'It's too much, I'm getting really tired of it': Overdose response and structural vulnerabilities among harm reduction workers in community settings

Overdose responses among rural people who use drugs: A multi-regional qualitative study

BACKGROUND

Efforts to distribute naloxone have equipped more people with the ability to reverse opioid overdoses but people who use drugs are often reluctant to call 911 due to concerns for legal repercussions. Rural communities face unique challenges in reducing overdose deaths compared to urban communities, including limited access to harm reduction services as well as greater concerns about stigma and privacy.

METHODS

The Rural Opioid Initiative was funded in 2017 to better understand the health-related harms associated with the opioid crisis in rural US communities and consists of eight studies spanning ten states and 65 counties. Each study conducted semi-structured qualitative interviews with people who use drugs to understand contextual factors influencing drug use and health behaviors. We analyzed qualitative data from seven studies with data available at the time of analysis to understand peer response to overdose.

RESULTS

Of the 304 participants interviewed, 55% were men, 70% were white, 80% reported current injection drug use, and 60% reported methamphetamine use. Similar to what has been found in studies focused on urban settings, people who use drugs in rural communities use a range of strategies to reverse overdoses, including non-evidence-based approaches. Several reported that multiple doses of naloxone are needed to reverse overdose. Three themes emerged around the willingness to call 911, including (1) hesitancy to call 911 for fear of legal consequences, (2) negative perceptions or experiences with law enforcement officers, and (3) efforts to obtain medical intervention while avoiding identification/law enforcement involvement.

CONCLUSION

People who use drugs employ multiple strategies to attempt overdose reversal, including non-evidence-based approaches. Greater education about the most effective and least harmful strategies is needed. Reluctance to call 911 is rooted in concerns about potential legal consequences as well as perceptions about law enforcement officers, which may be heightened in rural communities where people who use drugs are more easily identified by law enforcement. People who use drugs will go to great strides to connect their peers to needed medical services, suggesting that comprehensive interventions to reduce interactions with law enforcement officers and eliminate legal consequences for reporting overdoses are critical.

"Everybody is impacted. Everybody's hurting": Grief, loss and the emotional impacts of overdose on harm reduction workers

BACKGROUND

The emotional impacts of witnessing and responding to overdose and overdose-related deaths have been largely overlooked during the drug toxicity overdose crisis in North America. Scarce research has analyzed these impacts on the health and well-being of harm reduction workers, and the broader determinants of harm reduction work. Our study investigates the experiences and impacts of witnessing and responding to frequent and escalating rates of overdose on harm reduction workers in Toronto, Canada.

METHODS

Using semi-structured interviews, 11 harm reduction workers recruited from harm reduction programs with supervised consumption services in Toronto, Canada, explored experiences with and reactions to overdose in both their professional and personal lives. They also provided insights on supports necessary to help people cope with overdose-related loss. We used thematic analysis to develop an initial coding framework, subsequent iterations of codes and emergent themes.

RESULTS

Results revealed that harm reductions workers experienced physical, emotional, and social effects from overdose-related loss and grief. While some effects were due to the toll of overdose response and grief from overdose-related losses, they were exacerbated by the lack of political response to the scale of the drug toxicity overdose crisis and the broader socio-economic-political environment of chronic underfunding for harm reduction services. Harm reduction workers described the lack of appropriate workplace supports for trauma from repeated overdose response and overdose-related loss, alongside non-standard work arrangements that resulted in a lack of adequate compensation or access to benefits.

CONCLUSIONS

Our study highlights opportunities for organizational practices that better support harm reduction workers, including formal emotional supports and community-based supportive care services. Improvement to the socio-economic-political determinants of work such as adequate compensation and access to full benefit packages are also needed in the harm reduction sector for all workers.

Drug network identification predicts injecting risk behavior among people who inject drugs on hepatitis C virus treatment in Tayside, Scotland

The risk of Hepatitis C Virus (HCV) acquisition among People Who Inject Drugs (PWID) remains high when injecting risk behavior within networks endures. Several psychosocial factors influence such behavior. Following a drive within Tayside, a geographic region in Scotland, to achieve World Health Organization HCV elimination targets, addressing HCV re-infection risk as a barrier to elimination is critically important. This cross-sectional study seeks to address this barrier to elimination by investigating associations between group identification (one's subjective sense of belonging and connectedness to a social group coupled with a sense of shared goals, beliefs and values with the other members of the group) and injecting risk behavior among PWID on HCV treatment at needle and syringe provision sites in Tayside. Participants completed psychosocial questionnaires between treatment weeks zero and three of treatment. Correlation analyses were undertaken, and significant factors included in multiple linear regression models for injecting risk behavior. Injecting frequency, drug network identification, and family identification, were correlated with injecting risk behavior, and drug network identification had a positive predictive on injecting risk behavior. Identification with a social group, conventionally associated with improved health, may pose health risks in specific contexts. Healthcare providers should consider stratifying individuals with higher group identification with PWID networks for enhanced harm reduction engagement to mitigate transmissible infection risk among PWID. Additionally, psychological interventions to strengthen group identification with networks which impact positively on health behavior should be explored.

"Wanna cry this out real quick?": an examination of secondary traumatic stress risk and resilience among post-overdose outreach staff in Massachusetts

BACKGROUND

Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff.

METHODS

We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience).

RESULTS

Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams.

CONCLUSION

Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.

Changes in harm reduction service providers professional quality of life during dual public health emergencies in Canada

BACKGROUND

Harm reduction (HR) is a critical response to the pronounced toxicity deaths being experienced in Canada. HR providers report many benefits of their jobs, but also encounter chronic stress from structural inequities and exposure to trauma and death. This research study sought to quantify the emotional toll the toxicity emergency placed on HR providers (Cycle One; 2019). Study objectives were later expanded to determine the impact of the ongoing toxicity as well as the pandemic's impact on well-being (Cycle Two; 2021).

METHODS

Standardized measures of job satisfaction, burnout, secondary traumatic stress, and vulnerability to grief were used in an online national survey. Open-ended questions addressed resources and supports. HR partners across Canada validated the findings and contributed to alternative interpretations and implications.

RESULTS

651 respondents in Cycle One and 1,360 in Cycle Two reported moderately high levels of job satisfaction; they reported finding great meaning in their work. Yet, mean levels of burnout and secondary traumatic stress were moderate, with the latter significantly increasing in Cycle Two. Reported vulnerability to grief was moderate but increased significantly during COVID. When available, supports lacked the quality necessary to respond to the complexities of HR workers' experiences, or an insufficient number of sessions were covered through benefits. Respondents shared that their professional quality of life was affected more by policy failures and gaps in the healthcare system than it was by the demands of their jobs.

