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Pauly BB, Kurz M, Dale LM, Macevicius C, Kalicum J, Pérez DG, McCall J, Urbanoski K, Barker B, Slaunwhite A, Lindsay M, Nosyk B. Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209341. [PMID: 38490334 DOI: 10.1016/j.josat.2024.209341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.
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Affiliation(s)
- Bernadette Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Nursing, Box 1700 Stn CSC, Victoria, BC 250, Canada.
| | - Megan Kurz
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Laura M Dale
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Celeste Macevicius
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jeremy Kalicum
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Daniel Gudiño Pérez
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Brittany Barker
- School of Public Health and Social Policy, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada; First Nations Health Authority, 501 - 100 Park Royal South, 170-6371 Crescent Road, Coast Salish Territory (West Vancouver), BC V7T 1A2, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada.
| | - Amanda Slaunwhite
- BC Centre for Disease Control, 655 W 12th Ave, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada; Centre for Advancing Health Outcomes, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
| | - Morgan Lindsay
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada.
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada; Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
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Friederich LW, Cox ME, Hyson BE, Bishop-Freeman SC. Suspected North Carolina counterfeit pill-involved deaths, 2020-2022. J Anal Toxicol 2024; 48:242-251. [PMID: 38676414 DOI: 10.1093/jat/bkae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/19/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
The NC Office of the Chief Medical Examiner regularly assumes jurisdiction over deaths that are suspicious, unusual or unattended by a medical professional. In recent years, the presence of counterfeit pills is occasionally suggested by investigatory notes and/or scene findings that document reported consumption of prescription drugs, or prescription drugs on scene, which are not reflected in the final autopsy findings after toxicological analysis of the decedent's blood samples. Counterfeit pill consumption is a major public health hazard worthy of attention from the forensic toxicology community. Seventy-five cases from January 2020 to December 2022 serve as a convenience sample of cases where prescription pills including formulations of alprazolam, oxycodone and hydrocodone were specifically referenced during the death scene investigation as recently consumed, yet an unexpected substance was found during toxicological analysis rather than the expected pharmaceutical drug. Of note, novel benzodiazepines detected included flualprazolam, etizolam, clonazolam metabolite (8-aminoclonazolam), bromazolam, flubromazolam and desalkylflurazepam. Decedents' ages ranged from 16 to 69, across 33 different NC counties. Case notes indicated that eight of the decedents obtained pills through direct personal relationships, six decedents obtained them from "the street" and one decedent likely purchased pills online. Pills were largely consumed orally or through insufflation. Seven case reports contained indication that decedents knew or suspected the counterfeit nature of their pills. This study describes the context and characteristics of 2020-2022 suspected counterfeit pill-involved deaths in NC to further the understanding of the forensic science community, law enforcement partners, public health stakeholders and those potentially at risk through the consumption of counterfeit pills.
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Affiliation(s)
- Laura W Friederich
- Toxicology Department, North Carolina Office of the Chief Medical Examiner, 4312 District Dr, Raleigh, NC 27607, United States
| | - Mary E Cox
- Injury and Violence Prevention Branch, North Carolina Division of Public Health, 5505 Six Forks Rd, Raleigh, NC 27609, United States
| | - Brian E Hyson
- Investigations Department, North Carolina Office of the Chief Medical Examiner, 4312 District Drive, Raleigh, NC 27607, United States
| | - Sandra C Bishop-Freeman
- Toxicology Department, North Carolina Office of the Chief Medical Examiner, 4312 District Dr, Raleigh, NC 27607, United States
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, 160 Medical Dr, Chapel Hill, NC 27559, United States
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Henderson N, Marris J, Woodend K. "And this is the life jacket, the lifeline they've been wanting": Participant perspectives on navigating challenges and successes of prescribed safer supply. PLoS One 2024; 19:e0299801. [PMID: 38517923 PMCID: PMC10959334 DOI: 10.1371/journal.pone.0299801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/04/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND In 2021, 43% of drug toxicity deaths in Ontario were reported by public health units serving medium-sized urban and rural communities. Safer supply programs (SSPs) have been primarily established in large urban centres. Given this, the current study is based on an evaluation of a SSP based in a medium-sized urban centre with a large catchment area that includes rural and Indigenous communities. The aim of this research paper is to understand the challenges and successes of the nurse practitioner-led SSP from the perspective of program participants. METHODS Interpretive description was used to understand the experiences of 14 participants accessing a SSP. Each participant was interviewed using a semi-structured approach, and 13 of the interviewees also completed surveys accessed through Qualtrics. An iterative process using NVivo software was used to code interviews, and a constant comparative data analysis approach was used to refine and categorize codes to themes. FINDINGS Three overarching themes were the result of this analysis: feeling better, renewed hope, and safety. These three themes capture the experiences of participants in the SSP, including both the challenges and successes they faced. CONCLUSION The findings and subsequent discussion focus on both the key best practices of the program, and areas for future development and improvement. Despite barriers to services, prescribed SSPs are improving the lives of people who use drugs, and the current outcomes align with reports and evaluations from other SSPs across Canada.
