Electronic harm reduction interventions for drug overdose monitoring and prevention: A scoping review

Perspectives of Canadian Healthcare and Harm Reduction Workers on Mobile Overdose Response Services: A Qualitative Study

BACKGROUND

Supervised consumption sites (SCS) are an evidence-based intervention proven effective for preventing drug overdose deaths. Obstacles to accessing SCS include stigma, limited hours of operation, concerns about policing, and limited geographic availability. Mobile overdose response services (MORS) are novel technologies that provide virtual supervised consumption to help reduce the risk of fatal overdoses, especially for those who use alone. MORS can take various forms, such as phone-based hotlines and mobile apps. The aim of this article is to assess the perceptions of MORS among healthcare and harm reduction staff to determine if they would be comfortable educating clients about these services.

METHODS

Twenty-two healthcare and harm reduction staff were recruited from Canada using convenience, snowball, and purposive sampling techniques to complete semistructured interviews. Inductive thematic analysis informed by grounded theory was used to identify main themes and subthemes.

RESULTS

Four themes were identified: (1) increasing MORS awareness among healthcare providers was seen as useful; (2) MORS might lessen the burden of drug overdoses on the healthcare system but could also increase ambulance callouts; (3) MORS would benefit from certain improvements such as providing harm reduction resources and other supports; and (4) MORS are viewed as supplements for harm reduction, but SCS were preferred.

CONCLUSIONS

This research provides valuable perspectives from healthcare and harm reduction workers to understand their perception of MORS and identifies key areas of potential improvement. Practical initiatives to improve MORS implementation outcomes exist.

Implementing Canada's first national virtual phone based overdose prevention service: lessons learned from creating the National Overdose Response Service (NORS)

The opioid epidemic remains one of the largest public health crises in North America to date. While there have been many diverse strategies developed to reduce the harms associated with substance use, these are primarily concentrated within a few large urban centers. As a result, there have been increased calls for equitable access to harm reduction services for those who cannot or choose not to access in-person harm reduction services. In December 2020, Canada's National Overdose Response Service (NORS) a telephone based overdose response hotline and virtual supervised consumption service, was established in collaboration with various agencies and people with lived and living experience of substance use (PWLLE) across Canada to expand access to harm reduction services using novel Opioid Response Technology. In this manuscript we explore the lessons learned from the establishment and continued operation of the service exploring topics related to the initial establishment of the service, securing a phone line, routing technology, EMS dispatch solutions, peer and volunteer recruitment, legal and ethical support, policy and procedure development, securing funding, and marketing. Furthermore, we detail how this service has grown and changed in response to the various needs of service users.

Perceptions of Overdose Response Hotlines and Phone Application Services Among Women and Gender-diverse Individuals Who Use Drugs in Canada: A Qualitative Study

OBJECTIVES

In 2021, opioid-related deaths have increased by 96% and continue to be higher than prepandemic levels. In particular, women and gender-diverse individuals face numerous challenges when assessing harm reduction supports, including physical supervised consumption sites, compared with male counterparts. Mobile overdose response services (MORSs) including overdose response hotlines and phone-based overdose response applications are novel virtual overdose response technologies that may help mitigate this issue. This study aims to explore how women and gender-diverse individuals engage with and perceive these services.

METHODS

A qualitative study using grounded theory was conducted. Using existing peer networks and purposive and snowball sampling between March and July 2023, 19 semistructured interviews were conducted with women and gender-diverse individuals in Canada who have lived experience using substances. NVivo was used for thematic analysis, which continued until saturation was reached.

RESULTS

The interviews elucidated the following 5 themes: Overdose response hotlines and applications were generally preferred over supervised consumption sites due to (1) perceived gender-based safety; (2) better accommodation for mothers concerned with stigma, childcare, and child welfare systems; and (3) eased accessibility for those involved in sex work. It was also noted that (4) judgment-free spaces and trauma-informed care provided by staff with lived experiences were invaluable, and (5) decriminalization of illicit substances will encourage uptake of these harm reduction services.

