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Kolla G, Pauly B, Cameron F, Hobbs H, Ranger C, McCall J, Majalahti J, Toombs K, LeMaistre J, Selfridge M, Urbanoski K. "If it wasn't for them, I don't think I would be here": experiences of the first year of a safer supply program during the dual public health emergencies of COVID-19 and the drug toxicity crisis. Harm Reduct J 2024; 21:111. [PMID: 38849866 PMCID: PMC11157725 DOI: 10.1186/s12954-024-01029-3] [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: 01/20/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model. METHODS This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study. RESULTS Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability. CONCLUSIONS Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets.
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Affiliation(s)
- Gillian Kolla
- Memorial University, St. John's, Canada.
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada.
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | | | - Corey Ranger
- AVI Health and Community Services, Victoria, Canada
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | - Kim Toombs
- AVI Health and Community Services, Victoria, Canada
| | | | - Marion Selfridge
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
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Michaud L, Kolla G, Rudzinski K, Guta A. Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104423. [PMID: 38642543 DOI: 10.1016/j.drugpo.2024.104423] [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: 10/30/2023] [Revised: 02/26/2024] [Accepted: 04/06/2024] [Indexed: 04/22/2024]
Abstract
The ongoing overdose and drug toxicity crisis in North America has contributed momentum to the emergence of safer supply prescribing and programs in Canada as a means of providing an alternative to the highly volatile unregulated drug supply. The implementation and scale-up of safer supply have been met with a vocal reaction on the part of news media commentators, conservative politicians, recovery industry representatives, and some prominent addiction medicine physicians. This reaction has largely converged around several narratives, based on unsubstantiated claims and anecdotal evidence, alleging that safer supply programs are generating a "new opioid epidemic", reflecting an emerging alignment among key institutional and political actors. Employing situational analysis method, and drawing on the policy studies and social science scholarship on moral panics, this essay examines news media coverage from January to July 2023, bringing this into dialogue with other existing empirical sources on safer supply (e.g. Coroner's reports, program evaluations, debates among experts in medical journals). We employ eight previously established criteria delineating moral panics to critically appraise public dialogue regarding safer supply, diverted medication, and claims of increased youth initiation to drug use and youth overdose. In detailing the emergence of a moral panic regarding safer supply, we trace historic continuities with earlier drug scares in Canadian history mobilized as tools of racialized poverty governance, as well as previous backlashes towards healthcare interventions for people who use drugs (PWUD). The essay assesses the claims of moral entrepreneurs against the current landscape of opioid use, diversion, and overdose among youth, notes the key role played by medical expertise in this and previous moral panics, and identifies what the convergence of these narratives materialize for PWUD and healthcare access, as well as the broader policy responses such narratives activate.
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Affiliation(s)
- Liam Michaud
- Graduate Program in Socio-Legal Studies, York University, Toronto, ON, Canada; Nathanson Centre on Transnational Human Rights, Crime and Security, York University, Toronto, ON, Canada.
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada; Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | | | - Adrian Guta
- School of Social Work, University of Windsor, ON, Canada
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Henderson N, Marris J, Woodend K. "And this is the life jacket, the lifeline they've been wanting": Participant perspectives on navigating challenges and successes of prescribed safer supply. PLoS One 2024; 19:e0299801. [PMID: 38517923 PMCID: PMC10959334 DOI: 10.1371/journal.pone.0299801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/04/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND In 2021, 43% of drug toxicity deaths in Ontario were reported by public health units serving medium-sized urban and rural communities. Safer supply programs (SSPs) have been primarily established in large urban centres. Given this, the current study is based on an evaluation of a SSP based in a medium-sized urban centre with a large catchment area that includes rural and Indigenous communities. The aim of this research paper is to understand the challenges and successes of the nurse practitioner-led SSP from the perspective of program participants. METHODS Interpretive description was used to understand the experiences of 14 participants accessing a SSP. Each participant was interviewed using a semi-structured approach, and 13 of the interviewees also completed surveys accessed through Qualtrics. An iterative process using NVivo software was used to code interviews, and a constant comparative data analysis approach was used to refine and categorize codes to themes. FINDINGS Three overarching themes were the result of this analysis: feeling better, renewed hope, and safety. These three themes capture the experiences of participants in the SSP, including both the challenges and successes they faced. CONCLUSION The findings and subsequent discussion focus on both the key best practices of the program, and areas for future development and improvement. Despite barriers to services, prescribed SSPs are improving the lives of people who use drugs, and the current outcomes align with reports and evaluations from other SSPs across Canada.
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Affiliation(s)
- Nancy Henderson
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - John Marris
- John Marris Consulting, Peterborough, ON, Canada
| | - Kirsten Woodend
- School of Nursing, Trent University, Peterborough, ON, Canada
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McCall J, Hobbs H, Ranger C, Cameron F, Stuart H, Nelken J, Majalahti J, Urbanoski K, Kolla G, LeMaistre J, Toombs K, Herriot R, Pauly B. Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation. Subst Abuse Treat Prev Policy 2024; 19:19. [PMID: 38444035 PMCID: PMC10913403 DOI: 10.1186/s13011-024-00598-7] [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: 11/08/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Within North America and worldwide, drug related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply to replace unregulated substances and to reduce toxicity and overdoses. Service providers play an integral role in the delivery of safer supply but there is little empirical evidence that conceptualizes effective safer supply from their perspectives. This study explored early implementation and impacts of a safer supply program, capturing the perspectives of an interdisciplinary team of service providers on tensions and issues encountered in the development of the SAFER program. METHODS Using a community-based participatory approach, we conducted individual interviews with program providers (n = 9). The research team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The Consolidated Framework for Implementation Research (CFIR) informed the interview guide. Data was analyzed using thematic analysis. RESULTS There are six themes describing early implementation: (1) risk mitigation prescribing as context for early implementation; (2) developing SAFER specific clinical protocols; (3) accessibility challenges and program innovations; (4) interdisciplinary team and wraparound care; (5) program tensions between addiction medicine and harm reduction; (6) the successes of safer supply and future visions. CONCLUSION Early implementation issues and tensions included prescriber concerns about safer supply prescribing in a highly politicized environment, accessibility challenges for service users such as stigma, encampment displacement, OAT requirements, program capacity and costs, and tensions between addiction medicine and harm reduction. Navigating these tensions included development of clinical protocols, innovations to reduce accessibility challenges such as outreach, wraparound care, program coverage of medication costs and prescribing safer supply with/without OAT. These findings contribute important insights for the development of prescribed safer supply programs.
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Affiliation(s)
- J McCall
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - H Hobbs
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - C Ranger
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - F Cameron
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - H Stuart
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - J Nelken
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - J Majalahti
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - K Urbanoski
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - G Kolla
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - J LeMaistre
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - K Toombs
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - R Herriot
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - Bernie Pauly
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada.
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada.
