M, Purssell R, Graham B, Buxton J. Crystal methamphetamine use in British Columbia, Canada: A cross-sectional study of people who access harm reduction services. PLoS One 2021; 16:e0252090. [PMID: 34038452 PMCID: PMC8153500 DOI: 10.1371/journal.pone.0252090] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/09/2021] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Increased use of crystal methamphetamine ("crystal meth") has been observed across North America and international jurisdictions, including a notable increase in the presence of methamphetamines in illicit drug toxicity deaths in British Columbia (BC), Canada. We used data from a cross-sectional survey and urine toxicology screening to report the prevalence, correlates, and validity of self-reported crystal meth use among clients of harm reduction sites in BC. MATERIALS AND METHODS Survey data were collected from 1,107 participants across 25 communities in BC, through the 2018 and 2019 Harm Reduction Client Survey. We described reported substance use and used a multivariate logistic regression model to characterize crystal meth use. Urine samples provided by a subset of participants were used to derive validity of self-reported three-day crystal meth use compared to urine toxicology screening. RESULTS Excluding tobacco, crystal meth was the most frequently reported substance used in the past three days in 2018 and 2019 (59.7% and 71.7%, respectively). Smoking was the dominant route of administration for crystal meth, crack, heroin, and fentanyl. Multivariate analysis determined significantly higher odds of crystal meth use among those who used opioids (Adjusted Odds Ratio [AOR] = 3.13), cannabis (AOR = 2.10), and alcohol (1.41), and among those who were not regularly housed (AOR = 2.08) and unemployed (AOR = 1.75). Age ≥50 was inversely associated with crystal meth use (AOR = 0.63). Sensitivity of self-reported crystal meth use was 86%, specificity was 86%, positive predictive value was 96%, and negative predictive value was 65%. CONCLUSIONS Crystal meth was the most commonly used substance among clients of harm reduction sites in BC in 2018 and 2019, and was frequently used concurrently with opioids. Comparison to urine samples demonstrated high validity of self-reported crystal meth use. Understanding evolving patterns of substance use will be imperative in tailoring harm reduction and substance use services for individuals that use crystal meth.
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Affiliation(s)
- Kristi Papamihali
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Dylan Collins
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammad Karamouzian
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Roy Purssell
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Drug and Poison Information Centre, Vancouver, British Columbia, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Williams S, King T, Papamihali K, Buxton JA. The implementation and role of a staff naloxone program for non-profit community-based sites in British Columbia: A descriptive study. PLoS One 2021; 16:e0251112. [PMID: 33983996 PMCID: PMC8118334 DOI: 10.1371/journal.pone.0251112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/20/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The BC Centre for Disease Control implemented the Facility Overdose Response Box (FORB) program December 1st, 2016 to train and support non-healthcare service providers who may respond to an overdose in the workplace. The program aims to support staff at non-profit community-based organizations by ensuring policy development, training, practice overdose response exercises, and post-overdose debriefing opportunities are established and implemented. MATERIALS AND METHODS Three data sources were used in this descriptive cross-sectional study: FORB site registration data; naloxone administration forms; and a survey that was distributed to FORB sites in February 2019. FORB program site and naloxone administration data from December 1st, 2016 to December 31st, 2019 were analyzed using descriptive statistics. A Cochran-Armitage test was used to assess trends over time in naloxone administration event characteristics. Site coordinator survey results are reported to supplement findings from administrative data. RESULTS As of December 31st, 2019, FORB was implemented at 613 sites across BC and 1,758 naloxone administration events were reported. The majority (86.3%, n = 1,517) were indicated as overdose reversals. At registration, 43.6% of sites provided housing services, 26.3% offered harm reduction supplies, and 18.6% provided Take Home Naloxone. Refusal to be transported to hospital following overdose events when emergency services were called showed an increasing trend over time. Most respondents (81.3%) reported feeling confident in their ability to respond to the overdose and 59.6% were offered staff debrief. Based on the 89 site survey responses, supports most commonly made available following an overdose were debrief with a fellow staff member (91.0%), debrief with a supervisor (89.9%), and/or counselling services (84.3%). CONCLUSIONS The uptake of the FORB program has contributed to hundreds of overdose reversals in community settings in BC. Findings suggest that the FORB program supports developing staff preparedness and confidence in overdose response in community-based settings.
