1
|
Howard-Azzeh M, Wasfi R, Kakkar T, Flynn M, Rotondo J, Schleihauf E, Bowes M, Rees EE. Spatiotemporal epidemiology of substance-related accidental acute toxicity deaths in Canada from 2016 to 2017. BMC Public Health 2024; 24:1641. [PMID: 38898445 PMCID: PMC11188508 DOI: 10.1186/s12889-024-18883-2] [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: 01/23/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES In Canada, substance-related accidental acute toxicity deaths (AATDs) continue to rise at the national and sub-national levels. However, it is unknown if, where, when, and to what degree AATDs cluster in space, time, and space-time across the country. The objectives of this study were to 1) assess for clusters of AATDs that occurred in Canada during 2016 and 2017 at the national and provincial/territorial (P/T) levels, and 2) examine the substance types detected in AATD cases within each cluster. METHODS Two years of person-level data on AATDs were abstracted from coroner and medical examiner files using a standardized data collection tool, including the decedent's postal code and municipality information on the places of residence, acute toxicity (AT) event, and death, and the substances detected in the death. Data were combined with Canadian census information to create choropleth maps depicting AATD rates by census division. Spatial scan statistics were used to build Poisson models to identify clusters of high rates (p < 0.05) of AATDs at the national and P/T levels in space, time, and space-time over the study period. AATD cases within clusters were further examined for substance types most present in each cluster. RESULTS Eight clusters in five regions of Canada at the national level and 24 clusters in 15 regions at the P/T level were identified, highlighting where AATDs occurred at far higher rates than the rest of the country. The risk ratios of identified clusters ranged from 1.28 to 9.62. Substances detected in clusters varied by region and time, however, opioids, stimulants, and alcohol were typically the most commonly detected substances within clusters. CONCLUSION Our findings are the first in Canada to reveal the geographic disparities in AATDs at national and P/T levels using spatial scan statistics. Rates associated with substance types within each cluster highlight which substance types were most detected in the identified regions. Findings may be used to guide intervention/program planning and provide a picture of the 2016 and 2017 context that can be used for comparisons of the geographic distribution of AATDs and substances with different time periods.
Collapse
Affiliation(s)
- Mohammad Howard-Azzeh
- Health Promotion and Chronic Disease Prevention Branch, Substance-Related Harms Division, Public Health Agency of Canada, Ontario, Canada.
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Ontario, Canada.
| | - Rania Wasfi
- Public Health Risk Sciences Division, National Microbiology Laboratory, Public Health Agency of Canada, Quebec, Canada
| | - Tanya Kakkar
- Health Promotion and Chronic Disease Prevention Branch, Substance-Related Harms Division, Public Health Agency of Canada, Ontario, Canada
| | - Mallory Flynn
- Department of Statistics, University of British Columbia, British Columbia, Canada
| | - Jenny Rotondo
- Health Promotion and Chronic Disease Prevention Branch, Substance-Related Harms Division, Public Health Agency of Canada, Ontario, Canada
| | - Emily Schleihauf
- Canadian Public Health Service, Public Health Agency of Canada, Ontario, Canada
| | - Matthew Bowes
- Nova Scotia Medical Examiner Service, Department of Justice, Nova Scotia, Canada
| | - Erin E Rees
- Public Health Risk Sciences Division, National Microbiology Laboratory, Public Health Agency of Canada, Quebec, Canada
- Department of Pathology and Microbiology, Faculty of Veterinary Medicine, University of Montreal, Quebec, Canada
| |
Collapse
|
2
|
Min JE, Guerra-Alejos BC, Yan R, Palis H, Barker B, Urbanoski K, Pauly B, Slaunwhite A, Bach P, Ranger C, Heaslip A, Nosyk B. Opioid Coprescription Through Risk Mitigation Guidance and Opioid Agonist Treatment Receipt. JAMA Netw Open 2024; 7:e2411389. [PMID: 38748421 PMCID: PMC11096992 DOI: 10.1001/jamanetworkopen.2024.11389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/12/2024] [Indexed: 05/18/2024] Open