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Nguyen HV, Mital S, Bugden S, McGinty EE. British Columbia's Safer Opioid Supply Policy and Opioid Outcomes. JAMA Intern Med 2024; 184:256-264. [PMID: 38227344 PMCID: PMC10792500 DOI: 10.1001/jamainternmed.2023.7570] [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: 10/05/2023] [Accepted: 11/13/2023] [Indexed: 01/17/2024]
Abstract
Importance In March 2020, British Columbia, Canada, became the first jurisdiction globally to launch a large-scale provincewide safer supply policy. The policy allowed individuals with opioid use disorder at high risk of overdose or poisoning to receive pharmaceutical-grade opioids prescribed by a physician or nurse practitioner, but to date, opioid-related outcomes after policy implementation have not been explored. Objective To investigate the association of British Columbia's Safer Opioid Supply policy with opioid prescribing and opioid-related health outcomes. Design, Setting, and Participants This cohort study used quarterly province-level data from quarter 1 of 2016 (January 1, 2016) to quarter 1 of 2022 (March 31, 2022), from British Columbia, where the Safer Opioid Supply policy was implemented, and Manitoba and Saskatchewan, where the policy was not implemented (comparison provinces). Exposure Safer Opioid Supply policy implemented in British Columbia in March 2020. Main Outcomes and Measures The main outcomes were rates of prescriptions, claimants, and prescribers of opioids targeted by the Safer Opioid Supply policy (hydromorphone, morphine, oxycodone, and fentanyl); opioid-related poisoning hospitalizations; and deaths from apparent opioid toxicity. Difference-in-differences analysis was used to compare changes in outcomes before and after policy implementation in British Columbia with those in the comparison provinces. Results The Safer Opioid Supply policy was associated with statistically significant increases in rates of opioid prescriptions (2619.6 per 100 000 population; 95% CI, 1322.1-3917.0 per 100 000 population; P < .001) and claimants (176.4 per 100 000 population; 95% CI, 33.5-319.4 per 100 000 population; P = .02). There was no significant change in prescribers (15.7 per 100 000 population; 95% CI, -0.2 to 31.6 per 100 000 population; P = .053). However, the opioid-related poisoning hospitalization rate increased by 3.2 per 100 000 population (95% CI, 0.9-5.6 per 100 000 population; P = .01) after policy implementation. There were no statistically significant changes in deaths from apparent opioid toxicity (1.6 per 100 000 population; 95% CI, -1.3 to 4.5 per 100 000 population; P = .26). Conclusions and Relevance Two years after its launch, the Safer Opioid Supply policy in British Columbia was associated with higher rates of safer supply opioid prescribing but also with a significant increase in opioid-related poisoning hospitalizations. These findings will help inform ongoing debates about this policy not only in British Columbia but also in other jurisdictions that are contemplating it.
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Affiliation(s)
- Hai V. Nguyen
- School of Pharmacy, Memorial University, St John’s, Newfoundland and Labrador, Canada
| | - Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- School of Pharmacy, Memorial University, St John’s, Newfoundland and Labrador, Canada
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Kolla G, Tarannum CN, Fajber K, Worku F, Norris K, Long C, Fagundes R, Rucchetto A, Hannan E, Kikot R, Klaiman M, Firestone M, Bayoumi A, Laurence G, Hayman K. Substance use care innovations during COVID-19: barriers and facilitators to the provision of safer supply at a toronto COVID-19 isolation and recovery site. Harm Reduct J 2024; 21:17. [PMID: 38243267 PMCID: PMC10799497 DOI: 10.1186/s12954-024-00935-w] [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: 05/23/2023] [Accepted: 01/09/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Early in the COVID-19 pandemic, there was an urgent need to establish isolation spaces for people experiencing homelessness who were exposed to or had COVID-19. In response, community agencies and the City of Toronto opened COVID-19 isolation and recovery sites (CIRS) in March 2020. We sought to examine the provision of comprehensive substance use services offered to clients on-site to facilitate isolation, particularly the uptake of safer supply prescribing (prescription of pharmaceutical opioids and/or stimulants) as part of a spectrum of comprehensive harm reduction and addiction treatment interventions. METHODS We conducted in-depth, semi-structured interviews with 25 clients and 25 staff (including peer, harm reduction, nursing and medical team members) from the CIRS in April-July 2021. Iterative and thematic analytic methods were used to identify key themes that emerged in the interview discussions. RESULTS At the time of implementation of the CIRS, the provision of a safer supply of opioids and stimulants was a novel and somewhat controversial practice. Prescribed safer supply was integrated to address the high risk of overdose among clients needing to isolate due to COVID-19. The impact of responding to on-site overdoses and presence of harm reduction and peer teams helped clinical staff overcome hesitation to prescribing safer supply. Site-specific clinical guidance and substance use specialist consults were crucial tools in building capacity to provide safer supply. Staff members had varied perspectives on what constitutes 'evidence-based' practice in a rapidly changing, crisis situation. CONCLUSION The urgency involved in intervening during a crisis enabled the adoption of prescribed safer supply, meeting the needs of people who use substances and assisting them to complete isolation periods, while also expanding what constitutes acceptable goals in the care of people who use drugs to include harm reduction approaches.
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Affiliation(s)
- Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada.
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada.
- Memorial University, St. John's, NL, Canada.
| | | | - Kaitlin Fajber
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Fiqir Worku
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Kris Norris
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Cathy Long
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Raphaela Fagundes
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
- The Neighbourhood Group, Toronto, ON, Canada
| | - Anne Rucchetto
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Eileen Hannan
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
- The Neighbourhood Group, Toronto, ON, Canada
| | - Richard Kikot
- Parkdale Queen West Community Health Centre, Toronto, ON, Canada
| | - Michelle Klaiman
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Michelle Firestone
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Ahmed Bayoumi
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
- Faculty of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of General Internal Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Gab Laurence
- Parkdale Queen West Community Health Centre, Toronto, ON, Canada
| | - Kate Hayman
- University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Palis H, Haywood B, McDougall J, Xavier CG, Desai R, Tobias S, Burgess H, Ferguson M, Liu L, Kinniburgh B, Slaunwhite AK, Crabtree A, Buxton JA. Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey. Harm Reduct J 2024; 21:5. [PMID: 38184576 PMCID: PMC10771687 DOI: 10.1186/s12954-024-00928-9] [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: 03/31/2023] [Accepted: 01/03/2024] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply. METHODS Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply. RESULTS A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00-2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20-3.60)) of prescribed safer supply access, compared to people who did not access these services. CONCLUSIONS Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.
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Affiliation(s)
- Heather Palis
- Department of Psychiatry, University of British Columbia, 255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada.
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada.
| | - Beth Haywood
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Jenny McDougall
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
- Coalition of Substance Users of the North (CSUN), Quesnel, Canada
| | - Chloé G Xavier
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Roshni Desai
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Samuel Tobias
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Heather Burgess
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
- Public Health Agency of Canada, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Max Ferguson
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Lisa Liu
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Brooke Kinniburgh
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Amanda K Slaunwhite
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Alexis Crabtree
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Jane A Buxton
- Department of Psychiatry, University of British Columbia, 255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
- British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
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Bharat C, Gisev N, Barbieri S, Dobbins T, Larney S, Buizen L, Degenhardt L. Prescription opioid use among people with opioid dependence and concurrent benzodiazepine and gabapentinoid exposure: An analysis of overdose and all-cause mortality. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 123:104287. [PMID: 38088003 DOI: 10.1016/j.drugpo.2023.104287] [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: 07/24/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Studies investigating mortality risk associated with use of opioid analgesics, benzodiazepines, gabapentinoids, and opioid agonist treatment (OAT) among people with opioid dependence (PWOD) are lacking. This study addresses this gap using a cohort of 37,994 PWOD initiating opioid analgesics between July 2003 and July 2018 in New South Wales, Australia. METHODS Linked administrative records provided data on dispensings, sociodemographics, clinical characteristics, OAT, and mortality. Cox proportional hazards models assessed associations between time-varying measures of individual and concurrent medicine use and OAT with all-cause mortality, accidental opioid overdose, non-drug induced accidents, and non-drug-induced suicide. Opioid analgesic dose effects, expressed as oral morphine equivalents (OMEs) per day, were also examined. OUTCOMES During the study period, 3167 individuals died. Compared with no use, all medicines of interest were associated with increased accidental opioid overdose risk; hazard ratios (HR) ranged from 1.33 (95 % CI: 1.05-1.68) for opioid analgesic use to 6.10 (95 % CI: 4.11-9.06) for opioid analgesic, benzodiazepine and gabapentinoid use. Benzodiazepine use was associated with increased non-drug-induced accidents and non-drug-induced suicides. For all-cause mortality, all combinations of benzodiazepines and gabapentinoids with opioid analgesics were associated with increased risk (aHRs ranged from 1.35 to 2.73). For most medicines/medicine combinations, all-cause mortality risk was reduced when in OAT compared to out of OAT. Higher opioid analgesic doses were associated with increased all-cause mortality (e.g., 90-199 mg vs 1-49 mg OME per day: HR 1.90 [95 % CI: 1.52-2.40]). INTERPRETATION The increased mortality risk associated with benzodiazepines and gabapentinoids among PWOD appear to be reduced when engaged in OAT. A greater focus on encouraging OAT engagement, providing overdose prevention education, and access and coverage of overdose antidotes is necessary to minimise the unintended consequences of medicines use in this population.