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Affiliation(s)
- Nancy Henderson
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - John Marris
- John Marris Consulting, Peterborough, ON, Canada
| | - Kirsten Woodend
- School of Nursing, Trent University, Peterborough, ON, Canada
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Fischer B, Robinson T, Jutras-Aswad D. Three noteworthy idiosyncrasies related to Canada's opioid-death crisis, and implications for public health-oriented interventions. Drug Alcohol Rev 2024; 43:562-566. [PMID: 38098180 DOI: 10.1111/dar.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/25/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023]
Abstract
Canada has been experiencing a prolonged public health-crisis of high rates of overdose deaths caused by exceptionally potent/toxic, illicit opioid use. While many key features of this drug death epidemic are well-documented, several idiosyncratic aspects with relevance for public health-oriented interventions are not adequately recognised. These include: (i) the discrepant opioid patterns pan-Canada, with large majorities of opioid deaths caused by illicit fentanyl drugs in Western, but not Eastern regions where prescription-type opioid prevail; (ii) the environments of overdose deaths, where vast majorities occur in 'residential' or other shelter-type settings, presenting barriers for emergency interventions rather than health protection; and (iii) shifting drug use modes, where now majorities of overdose deaths are associated with drug 'inhalation' (instead of 'injection') in contexts of potent/toxic drug supply. We briefly describe these factors and related implications for intervention programming towards an improved response to the drug death-crisis.
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Affiliation(s)
- Benedikt Fischer
- Research & Graduate Studies, University of the Fraser Valley, Abbotsford, Canada
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
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Bowles J, Mansoor M, Werb D, Kerr T, Bardwell G. A qualitative assessment of tablet injectable opioid agonist therapy (TiOAT) in rural and smaller urban British Columbia, Canada: Motivations and initial impacts. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209185. [PMID: 37865289 DOI: 10.1016/j.josat.2023.209185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/19/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND The evolving and unpredictable unregulated drug market has driven an unprecedented overdose crisis that requires effective intervention. Growing evidence suggests that novel opioid agonist treatments, such as tablet injectable opioid agonist therapy (TiOAT), have potential to prevent overdoses and other drug-related harms. More evidence is needed to characterize their utility in achieving these outcomes. The current article is an analysis of two TiOAT programs implemented in British Columbia, Canada, to assess impact on health and well-being, including overdose risk. Moreover, we explored participants' enrollment goals and if they were achieved. METHODS The study employed qualitative methods to evaluate the TiOAT program in two sites between October 2021 and April 2022. We developed a semi-structured interview tool to guide in depth interviews. All interviews (n = 32) took place on teleconference software or in person. Thematic analysis allowed for the emergence of themes associated with TiOAT participation. RESULTS Participants discussed various motivations for enrolling in TiOAT, which included gaining financial stability, reducing or eliminating drug use, addressing withdrawal symptoms, wanting to work, and improving social circumstances. An assessment of initial programmatic impacts revealed that many participant-identified motivators were achieved. Participants also reported fewer or no overdoses since starting TiOAT, and many reported switching from injecting to smoking drugs. Some challenges included adequate dosing as evidenced by ongoing withdrawal and pain. Some participants requested additional opioids, such as diacetylmorphine, to aid in reducing illicit drug use. CONCLUSION Participants described how TiOAT helped them to achieve many of their goals. Suggested programmatic improvements include enhanced patient-provider co-design with respect to dosing to address ongoing withdrawal and pain. As the unpredictability the unregulated drug market worsens, novel options, such as TiOAT, ought to be implemented broadly to reduce overdose events and improve quality of life for people who use drugs.
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Affiliation(s)
- Jeanette Bowles
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Manal Mansoor
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Dan Werb
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States; Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital: Toronto, ON, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada
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Fischer B, Robinson T. The marked oscillatory pattern in prescription opioid utilization in Canada since 2000: Selected observations and questions for outcomes and policy. Pharmacoepidemiol Drug Saf 2024; 33:e5748. [PMID: 38158387 DOI: 10.1002/pds.5748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/30/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Benedikt Fischer
- Research and Graduate Studies, University of the Fraser Valley, Abbotsford, British Columbia, Canada
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Guerra-Alejos BC, Kurz M, Min JE, Dale LM, Piske M, Bach P, Bruneau J, Gustafson P, Hu XJ, Kampman K, Korthuis PT, Loughin T, Maclure M, Platt RW, Siebert U, Socías ME, Wood E, Nosyk B. Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol. BMJ Open 2023; 13:e068729. [PMID: 37258082 PMCID: PMC10255039 DOI: 10.1136/bmjopen-2022-068729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020. METHODS AND ANALYSIS We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results. ETHICS AND DISSEMINATION The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.