Abstract
Importance At the onset of the COVID-19 pandemic, the government of British Columbia, Canada, released clinical guidance to support physicians and nurse practitioners in prescribing pharmaceutical alternatives to the toxic drug supply. These alternatives included opioids and other medications under the risk mitigation guidance (RMG), a limited form of prescribed safer supply, designed to reduce the risk of SARS-CoV-2 infection and harms associated with illicit drug use. Many clinicians chose to coprescribe opioid medications under RMG alongside opioid agonist treatment (OAT). Objective To examine whether prescription of hydromorphone tablets or sustained-release oral morphine (opioid RMG) and OAT coprescription compared with OAT alone is associated with subsequent OAT receipt. Design, Setting, and Participants This population-based, retrospective cohort study was conducted from March 27, 2020, to August 31, 2021, included individuals from 10 linked health administrative databases from British Columbia, Canada. Individuals who were receiving OAT at opioid RMG initiation and individuals who were receiving OAT and eligible but unexposed to opioid RMG were propensity score matched at opioid RMG initiation on sociodemographic and clinical variables. Data were analyzed between January 2023 and February 2024. Exposure Opioid RMG receipt (≥4 days, 1-3 days, or 0 days of opioid RMG dispensed) in a given week. Main Outcome and Measures The main outcome was OAT receipt, defined as at least 1 dispensed dose of OAT in the subsequent week. A marginal structural modeling approach was used to control for potential time-varying confounding. Results A total of 4636 individuals (2955 [64%] male; median age, 38 [31-47] years after matching) were receiving OAT at the time of first opioid RMG dispensation (2281 receiving ongoing OAT and 2352 initiating RMG and OAT concurrently). Opioid RMG receipt of 1 to 3 days in a given week increased the probability of OAT receipt by 27% in the subsequent week (adjusted risk ratio, 1.27; 95% CI, 1.25-1.30), whereas receipt of opioid RMG for 4 days or more resulted in a 46% increase in the probability of OAT receipt in the subsequent week (adjusted risk ratio, 1.46; 95% CI, 1.43-1.49) compared with those not receiving opioid RMG. The biological gradient was robust to different exposure classifications, and the association was stronger among those initiating opioid RMG and OAT concurrently. Conclusions and Relevance This cohort study, which acknowledged the intermittent use of both medications, demonstrated that individuals who were coprescribed opioid RMG had higher adjusted probability of continued OAT receipt or reengagement compared with those not receiving opioid RMG.
Collapse
Affiliation(s)
- Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | | | - Ruyu Yan
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Heather Palis
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Brittany Barker
- First Nations Health Authority, Vancouver, British Columbia, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Karen Urbanoski
- School of Public Health and Social Policy, University of Victoria, Victoria, British Columbia, Canada
- Canadian Institute for Substance Use Research, Victoria, British Columbia, Canada
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, Victoria, British Columbia, Canada
- Department of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Amanda Slaunwhite
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Corey Ranger
- AVI Health and Community Services, Victoria, British Columbia, Canada
| | - Ashley Heaslip
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Island Medical Program, University of Victoria, Victoria, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
3
|