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Affiliation(s)
- Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | | | | | - Sarah Larney
- Université de Montréal and Centre de Recherche du CHUM, Montreal, Canada
| | - Luke Buizen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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Young S, Gomes T, Kolla G, McCormack D, Dodd Z, Raboud J, Bayoumi AM. Initiations of safer supply hydromorphone increased during the COVID-19 pandemic in Ontario: An interrupted time series analysis. PLoS One 2023; 18:e0295145. [PMID: 38113220 PMCID: PMC10729949 DOI: 10.1371/journal.pone.0295145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/14/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS Calls to prescribe safer supply hydromorphone (SSHM) as an alternative to the toxic drug supply increased during the COVID-19 pandemic but it is unknown whether prescribing behaviour was altered. We aimed to evaluate how the number of new SSHM dispensations changed during the pandemic in Ontario. METHODS We conducted a retrospective interrupted time-series analysis using provincial administrative databases. We counted new SSHM dispensations in successive 28-day periods from March 22, 2016 to August 30, 2021. We used segmented Poisson regression methods to test for both a change in level and trend of new dispensations before and after March 17, 2020, the date Ontario's pandemic-related emergency was declared. We adjusted the models to account for seasonality and assessed for over-dispersion and residual autocorrelation. We used counterfactual analysis methods to estimate the number of new dispensations attributable to the pandemic. RESULTS We identified 1489 new SSHM dispensations during the study period (434 [mean of 8 per 28-day period] before and 1055 [mean of 56 per 28-day period] during the pandemic). Median age of individuals initiating SSHM was 40 (interquartile interval 33-48) with 61.7% (N = 919) male sex. Before the pandemic, there was a small trend of increased prescribing (incidence rate ratio [IRR] per period 1.002; 95% confidence interval [95CI] 1.001-1.002; p<0.001), with a change in level (immediate increase) at the pandemic date (relative increase in IRR 1.674; 95CI 1.206-2.322; p = 0.002). The trend during the pandemic was not statistically significant (relative increase in IRR 1.000; 95CI 1.000-1.001; p = 0.251). We estimated 511 (95CI 327-695) new dispensations would not have occurred without the pandemic. CONCLUSION The pandemic led to an abrupt increase in SSHM prescribing in Ontario, although the rate of increase was similar before and during the pandemic. The absolute number of individuals who accessed SSHM remained low throughout the pandemic.
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Affiliation(s)
- Samantha Young
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Addiction Medicine, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Tara Gomes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | | | - Zoë Dodd
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed M. Bayoumi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health, Toronto, Ontario, Canada
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10
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Fischer B, Robinson T. "Safer Drug Supply" Measures in Canada to Reduce the Drug Overdose Fatality Toll: Clarifying Concepts, Practices and Evidence Within a Public Health Intervention Framework. J Stud Alcohol Drugs 2023; 84:801-807. [PMID: 37796625 PMCID: PMC10765983 DOI: 10.15288/jsad.23-00195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/25/2023] [Indexed: 10/07/2023] Open
Abstract
North America has been home to an unprecedented crisis of drug overdose deaths, driven largely by drug users' exposure to highly potent and toxic, illicit opioid drugs (e.g., fentanyl). Although a large and diverse menu of interventions (e.g., targeted prevention or treatment measures) has been implemented or expanded in Canada, these have not effectively managed to revert and reduce this excessive death toll. Given the fact that these interventions do not directly aim to address toxic drug exposure as the primary vector and cause of acute overdose deaths, public health-oriented "safer drug supply" measures have been initiated in local settings across Canada. These safer supply initiatives provide users with prescribed, pharmaceutical-grade drug supply with the aim of reducing overdose and death risks. These measures have been criticized but also misconstrued from several angles, e.g., as representing inadequate medical or even unethical and harmful practice. Related concerns regarding "diversion" have been raised. In this Perspective, we briefly address some of these issues and clarify selected issues of elementary concepts, practices, and evidence related to safer supply measures within a public health-oriented intervention framework. These measures are also discussed in reference to other, comparable types of public health-oriented emergency health or survival care standards, while considering the extreme contexts of an ongoing, acute drug death crisis in Canada.
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Affiliation(s)
- Benedikt Fischer
- Research and Graduate Studies, University of the Fraser Valley, Abbotsford, British Columbia, Canada
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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11
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Schmidt RA, Kaminski N, Kryszajtys DT, Rudzinski K, Perri M, Guta A, Benoit AC, Bayoumi AM, Challacombe L, Hales J, Kenny K, Kolla G, O'Reilly E, Sereda A, Rai N, Strike C. 'I don't chase drugs as much anymore, and I'm not dead': Client reported outcomes associated with safer opioid supply programs in Ontario, Canada. Drug Alcohol Rev 2023; 42:1825-1837. [PMID: 37718646 DOI: 10.1111/dar.13745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/26/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION The ongoing opioid overdose crisis, which has killed over 30,000 people in Canada since 2016, is driven by the volatility of an unregulated opioid drug supply comprised primarily of fentanyl. The Canadian government has recently funded safer opioid supply (SOS) programs, which include off-label prescriptions of pharmaceutical-grade opioids to high risk individuals with the goal of reducing overdose deaths. METHODS In 2021, we examined the implementation and adaption of four SOS programs in Ontario. These programs use a primary care model and serve communities experiencing marginalisation. We conducted semi-structured interviews with program clients. We present the results of a thematic analysis with the aim of describing clients' self-reported impact of these programs on their health and well-being. RESULTS We interviewed 52 clients between June and October 2021 (mean age 47 years, 56% men, 17% self-identified Indigenous, 14% living with HIV). Our results indicate multifaceted pathways to improved self-reported health and well-being among clients including changes to drug use practices, fewer overdoses, reduced criminalised activity, improved trust and engagement in health care, and increased social stability (e.g., housing). DISCUSSION AND CONCLUSION Most clients reported that the intervention saved their life because of the reduced frequency of overdoses. Findings suggest that SOS programs improved clients' health outcomes and increase opportunities for engagement in health services. Our results provide insight into the mechanisms behind some of the emergent evidence on the impact of safer supply prescribing.
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Affiliation(s)
- Rose A Schmidt
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Nat Kaminski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - David T Kryszajtys
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Katherine Rudzinski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- School of Social Work, University of Windsor, Windsor, Canada
| | - Melissa Perri
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, Canada
| | - Anita C Benoit
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Health and Society, University of Toronto Scarborough, Scarborough, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Ahmed M Bayoumi
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | | | - Jessica Hales
- Regent Park Community Health Centre, Toronto, Canada
| | - Kathleen Kenny
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Emmet O'Reilly
- South Riverdale Community Health Centre, Toronto, Canada
| | | | - Nanky Rai
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Parkdale Queen West Community Health Centre, Toronto, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Ferguson M, Sedgemore KO, Scow M, Choisil P, Haywood B, Xavier J, Crabtree A, Stitilis B, Liu L, Buxton JA. Preferred stimulant safer supply and associations with methamphetamine preference among people who use stimulants in British Columbia: Findings from a 2021 cross-sectional survey. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104186. [PMID: 37708585 DOI: 10.1016/j.drugpo.2023.104186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND As safer supply programs expand in Canada, stimulant safer supply is often overlooked despite the harms and criminalization faced by people who use stimulants. METHODS The 2021 Harm Reduction Client Survey was administered at 17 harm reduction sites around British Columbia, Canada. The survey included a question about what specific substance participants would want to receive as stimulant safer supply. We investigated preference of stimulant safer substance by looking at frequency of stated preference and by using multivariable logistic regression to understand factors associated with the most frequently chosen substance. RESULTS Of 330 participants who reported a stimulant safer supply preference, 58.5% (n = 193) chose crystal methamphetamine, 13% (n = 43) crack cocaine and 12.4% (n = 41) cocaine powder. The options that were available by prescription at the time of data collection were chosen by under 11% of participants (dextroamphetamine n = 21, methylphenidate n = 15). A preference for crystal methamphetamine was associated with being 29 and under compared to 50 and over (AOR: 3.96, 95% CI: 1.42-11.07, p-value: 0.01); self-identifying as a cis man versus a cis woman (AOR: 1.75, 95% CI: 1.03-2.97, p-value: 0.04); and using drugs every day (AOR: 15.43, 95% CI: 3.38-70.51, p-value: < 0.01) or a few times a week (AOR: 8.90, 95% CI: 1.78-44.44, p-value: 0.01) compared to a few times a month. CONCLUSIONS Preference of stimulant safer supply is associated with age, gender, and substance use characteristics. Safer supply programs that offer limited substances risk being poorly accessed, resulting in a continued reliance on an unregulated supply. Moreover, programs that do not offer a range of substances can contribute to health inequities.