CONCLUSION

Both the benefits and the strain of providing harm reduction services cannot be underestimated. For HR providers, these impacts are compounded by the drug toxicity emergency, making the service gaps experienced by them all the more critical to address. Implications highlight the need for integration of HR into the healthcare system, sustainable and reliable funding, sufficient counselling supports, and equitable staffing models. Support for this essential workforce is critical to ensuring the well-being of themselves, the individuals they serve, and the health of the broader healthcare system.

Using alone at home: What's missing in housing-based responses to the overdose crisis?

BACKGROUND

Against the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis.

HARM REDUCTION AND OVERDOSE PREVENTION IN HOUSING

In response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts.

CONCLUSION

Emerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings.

Remaking the 'angry Narcanned subject': Affording new subject positions through take-home naloxone training

Naloxone is a medication used to reverse opioid overdose. Alongside its lifesaving effects, it also has a reputation for producing distress, aggression and occasionally violence upon administration. This article analyses how take-home naloxone (THN) training initiatives address naloxone's reputation for producing aggression and conflict, and how new subject positions emerge in the context of this training. While the role of naloxone in producing aggression has been discussed in a range of research, this work emphasises that such conflict is neither inevitable nor even likely because it is contingent on several other issues such as administration practices. Building on this scholarship, we work with Bruno Latour's theorisation of technological 'affordances' to analyse THN as a socially co-produced technology that, rather than either determining or neutrally communicating actions and effects, 'affords' possibilities, capacities and subjects. Analysing data drawn from observations of THN training in Victoria, Australia, and in-depth interviews with training participants, we argue that the issue of conflict upon revival affords a subject position we term the 'angry Narcanned subject'. This subject, we note, has come to hold a powerful position in understandings of naloxone, not least because it tends to accord with stereotypes of antisocial drug users. From here, we argue that a much of THN training is focused on challenging and reframing naloxone's reputation for conflict and questioning related subject positions, especially that of the angry Narcanned subject. We argue that this process of challenging and reframing affords two new subject positions for consumers: the 'capable administrator' and the 'calmer revivee'. We conclude that while THN training affords multiple, potentially positive, subject positions, unless these initiatives are accompanied by broader interventions such as decriminalisation campaigns, they may inadvertently responsibilise people who consume opioids for addressing overdose and erase the role of prohibition, criminalisation and stigmatisation in producing overdose events.

"I Don't Go Overboard": Perceptions of Overdose Risk and Risk Reduction Strategies among People Who Use Drugs in Rhode Island

Background: North America experiencing an unprecedented overdose epidemic, with data estimating almost 110,000 overdose deaths occurring in 2022 in the United States (US). To address fatal overdoses in the US, community organizations and local health departments in some jurisdictions have expanded community distribution of naloxone, and increased overdose prevention education, and other harm reduction supplies and services (e.g., fentanyl test strips, drug checking programs) to reduce harm for people who use drugs (PWUD). Objectives: Understanding how PWUD manage overdose risk within the context of these expanded services is important for ensuring public health services are meeting their needs. Semi-structured qualitative interviews were conducted with 25 PWUD who were accessing harm reduction services in Rhode Island. Data were imported into NVivo where they were coded and analyzed thematically. Results: Our findings demonstrate the complexity of managing overdose risk in the context of a fentanyl drug supply. While most participants were concerned about overdosing, they sought to manage overdose risk through their own harm reduction practices (e.g., testing their drugs, going slow) and drug purchasing dynamics, even when using alone. Conclusions: Study findings point to the need to implement and scale-up community-level interventions to better support PWUD within the context of the current US overdose crisis.

Exploring trauma and wellbeing of people who use drugs after witnessing overdose: A qualitative study

BACKGROUND

The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior.

METHODS

We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti.

RESULTS

A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices.

CONCLUSION

Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.

"It's starting to weigh on me": Exploring the Experiences and Support Needs of Harm Reduction Staff in Connecticut using the Social-Ecological Model

BACKGROUND

The experiences and perceived support needs of harm reduction workers in the USA have been understudied. While previous research has explored staff burnout and role-related stress, there is a research gap around potential supports for staff wellbeing and individual longevity in their roles. This is especially critical given the growing overdose crisis and the need for sustainable harm reduction programming. Thus, we sought to describe the experiences of harm reduction staff and identify the perceived support that could empower harm reduction staff to successfully navigate their roles.

METHODS

Purposive sampling methods were used to recruit harm reduction staff working in Connecticut. Seventeen semi-structured, one-on-one interviews were conducted between December 2022 and March 2023. Participants were asked about their experiences with role-related stressors and supports. Informed by the Social-Ecological Model, transcripts were coded using both inductive and deductive codes, and themes were developed using thematic analysis approaches.

RESULTS

Study participants described their experiences working in harm reduction and the numerous ways they already are or could be receiving support in their roles. These experiences were organized into eight themes according to the levels of the Social-Ecological Model. At the individual level, participants explained that support could help them navigate the variability of the physical environment, boundary setting, and self-care. Relationships between clients and co-workers were both identified as means of support at the interpersonal level, helping participants navigate difficult situations and feelings of stress. At the organizational level, study participants explained how they look to their organization to provide sufficient support by way of training, staffing, compensation, and benefits. Additionally, participants stressed the importance of having supervisors who valued their work and provided emotional support. Lastly, at the community level, participants discussed how support was needed to help them navigate complex systems while working with a stigmatized population in an often-stigmatized field.

CONCLUSIONS

To best support harm reduction staff in their day-to-day roles, our findings underscore the need for support on multiple levels. Future research could explore how the provision of support to harm reduction staff impacts not only staff perceptions of support but also the success of clients accessing harm reduction services.

Saving lives in our homes: Qualitative evaluation of a tenant overdose response program in supportive, single-room occupancy (SRO) housing

BACKGROUND

People using opioids alone in private settings are at elevated risk of dying in the event of an overdose. In San Francisco, single room occupancy (SRO) tenants are 19 times more likely to die of overdose than non-SRO residents. The "SRO Project" pilot aimed to reduce fatal overdoses in SROs by recruiting and training tenants to distribute naloxone and provide overdose education in their buildings. We explore the implementation and program impacts of the SRO Project pilot in two permanent supportive housing SROs.