CONCLUSION

This study found that women and gender-diverse individuals felt positively toward overdose response hotlines and applications with the potential to fill a need in providing harm reduction services that create feelings of safety, support roles of motherhood and sex work, and generate nonstigmatizing spaces.

Preference for hotline versus mobile application/countdown-based mobile overdose response services: a qualitative study

BACKGROUND

In response to the exacerbated rates of morbidity and mortality associated with the overlapping overdose and COVID-19 epidemics, novel strategies have been developed, implemented, operationalized and scaled to reduce the harms resulting from this crisis. Since the emergence of mobile overdose response services (MORS), two strategies have aimed to help reduce the mortality associated with acute overdose including staffed hotline-based services and unstaffed timer-based services. In this article, we aim to gather the perspectives of various key interest groups on these technologies to determine which might best support service users.

METHODS

Forty-seven participants from various interested groups including people who use substances who have and have not used MORS, healthcare workers, family members, harm reduction employees and MORS operators participated in semi-structured interviews. Transcripts were coded and analyzed using a thematic analysis approach.

RESULTS

Four major themes emerged regarding participant perspectives on the differences between services, namely differences in connection, perceived safety, privacy and accessibility, alongside features that are recommended for MORS in the future.

CONCLUSIONS

Overall, participants noted that individuals who use substances vary in their desire for connection during a substance use session offered by hotline and timer-based service modalities. Participants perceived hotline-based approaches to be more reliable and thus potentially safer than their timer-based counterparts but noted that access to technology is a limitation of both approaches.

Understanding the barriers and facilitators to implementing and sustaining Mobile Overdose Response Services from the perspective of Canadian key interest groups: a qualitative study

INTRODUCTION

Unregulated supply of fentanyl and adulterants continues to drive the overdose crisis. Mobile Overdose Response Services (MORS) are novel technologies that offer virtual supervised consumption to minimize the risk of fatal overdose for those who are unable to access other forms of harm reduction. However, as newly implemented services, they are also faced with numerous limitations. The aim of this study was to examine the facilitators and barriers to the adoption of MORS in Canada.

METHODS

A total of 64 semi-structured interviews were conducted between November 2021 and April 2022. Participants consisted of people who use substances (PWUS), family members of PWUS, health care professionals, harm reduction workers, MORS operators, and members of the general public. Inductive thematic analysis was used to identify the major themes and subthemes.

RESULTS

Respondents revealed that MORS facilitated a safe, anonymous, and nonjudgmental environment for PWUS to seek harm reduction and other necessary support. It also created a new sense of purpose for operators to positively contribute to the community. Further advertising and promotional efforts were deemed important to increase its awareness. However, barriers to MORS implementation included concerns regarding privacy/confidentiality, uncertainty of funding, and compassion fatigue among the operators.

CONCLUSION

Although MORS were generally viewed as a useful addition to the currently existing harm reduction services, it's important to monitor and tackle these barriers by engaging the perspectives of key interest groups.

Perspectives of healthcare workers on the integration of overdose detection technologies in acute care settings

BACKGROUND

People who use drugs (PWUD) face disproportionately high rates of hospitalizations and patient-initiated discharge (leaving against medical advice), explained by a combination of stigma, withdrawal, judgment, blame, and improper pain management. In addition, evidence has shown that despite abstinence-based policies within healthcare settings, PWUD continue to use their substances in healthcare environments often hidden away from hospital staff, resulting in fatalities. Various novel overdose detection technologies (ODTs) have been developed with early adoption in a few settings to reduce the morbidity and mortality from risky substance use patterns within healthcare environments. Our study aimed to gain the perspectives of healthcare workers across Canada on implementing ODTs within these settings.

METHOD

We used purposive and snowball sampling to recruit 16 healthcare professionals to participate in semi-structured interviews completed by two evaluators. Interview transcripts were analyzed using thematic analysis to identify key themes and subthemes.