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Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kali-Olt Sedgemore
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Marnie Scow
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Paul Choisil
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Beth Haywood
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jessica Xavier
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Alexis Crabtree
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Blake Stitilis
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Lisa Liu
- 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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13
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Karamouzian M, Rafat B, Kolla G, Urbanoski K, Atkinson K, Bardwell G, Bonn M, Touesnard N, Henderson N, Bowles J, Boyd J, Brunelle C, Eeuwes J, Fikowski J, Gomes T, Guta A, Hyshka E, Ivsins A, Kennedy MC, Laurence G, Martignetti L, Nafeh F, Salters K, Tu D, Strike C, Pauly B, Werb D. Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104157. [PMID: 37574645 DOI: 10.1016/j.drugpo.2023.104157] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase. METHODS We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research. RESULTS We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models). CONCLUSIONS Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.
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Affiliation(s)
- Mohammad Karamouzian
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Bijan Rafat
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Kate Atkinson
- Parkdale Queen West Community Health Centre, Toronto, ON, Canada
| | - Geoff Bardwell
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada; British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Matthew Bonn
- Canadian Association of People Who Use Drugs, Dartmouth, NS, Canada
| | | | - Nancy Henderson
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada; Peterborough 360 Degree Nurse Practitioner-Led Clinic, Peterborough, ON, Canada
| | - Jeanette Bowles
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Caroline Brunelle
- Department of Psychology, University of New Brunswick-Saint John campus, Saint John, NB, Canada
| | - Jolene Eeuwes
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Jill Fikowski
- Changemark Research + Evaluation, Vancouver, BC, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, ON, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Alberta, AB, Canada
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Mary Clare Kennedy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; School of Social Work, University of British Columbia (Okanagan Campus), BC, Canada
| | - Gab Laurence
- Parkdale Queen West Community Health Centre, Toronto, ON, Canada
| | - Lucas Martignetti
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Frishta Nafeh
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Kate Salters
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - David Tu
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada; Kilala Lelum, Urban Indigenous Health and Healing Co-operative, Vancouver, BC, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Bernadette Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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14
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Brothers TD, Bonn M, Lewer D, Comeau E, Kim I, Webster D, Hayward A, Harris M. Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis. Addiction 2023; 118:1853-1877. [PMID: 37170877 DOI: 10.1111/add.16257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections. METHODS We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes. RESULTS We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission). CONCLUSIONS Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.
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Affiliation(s)
- Thomas D Brothers
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Matthew Bonn
- Canadian Association of People who Use Drugs (CAPUD), Dartmouth, Canada
| | - Dan Lewer
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Emilie Comeau
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Inhwa Kim
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Duncan Webster
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
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15
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Palis H, MacDonald S. Prescription de psychostimulants aux personnes présentant un trouble lié à l’utilisation de stimulants dans le continuum de soins au Canada. CMAJ 2023; 195:E1200-E1202. [PMID: 37696557 PMCID: PMC10495175 DOI: 10.1503/cmaj.230266-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Affiliation(s)
- Heather Palis
- Département de psychiatrie (Palis), Université de la Colombie-Britannique; Fournisseur de soins de santé Providence Health Care (MacDonald), Vancouver, C.-B
| | - Scott MacDonald
- Département de psychiatrie (Palis), Université de la Colombie-Britannique; Fournisseur de soins de santé Providence Health Care (MacDonald), Vancouver, C.-B
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Kerman N, Kidd SA, Voronov J, Marshall CA, O'Shaughnessy B, Abramovich A, Stergiopoulos V. Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis. Health Place 2023; 83:103092. [PMID: 37515964 DOI: 10.1016/j.healthplace.2023.103092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters. Service users' perceptions of shelter dangerousness were shaped by the service model and environment, interpersonal relationships and interactions in shelter, availability of drugs, and previous living arrangements. 2SLGBTQ+ individuals were identified as being at heightened risk of victimization in shelters. No studies examined rates of shelter-based victimization or tested interventions to improve safety, with the exception of overdose risk. These knowledge gaps hinder the establishment of evidence-based practices for promoting safety and preventing violence in shelter settings.
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Affiliation(s)
- Nick Kerman
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
| | - Sean A Kidd
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Voronov
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | | | | | - Alex Abramovich
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Paradise RK, Desmarais J, O'Malley SE, Hoyos-Cespedes A, Nurani A, Walley AY, Clarke J, Taylor S, Dooley D, Bazzi AR, Kimmel SD. Perspectives and recommendations of opioid overdose survivors experiencing unsheltered homelessness on housing, overdose, and substance use treatment in Boston, MA. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104127. [PMID: 37523844 DOI: 10.1016/j.drugpo.2023.104127] [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: 03/08/2023] [Revised: 06/04/2023] [Accepted: 07/07/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Opioid overdose causes one in four deaths among people experiencing homelessness in Boston, MA. To reduce overdose risks, the experience and perspectives of people experiencing homelessness should be incorporated into housing, overdose prevention, and substance use treatment efforts. METHODS In 2021, we conducted qualitative interviews with 59 opioid overdose survivors to inform equitable access to treatment services. In response to policy debate surrounding a public drug scene near a key recruitment site, we conducted a targeted thematic analysis of transcribed interview data from a subset of participants experiencing unsheltered homelessness (n=29) to explore their perspectives and recommendations on housing, overdose prevention, and substance use treatment. RESULTS Among 29 participants who identified as non-Hispanic Black (n=10), Hispanic/Latinx (n=10), or as non-Hispanic White (n=9), the median number of self-reported opioid overdoses in the past three months was 2.0 (SD 3.7). Three themes emerged from this targeted analysis: (1) Participants described inadequate housing resources and unwelcoming shelter environments. (2) Participants near a large public drug scene explained how unsheltered homelessness was chaotic, dangerous, and disruptive to recovery goals. (3) Participants provided recommendations for improving housing and addiction treatment systems and including their perspectives in the development of solutions to the intersecting housing and opioid overdose crises. CONCLUSIONS The overdose prevention, housing and substance use treatment systems must address the needs of opioid overdose survivors experiencing unsheltered homelessness. Overdose survivors experiencing unsheltered homelessness described a chaotic public drug scene but resorted to residing in nearby encampments because the existing shelter, housing, and addiction treatment systems were unwelcoming, difficult to navigate, or unaffordable. Despite efforts to provide low-threshold housing in Boston, additional low-barrier housing services (i.e., including harm reduction resources and without "sobriety" requirements) could promote the health and safety of people who use drugs and are experiencing homelessness.
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Affiliation(s)
- Ranjani K Paradise
- Institute for Community Health, 350 Main Street, Malden, MA 02148, United States; Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA 02111, United States
| | - Jeffrey Desmarais
- Institute for Community Health, 350 Main Street, Malden, MA 02148, United States
| | - Shannon E O'Malley
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | | | - Alykhan Nurani
- Boston Medical Center, 801 Massachusetts Avenue, 2(nd) Floor Crosstown Building, Boston MA 02118, United States
| | - Alexander Y Walley
- Boston Medical Center, 801 Massachusetts Avenue, 2(nd) Floor Crosstown Building, Boston MA 02118, United States; Boston University Chobanian and Avedisian School of Medicine, 801 Massachusetts Avenue, 2nd Floor Crosstown Building, Boston, MA 02118, United States
| | - Jaylen Clarke
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | - Sunday Taylor
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | - Daniel Dooley
- Boston Public Health Commission, 1010 Massachusetts Avenue, Boston, MA 02118, United States
| | - Angela R Bazzi
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States; Boston University School of Public Health, 801 Massachusetts Avenue, 4(th) Floor Crosstown Building, Boston, MA 02118, United States
| | - Simeon D Kimmel
- Boston Medical Center, 801 Massachusetts Avenue, 2(nd) Floor Crosstown Building, Boston MA 02118, United States; Boston University Chobanian and Avedisian School of Medicine, 801 Massachusetts Avenue, 2nd Floor Crosstown Building, Boston, MA 02118, United States.