METHODS

We conducted eight months of ethnographic fieldwork (May 2021 - Feb 2022), including 35 days observing SRO Project pilot activities, and semi-structured interviews with 11 housing staff and 8 tenant overdose prevention specialists ('specialists'). Data were analyzed using a grounded theory approach to characterize program impacts, implementation strengths, and implementation challenges from the perspective of specialists and housing staff.

FINDINGS

We found that the SRO project increased awareness, access to, and understanding of naloxone; facilitated other mutual-aid practices; supported privacy and autonomy of tenants regarding their drug use; and improved rapport, communication and trust between tenants and housing staff. Strengths of the implementation process included involvement of tenants with diverse social locations and skill sets and, at one site, a team-based approach that fostered program innovation, tenant solidarity and a sense of collective ownership over the project. Program implementation was challenged by frequent turnover and capacity constraints of housing staff, particularly during overnight shifts when overdose risks were greatest. Additional challenges arose due to the psychosocial burden of overdose response work, gendered violence, issues with compensation methods, and scope creep in specialists' roles.

CONCLUSION

This evaluation contributes further evidence regarding the effectiveness of tenant-led naloxone distribution and overdose education in permanent supportive and SRO housing environments. Findings indicate program implementation and sustainability can be improved by expanding tenant specialist training, compensating specialists in cash, and building stronger psychosocial support for tenants responding to overdoses in their homes.

A cross sectional survey of provider experiences with patient drug overdose death

INTRODUCTION

A record number of drug overdose (OD) deaths occurred in the United States in 2021. We know little regarding the impact of patient drug OD deaths on providers within health care settings. The aim of this study was to assess provider preparedness and experience with patient drug OD death.

METHODS

The study distributed an email invitation to individuals in the Provider Clinical Support System database in December 2020 to complete an anonymous web-based survey. We used multiple choice questions to assess provider demographics, preparedness to cope with patient OD death, and experience with patient OD death. The study evaluated stress associated with patient OD death using the Impact of Event Scale-Revised. We summarized responses using descriptive statistics. Associations between high stress after patient OD death and the impact of the death on clinical practice and the helpfulness of individuals and processes were assessed using Chi-square and Fisher's Exact tests.

RESULTS

Among the 12,204 individuals who read the email invitation, 1064 opened the survey link, and 523 completed the survey. Participants were predominantly physicians (40.2 %) and counselors (25 %), 70 % female, 78.4 % white, with a mean age of 52 years. Among the participants 26.4 % felt at least very well prepared to cope with an OD death, and 27.7 % felt at least very well prepared to support a colleague with a patient OD death. Most respondents (55.1 %) had a history of a patient OD death. Many patient OD deaths were not discussed by providers with other colleagues, but when providers did discuss these deaths providers identified colleagues as being very helpful. Compared to providers with low stress after patient OD death, those with high levels of stress were more likely to refer patients to a higher level of care (p = 0.035).

CONCLUSIONS

Many providers did not feel prepared themselves to cope with a patient OD death or support a colleague following this type of event. Patient OD deaths were a common experience, and providers did not frequently discuss their patient's deaths with others. A patient OD death can change clinical decision-making for providers experiencing high levels of stress related to the OD death.

"It's just a perfect storm": Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances

BACKGROUND

Despite the implementation and expansion of public health and harm reduction strategies aimed at preventing and reversing overdoses, rates of overdose-related events and fatalities continue to rise in British Columbia. The COVID-19 pandemic created a second, concurrent public health emergency that further exacerbated the illicit drug toxicity crisis, reinforced existing social inequities and vulnerabilities, and highlighted the precariousness of systems in place that are meant to protect the health of communities. By exploring the perspectives of people with recent experience of illicit substance use, this study sought to characterize how the COVID-19 pandemic and associated public health measures influenced risk and protective factors related to unintentional overdose by altering the environment in which people live and use substances, influencing the ability of people who use substances to be safe and well.

METHODS

One-on-one semi-structured interviews were conducted by phone or in-person with people who use illicit substances (n = 62) across the province. Thematic analysis was performed to identify factors shaping the overdose risk environment.

RESULTS

Participants pointed to factors that increased risk of overdose, including: [1] physical distancing measures that created social and physical isolation and led to more substance use alone without bystanders nearby able to respond in the event of an emergency; [2] early drug price spikes and supply chain issues that created inconsistencies in drug availability; [3] increasing toxicity and impurities in unregulated substances; [4] restriction of harm reduction services and supply distribution sites; and [5] additional burden placed on peer workers on the frontlines of the illicit drug toxicity crisis. Despite these challenges, participants highlighted factors that protected against overdose and substance-related harm, including the emergence of new programs, the resiliency of communities of people who use substances who expanded their outreach efforts, the existence of established social relationships, and the ways that individuals consistently prioritized overdose response over concerns about COVID-19 transmission to care for one another.

CONCLUSIONS

The findings from this study illustrate the complex contextual factors that shape overdose risk and highlight the importance of ensuring that the needs of people who use substances are addressed in future public health emergency responses.

"The new normal has become a nonstop crisis": a qualitative study of burnout among Philadelphia's harm reduction and substance use disorder treatment workers during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic worsened the ongoing overdose crisis in the United States (US) and caused significant mental health strain and burnout among health care workers (HCW). Harm reduction, overdose prevention, and substance use disorder (SUD) workers may be especially impacted due to underfunding, resources shortages, and chaotic working environments. Existing research on HCW burnout primarily focuses on licensed HCWs in traditional environments and fails to account for the unique experiences of harm reduction workers, community organizers, and SUD treatment clinicians.

METHODS

We conducted a qualitative secondary analysis descriptive study of 30 Philadelphia-based harm reduction workers, community organizers, and SUD treatment clinicians about their experiences working in their roles during the COVID-19 pandemic in July-August 2020. Our analysis was guided by Shanafelt and Noseworthy's model of key drivers of burnout and engagement. We aimed to assess the applicability of this model to the experiences of SUD and harm reduction workers in non-traditional settings.

RESULTS

We deductively coded our data in alignment with Shanafelt and Noseworthy's key drivers of burnout and engagement: (1) workload and job demands, (2) meaning in work, (3) control and flexibility, (4) work-life integration, (5) organizational culture and values, (6) efficiency and resources and (7) social support and community at work. While Shanafelt and Noseworthy's model broadly encompassed the experiences of our participants, it did not fully account for their concerns about safety at work, lack of control over the work environment, and experiences of task-shifting.