RESULTS

Participants recognized ODTs as a potentially feasible solution for increasing the safety of PWUD in healthcare settings. Our results suggest the mixed ability of these services to decrease stigma and build rapport with PWUD. Participants further highlighted barriers to implementing these services, including pre-established policies, legal recourse, and coordination of emergency responses to suspected overdoses. Lastly, participants highlight that ODTs should only be one part of a multifaceted approach to reducing harm in healthcare settings and could currently be integrated into discharge planning.

CONCLUSION

Healthcare professionals from across Canada found ODTs to be an acceptable intervention, but only as part of a larger suite of harm reduction interventions to reduce the harms associated with illicit drug use in healthcare settings. In contrast, participants noted institutional policies, stigma on behalf of healthcare workers and leadership would present significant challenges to their uptake and dissemination.

Investigating uses of peer-operated Virtual Overdose Monitoring Services (VOMS) beyond overdose response: a qualitative study

Background: Virtual overdose monitoring services (VOMS) are novel technologies that allow remote monitoring of individuals while they use substances (especially those who use alone) electronically.Objectives: The authors explored key partner perspectives regarding services offered by VOMS beyond overdose response with the aim of understanding the breadth and perception of the services amongst those that use these services and are impacted by them.Methods: Forty-seven participants from six key partner groups [peers who had used VOMS (25%), peers who had not used VOMS (17%), family members of peers (11%), health professionals (21%), harm reduction sector employees (15%), and VOMS operators (15%)] underwent 20-to-60-minute semi-structured telephone interviews. Of peer and family groups, thirteen participants identified as female, eleven as male and one as non-binary, gender data was not recorded for other key partner groups. Interview guides were developed and interviews were conducted until saturation was reached across all participants. Themes and subthemes were identified and member checked with partner groups.Results: Participants indicated that uses of VOMS beyond overdose monitoring included: (1) providing mental health support and community referral; (2) methamphetamine agitation de-escalation; (3) advice on self-care and harm reduction; and (4) a sense of community and peer support. Respondents were divided on how VOMS might affect emergency services (5).Conclusions: VOMS are currently being used for purposes beyond drug poisoning prevention, including community methamphetamine psychosis de-escalation, mental health support, and community peer support. VOMS are capable of delivering a broad suite of harm reduction services and referring clients to recovery-oriented services.

Virtual overdose monitoring services/mobile overdose response services: estimated number of potentially averted drug poisoning fatality events by various telephone and digital-based overdose prevention/harm reduction services in North America

Background

Virtual overdose monitoring services or Mobile Overdose Response Services (MORS) are novel virtual harm reduction tools which have gained popularity as an adjunct public health intervention especially for those who cannot access harm reduction resources through traditional means. At this time, relatively little is known about their ability to reach their goals of reducing overdose mortality. Our study aims to summarize the potential effectiveness of various MORS collectively to avoid potential mortality from a drug poisoning event/drug overdose.

Methods

Utilizing publicly available data from various MORS alongside some usage data provided by these services for this study, we model the impact of these services on fatal drug poisoning/overdose. In order to calculate the number of deaths averted, a Monte Carlo simulation was used to calculate point estimates with 95% confidence for fatal drug poisonings/drug overdose potentially averted through the utilization of various MORS.

Results

From the earliest mention of MORS in current literature (2019), a total of 299 drug poisoning/overdose events occurred across these services. Noting the broad range of mortality statistics available in current literature, these technologies have potentially prevented between 33 to 243 deaths. Our Monte Carlo estimates 135 potentially fatal drug poisonings/overdose were overall averted by the various MORS.

Conclusions

While there is yet to be a robust data set proving the effectiveness of these services, conservative estimates show that MORS can reduce mortality associated with substance use and therefore should be considered as a viable harm-reduction strategy but as an adjunct to more established harm reduction services such as supervised consumption sites and supervised injection facilities. While more research is needed, clinicians and practitioners should consider the suggestion of these tools for patients who use drugs.