Schneider KE, Martin EM, Allen ST, Morris M, Haney K, Saloner B, Sherman SG. Volatile drug use and overdose during the first year of the COVID-19 pandemic in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104371. [PMID: 38447262 PMCID: PMC11056297 DOI: 10.1016/j.drugpo.2024.104371] [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: 09/25/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Overdose deaths in the United States rose substantially during the COVID-19 pandemic. Disruptions to the drug supply and service provision introduced significant instability into the lives of people who use drugs (PWUD), including volatility in their drug use behaviors. METHODS Using data from a multistate survey of PWUD, we examined sociodemographic and drug use correlates of volatile drug use during COVID-19 using multivariable linear regression. In a multivariable logistic regression model, we assessed the association between volatile drug use and past month overdose adjusting for sociodemographic and other drug use characteristics. RESULTS Among participants, 52% were male, 50% were white, 29% had less than a high school education, and 25% were experiencing homelessness. Indicators of volatile drug use were prevalent: 53% wanted to use more drugs; 45% used more drugs; 43% reported different triggers for drug use, and 23% used drugs that they did not typically use. 14% experienced a past-month overdose. In adjusted models, hunger (β=0.47, 95% CI: 0.21-0.72), transactional sex (β=0.50, 95% CI: 0.06-0.94), and the number of drugs used (β=0.16, 95% CI: 0.07-0.26) were associated with increased volatile drug use. Volatile drug use was associated with increased overdose risk (aOR=1.42, 95% CI: 1.17-1.71) in the adjusted model. CONCLUSIONS Volatile drug use during the COVID-19 pandemic was common, appeared to be driven by structural vulnerability, and was associated with increased overdose risk. Addressing volatile drug use through interventions that ensure structural stability for PWUD and a safer drug supply is essential for mitigating the ongoing overdose crisis.
Collapse
Affiliation(s)
- Kristin E Schneider
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Emily M Martin
- 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
| | - Miles Morris
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Katherine Haney
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Brendan Saloner
- Department of Health Policy and Management, 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
| |
Collapse
|
4
|
Saatchi A, Zarkovic T, Borden S, Palaty J, Gill C. Therapeutic drug monitoring of clozapine in human serum by high-throughput paper spray mass spectrometry. J Mass Spectrom Adv Clin Lab 2024; 32:41-46. [PMID: 38419980 PMCID: PMC10899010 DOI: 10.1016/j.jmsacl.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Monitoring the atypical antipsychotic drug clozapine is crucial to ensure patient safety. This article showcases a high-throughput analytical method for measuring clozapine and its primary metabolite norclozapine (N-desmethylclozapine) in serum using paper spray mass spectrometry (PS-MS). Objectives This study aimed to assess the viability of a PS-MS method for the rapid measurement of clozapine and norclozapine in human serum samples as an alternative to liquid chromatography mass spectrometry (LC-MS). Methods Serum samples were processed by protein precipitation followed by deposition of the supernatant containing labelled internal standards onto paper spray substrates mounted in cartridges. Analytes were then analyzed using a triple quadrupole mass spectrometer equipped with a commercial paper spray ionization source. The results obtained from the patient samples were compared to those from a validated LC-MS assay. Results PS-MS calibrations for clozapine and norclozapine were linear (R2 > 0.99) over five days. Between-run precision was below 8 %, and within-run precision did not exceed 10 %. When compared to a validated LC-MS method, the mean bias for 39 patient samples was -9% for clozapine and -1% for norclozapine, with no outliers. Mass spectrometry ion ratio comparisons indicated no interference for patient samples above the lower limit of quantification. There was less than 7 % change in the measured concentrations of both analytes over five days for samples dried on paper substrates. Notably, virtually no maintenance of the MS source was required during this study. Conclusion This study illustrates the potential of PS-MS for serum drug monitoring in the clinical laboratory.