CONCLUSIONS

Burnout among healthcare providers is receiving increasing attention nationally. Much of this coverage and the existing research have focused on workers in traditional healthcare spaces and often do not consider the experiences of community-based SUD treatment, overdose prevention, and harm reduction providers. Our findings indicate a gap in existing frameworks for burnout and a need for models that encompass the full range of the harm reduction, overdose prevention, and SUD treatment workforce. As the US overdose crisis continues, it is vital that we address and mitigate experiences of burnout among harm reduction workers, community organizers, and SUD treatment clinicians to protect their wellbeing and to ensure the sustainability of their invaluable work.

Spotting as a risk mitigation method: A qualitative study comparing organization-based and informal methods

OBJECTIVES

To explore the similarities and differences of organization-based and informal spotting (remote supervision of substance use) from the perspectives of spotters and spottees across Canada.

METHODS

Spotters and spottees who spot informally and for organizations were recruited across Ontario and Nova Scotia. We interviewed 20 informal and 10 organization-based participants by phone using semi-structured interviews between 08/2020 and 11/2020. Participants were asked about each methods benefits and limitations. Interviews were audio-recorded, transcribed, and analyzed thematically.

RESULTS

Benefits of informal spotting included its ability to strengthen social connections and foster autonomy in overdose response planning. The lack of support for informal spotters created stress and burnout. Organization-based spotters enjoyed the spotting training and support provided. However, regulations surrounding having to call ambulance in overdose events deterred many people from wanting to work for or call these services.

CONCLUSIONS

Both organization-based and informal spotting have a role in mitigating harms associated with the overdose crisis. Moving forward, further research is needed on how to optimize these services for all people who use drugs in varying jurisdictions internationally.

(Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada

Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of supportive environments and team-based approaches for overdose response; and the benefits of community-driven training that extends beyond technical skills of overdose identification and naloxone administration.

"Once you open that door, it's a floodgate": Exploring work-related grief among community service workers providing care for structurally vulnerable populations at the end of life through participatory action research

BACKGROUND

At the end of life, people experiencing structural vulnerability (e.g. homelessness, poverty, stigmatization) rely on community service workers to fill gaps in access to traditional palliative services. Although high levels of burnout are reported, little is known about these workers' experiences of grief.

AIM

To explore community service workers' experiences of grief to identify ways of providing more tailored, meaningful, and equitable supports.

DESIGN

A community-based participatory action research methodology, informed by equity perspectives, was employed.

SETTING/PARTICIPANTS

In an urban center in western Canada, community service worker (primary) participants (n = 18) were engaged as members of an action team. A series of 18 action cycles took place, with secondary participants (n = 48) (e.g. palliative, social care, housing support, etc.) being recruited throughout the research process. Focus groups (n = 5) and evaluative interviews (n = 13) with participants were conducted. Structured observational field notes (n = 34) were collected during all team meetings and community interventions. Interpretive thematic analysis ensued through a collaborative and iterative process.

RESULTS

During initial meetings, action team participants described experiences of compounding distress, grief, and multiple loss. Analysis showed workers are: (1) grieving as family, not just providers; (2) experiencing complex layers of compounded grief; and (3) are fearful to open the "floodgates" to grief.

CONCLUSIONS

Findings contribute to our understanding on the inequitable distribution of grief across society. A collective and material response is needed, including witnessing, acknowledging and valuing the grief process; facilitating community wellness, collective grieving, and advocacy; and providing training and tools in a palliative approach to care.

Individual and social network correlates of responding to multiple overdoses among a cohort of people who use drugs

Background

The purpose of this study was to identify characteristics of people who respond to two or more overdoses (i.e., multiple overdose responders; MOR) compared to those who respond to zero or one, and the association between MOR status and changes in network size.

Methods

Secondary analysis of data from a randomized trial among 199 PWUD in Baltimore, MD (2016-2019). We used cross-tabulation, 𝜒 ² , and ANOVA models to identify cross-sectional associations between overdose response and demographic, drug use, and network size; and ANCOVA models to examine the relationship between baseline MOR status and change in network size.

Results

From the cohort of 199, 185 people provided data on overdose response at baseline; 197 provided data at 6-month follow-up. At baseline, 27.6% of participants were classified as MORs (ever). Correlates of MOR status included homelessness; age; injecting drug use; quality of interactions with police (respectful vs. not); and use of powder cocaine, prescription opioids, and heroin. MORs had larger networks and their network size decreased more over time, but the association was not statistically significant. At follow-up, 16% were classified as MORs (past 6 months); correlates of follow-up MOR status were similar to those at baseline.

Conclusions

Overdose prevention interventions rely on PWUD to respond to overdoses. Identifying factors associated with MOR status could increase intervention efficiency and providing MORs with support could increase sustainability. Our findings suggest that PWUD experiencing homelessness, using cocaine and heroin, and demonstrating increased salience of overdose in their lives would benefit from targeted programs.

"I don't go to funerals anymore": how people who use opioids grieve drug-related death in the US overdose epidemic

BACKGROUND

Opioid-related overdose death is a public health epidemic in much of the USA, yet little is known about how people who use opioids (PWUO) experience overdose deaths in their social networks. We explore these experiences through a qualitative study of opioid-related overdose death bereavement among PWUO.

METHODS

We recruited 30 adults who inject opioids from a syringe service program in the Midwestern USA and interviewed them using a semi-structured guide that addressed experiences of opioid use, opioid-related overdose, and overdose reversal via the medication naloxone. Interviews were transcribed verbatim and analyzed thematically.

FINDINGS

Participants described overdose death as ever-present in their social worlds. Most (approximately 75%) reported at least one overdose death in their social network, and many came to consider death an inevitable end of opioid use. Participants described grief shaped by complex social relations and mourning that was interrupted due to involvement with social services and criminal legal systems. They also reported several ways that overdose deaths influenced their drug use, with some increasing their use and others adopting safer drug use practices. Despite the high prevalence of overdose deaths in their social networks, only one participant reported receiving grief support services.

DISCUSSION

Findings underscore the need for interventions that not only maintain life, such as naloxone distribution, but also improve quality of life by attending to grief related to overdose death bereavement. We discuss policies and practices with the potential to address the unique psychological, social, and structural challenges of grief for this population.

A Structural Competency Framework for Emergency Medicine Research: Results from a Scoping Review and Consensus Conference

INTRODUCTION

The application of structural competency and structural vulnerability to emergency medicine (EM) research has not been previously described despite EM researchers routinely engaging structurally vulnerable populations. The purpose of this study was to conduct a scoping review and consensus-building process to develop a structurally competent research approach and operational framework relevant to EM research.

METHODS

We conducted a scoping review focused on structural competency and structural vulnerability. Results of the review informed the development of a structural competency research framework that was presented throughout a multi-step consensus process culminating in the 2021 Society for Academic Emergency Medicine Consensus Conference. Feedback to the framework was incorporated throughout the conference.