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Affiliation(s)
- Sierra Williams
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Tanis King
- University of British Columbia, Vancouver, BC, Canada
| | | | - Jane A. Buxton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
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Schneider KE, Urquhart GJ, Rouhani S, Park JN, Morris M, Allen ST, Sherman SG. Practical implications of naloxone knowledge among suburban people who use opioids. Harm Reduct J 2021; 18:47. [PMID: 33910565 PMCID: PMC8080996 DOI: 10.1186/s12954-021-00466-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available. METHODS We used data from 173 PWUO from Anne Arundel County, Maryland, which is located between Baltimore City and Washington, DC. We assessed the prevalence of recently (past 6 months) receiving naloxone and currently having naloxone, the type(s) of the naloxone kits received, and the perceived ease/difficultly of accessing naloxone. We also assessed participants knowledge of where naloxone was available in the community. RESULTS One third (35.7%) of participants had recently received naloxone. Most who had received naloxone received two doses (72.1%), nasal naloxone (86.9%), and education about naloxone use (72.1%). Most currently had naloxone in their possession (either on their person or at home; 78.7%). One third (34.4%) believed naloxone was difficult to obtain in their community. Only half (56.7%) knew of multiple locations where they could get naloxone. The health department was the most commonly identified naloxone source (58.0%). Identifying multiple sources of naloxone was associated with being more likely to perceive that naloxone is easy to access. DISCUSSION Our results suggest that additional public health efforts are needed to make PWUO aware of the range of sources of naloxone in their communities in order to ensure easy and continued naloxone access to PWUO.
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Affiliation(s)
- Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, HH886, Baltimore, MD, 21205, USA.
| | - Glenna J Urquhart
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Saba Rouhani
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Ju Nyeong Park
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Miles Morris
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
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21
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Bardwell G, Lappalainen L. The need to prioritize research, policy, and practice to address the overdose epidemic in smaller settings in Canada. Canadian Journal of Public Health 2021; 112:733-736. [PMID: 33782915 DOI: 10.17269/s41997-021-00504-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/04/2021] [Indexed: 11/17/2022]
Abstract
The majority of research and policy directives targeting opioid use and overdose prevention are based in larger urban settings and not easily adaptable to smaller Canadian settings (i.e., small- to mid-sized cities and rural areas). We identify a variety of research and policy gaps in smaller settings, including limited access to supervised consumption services, safer supply and novel opioid agonist therapy programs, as well as housing-based services and supports. Additionally, we identify the need for novel strategies to improve healthcare access and health outcomes in a more equitable way for people who use drugs, including virtual opioid agonist therapy clinics, episodic overdose prevention services, and housing-based harm reduction programs that are better suited for smaller settings. These programs should be coupled with rigorous evaluation, in order to understand the unique factors that shape overdose risk, opioid use, and service uptake in smaller Canadian settings.