Collapse
Affiliation(s)
- A. Saatchi
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - T.M. Zarkovic
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - S.A. Borden
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - J. Palaty
- Fraser Health Authority, Vancouver, BC, Canada
| | - C.G. Gill
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
- Department of Chemistry, Simon Fraser University, Burnaby, BC, Canada
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
- Canadian Institute for Substance Use Research (CISUR), University of Victoria, Victoria, BC, Canada
| |
Collapse
|
5
|
Gozdzialski L, Louw R, Kielty C, Margolese A, Poarch E, Sherman M, Cameron F, Gill C, Wallace B, Hore D. Beyond a spec: assessing heterogeneity in the unregulated opioid supply. Harm Reduct J 2024; 21:63. [PMID: 38491435 PMCID: PMC10941387 DOI: 10.1186/s12954-024-00980-5] [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: 01/24/2024] [Accepted: 03/03/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Drug checking services aim to provide compositional information for the illicit drug supply and are being employed in public health responses to extreme rates of overdose associated with fentanyl within street opioids. The technologies used within these services range from basic qualitative tests, such as immunoassay test strips, to comprehensive quantitative analyses, such as mass spectrometry. In general, there is concern that heterogeneity of a drug mixture adds significant uncertainty when using drug checking results based on a small subsamples. The presence of hot spots of active drug components in this context is often termed the 'chocolate chip cookie effect'. Establishing the limitations of the service are essential for interpretation of the results. METHODS This study assesses the consequence of drug heterogeneity and sampling of consumer level opioid purchased in Victoria, British Columbia ( n = 21 , 50-100 mg each) on quantitative fentanyl results determined from testing with paper spray mass spectrometry. RESULTS Using descriptive statistics, such as relative standard deviation and interquartile range, the results demonstrate varied distributions of fentanyl concentrations within a single drug batch. However, the presence of hot spots, defined as outliers, were relatively rare. CONCLUSIONS This study found that the variability in fentanyl concentration from drug heterogeneity and sampling is greater than that attributed to the analytical technique. On a practical level, this provides data to help guide communication of limitations of drug checking services, supporting the aim of trust and transparency between services and people who use drugs. However, if drug checking services continue to be restricted from fully engaging with the reality of manufacturing, buying, selling, mixing and dosing practices, the accuracy, usefulness, and impact will always be limited.
Collapse
Affiliation(s)
- Lea Gozdzialski
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | - Rebecca Louw
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | - Collin Kielty
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | - Ava Margolese
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | - Eric Poarch
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | - Miriam Sherman
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | | | - Chris Gill
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
- Applied Environmental Research Laboratories (AERL), Department of Chemistry, Vancouver Island University, Nanaimo, V9R 5S5, Canada
- Department of Chemistry, Simon Fraser University, Burnaby, V5A 1S6, Canada
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, 98195, USA
| | - Bruce Wallace
- School of Social Work, University of Victoria, Victoria, V8W 2Y2, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada
| | - Dennis Hore
- Department of Chemistry, University of Victoria, Victoria, V8W 2Y2, Canada.
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, V8N 5M8, Canada.
- Department of Computer Science, University of Victoria, Victoria, V8W 3P6, Canada.
| |
Collapse
|
6
|
Duhart Clarke SE, Victor G, Lynch P, Suen LW, Ray B. Cannabis donation as a harm reduction strategy: a case study. Harm Reduct J 2024; 21:58. [PMID: 38449029 PMCID: PMC10916026 DOI: 10.1186/s12954-024-00974-3] [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: 01/11/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND The United States (US) continues to experience unprecedented rates of overdose mortality and there is increased need to identify effective harm reduction practices. Research from Canada describes cannabis donation through harm reduction agencies as an adjunctive strategy to mitigate the negative consequences of more harmful drugs. This case study describes the operational logistics, feasibility, and potential benefits of a cannabis donation program that was operated through a harm reduction program in rural Michigan. CASE PRESENTATION We applied a community driven research approach to gather information from harm reduction program staff about the implementation and evolution of cannabis donation efforts in Michigan. We also examined 20-months (September 2021 through May 2023) of administrative data from a cannabis company to compare the sale and donation of cannabis products. Ten cannabis-experienced harm reduction clients received cannabis donations, with clinical staff determining client interest and appropriateness, and providing weekly pick-up or delivery. To expand product availability and sustainability, we examined administrative data from a commercialcannabis company that volunteered to provide donations. This administrative data suggests that while flower products constitute most of the adult and medical sales, edible, oil, and topical products predominated donations. Further, cost analysis suggests that donations represent only 1% of total gross sales and account for much less than the expected yearly donation amount. CONCLUSIONS Research suggests there is potential to reduce alcohol and drug use related harms of more dangerous substances through substitution with cannabis. This case study is the first to document cannabis donation as a harm reduction practice in the US and suggests potential for sustainability dependent on state laws. Findings from this case study provide a starting point for inquiry into cannabis donation as a harm reduction strategy in the US; future research is needed to fully understand the individual-level outcomes, public health impacts, necessary legal regulations, and best practices for cannabis donation programs through harm reduction organizations.