RESULTS

The scoping review produced 291 articles with 123 articles relevant to EM research. All 123 articles underwent full-text review and data extraction following a standardized data extraction form. Most of the articles acknowledged or described structures that lead to inequities with a variety of methodological approaches used to operationalize structural competency and/or structural vulnerability. The framework developed aligned with components of the research process, drawing upon methodologies from studies included in the scoping review.

CONCLUSION

The framework developed provides a starting point for EM researchers seeking to understand, acknowledge, and incorporate structural competency into EM research. By incorporating components of the framework, researchers may enhance their ability to address social, historical, political, and economic forces that lead to health inequities, reframing drivers of inequities away from individual factors and focusing on structural factors.

Drug use behaviors, trauma, and emotional affect following the overdose of a social network member: A qualitative investigation

BACKGROUND

Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network.

METHODS

We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes.

RESULTS

We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living.

CONCLUSIONS

Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.

COVID-19 and the opportunity for gender-responsive virtual and remote substance use treatment and harm reduction services

The COVID-19 pandemic has increased the uptake of virtual and remote service delivery in the substance use field, which was previously uncommon. This swift uptake of virtual services provides an opportunity to improve service design to meet the diverse needs of women and gender-diverse people. Such services have the potential to better meet the needs of women and gender-diverse people by allowing for increased choice, control, and autonomy, enabling empowerment, facilitating greater considerations of power relations, violence, childcare responsibilities, and fostering greater inclusion of trans and non-binary people. This commentary aims to identify how virtual and remote delivery of substance use treatment and harm reduction services can be gender-responsive. We highlight the role gender transformative services play in meeting the unique needs of women and gender-diverse people who use drugs both during and after the COVID-19 pandemic. By using the unique window of opportunity COVID-19 has created to develop and deliver gender-transformative programs, we can help address the detrimental gaps in service accessibility and effectiveness that have persistently been experienced by women and gender-diverse people who use drugs.

Frequency of fatal and non-fatal overdoses and response to grief and loss among people who inject drugs: An unexplored dimension of the opioid overdose crisis

BACKGROUND

We investigated the relationship between overdose events and grief and loss responses among people who inject drugs.

METHODS

We conducted a cross-sectional, tablet-based survey with a convenience sample of people who inject drugs (n = 249) from four community-based harm reduction programs in Toronto in 2019. We examined the association between frequency and types of overdose events (own, witnessed, death of significant person) in the last 6 months with grief and loss responses, identified using latent class analysis.

RESULTS

Among respondents, 70 (48.6 %) reported 2 or more personal overdoses, 173 (79.5 %) witnessed 2 or more overdoses, and 69 (41.4 %) experienced overdose deaths of 2 or more significant persons in the last 6 months. We identified 2 latent classes with probability of membership of 38.6 % (95 % confidence interval [CI]=31.0, 46.7) for medium/low intensity of responses to grief/loss and 61.4 % (95 % CI= 53.3, 69.0) for severe responses to grief/loss. In adjusted Poisson regression models with robust standard error estimators, severe responses to grief/loss were associated with exposure to two or more own overdoses (prevalence ratio [PR] = 1.44; 95 % CI=1.12, 1.84, p-value=0.004), and having witnessed one (PR=2.09; 95 % CI=1.05, 4.15, p-value=0.04) or witnessed two or more overdoses (PR=2.25; 95 % CI=1.24, 4.09, p-value=0.008). Severe grief/loss responses were also more common in individuals exposed to all three types of overdose events (PR=2.42; 95 % CI=1.08, 5.41, p-value=0.03).

CONCLUSIONS

Cumulative overdose events were associated with severe responses to grief and loss. Bereavement interventions should consider the complex nature of grief and loss following overdoses.

Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach

Background

Opioid-related overdose deaths have surged in the USA over the last two decades. Overdose fatalities are preventable with the timely administration of naloxone. Syringe service programs (SSP) have pioneered community-based naloxone distribution through overdose prevention and naloxone distribution (OEND) programs. There is a dearth of information with regards to best practices for community-based OEND.

Methods

We utilized a modified Delphi approach to develop a set of best practices for OEND delivery. Starting with an initial list of best practices, we engaged 27 experts, in the field of OEND programming who reviewed, made recommendations for changes, and assigned a priority to each best practice.

Results

Two rounds of input resulted in a final list of 20 best practices organized into four categories. The mean priority scores ranged from 1.17 to 2.17 (range 1 to 3). The top 5 ranked best practices were ensuring that SSP participants have low barrier, consistent, needs-based access to naloxone and that there is ample naloxone available within communities. While the remaining fifteen best practices were deemed important, they had more to do with organizational culture and implementation climate.

Conclusions

Increasing community-based OEND delivery is essential to reduce opioid overdose deaths; however, it will be insufficient to add programs without an eye toward quality of implementation and fidelity to the model upon which the evidence is based. This list of best practices summarizes the consensus among OEND experts and can serve as a tool for SSPs providing OEND programming to improve services.

More than saving lives: Qualitative findings of the UNODC/WHO Stop Overdose Safely (S-O-S) project

BACKGROUND

The Stop Overdose Safely (S-O-S) initiative-developed in compliance with WHO guidelines-aims to prevent opioid overdose deaths. Under the umbrella of this initiative a multi-country project was implemented in Kazakhstan, Kyrgyzstan, Tajikistan, and Ukraine, that involved overdose recognition and response training, including the provision of take-home naloxone (THN). More than 14,000 potential overdose witnesses were trained and more than 16,000 THN kits were distributed across the participating countries. This paper reports on the qualitative component of an evaluation aiming to understand the views and experiences of S-O-S project participants.

METHODS

Data were drawn from focus group discussions with 257 project participants from across all four countries, including people who use and inject drugs, and others likely to witness an opioid overdose. Data were analysed thematically.

RESULTS

Findings revealed how past experiences of trauma and loss related to overdose death were common, as was appreciation and gratitude for the opportunity to participate in the S-O-S training. Participants described how they shared knowledge and skills with others. Empowerment and destigmatising narratives featured prominently, and highlighted how for people who use drugs, feeling valued and cared about-not only by families and friends, but by health care providers, and sometimes police-was a positive outcome of their participation. Nevertheless, findings also revealed how real experiences of fear regarding police intervention was a barrier to carrying naloxone and intervening when faced with an overdose situation.