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Affiliation(s)
- Geoff Bardwell
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Leslie Lappalainen
- Department of Family Medicine, Kelowna General Hospital, 2268 Pandosy Street, Kelowna, BC, V1Y 1T2, Canada.,Interior Health Authority, Mental Health and Substance Use, 505 Doyle Ave, Kelowna, BC, V1Y 6V8, Canada
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Papamihali K, Yoon M, Graham B, Karamouzian M, Slaunwhite AK, Tsang V, Young S, Buxton JA. Convenience and comfort: reasons reported for using drugs alone among clients of harm reduction sites in British Columbia, Canada. Harm Reduct J 2020; 17:90. [PMID: 33228676 PMCID: PMC7682134 DOI: 10.1186/s12954-020-00436-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background North American communities are severely impacted by the overdose crisis, particularly in British Columbia (BC), which has the highest toxic drug overdose death rate in Canada. Most fatal overdoses in BC occurred among individuals using alone and in private residences. This study aimed to assess prevalence and reasons for using drugs alone among people accessing harm reduction services in BC. Methods We recruited harm reduction supply distribution site clients from 22 communities across BC. Descriptive statistics and multivariable logistic regression were used to describe factors associated with using alone. Thematic analysis of free-text responses providing reasons for using alone were grouped with survey data and additional themes identified. Results Overall, 75.8% (n = 314) of the study sample (N = 414) reported using drugs alone within the last week. Those that reported using alone did not differ from those that did not by gender, age, urbanicity, or preferred drug use method. Among those that used alone, 73.2% (n = 230) used opioids, 76.8% (n = 241) used crystal meth, 41.4% (n = 130) used crack/cocaine, and 44.6% (n = 140) used alcohol in the past week. Polysubstance use involving stimulants, opioids, and/or benzodiazepines was reported by 68.5% (n = 215) of those that used alone. Additionally, 22.9% (n = 72) of those that used alone had experienced an opioid and/or stimulant overdose in the past 6 months. In a multivariable logistic regression model, having no regular housing and past week crack/cocaine use were associated with using alone (adjusted odds ratio (AOR): 2.27; 95% CI 1.20–4.27 and AOR: 2.10; 95% CI 1.15–3.82, respectively). The most common reason reported for using alone was convenience and comfort of using alone (44.3%). Additional reasons included: stigma/hiding drug use (14.0%); having no one around (11.7%); safety (9.6%); and not wanting to share drugs with others (8.6%). Conclusions Using drugs alone, particularly for convenience and comfort, is ubiquitous among people accessing harm reduction services. Overdose prevention measures that go beyond individual behaviour changes, including providing a safer supply of drugs and eliminating stigma, are paramount to mitigate harms. These interventions are especially necessary as emergence of coronavirus disease may further exacerbate unpredictability of illicit drug content and overdose risk.
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Affiliation(s)
- Kristi Papamihali
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Minha Yoon
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main Street W, Hamilton, ON, L8S 4K1, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Mohammad Karamouzian
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada.,British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Amanda K Slaunwhite
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Vivian Tsang
- Faculty of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Sara Young
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada. .,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada.
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Known fentanyl use among clients of harm reduction sites in British Columbia, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 77:102665. [PMID: 31962283 DOI: 10.1016/j.drugpo.2020.102665] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/30/2019] [Accepted: 01/09/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND North America is in the midst of an opioid overdose epidemic and it is commonly suggested that exposure to fentanyl is unknown. Using a provincial survey of harm reduction site clients, we aimed to characterize known and unknown fentanyl use and their correlates among people who use drugs in British Columbia, Canada. METHODS We recruited 486 clients who were >18 years old and 316 agreed to provide a urine sample for substance use testing. Reported known fentanyl use was defined as a three-level categorical variable assessing recent (i.e., in the previous three days) fentanyl exposure: (i) known exposure; (ii) unknown exposure; and (iii) no exposure. We also assessed any exposure to fentanyl (Yes vs. No) confirmed by urinalysis. Survey data were summarized using descriptive statistics. Multinomial logistic regression and modified Poisson regression models were built to examine different correlates of exposure to fentanyl. RESULTS Median age of the participants was 40 (IQR: 32-49). Out of the 303 eligible participants, 38.7% (117) reported known fentanyl use, 21.7% (66) had unknown fentanyl use, and 39.6% (120) had no recent fentanyl use. In the adjusted multinomial logistic regression model and in comparison with unknown fentanyl use, recent known fentanyl use was significantly associated with self-report of methadone use (aRRR = 3.18), heroin/morphine use (aRRR = 4.40), and crystal meth use (aRRR = 2.95). Moreover, any recent exposure to fentanyl (i.e., positive urine test for fentanyl) was significantly associated with living in urban settings (aPR = 1.49), and self-reporting recent cannabis use (aPR = 0.73), crystal meth (aPR = 1.45), and heroin/morphine use (aPR = 2.48). CONCLUSION The landscape of illicit opioid use is changing in BC and more people are using fentanyl knowingly. The increasing prevalence of known fentanyl use is concerning and calls for further investments in public awareness and public policy efforts regarding fentanyl exposure and risks.
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