Collapse
Affiliation(s)
| | - Grant Victor
- School of Social Work, Rutgers University, 120 Albany Street, New Brunswick, NJ, 08901, USA
| | - Pamela Lynch
- RTI International, 3040 Cornwallis Road, 27709, Research Triangle Park, NC, USA
| | - Leslie W Suen
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, 2540 23rd Street, San Francisco, CA, USA
| | - Bradley Ray
- RTI International, 3040 Cornwallis Road, 27709, Research Triangle Park, NC, USA
| |
Collapse
|
7
|
Kurz M, Guerra-Alejos BC, Min JE, Barker B, Pauly B, Urbanoski K, Nosyk B. Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia. Implement Sci 2024; 19:3. [PMID: 38184548 PMCID: PMC10771688 DOI: 10.1186/s13012-023-01331-x] [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: 08/02/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers. METHODS We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals' peers, defined as the proportion of a prescribers' professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after. RESULTS Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers. CONCLUSIONS The uptake of PSS in BC was highly dependent on the behavior of prescribers' peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.
Collapse
Affiliation(s)
- Megan Kurz
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada
| | | | - Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | - Brittany Barker
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada
- First Nations Health Authority, Vancouver, BC, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Bernadette Pauly
- Department of Nursing, University of Victoria, Victoria, BC, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Karen Urbanoski
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada.
| |
Collapse
|
8
|
Kennedy MC, Dong H, Tobias S, Buxton JA, Lysyshyn M, Tupper KW, Ti L. Fentanyl Concentration in Drug Checking Samples and Risk of Overdose Death in Vancouver, Canada. Am J Prev Med 2024; 66:10-17. [PMID: 37633426 DOI: 10.1016/j.amepre.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION The proliferation of fentanyl and its analogs in illegal, unregulated drug markets remains a major driver of the overdose crisis in North America. Drug checking services have been implemented as a harm reduction strategy to address the crisis. However, little is known about their potential utility as a mechanism for monitoring population-level risk of overdose stemming from changing fentanyl concentration in unregulated drugs over time. Therefore, this study assessed the relationship between median fentanyl concentration in expected opioid drug checking samples and the death rate due to illicit drug toxicity over time in Vancouver, Canada. METHODS Monthly population-based rates of death due to illicit drug toxicity were drawn from provincial coroner records. Monthly median percent fentanyl concentration was calculated using a validated quantification model from point-of-care Fourier-transform infrared spectra among expected opioid samples that tested positive for fentanyl at community drug checking services. A time-series analysis using generalized additive modeling was conducted to examine the association between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, controlling for calendar month. Analyses were conducted in 2021-2022. RESULTS Between January 2019 and October 2020, 577 deaths due to illicit drug toxicity occurred in Vancouver, and the observed monthly rate ranged from 1.75 to 7.65 deaths per 100,000 population. A significant, positive association was observed between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, adjusting for calendar month (chi-square=52.21, p<0.001). CONCLUSIONS Findings suggest a role for point-of-care drug checking as a tool for monitoring evolving overdose risk at the population level.