CONCLUSION

Our analysis found that the S-O-S project produced positive outcomes that go well beyond saving lives. Despite identifying barriers to THN uptake, our findings support a growing body of evidence that broad access to THN as part of a continuum of care can enhance the health and wellbeing of people who use drugs and their communities, in low- to middle-income countries.

Peer Support and Overdose Prevention Responses: A Systematic 'State-of-the-Art' Review

Overdose prevention for people who use illicit drugs is essential during the current overdose crisis. Peer support is a process whereby individuals with lived or living experience of a particular phenomenon provide support to others by explicitly drawing on these experiences. This review provides a systematic search and evidence synthesis of peer support within overdose prevention interventions for people who use illicit drugs. A systematic search of six databases (CINAHL, SocINDEX, PsycINFO, MEDLINE, Scopus, and Web of Knowledge) was conducted in November 2020 for papers published in English between 2000 and 2020. Following screening and full-text review, 46 papers met criteria and were included in this review. A thematic analysis approach was used to synthesize themes. Important findings include: the value of peers in creating trusted services; the diversity of peers' roles; the implications of barriers on peer-involved overdose prevention interventions; and the stress and trauma experienced by peers. Peers play a pivotal role in overdose prevention interventions for people who use illicit drugs and are essential to the acceptability and feasibility of such services. However, peers face considerable challenges within their roles, including trauma and burnout. Future interventions must consider how to support and strengthen peer roles in overdose settings.

Physician trainees' compassion satisfaction, burnout, and self-efficacy when caring for people who inject drugs

BACKGROUND

Front-line providers working with people who inject drugs (PWID) are at increased risk of experiencing burnout. Few studies have examined protective factors against burnout incurred in the care of PWID, including harm reduction counseling skills. We measured self-efficacy in harm reduction counseling, burnout, and compassion satisfaction among Internal Medicine (IM) trainees caring for PWID. Methods: In this cross-sectional study, we surveyed IM interns and residents. Self-efficacy was assessed by asking trainees about attitudes, comfort, and knowledge in harm reduction counseling on a five-point Likert scale. Burnout and compassion satisfaction were assessed via an adapted 20-question Professional Quality of Life Scale. We compared self-efficacy in harm reduction counseling, compassion satisfaction, and burnout between interns and residents using ANOVA and Mann-Whitney U tests. We used Spearman's rho correlational analysis to examine the relationship between these three variables. Results: Seventy-nine IM trainees (36 interns, 43 residents) completed the survey for a 52% response rate. Residents reported higher self-efficacy in harm reduction counseling, similar levels of burnout, and higher compassion satisfaction compared to interns. Across training levels, we found a negative correlation between burnout and compassion satisfaction (r = -0.55, p < 0.01) and a positive correlation between compassion satisfaction and comfort counseling PWID on harm reduction (r = 0.30, p < 0.01). Conclusions: Among IM trainees at an urban institution serving a large population of PWID, self-efficacy in harm reduction counseling and compassion satisfaction increase with time in training while burnout remains similar. Strengthening trainees' capacity to counsel PWID on harm reduction may improve their compassion satisfaction in caring for this population, potentially leading to improved care. This relationship should be explored longitudinally in larger cohorts and through evaluations of harm reduction-focused medical education.

Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event

Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders' feelings about helping in an overdose situation in the future. Methods: For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Results: Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. Conclusions: The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.

Investigating a bidirectional relationship between overdose and provision of injection initiation assistance among persons who inject drugs in Vancouver, Canada and Tijuana, Mexico

BACKGROUND

Individuals who initiate injection drug use often receive assistance from an injection-knowledgeable peer. Persons who assist peers in injection initiation events often inject frequently, which heightens overdose risk. As such, overdose and injection initiation events may be correlated. To explore a potential relationship, we assessed temporal associations between experiencing a non-fatal overdose and assisting others in initiating injection drug use among persons who inject drugs in two North American cities - Vancouver, Canada and Tijuana, Mexico.

METHODS

From 2014 to 2018, this retrospective cohort study included people who inject drugs from Vancouver (n=1332) and Tijuana (n=666) who completed a baseline and six-month follow-up interview. Within each site, we assessed bidirectional temporal associations using two separate multivariable logistic regression models: for model 1, recent provision of injection initiation assistance (at six months) was the outcome and recent overdose (at baseline) was the exposure; for model 2, recent overdose (at six months) was the outcome and recent provision of injection initiation assistance (at baseline) was the exposure. Both models adjusted for potential confounders.

RESULTS

Vancouver-based participants reporting overdose at baseline had 163% greater odds of reporting provision of injection initiation assistance at follow-up (adjusted Odds Ratio [aOR] 2.63; 95% Confidence Interval [CI] 1.41-4.90); while participants reporting provision of injection initiation assistance at baseline had 89% greater odds of reporting a non-fatal overdose at follow-up (aOR 1.89; 95% CI 1.00-3.57). Among Tijuana-based participants, we did not observe a statistically significant association in either direction.

CONCLUSION

Findings in Vancouver suggest that injection initiation assistance and overdose are bidirectionally-associated phenomena. The present findings highlight the need for interventions that ensure that persons who provide injection initiation assistance are given overdose prevention support, both for themselves and for those they assist to initiate injection drug use. While our Tijuana-based results did not suggest a bidirectional relationship, preventative approaches should nonetheless be undertaken.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone

BACKGROUND

Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees.

METHODS

Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used.

RESULTS

We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings.

CONCLUSION

Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

"I wanted to close the chapter completely … and I feel like that [carrying naloxone] would keep it open a little bit": Refusal to carry naloxone among newly-abstinent opioid users and 12-step identity

BACKGROUND

12-step programs aim to address drug-related harms, like opioid overdose, via abstinence. However, abstaining from opioids can diminish tolerance, which increases risk for overdose death upon resumption. A recent study found that desire to abstain from drugs inhibited willingness to participate in take-home naloxone programming, which was linked to perceptions of harm reduction strategies being tied to drug use. In the present study, we uncovered a similar phenomenon occurring among newly-abstinent participants who were refusing to carry naloxone.

METHODS

This study is an analysis of broader qualitative data collected throughout Southern California among persons who use opioids, including those recently abstinent. Preliminary analysis revealed that those newly abstinent refused to accept naloxone at the end of interviews, and so we began probing about this (N=44). We used thematic analysis and author positionality to explicate the emergent phenomenon and applied social identity theory to conceptualize findings.