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Palis H, MacDonald S. Incorporating prescription psychostimulants into the continuum of care for people with stimulant use disorder in Canada. CMAJ 2023; 195:E934-E935. [PMID: 37460124 PMCID: PMC10356010 DOI: 10.1503/cmaj.230266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Affiliation(s)
- Heather Palis
- Department of Psychiatry (Palis), University of British Columbia; Providence Health Care (MacDonald), Vancouver, BC
| | - Scott MacDonald
- Department of Psychiatry (Palis), University of British Columbia; Providence Health Care (MacDonald), Vancouver, BC
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19
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Novotna G, Nielsen E, Berenyi R. Harm Reduction Strategies for Severe Alcohol Use Disorder in the Context of Homelessness: A Rapid Review. Subst Abuse 2023; 17:11782218231185214. [PMID: 37448810 PMCID: PMC10336757 DOI: 10.1177/11782218231185214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
Severe alcohol use disorder (AUD) in the context of housing instability remains one of the most complex health and social issues. Homelessness is related to increased vulnerability to stigma, marginalization and harmful ways of alcohol consumption, including non-beverage alcohol use (NBA). As a result, severe intoxication, alcohol poisoning, injury and death are common occurrences. Although harm minimization strategies have been readily proposed and examined in the context of drug use, applying the same principles to severe AUD remains controversial within the research and treatment community. This article summarizes the emerging research on managed alcohol programs to increase awareness about alcohol-related strategies that address severe AUD and provide other wrap-around supports such as housing, health and social services to mitigate various harms, including COVID-19.
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Affiliation(s)
- Gabriela Novotna
- Faculty of Social Work, University of Regina, Regina, SK, Canada
| | - Erin Nielsen
- Faculty of Social Work, University of Regina, Regina, SK, Canada
| | - Rochelle Berenyi
- Carmichael Outreach Inc., University of Regina, Regina, SK, Canada
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20
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Gagnon M, Rudzinski K, Guta A, Schmidt RA, Kryszajtys DT, Kolla G, Strike C. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J 2023; 20:81. [PMID: 37380995 DOI: 10.1186/s12954-023-00817-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVES Fentanyl has contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses in Canada. It has also changed injection practices. Injection frequency has increased as a result and so has equipment sharing and health-related risks. The aim of this analysis was to explore the impact of safer supply programs on injection practices from the perspective of clients and providers in Ontario, Canada. METHODS The data set included qualitative interviews with 52 clients and 21 providers that were conducted between February and October 2021 across four safer supply programs. Interview excerpts discussing injection practices were extracted, screened, coded and then grouped into themes. RESULTS We identified three themes, each theme corresponding to a change in injection practices. The first change was a decrease in the amount of fentanyl used and a decrease in injection frequency. The second change involved switching to injecting hydromorphone tablets instead of fentanyl. Finally, the third change was stopping injecting altogether and taking safer supply medications orally. CONCLUSION Safer supply programs can contribute to reducing injection-related health risks in addition to overdose risks. More specifically, they have the potential to address disease prevention and health promotion gaps that stand-alone downstream harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.
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Affiliation(s)
- Marilou Gagnon
- School of Nursing, University of Victoria, Victoria, BC, Canada.
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Avenue, Victoria, BC, V8N 5M8, Canada.
| | | | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, ON, Canada
| | - Rose A Schmidt
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - David T Kryszajtys
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Avenue, Victoria, BC, V8N 5M8, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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21
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Hörig M, Klaes SM, Krasovski-Nikiforovs S, van Loon W, Murajda L, Rodriguez RCO, Schade C, Specht A, Equihua Martinez G, Zimmermann R, Mockenhaupt FP, Seybold J, Lindner AK, Sarma N. A COVID-19 isolation facility for people experiencing homelessness in Berlin, Germany: a retrospective patient record study. Front Public Health 2023; 11:1147558. [PMID: 37346103 PMCID: PMC10281190 DOI: 10.3389/fpubh.2023.1147558] [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: 02/01/2023] [Accepted: 04/28/2023] [Indexed: 06/23/2023] Open
Abstract
Introduction People experiencing homelessness (PEH) are disproportionately affected by the COVID-19 pandemic. For many PEH it is impossible to isolate due to the lack of permanent housing. Therefore, an isolation facility for SARS-CoV-2 positive PEH was opened in Berlin, Germany, in May 2020, offering medical care, opioid and alcohol substitution therapy and social services. This study aimed to assess the needs of the admitted patients and requirements of the facility. Materials and methods This was a retrospective patient record study carried out in the isolation facility for PEH in Berlin, from December 2020 to June 2021. We extracted demographic and clinical data including observed psychological distress from records of all PEH tested positive for SARS-CoV-2 by RT-PCR. Data on duration and completion of isolation and the use of the facilities' services were analyzed. The association of patients' characteristics with the completion of isolation was assessed by Student's t-test or Fisher's exact test. Results A total of 139 patients were included in the study (89% male, mean age 45 years, 41% with comorbidities, 41% non-German speakers). 81% of patients were symptomatic (median duration 5 days, range 1-26). The median length of stay at the facility was 14 days (range 2-41). Among the patients, 80% had non-COVID-19 related medical conditions, 46% required alcohol substitution and 17% opioid substitution therapy. Three patients were hospitalized due to low oxygen saturation. No deaths occurred. Psychological distress was observed in 20%, and social support services were used by 65% of PEH. The majority (82%) completed the required isolation period according to the health authority's order. We did not observe a statistically significant association between completion of the isolation period and sociodemographic characteristics. Conclusion The specialized facility allowed PEH a high compliance with completion of the isolation period. Medical care, opioid and alcohol substitution, psychological care, language mediation and social support are essential components to address the specific needs of PEH. Besides contributing to infection prevention and control, isolation facilities may allow better access to medical care for SARS-CoV-2 infected PEH with possibly positive effects on the disease course.
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Affiliation(s)
- Merle Hörig
- Charité Center for Global Health, Institute of International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Welmoed van Loon
- Charité Center for Global Health, Institute of International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Anabell Specht
- Charité Center for Global Health, Institute of International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Gabriela Equihua Martinez
- Charité Center for Global Health, Institute of International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ruth Zimmermann
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Frank P. Mockenhaupt
- Charité Center for Global Health, Institute of International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Seybold
- Medical Directorate, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas K. Lindner
- Charité Center for Global Health, Institute of International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Navina Sarma
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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22
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Hughto JMW, Tapper A, Rapisarda SS, Stopka TJ, Palacios WR, Case P, Silcox J, Moyo P, Green TC. Drug use patterns and factors related to the use and discontinuation of medications for opioid use disorder in the age of fentanyl: findings from a mixed-methods study of people who use drugs. Subst Abuse Treat Prev Policy 2023; 18:30. [PMID: 37217975 DOI: 10.1186/s13011-023-00538-x] [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: 11/13/2022] [Accepted: 05/05/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation. METHODS From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use. RESULTS Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose. CONCLUSIONS Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.
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Affiliation(s)
- Jaclyn M W Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.
- Department of Epidemiology, School of Public Health, Brown University School of Public Health, Providence, RI, USA.
- Center for Promotion and Health Equity, Brown University, Providence, RI, USA.