Collapse
Affiliation(s)
- Mary Clare Kennedy
- School of Social Work, Faculty of Health and Social Development, The University of British Columbia - Okanagan Campus, Kelowna, British Columbia, Canada; British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.
| | - Huiru Dong
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; Harvard Medical School, Boston, Massachusetts; Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel Tobias
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mark Lysyshyn
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Kenneth W Tupper
- School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada; School of Child and Youth Care, Faculty of Human and Social Development, University of Victoria, Victoria, British Columbia, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
9
|
Falzon D, Parkes T, Carver H, Masterton W, Wallace B, Craik V, Measham F, Sumnall H, Gittins R, Hunter C, Watson K, Mooney JD, Aston EV. "It would really support the wider harm reduction agenda across the board": A qualitative study of the potential impacts of drug checking service delivery in Scotland. PLoS One 2023; 18:e0292812. [PMID: 38096231 PMCID: PMC10721102 DOI: 10.1371/journal.pone.0292812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/28/2023] [Indexed: 12/17/2023] Open
Abstract
Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures.
Collapse
Affiliation(s)
- Danilo Falzon
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, United Kingdom
| | - Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, United Kingdom
| | - Hannah Carver
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, United Kingdom
| | - Wendy Masterton
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, United Kingdom
| | - Bruce Wallace
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Vicki Craik
- Public Health Scotland, Glasgow, United Kingdom
| | - Fiona Measham
- Department of Sociology, Social Policy and Criminology, University of Liverpool, Liverpool, United Kingdom
- The Loop, Registered Charity, Manchester, United Kingdom
| | - Harry Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | | | - Carole Hunter
- Alcohol and Drug Services, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Kira Watson
- Scottish Ambulance Service, Edinburgh, United Kingdom
| | - John D. Mooney
- Public Health Directorate, NHS Grampian, Aberdeen, United Kingdom
| | - Elizabeth V. Aston
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| |
Collapse
|
10
|
Ferguson M, Choisil P, Lamb J, Burmeister C, Newman C, Lock K, Tobias S, Liu L, Buxton JA. Associations with experience of non-fatal opioid overdose in British Columbia, Canada: a repeated cross sectional survey study. Harm Reduct J 2023; 20:178. [PMID: 38093272 PMCID: PMC10717189 DOI: 10.1186/s12954-023-00912-9] [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: 10/15/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Lives lost in North America due to the unregulated drug poisoning emergency are preventable and those who survive an opioid overdose may suffer long-term disability. Rates of opioid overdose more than doubled following the onset of the COVID-19 pandemic in British Columbia, Canada. MATERIALS AND METHODS Our analytical sample was comprised of 1447 participants from the 2018, 2019, and 2021 Harm Reduction Client Survey who responded yes or no to having experienced an opioid overdose in the past 6 months. Participants were recruited from harm reduction sites from across British Columbia. We used logistic regression to explore associations of experiencing an opioid overdose. RESULTS Overall, 21.8% of participants reported experiencing an opioid overdose in the last six months (18.2% in 2019 and 26.6% in 2021). The following factors were positively associated with increased adjusted odds of experiencing a non-fatal opioid overdose: cis men relative to cis women (AOR 1.49, 95% CI 1.10-2.02), unstably housed compared to people with stable housing (AOR 1.87, 95% CI 1.40-2.50), and participants from 2021 compared to those from 2019 (AOR 3.06, 95% CI 1.57-5.97). The effects of both previous experience of a stimulant overdose and having witnessed an opioid overdose depended on the year of study, with both effects decreasing over subsequent years. CONCLUSIONS Overdoses have increased over time; in 2021 more than one in four participants experienced an overdose. There is an urgent need for policy and program development to meaningfully address the unregulated drug poisoning emergency through acceptable life-saving interventions and services to prevent overdoses and support overdose survivors.