RESULTS

Mechanisms underlying naloxone refusal included its tie to a drug-using identity that newly-abstinent participants were attempting to retire. Carrying naloxone was also viewed as pointless due to doubt of witnessing an overdose again. Furthermore, the thought of being equipped with naloxone was not believed to be congruent with an abstinent identity, e.g. "me carrying it [naloxone] is making me feel like I'm going to be hanging out with people that are doing it [using drugs]."

CONCLUSION

Recent detoxification heightens vulnerability to overdose, which other newly-abstinent peers might be positioned to respond to as bonds are formed through 12-step identity formation. However, naloxone is often refused by this group due to perceived 12-step identity clash. While some treatment spaces distribute naloxone, 12-step identity associated behavioral expectations appear to conflict with this strategy. Reframing these disconnects is essential for expanding the lifesaving naloxone community safety net.

"They went down that road, and they get it": A qualitative study of peer support worker roles within perinatal substance use programs

BACKGROUND

Perinatal substance use programs employ multidisciplinary teams to support women who use drugs through pregnancies and parenting, with some programs expanding to include peer support workers with lived experience of parenting and substance use. Research has shown peer support to enhance care in substance use treatment; however, little research exists that examines this model of support within perinatal substance use programs. We explore the current and potential role of peer support workers within perinatal substance use programs, from the perspectives of mothers accessing these programs.

METHODS

We conducted focus groups with 20 mothers enrolled in three perinatal substance use programs serving the greater Vancouver area, including two community-based programs that employed peer workers and an acute care maternity ward that did not. We recorded focus groups, had them professionally transcribed, and analyzed them thematically.

RESULTS

Participants characterized peer support workers as extending and complementing informal care practices already occurring within programs, including mother-to-mother support with breastfeeding, childcare, and system navigation. Integrating peer workers shifted care relations and practices in ways that participants found beneficial. Participants emphasized how support workers with similar social locations and life experiences-beyond just their substance use-helped to foster trust and safety for mothers in the program. Indigenous mothers discussed the importance of having Indigenous support workers whose practice is grounded in their cultures and experiences under colonization. Participants ascribed an aspirational status to peer support workers, conveying that it was motivational to see other mothers working in the program, and described the role as a means of maintaining connection and community. However, some expressed concerns about managing professional-personal boundaries and being emotionally "triggered" by the work.

CONCLUSION

This study evidences benefits of employing peer support workers within perinatal substance use programs, while also indicating the need for organizational processes to ensure that peer staff are integrated equitably and supported adequately.

Positive effects of community attachment on internalised stigma and wellbeing among people who inject drugs

BACKGROUND

Internalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment.

METHODS

PWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing.

RESULTS

Greater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment.

CONCLUSIONS

This research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma.

Circumstances of overdose among suburban women who use opioids: Extending an urban analysis informed by drug, set, and setting

BACKGROUND

Opioid overdoses are primarily discussed by the pharmacological properties of the drugs used. Research shows that other factors such as the social/physical environment and the mental/emotional states can have an impact on overdose events. Ataiants and colleagues (2020) used Zinberg's "drug, set, and setting" framework to identify circumstances surrounding overdose experiences of street-involved women in Philadelphia. The aim of this paper is to extend their analysis to a diverse sample of suburban women who experienced overdoses.

METHODS

The mixed-methods design consisted of ethnographic fieldwork, in-depth interviews, and brief surveys with 32 suburban women who use opioids. Inductive theoretical reasoning and constant comparative analysis facilitated themes emerging within the "drug, set, and setting" framework.

RESULTS

Eighteen out of 32 women identified "drug" as the primary factor involved in their overdose events. Major themes were an inability to identify the synthetic opioid fentanyl, lack of knowledge or control over how much to use, poly-substance use, and an insufficient understanding of risks. Eleven out of 32 women linked "set" to their overdose experiences. Themes included emotional trauma, such as death of a child, child custody issues, and mental health conditions, such as depression. Six out of 32 women associated "setting" with one of their overdose experiences. Themes were related to being with friends or partners that used, and having recently been released from treatment or incarceration.

CONCLUSION

Findings show similar themes found among an urban sample, adding insight on the need for effective overdose interventions targeted for suburban populations. The opioid crisis is not confined to the cities, and neither should services aimed at addressing opioid overdose. The knowledge provided here can help policy makers support female-centered harm reduction services not only in urban areas but also in the suburbs.

"Running myself ragged": stressors faced by peer workers in overdose response settings

Background

Peer workers or “peers” (workers with past or present drug use experience) are at the forefront of overdose response initiatives, and their role is essential in creating safe spaces for people who use drugs (PWUD). Working in overdose response settings has benefits for peer workers but is also stressful, with lasting emotional and mental health effects. Yet, little is known about the stressors peer workers face and what interventions can be implemented to support them in their roles.

Methods

This project used a community-based sequential mixed-methods research design. Eight peer researcher-led focus groups (n = 31) were conducted between November 2018 and March 2019 to assess needs of peer workers. The transcripts were thematically coded and analysed using interpretative description. These results informed a survey, which was conducted (n = 50) in September 2019 to acquire quantitative data on peer workers’ perception of health, quality of life, working conditions and stressors. Frequency distributions were used to describe characteristics of participants. X² distribution values with Yates correction were conducted to check for association between variables.

Results

Five themes emerged from the focus groups that point to stressors felt by peer workers: (1) financial insecurity; (2) lack of respect and recognition at work; (3) housing challenges; (4) inability to access and/or refer individuals to resources; and (5) constant exposure to death and trauma. Consistent with this, the factors that survey participants picked as one of their “top three stressors” included financial situation, work situation, and housing challenges.

Conclusion

Peer workers are faced with a diversity of stressors in their lives which often reflect societal stigmatization of drug use. Recognition of these systemic stressors is critical in designing interventions to ease the emotional, physical and financial burden faced by peer workers.