- The Fenway Institute, Fenway Health, Boston, MA, USA.
| | - Abigail Tapper
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Sabrina S Rapisarda
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
- School of Criminology and Justice Studies, University of Massachusetts Lowell, Lowell, MA, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Wilson R Palacios
- School of Criminology and Justice Studies, University of Massachusetts Lowell, Lowell, MA, USA
| | - Patricia Case
- Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Joseph Silcox
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
- Department of Sociology, University of Massachusetts Boston, Boston, MA, USA
| | - Patience Moyo
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI, USA
| | - Traci C Green
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
- Division of General Internal Medicine Research, Department of Community Health, Warren Alpert School of Medicine, Providence, RI, USA
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23
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Azevedo FO, Neto A, Gama A, Subtil A, Fuertes R, Pereira C, Tavares J, Medinas RL, Silva AV, Dias S. Problemas ligados ao álcool em centros de emergência (PLACE)-People experiencing homelessness with alcohol-related problems in Lisbon's emergency shelters during the COVID-19 pandemic: a description and analysis of a harm reduction intervention. Front Psychol 2023; 14:1165322. [PMID: 37275696 PMCID: PMC10236796 DOI: 10.3389/fpsyg.2023.1165322] [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: 02/13/2023] [Accepted: 04/10/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction Alcohol-related problems disproportionally affect people experiencing homelessness. As the first wave of the COVID-2019 pandemic spread in 2020, a number of emergency shelters were opened in Lisbon. Increased difficulties in obtaining alcohol could have led to an increased incidence of alcohol withdrawal. Therefore, a low-threshold harm reduction intervention was introduced to these emergency shelters. This consisted of a fixed medication treatment, made available immediately for those with specific conditions, without the need for a medical evaluation or abstinence from alcohol, together with an offer of subsequent access to specialized addiction centers. The Problemas Ligados ao Álcool em Centros de Emergência (PLACE) study (alcohol-related problems in emergency shelters) is a retrospective mixed-methods observational study. It describes the demographic, health, and social characteristics of shelter users participating in the program and aims to evaluate the intervention as well as the experience of the patients, professionals, and decision-makers involved. Results A total of 69 people using shelters self-reported alcohol-related problems. Among them, 36.2% of the people accepted a pharmacological intervention, and 23.2% selected an addiction appointment. The take-up of the intervention was associated with better housing outcomes. A description of an individual's trajectory after leaving the shelter is provided. Discussion This study suggests that non-abstinence-focused interventions can be useful and well-tolerated in treating addiction in this population.
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Affiliation(s)
- Filipe Oliveira Azevedo
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ana Neto
- Unidade de Alcoologia de Lisboa, Divisão para a Intervenção em Comportamentos Aditivos e Dependências, Associação Regional de Saúde, Instituto Público, Lisbon, Portugal
| | - Ana Gama
- Nova Escola Nacional de Saúde Pública, Public Health Research Centre, Comprehensive Health Research Center, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ana Subtil
- Nova Escola Nacional de Saúde Pública, Public Health Research Centre, Comprehensive Health Research Center, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | | | | | - Raquel Luis Medinas
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Ana V. Silva
- Unidade de Alcoologia de Lisboa, Divisão para a Intervenção em Comportamentos Aditivos e Dependências, Associação Regional de Saúde, Instituto Público, Lisbon, Portugal
| | - Sónia Dias
- Nova Escola Nacional de Saúde Pública, Public Health Research Centre, Comprehensive Health Research Center, Universidade Nova de Lisboa, Lisbon, Portugal
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24
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Adams A, Blawatt S, MacDonald S, Finnick R, Lajeunesse J, Harrison S, Byres D, Schechter MT, Oviedo-Joekes E. Provider experiences with relaxing restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic: A qualitative systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 117:104058. [PMID: 37182352 PMCID: PMC10165059 DOI: 10.1016/j.drugpo.2023.104058] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Historical restrictions on take-home medications for opioid use disorder have generated considerable debate. The COVID-19 pandemic shifted the perceived risks and benefits of daily clinic attendance and led to widespread policy reform, creating an unprecedented opportunity to explore the impact of more flexible prescribing. We conducted a qualitative systematic review to synthesize the evidence on providers' experiences with relaxing restrictions on take-home doses of medications prescribed for opioid use disorder during the COVID-19 pandemic. METHODS The protocol for this systematic review was registered in PROSPERO (CRD42022360589; https://www.crd.york.ac.uk/prospero/). From Sept.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, the Cochrane Register of Controlled Trials, and the grey literature from 2020 onward. Studies were eligible for inclusion if they used qualitative methods to investigate providers' experiences with relaxed restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic. We appraised study quality using the CASP qualitative checklist and used thematic synthesis and GRADE-CERQual to synthesize the results. RESULTS We retrieved 13 articles representing 11 studies. Six were conducted in the United States and most focused on changes to methadone treatment. Providers' experiences with increased flexibilities around take-homes were broadly positive, despite widespread initial concern over client safety and the potential for medication misuse. For a small number of providers, concerns about diversion were a specific manifestation of more general unease with loss of control over clients and the treatment process. Most providers appreciated increased flexibilities and described them as enabling more individualized, person-centered care. CONCLUSION Our findings support the continuation of flexibilities around take-homes and demonstrate that regulations and policies that reduce flexibility around take-homes conflict with person-centered approaches to care. Stronger guidance and support from professional regulatory agencies may help increase uptake of flexibilities around take-homes.
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Affiliation(s)
- Alison Adams
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Sarin Blawatt
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Rhys Finnick
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Julie Lajeunesse
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - David Byres
- Provincial Health Services Authority, 200-1333 W Broadway, Vancouver, BC V6H 4C1, Canada
| | - Martin T Schechter
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
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25
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Giang K, Charlesworth R, Thulien M, Mulholland A, Barker B, Brar R, Pauly B, Fast D. Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 115:104023. [PMID: 37059025 PMCID: PMC10067449 DOI: 10.1016/j.drugpo.2023.104023] [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: 11/03/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023]
Abstract
Across North America, overlapping overdose and COVID-19 emergencies have had a substantial impact on young people who use drugs (YPWUD). New risk mitigation guidance (RMG) prescribing practices were introduced in British Columbia, Canada, in 2020 to allow people to decrease risk of overdose and withdrawal and better self-isolate. We examined how the prescribing of hydromorphone tablets specifically impacted YPWUD's substance use and care trajectories. Between April 2020 and July 2021, we conducted virtual interviews with 30 YPWUD who had accessed an RMG prescription of hydromorphone in the previous six months and 10 addiction medicine physicians working in Vancouver. A thematic analysis was conducted. YPWUD participants highlighted a disjuncture between risk mitigation prescriptions and the safe supply of unadulterated substances such as fentanyl, underscoring that having access to the latter is critical to reducing their reliance on street-based drug markets and overdose-related risks. They described re-appropriating these prescriptions to meet their needs, stockpiling hydromorphone so that it could be used as an “emergency backup” when they were unable to procure unregulated, illicit opioids. In the context of entrenched poverty, hydromorphone was also used to generate income for the purchase of drugs and various necessities. For some YPWUD, hydromorphone prescriptions could be used alongside opioid agonist therapy (OAT) to reduce withdrawal and cravings and improve adherence to OAT. However, some physicians were wary of prescribing hydromorphone due to the lack of evidence for this new approach. Our findings underscore the importance of providing YPWUD with a safe supply of the substances they are actively using alongside a continuum of substance use treatment and care, and the need for both medical and community-based safe and safer supply models.
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Affiliation(s)
- Karen Giang
- Department of Family Practice, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Reith Charlesworth
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Madison Thulien
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Alanna Mulholland
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Vancouver Coastal Health Authority, 520 West 6(th) Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Brittany Barker
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Canadian Institute of Substance Use Research, 2300 McKenzie Avenue, Victoria, BC V8N 5M8, Canada
| | - Rupinder Brar
- Department of Family Practice, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Vancouver Coastal Health Authority, 520 West 6(th) Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Bernie Pauly
- Canadian Institute of Substance Use Research, 2300 McKenzie Avenue, Victoria, BC V8N 5M8, Canada; School of Nursing, University of Victoria, PO Box 1700 STN CSC, Victoria BC V8W 2Y2, Canada
| | - Danya Fast
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine (Division of Social Medicine), 317-2914 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada.