Collapse
Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Paul Choisil
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jessica Lamb
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | | | - Cheri Newman
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Samuel Tobias
- British Centre on Substance Use, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Liu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
| |
Collapse
|
11
|
Small W, O'Callaghan S. Commentary on Brothers et al.: The role of safer environment interventions in addressing injecting-related bacterial and fungal infections. Addiction 2023; 118:1878-1880. [PMID: 37544882 DOI: 10.1111/add.16313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Will Small
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Sean O'Callaghan
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| |
Collapse
|
12
|
Swartz JA, Lieberman M, Jimenez AD, Mackesy-Amiti ME, Whitehead HD, Hayes KL, Taylor L, Prete E. Current attitudes toward drug checking services and a comparison of expected with actual drugs present in street drug samples collected from opioid users. Harm Reduct J 2023; 20:87. [PMID: 37420196 DOI: 10.1186/s12954-023-00821-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND The opioid epidemic continues to be associated with high numbers of fatalities in the USA and other countries, driven mainly by the inclusion of potent synthetic opioids in street drugs. Drug checking by means of various technologies is being increasingly implemented as a harm reduction strategy to inform users about constituent drugs in their street samples. We assessed how valued drug checking services (DCS) would be for opioid street drug users given the ubiquity of fentanyl and related analogs in the drug supply, the information they would most value from drug checking, and compared expected versus actual constituent drugs in collected samples. METHODS A convenience sample of opioid street drug users (N = 118) was recruited from two syringe service exchange programs in Chicago between 2021 and 2022. We administered brief surveys asking about overdose history, whether fentanyl was their preferred opioid, and interest in DCS. We also collected drug samples and asked participants what drug(s) they expected were in the sample. Provided samples were analyzed using LC-MS technology and the results compared to their expected drugs. RESULTS Participants reported an average of 4.4 lifetime overdoses (SD = 4.8, range = 0-20) and 1.1 (SD = 1.8, range = 0-10) past-year overdoses. A majority (92.1%) believed they had recently used drugs containing fentanyl whether intentionally or unintentionally. Opinions about the desirability of fentanyl were mixed with 56.1% indicating they did not and 38.0% indicating they did prefer fentanyl over other opioids, mainly heroin. Attitudes toward DCS indicated a general but not uniform receptiveness with a majority indicating interest in DCS though sizeable minorities believed DCS was "too much trouble" (25.2%) or there was "no point" in testing (35.4%). Participants were especially inaccurate identifying common cutting agents and potentiating drugs such as diphenhydramine in their samples (sensitivity = .17). CONCLUSIONS Results affirmed street drug users remain interested in using DCS to monitor their drugs and such services should be more widely available. Advanced checking technologies that provide information on the relative quantities and the different drugs present in a given sample available at point-of-care, would be most valuable but remain challenging to implement.
Collapse
Affiliation(s)
- James A Swartz
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison Street, (MC 309), Chicago, IL, 60607, USA.
| | - Marya Lieberman
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, USA
| | - A David Jimenez
- Community Health Sciences, School of Public Health, University of Illinois Chicago, Chicago, USA
| | - Mary Ellen Mackesy-Amiti
- Community Health Sciences, School of Public Health, University of Illinois Chicago, Chicago, USA
| | - Heather D Whitehead
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, USA
| | - Kathleen L Hayes
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, USA
| | | | | |
Collapse
|
13
|
Al Bahri AA, Hamnett HJ. Etizolam and Its Major Metabolites: A Short Review. J Anal Toxicol 2023; 47:216-226. [PMID: 36477341 DOI: 10.1093/jat/bkac096] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/16/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Etizolam is a benzodiazepine (BZD). Etizolam is structurally different from BZDs as a thiophene replaces the benzene ring and a triazole ring is fused to the diazepine ring, but etizolam's pharmacological profile is similar. Etizolam has been used to treat anxiety and panic disorders, to reduce depressive and somatization symptoms and to induce muscle relaxation. Etizolam is used recreationally due to its reinforcing and sedative effects. Etizolam is available in tablet or powder form or administered on blotter paper that can be placed on the tongue for oral absorption. Etizolam metabolizes into two major metabolites: α-hydroxyetizolam and 8-hydroxyetizolam, and all three compounds can be detected in different biological specimens using various common analytical techniques such as immunoassay, chromatography and mass spectrometry. Etizolam is a controlled drug in many countries around the globe but is approved for medical use in some countries, such as Japan, South Korea and Italy. This work is a collation and review of available literature on etizolam to help improve the fundamental understanding of its toxicology, outline best analytical practice, and aid interpretation of toxicology results.
