A public health based vision for the management and regulation of opioids

Defining a public health approach to substance use: Perspectives from professionals and practitioners across Canada

BACKGROUND

While increasingly referenced in the literature and policy discussions, a "public health approach" (PHA) to substance use has been inconsistently defined or remained undefined. As part of a larger project on building the capacity to implement a PHA to substance use, we aimed to understand how professionals and practitioners across Canada who work with or whose work directly impacts the lives of people who use substances conceptualize a PHA.

METHODS

We conducted a cross-sectional national online survey of public health professionals, public safety professionals, health and social service providers, and other relevant professionals and practitioners. The survey contained closed- and open-ended questions designed to gauge familiarity and comfort with application of a PHA to substance use, and perspectives on an organizational definition of such an approach. Survey recruitment was active between May and July 2021. Data analysis included descriptive statistics and thematic analysis.

RESULTS

A total of 1041 surveys were completed. Most respondents (76 %) reported having heard of a PHA to substance use, as it was defined. Over half (54 %) indicated a high level of comfort with applying such an approach within their work. In relation to defining a PHA to substance use, the following thematic suggestions emerged from respondent's open-ended answers: explicitly recognize people with lived/living experience of substance use; incorporate trauma-informed understanding and acknowledge the varied underlying reasons for substance use; decolonize approaches to substance use and empower communities; and consider a more critical appraisal of a PHA and the terminology in its definition.

CONCLUSION

Empirically unpacking multi-stakeholder understandings of a PHA to substance use can help to inform a more cohesive definition and build the consensus needed for more effective, coordinated, and community-led responses to substance use. Future work, especially qualitative research, will provide richer and more practical understandings of a PHA to substance use.

Between Care and Control: Examining Surveillance Practices in Harm Reduction

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

What is a public health approach to substance use? A qualitative systematic review and thematic synthesis

BACKGROUND

Psychoactive substance use and the regulations that govern it both have the potential to lead to harm. A 'public health approach' (PHA) is frequently invoked as a means of addressing these harms, but the term is used in inconsistent and contradictory ways. This study systematically reviewed the English-language academic literature to understand how a public health approach to substance use is defined and described.

METHODS

This review employed thematic synthesis, a methodology designed to rigorously synthesize qualitative evidence. Eligible articles were published in peer-reviewed journals, in the English language, with full text available, and focused primarily on substance use. There were no limits on year of publication. Original research, opinion/commentary, and reviews were included. The searches were conducted in October 2021 in CINAHL, Embase, Medline, PAIS Index, PsycINFO, Scopus, Sociological Abstracts, and Web of Science.

RESULTS

272 articles from 25 countries, published between 1950 and 2021, were synthesized. Definitions of a PHA have changed over time and differ by substance. The most commonly cited characteristics of a PHA were: for alcohol, regulation, e.g. of price and availability (54% of articles); for cannabis: regulation (68%); for illicit drugs: that a PHA is distinct from a criminal justice approach (63%); for opioids: substance use disorder treatment (55%); and for tobacco: regulation (62%).

CONCLUSION

There is no consensus on the definition of a public health approach to substance use, but there is substantial agreement when it comes to PHAs to specific substances. There are also similarities in how they are described for legal substances versus illicit ones. This review found areas of disagreement regarding the extent to which PHAs should focus on individual-level factors. Policymakers, academics, and others developing or implementing PHAs to substance use should be explicit about their aims and objectives - as well as the premises and assumptions underlying them.

What is a public health approach to substance use? Protocol for a qualitative systematic review

INTRODUCTION

The concept of a 'public health approach' to substance use is frequently but inconsistently invoked. This inconsistency is reflected in public policy, with governments using the term 'public health approach' in contradictory ways. This aim of this study is to clarify what is meant and understood when the term 'public health approach' is used in the context of substance use.

METHODS AND ANALYSIS

We will conduct a systematic search of Medline, Embase, Scopus, CINAHL, PsycINFO, Sociological Abstracts and PAIS Index. Eligible articles will be from peer-reviewed journals, in English, with full text available. There will be no limits on year of publication. Substance use must be the primary topic of the article. Editorials, commentaries and letters to the editor will be included, but not commentaries on other articles, unless the definition of a public health approach is central to the commentary. Data selection and collection will be conducted independently by two researchers, with a third separately resolving any disagreement. To answer the research question, we will extract authors' definitions of a public health approach to substance use as well as any descriptions of the central principles, characteristics and components of such an approach. To synthesise the data, we will employ thematic synthesis. Coding will be conducted by one researcher and verified by a second; two researchers will then group the codes into themes using an inductive process. Finally, the full research team will develop a set of analytic themes, which will be presented as a narrative.

ETHICS AND DISSEMINATION

Ethics approval is not needed since the research will only involve published work. Our findings will be disseminated in a peer-reviewed journal and, if possible, at conferences.

PROSPERO REGISTRATION NUMBER

CRD42021270632.