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26
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Brothers TD, Walley AY, Rivers-Bowerman H, McLeod M, Genge L. Grayken lessons: between a rock and a hard place? A 37-year-old man with acute liver injury while enrolled in a managed alcohol program for severe alcohol use disorder. Addict Sci Clin Pract 2023; 18:14. [PMID: 36879279 PMCID: PMC9988200 DOI: 10.1186/s13722-023-00370-5] [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: 11/09/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
Managed alcohol programs aim to reduce health and social harms associated with severe alcohol use disorder. Here, we describe a young man with severe alcohol use disorder enrolled in a managed alcohol program, who was admitted to hospital with acute liver injury. Fearing that alcohol was contributing, the inpatient care team discontinued the managed alcohol dose in hospital. He was ultimately diagnosed with cephalexin-induced liver injury. After consideration of risks, benefits, and alternative options, the patient and care team jointly decided to restart managed alcohol after hospital discharge. With this case, we describe managed alcohol programs and summarize the emerging evidence-base, including eligibility criteria and outcome measures; we explore clinical and ethical dilemmas in caring for patients with liver disease within managed alcohol programs; and we emphasize principles of harm reduction and patient-centered care when establishing treatment plans for patients with severe alcohol use disorder and unstable housing.
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Affiliation(s)
- Thomas D Brothers
- Department of Medicine, Dalhousie University, Halifax, NS, Canada. .,Institute of Epidemiology and Health Care, UCL Collaborative Centre for Inclusion Health, University College London, London, UK.
| | - Alexander Y Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA
| | - Helen Rivers-Bowerman
- Mobile Outreach Street Health (MOSH), North End Community Health Centre, Halifax, NS, Canada
| | - Magnus McLeod
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Leah Genge
- Mobile Outreach Street Health (MOSH), North End Community Health Centre, Halifax, NS, Canada.,Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
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27
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Mattsson E, Lindblad M, Kneck Å, Salzmann-Eriksson M, Klarare A. Voices of women in homelessness during the outbreak of the COVID-19 pandemic: a co-created qualitative study. BMC Womens Health 2023; 23:11. [PMID: 36627642 PMCID: PMC9830620 DOI: 10.1186/s12905-023-02157-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Women in homelessness face extreme health- and social inequities. It could be postulated that during societal crises, they become even more vulnerable. Thus, the aim was to explore experiences related to the COVID-19 pandemic among women in homelessness. METHODS Ten interviews were conducted with women in homelessness, in Stockholm, Sweden, using researcher-driven photo elicitation. The data analysis was guided by the DEPICT model for collaborative data analysis and a qualitative content analysis was performed. A collaborative reference group of women with lived experience of homelessness contributed to the research process through designing the data collection, performing the data analysis, and providing feedback during report writing. RESULTS For women in homelessness, the COVID-19 pandemic was adding insult to injury, as it significantly affected everyday life and permeated most aspects of existence, leading to diminished interactions with others and reduced societal support. Thus, in an already dire situation, the virus amplified health- and social issues to another level. The women strived to find their balance on the shifting sands of guidelines and restrictions due to the pandemic. Adhering to the new social distancing rules and guidelines in line with the rest of society, was simply impossible when experiencing homelessness. However, for some women the pandemic was nothing but a storm in a teacup. The harsh reality continued irrespectively, living one day at a time and prioritizing provision for basic human needs. CONCLUSIONS The COVID-19 pandemic and homelessness can be viewed as two intersecting crises. However, the women's aggregated experiences were greater than the sum of experiencing homelessness and meeting the threat of the virus. Gender, exposure to violence, poverty, social isolation, and substance use were additional factors that further marginalized the women during the pandemic. To rebuild a better and more sustainable post-pandemic future for all, global commitment to ending homelessness is crucial. In addition, addressing social determinants of health must be the number one health intervention.
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Affiliation(s)
- Elisabet Mattsson
- grid.8993.b0000 0004 1936 9457Department of Women’s and Children’s Health, Healthcare Sciences and e-Health, Uppsala University, 751 85 Uppsala, Sweden ,grid.412175.40000 0000 9487 9343Department of Health Care Sciences, Marie Cederschiöld University, Stigbergsgatan 30, Box 11189, 100 61 Stockholm, Sweden
| | - Marléne Lindblad
- Department of Health Sciences, Swedish Red Cross University, Box 1059, 141 21 Huddinge, Sweden
| | - Åsa Kneck
- grid.412175.40000 0000 9487 9343Department of Health Care Sciences, Marie Cederschiöld University, Stigbergsgatan 30, Box 11189, 100 61 Stockholm, Sweden
| | - Martin Salzmann-Eriksson
- grid.69292.360000 0001 1017 0589Department of Caring Sciences, Faculty of Health an Occupational Studies, University of Gävle, 801 76 Gävle, Sweden
| | - Anna Klarare
- grid.8993.b0000 0004 1936 9457Department of Women’s and Children’s Health, Healthcare Sciences and e-Health, Uppsala University, 751 85 Uppsala, Sweden ,grid.412175.40000 0000 9487 9343Department of Health Care Sciences, Marie Cederschiöld University, Stigbergsgatan 30, Box 11189, 100 61 Stockholm, Sweden
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Russell C, Law J, Bonn M, Rehm J, Ali F. The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:103933. [PMID: 36529033 DOI: 10.1016/j.drugpo.2022.103933] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
The overdose crisis in Canada has continuously evolved and is increasingly challenging to contain, while efforts from governments and policymakers to address it have often fallen short and resulted in unintended consequences. One of the main repercussions has been an unprecedented rise in adulterants in the illegal drug supply, including a wide array of pharmacological and psychoactive compounds and chemicals, which has resulted in a progressively toxic drug supply. Most recently, there has been a stark increase in synthetic benzodiazepine-laced opioids (i.e., 'benzodope') in some Canadian jurisdictions. This unique combination carries distinct and amplified risks for people who use drugs including fatal and non-fatal overdoses, increased dependence and withdrawal symptoms, and places them in extremely vulnerable positions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug-related morbidity and mortality in Canada, and has further complicated current public health initiatives and overdose prevention efforts. This reality underscores the need for effective and sustainable policy solutions to address the evolving overdose epidemic including increased knowledge and education on the specific harms of opioid and benzodiazepine co-use (especially in regards to the complexity of opioid/benzodiazepine overdoses), scaling-up harm reduction measures, and eliminating the toxic drug supply altogether.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1.
| | - Justine Law
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1
| | - Matthew Bonn
- Canadian Association of People Who Use Drugs, 102-68 Highfield Park Drive, Dartmouth, Nova Scotia, Canada B3A 1X4
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1; Department of Psychiatry, University of Toronto, 1 King's College Circle, Toronto, ON, Canada, M5S 1A8; Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, Canada, M5T 3M7; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 1001 Queen St. West, Toronto, ON, Canada, M6J 1H4; Institute of Medical Science (IMS), University of Toronto, 1 King's College Circle, Toronto, ON, Canada, M5S 1A8; Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany; Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 19с1, Moscow, Russia, 119146; Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, 20246 Hamburg, Germany
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St., Toronto, ON, Canada M5S 2S1
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Zolopa C, Brothers TD, Leclerc P, Mary JF, Morissette C, Bruneau J, Hyshka E, Martin NK, Larney S. Changes in supervised consumption site use and emergency interventions in Montréal, Canada in the first twelve months of the COVID-19 pandemic: An interrupted time series study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 110:103894. [PMID: 36308892 PMCID: PMC9574459 DOI: 10.1016/j.drugpo.2022.103894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/30/2022] [Accepted: 10/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The COVID-19 pandemic has impacted supervised consumption site (SCS) operations in Montréal, Canada, potentially including changes in SCS visits, on-site emergency interventions, injection of specific drugs, and distribution of harm reduction materials. METHOD We used administrative data from all four Montréal SCS from 1 March 2018 - 28 February 2021 to conduct an interrupted time series study with 13 March 2020 as the intervention point. We employed segmented regression using generalised least squares fit by maximum likelihood. We analysed monthly SCS visits and materials distributed as counts, and emergency interventions and drugs injected as proportions of visits. RESULTS SCS visits (level change = -1,286; 95% CI [-1,642, -931]) and the proportion of visits requiring emergency intervention (level = -0.27% [-0.47%, -0.06%]) decreased immediately in March 2020, followed by an increasing trend in emergency interventions (slope change = 0.12% [0.10%, 0.14%]) over the ensuing 12 months. Over the same period, the proportion of injections involving opioids increased (slope = 0.05% [0.03%, 0.07%]), driven by increasing pharmaceutical opioid and novel synthetic opioid injections. Novel synthetic opioids were the drugs most often injected prior to overdose. The proportion of injections involving unregulated amphetamines increased immediately (level = 7.83% [2.93%, 12.73%]), then decreased over the next 12 months (slope = -1.86% [-2.51%, -1.21%]). There was an immediate increase in needle/syringe distribution (level = 16,552.81 [2,373, 30,732]), followed by a decreasing trend (slope = -2,398 [-4,218, -578]). There were no changes in pre-existing increasing trends in naloxone or fentanyl test strip distribution. CONCLUSION Reduced SCS use and increasing emergency interventions at SCS are cause for serious concern. Findings suggest increased availability of novel synthetic opioids in Montréal, heightening overdose risk.