"And we just have to keep going": Task shifting and the production of burnout among overdose response workers with lived experience

Overdose response programs in North America increasingly employ task shifting-shifting overdose response tasks to less specialized workers-to increase effectiveness and promote involvement of people with lived/living experience of drug use (PWLE). In Canada, task shifting has occurred through community-driven implementation of overdose response programs staffed primarily by PWLE. The implications of this task shifting on workers' well-being and service delivery has received little scholarly consideration, despite reports of widespread burnout among frontline responders. This study examines experiences and drivers of burnout among PWLE working at low-barrier supervised consumption sites ("Overdose Prevention Sites" or OPSs) in Vancouver, Canada. Between December 2016 and March 2020, we conducted ethnographic fieldwork at four OPSs, including in-depth interviews with 23 overdose response workers, three site-based focus groups with 20 additional workers, and 150 h of naturalistic observation. Data were analyzed to explore how working conditions, labour arrangements, economic insecurity and social disadvantage shaped burnout. We found that overdose response workers commonly reported burnout, which they attributed to the precarious and demanding nature of their work. While casual positions offered low-barrier employment, PWLE often lacked the wages and benefits enjoyed by other frontline workers, with limited supports and opportunities for advancement. Due to their social position within drug-using networks, PWLE's work encompassed hidden care work that participants felt was constant and undervalued. The scarcity of permanent full-time positions, alongside barriers to transitioning into formal employment, prevented many PWLE from earning livable wages or taking time off to 'recharge.' This study highlights how the devaluing and casualization of overdose response labour, compounded by other dimensions of structural vulnerability, are central to burnout among overdose response workers with lived experience. Interventions to address burnout within this setting must extend beyond individual-level interventions (e.g. counselling, self-care) to also strengthen working conditions and economic security of PWLE.

Essential work, precarious labour: The need for safer and equitable harm reduction work in the era of COVID-19

This commentary highlights labour concerns and inequities within the harm reduction sector that hinder programs' ability to respond to converging public health emergencies (the overdose crisis and COVID-19), and potentially contribute to spread of the novel coronavirus. Many harm reduction programs continue to support people who use illicit drugs (PWUD) during the pandemic, yet PWUD working in harm reduction programs (sometimes termed 'peers') experience precarious labour conditions characterized by low wages, minimal employee benefits (such as paid sick leave) and high employment insecurity. Along with precarious labour conditions, PWUD face heightened vulnerabilities to COVID-19 and yet have been largely overlooked in global response to the pandemic. Operating under conditions of economic and legal precarity, harm reduction programs' reliance on precarious labour (e.g. on-call, temporary and unpaid work) renders some services vulnerable to staffing shortages and service disruptions during the pandemic, while also heightening the risk of virus transmission among workers, service users and their communities. We call for immediate policy and programmatic actions to strengthen working conditions within these settings with a priority on enhancing protections and supports for workers in peer roles.

'Peer' work as precarious: A qualitative study of work conditions and experiences of people who use drugs engaged in harm reduction work

In this study, we examine the qualitative accounts of people who use drugs engaged in 'peer' work in harm reduction settings across British Columbia, Canada. We found peer work was precarious, characterized by nonstandard or casual work arrangements, high job instability and insecurity, insufficient wages, and limited social benefits. Participants were reluctant to exercise their rights or negotiate work conditions, such as higher wages or more consistent work, out of fear of job loss. However, the flexibility of peer work was beneficial for some in that it worked within their life circumstances and provided a low-barrier entry into the labor market. If inequities in peer work are perpetuated, unrecognized and unaddressed, precarious work conditions may continue to undermine the potential benefits of harm reduction work for organizations, peer workers and the people to whom they engage with and support. This study adds people who use drugs to the many social groups that are impacted by precarious work conditions globally.

"Generally, you get 86'ed because you're a liability": An application of Integrated Threat Theory to frequently witnessed overdoses and social distancing responses

While rates of opioid overdose deaths in North American have increased exponentially in recent years, most overdoses are not fatal, especially when witnesses are present and can intervene. Previous research has found that some people who use drugs [PWUDs] trained in overdose response might cut social ties with frequent overdosers, leading to more solitary opioid use and risk of death if someone overdoses alone. To examine the phenomenon of social distancing of people who overdose frequently, we used data from fifty-two in-depth qualitative interviews collected in Southern California with PWUDs who had recently witnessed an opioid overdose. Transcripts were reviewed and coded thematically, using the Integrated Threat Theory (ITT) to conceptualize the observed phenomenon. ITT outlines how realistic and symbolic threats are experienced by a group. We found that while some participants acknowledged the role of adulterated street drugs in overdoses, individualized blame was nonetheless imposed. Accusations of careless drug use practices fostered negative stereotyping towards frequent overdosers. This was attributed to the need to summon 911 for rescue, which often resulted in police dispatch. The intergroup relationship between police and PWUDs is precarious as police pose realistic threats onto PWUDs - such as incarceration, eviction, and manslaughter charges - leading to intragroup anxiety among PWUDs about future overdose events, and labelled frequent overdosers as liabilities. These threats, and inter/intra-group conflict, explained one reason how and why non-fatal overdoses led to social distancing events. People who overdose frequently were also accused of breaking the norm of drug user surreptitiousness; a symbolic threat that endangered the group due to police exposure. Social distancing might dampen exposure to the protective effect of peer-led interventions such as take-home naloxone programs, increasing risk of overdose death. This phenomenon highlights how intergroup dynamics are driving intragroup processes. Suggestions for tailoring public health interventions are discussed.

Addiction stigma and the production of impediments to take-home naloxone uptake

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for all opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.

What is needed for implementing drug checking services in the context of the overdose crisis? A qualitative study to explore perspectives of potential service users

BACKGROUND

The current illicit drug overdose crisis within North America and other countries requires expanded and new responses to address unpredictable and potentially lethal substances, including fentanyl analogues, in the unregulated drug market. Community-wide drug checking is being increasingly explored as one such public health response. We explored how drug checking could be implemented as a potential harm reduction response to the overdose crisis, from the perspective of potential service users.

METHODS

The research was guided by the Consolidated Framework for Implementation Research (CFIR). We conducted a qualitative, pre-implementation study to inform development and implementation of drug checking services that are acceptable to people who use substances and meet their needs. University and community researchers conducted 27 in-depth interviews with potential service users at prospective drug checking sites. We inductively developed emerging themes to inform the implementation of drug checking services within the five domains of the CFIR, and identified the most relevant constructs.

RESULTS

Implementing community drug checking faces significant challenges within the current context of criminalization and stigmatization of substance use and people who use/sell drugs, and trauma experienced by potential service users. Participants identified significant risks in accessing drug checking, and that confidential and anonymous services are critical to address these. Engaging people with lived experience in the service can help establish trust. The relative advantage of drug checking needs to outweigh risks through provision of accurate results conveyed in a respectful, non-judgemental way. Drug checking should provide knowledge relevant to using and/or selling drugs and informing one's own harm reduction.

CONCLUSIONS

For service users, the extent to which the implementation of drug checking can respond to and mitigate the risks of being criminalized and stigmatized is critical to the acceptability and success of community drug checking. The culture and compatibility of the service, setting and staff with harm reduction principles and practices is essential.

Practices of care among people who buy, use, and sell drugs in community settings

BACKGROUND

Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.

METHODS

Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.

RESULTS

Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.

CONCLUSION

Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.