Collapse
Affiliation(s)
- Abdul Aziz Al Bahri
- Forensic Toxicologist Specialist, Forensic Science Laboratory, PO Box 446, Muscat, 113, Oman
| | - Hilary J Hamnett
- Associate Professor in Forensic Science, School of Chemistry, University of Lincoln, Green Lane, Lincoln, Lincolnshire, LN6 7DL, UK
| |
Collapse
|
14
|
Dart RC. What Is Old Is True in Drug Abuse: Street Level Emergency and An Epidemic of Drug-Related Deaths. Ann Emerg Med 2023; 81:323-324. [PMID: 36813437 DOI: 10.1016/j.annemergmed.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO.
| |
Collapse
|
15
|
Wallace B, van Roode T, Burek P, Hore D, Pauly B. Everywhere and for everyone: proportionate universalism as a framework for equitable access to community drug checking. Harm Reduct J 2022; 19:143. [PMID: 36539747 PMCID: PMC9763810 DOI: 10.1186/s12954-022-00727-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Illicit drug overdoses have reached unprecedented levels, exacerbated by the COVID-19 pandemic. Responses are needed that address the increasingly potent and unpredictable drug supply with better reach to a wide population at risk for overdose. Drug checking is a potential response offered mainly within existing harm reduction services, but strategies are needed to increase reach and improve equitable delivery of drug checking services. METHODS The purpose of this qualitative study was to explore how to extend the reach of drug checking services to a wide population at risk of overdose. We conducted 26 in-depth interviews with potential service users to identify barriers to service use and strategies to increase equitable delivery of drug checking services. Our analysis was informed by theoretical perspectives on equity, and themes were developed relevant to equitable delivery through attention to quality dimensions of service use: accessibility, appropriateness, effectiveness, safety, and respect. RESULTS Barriers to equitable service delivery included criminalization and stigma, geographic and access issues, and lack of cultural appropriateness that deter service use for a broad population with diverse needs. Strategies to enhance equitable access include 1ocating services widely throughout communities, integrating drug checking within existing health care services, reframing away from risk messaging, engaging peers from a broad range of backgrounds, and using discrete methods of delivery to help create safer spaces and better reach diverse populations at risk for overdose. CONCLUSIONS We propose proportionate universalism in drug checking as a guiding framework for the implementation of community drug checking as an equity-oriented harm reduction intervention and as a population health response. Both a universal equity-oriented approach and multiple tailored approaches are required to facilitate drug checking services that maximize reach and appropriateness to respond to diverse needs.
Collapse
Affiliation(s)
- Bruce Wallace
- grid.143640.40000 0004 1936 9465Canadian Institute for Substance Use Research (CISUR), University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada ,grid.143640.40000 0004 1936 9465School of Social Work, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Thea van Roode
- grid.143640.40000 0004 1936 9465Canadian Institute for Substance Use Research (CISUR), University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Piotr Burek
- grid.143640.40000 0004 1936 9465Canadian Institute for Substance Use Research (CISUR), University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Dennis Hore
- grid.143640.40000 0004 1936 9465Department of Chemistry, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC Canada ,grid.143640.40000 0004 1936 9465Department of Computer Science, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada
| | - Bernadette Pauly
- grid.143640.40000 0004 1936 9465Canadian Institute for Substance Use Research (CISUR), University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada ,grid.143640.40000 0004 1936 9465School of Nursing, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W 2Y2 Canada
| |
Collapse
|