A cost benefit analysis of a virtual overdose monitoring service/mobile overdose response service: the national overdose response service

BACKGROUND

The overdose crisis continues across Canada which calls for novel harm reduction strategies. Previous research indicates that a majority of eHealth solutions are cost-effective however current literature on the cost-benefit of eHealth for harm reduction is sparse. The National Overdose Response Service (NORS) is a Canada-wide telephone-based harm reduction service. Service users can call the phone number and connect to a peer who can virtually monitor the substance use session and dispatch appropriate interventions in the case of overdose.

OBJECTIVES OF THE RESEARCH/PROJECT

We aim to assess the cost-benefit of NORS by comparing the estimated cost-savings from prevented overdose mortality to the operating costs of the program, alongside healthcare costs associated with its operation.

METHODS

Data around systems costs and operational costs were gathered for our calculations. Our primary outcome was cost-benefit ratios, derived from estimates and models of mortality rates in current literature and value of life lost. We presented our main results across a range of values for costs and the probability of death following an unwitnessed overdose. These values were utilized to calculate cost-benefit ratios and value per dollar spent on service provision by NORS over the length of the program's operation (December 2020-2022).

RESULTS

Over the total funded lifespan of the program, and using a Monte Carlo estimate, the benefit-to-cost ratio of the NORS program was 8.59 (1.53-15.28) per dollar spent, depending on estimated mortality rates following unwitnessed overdose and program operation costs. Further, we conservatively estimate that early community-based naloxone intervention results in healthcare system savings of $4470.82 per overdose response.

CONCLUSIONS

We found the NORS program to have a positive benefit-to-cost ratio when the probability of death following an unwitnessed overdose was greater than 5%. NORS and potentially other virtual overdose monitoring services have the potential to be cost-effective solutions for managing the drug poisoning crisis.

Association of drug overdoses and user characteristics of Canada's national mobile/virtual overdose response hotline: the National Overdose Response Service (NORS)

BACKGROUND

Several novel overdose response technology interventions, also known as mobile overdose response services (MORS), have emerged as adjunct measures to reduce the harms associated with the drug poisoning epidemic. This retrospective observational study aims to identify the characteristics and outcomes of individuals utilizing one such service, the National Overdose Response Service (NORS).

METHODS

A retrospective analysis was conducted using NORS call logs from December 2020 to April 2023 imputed by operators. A variety of variables were examined including demographics, substance use and route, location, and call outcomes. Odds ratios and 95% confidence intervals were calculated around variables of interest to test the association between key indicators and drug poisonings.

RESULTS

Of the 6528 completed calls on the line, 3994 (61.2%) were for supervised drug consumption, 1703 (26.1%) were for mental health support, 354 (5.42%) were for harm reduction education or resources, and 477 (7.31%) were for other purposes. Overall, there were 77 (1.18%) overdose events requiring a physical/ in-person intervention. Of the total calls, 3235 (49.5%) were from women, and 1070 (16.3%) were from people who identified as gender diverse. Calls mostly originated from urban locations (n = 5796, 88.7%) and the province of Ontario (n = 4137, 63.3%). Odds ratios indicate that using opioids (OR 6.72, CI 95% 3.69-13.52), opioids in combination with methamphetamine (OR 9.70, CI 95% 3.24-23.06), multiple consumption routes (OR 6.54, CI 95% 2.46-14.37), and calls occurring in British Columbia (B.C) (OR 3.55, CI 95% 1.46-7.33) had a significantly higher likelihood of a drug poisoning. No deaths were recorded and only 3 false callouts had occurred. The overall drug poisoning event incidence to phone calls was 1.2%.

CONCLUSION

NORS presents a complimentary opportunity to access harm reduction services for individuals that prefer to use alone or face barriers to accessing in-person supervised consumption services especially gender minorities with high-risk use patterns.