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Affiliation(s)
- Camille Zolopa
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec H2X 0A9, Canada
| | - Thomas D Brothers
- Department of Medicine, Dalhousie University, 6299 South St., Halifax, Nova Scotia B3H 4R2, Canada; UCL Collaborative Centre for Inclusion Health, University College London, 1-19 Torrington Pl., London, WC1E 7HB, United Kingdom
| | - Pascale Leclerc
- Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (CIUSSS), 1560 rue Sherbrooke E, Montréal, Québec H2L 4M1, Canada
| | | | - Carole Morissette
- Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (CIUSSS), 1560 rue Sherbrooke E, Montréal, Québec H2L 4M1, Canada; Direction régionale de santé publique, 1560 rue Sherbrooke Est, Pavillon JA de Sève, Montréal, Québec, H2L 4M1, Canada
| | - Julie Bruneau
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec H2X 0A9, Canada; Department of Emergency and Family Medicine, Université de Montréal, 2900 blvd Edouard Montpetit, Montréal, Québec H3T 1J4, Canada
| | - Elaine Hyshka
- School of Public Health, College of Health Sciences, University of Alberta, 11405 87th ave NW, Edmonton, Alberta T6G 1C9, Canada
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California at San Diego, 9500 Gilman Dr, La Jolla, CA 92093, United States
| | - Sarah Larney
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec H2X 0A9, Canada; Department of Emergency and Family Medicine, Université de Montréal, 2900 blvd Edouard Montpetit, Montréal, Québec H3T 1J4, Canada; National Drug and Alcohol Research Centre, UNSW Sydney, Anzac Parade, Kensington NSW 2052, Australia.
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Palis H, Zhao B, Young P, Korchinski M, Greiner L, Nicholls T, Slaunwhite A. Stimulant use disorder diagnosis and opioid agonist treatment dispensation following release from prison: a cohort study. Subst Abuse Treat Prev Policy 2022; 17:77. [PMID: 36434706 PMCID: PMC9694574 DOI: 10.1186/s13011-022-00504-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Concurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC. METHODS Linked health and corrections records were retrieved for releases between January 1st 2015 and December 29th 2018 (N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC's Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC's provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release. RESULTS Cases of release among people with an opioid use disorder were identified (N = 13,380). Approximately 25% (N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64-0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70-1.13]. CONCLUSIONS People with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.
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Affiliation(s)
- Heather Palis
- grid.17091.3e0000 0001 2288 9830BC Centre for Disease Control, University of British Columbia, 655 W 12Th Avenue, BC V5Z 4R4 Vancouver, Canada ,grid.17091.3e0000 0001 2288 9830Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1 Canada
| | - Bin Zhao
- grid.17091.3e0000 0001 2288 9830BC Centre for Disease Control, University of British Columbia, 655 W 12Th Avenue, BC V5Z 4R4 Vancouver, Canada
| | - Pam Young
- Unlocking the Gates Services Society, 22838 Lougheed Hwy. Unit 104, Maple Ridge, BC V2X 2V6 Canada
| | - Mo Korchinski
- Unlocking the Gates Services Society, 22838 Lougheed Hwy. Unit 104, Maple Ridge, BC V2X 2V6 Canada
| | - Leigh Greiner
- BC Corrections, 1001 Douglas St, Victoria, BC V8W 2C5 Canada
| | - Tonia Nicholls
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1 Canada ,grid.498716.50000 0000 8794 2105BC Mental Health and Substance Use Services, 4949 Heather St, Vancouver, BC V5Z 3L7 Canada
| | - Amanda Slaunwhite
- grid.17091.3e0000 0001 2288 9830BC Centre for Disease Control, University of British Columbia, 655 W 12Th Avenue, BC V5Z 4R4 Vancouver, Canada ,grid.17091.3e0000 0001 2288 9830School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3 Canada
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Kenny KS, Kolla G, Greig S, Bannerman M, Phillips D, Altenberg J, Strike C, Bayoumi AM. Association of Illicit Fentanyl Use with Injection Risk Practices Among People who Inject Drugs. AIDS Behav 2022; 27:1757-1765. [PMID: 36401145 DOI: 10.1007/s10461-022-03908-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/19/2022]
Abstract
We investigated the association between fentanyl injection frequency and sharing of injection equipment among people who inject drugs. We surveyed 249 people who inject drugs in Toronto in 2019. We estimated predicted probabilities of associations between fentanyl injection frequency and injection risk practices. In prior 6 months, 117 (47.0%) of participants injected fentanyl daily, 49 (19.7%) less than daily, and 78 (31.3%) did not inject fentanyl. Participants who injected fentanyl daily shared syringes more often than those not injecting fentanyl (25.0% vs. 4.9%; χ2 = 11.54, p = 0.0007). Participants who injected fentanyl daily (42.4% vs. 11.3%; χ2 = 18.05, p < 0.0001) and less than daily (37.2% vs. 11.3%; χ2 = 5.88 p = 0.02) shared cookers more often than those not injecting fentanyl. Participants who injected fentanyl daily (30.2% vs. 9.7%; χ2 = 9.05, p = 0.003) and less than daily (30.3% vs. 9.7%; χ2 = 4.11, p = 0.04) shared filters more often than those not injecting fentanyl. No differences in probabilities of sharing equipment were detected between participants who injected fentanyl daily and less than daily. People using fentanyl reported injection practices that increased risk for infectious disease transmission.
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Palis H, Xavier C, Dobrer S, Desai R, Sedgemore KO, Scow M, Lock K, Gan W, Slaunwhite A. Concurrent use of opioids and stimulants and risk of fatal overdose: A cohort study. BMC Public Health 2022; 22:2084. [PMCID: PMC9664696 DOI: 10.1186/s12889-022-14506-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
Stimulant use has been rising among people with opioid use disorder in recent years in North America, alongside a parallel rise in illicit drug toxicity (overdose) deaths. This study aimed to examine the association between stimulant use and overdose mortality.
Methods
Data from a universal health insurance client roster were used to identify a 20% random general population sample (aged ≥12) in British Columbia, Canada between January 1 2015 and December 31 2018 (N = 1,089,682). Provincial health records were used to identify people who used opioids and/or stimulants. Fatal overdose observed during follow-up (January 12,015- December 312,018) was retrieved from Vital Statistics Death Registry and BC Coroners Service Data. Potential confounders including age, sex, health region, comorbidities and prescribed medications were retrieved from the provincial client roster and health records.
Results
We identified 7460 people who used stimulants and or opioids. During follow-up there were 272 fatal overdose events. People who used both opioids and stimulants had more than twice the hazard of fatal overdose (HR: 2.02, 95% CI: 1.47-2.78, p < 0.001) compared to people who used opioids only. The hazard of death increased over time among people who used both opioids and stimulants.
Conclusions
There is an urgent need to prioritize the service needs of people who use stimulants to reduce overdose mortality in British Columbia. Findings have relevance more broadly in other North American settings, where similar trends in opioid and stimulant polysubstance use have been observed.
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