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Affiliation(s)
- B Carolina Guerra-Alejos
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Québec, Canada
- Research Center, Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Paul Gustafson
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - X Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kyle Kampman
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Todd Korthuis
- School of Public Health, OHSU-PSU, Portland, Oregon, USA
- Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tom Loughin
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert W Platt
- Departments of Epidemiology, Biostatistics, and Occupational Health and of Pediatrics, McGill University, Montreal, Québec, Canada
| | - U Siebert
- Center for Health Decision Science, Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Public Health, Health Services Research and Health Technology Assessment, Private University of Health Sciences Medical Informatics and Technology Hall/Tyrol Institute for Health Information Systems, Hall in Tirol, Austria
| | - M Eugenia Socías
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Evan Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Oviedo-Joekes E, Dobischok S, Carvajal J, MacDonald S, McDermid C, Klakowicz P, Harrison S, LaJeunesse J, Chow N, Brown M, Gill S, Schechter M. Clients' experiences on North America's first take-home injectable opioid agonist treatment (iOAT) program: a qualitative study. BMC Health Serv Res 2023; 23:553. [PMID: 37237256 DOI: 10.1186/s12913-023-09558-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND To support public health measures during the COVID-19 pandemic, oral opioid agonist treatment (OAT) take-home doses were expanded in Western countries with positive results. Injectable OAT (iOAT) take-home doses were previously not an eligible option, and were made available for the first time in several sites to align with public health measures. Building upon these temporary risk-mitigating guidelines, a clinic in Vancouver, BC continued to offer two of a possible three daily doses of take-home injectable medications to eligible clients. The present study explores the processes through which take-home iOAT doses impacted clients' quality of life and continuity of care in real-life settings. METHODS Three rounds of semi-structured qualitative interviews were conducted over a period of seventeen months beginning in July 2021 with eleven participants receiving iOAT take-home doses at a community clinic in Vancouver, British Columbia. Interviews followed a topic guide that evolved iteratively in response to emerging lines of inquiry. Interviews were recorded, transcribed, and then coded using NVivo 1.6 using an interpretive description approach. RESULTS Participants reported that take-home doses granted them the freedom away from the clinic to have daily routines, form plans, and enjoy unstructured time. Participants appreciated the greater privacy, accessibility, and ability to engage in paid work. Furthermore, participants enjoyed greater autonomy to manage their medication and level of engagement with the clinic. These factors contributed to greater quality of life and continuity of care. Participants shared that their dose was too essential to divert and that they felt safe transporting and administering their medication off-site. In the future, all participants would like more accessible treatment such as access longer take-home prescriptions (e.g., one week), the ability to pick-up at different and convenient locations (e.g., community pharmacies), and a medication delivery service. CONCLUSIONS Reducing the number of daily onsite injections from two or three to only one revealed the diversity of rich and nuanced needs that added flexibility and accessibility in iOAT can meet. Actions such as licencing diverse opioid medications/formulations, medication pick-up at community pharmacies, and a community of practice that supports clinical decisions are necessary to increase take-home iOAT accessibility.
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Affiliation(s)
- Eugenia Oviedo-Joekes
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Sophia Dobischok
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - José Carvajal
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Cheryl McDermid
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Piotr Klakowicz
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Julie LaJeunesse
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Nancy Chow
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Murray Brown
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Sam Gill
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Martin Schechter
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
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Bardwell G, Bowles JM, Mansoor M, Werb D, Kerr T. Access to tablet injectable opioid agonist therapy in rural and smaller urban settings in British Columbia, Canada: a qualitative study. Subst Abuse Treat Prev Policy 2023; 18:14. [PMID: 36869358 PMCID: PMC9984129 DOI: 10.1186/s13011-023-00525-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs. METHODS Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically. RESULTS TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk. CONCLUSIONS This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.
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Affiliation(s)
- Geoff Bardwell
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, , Vancouver, BC, V6Z 1Y6, Canada.
| | - Jeanette M Bowles
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, , Vancouver, BC, V6Z 1Y6, Canada
| | - Manal Mansoor
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Dan Werb
- Centre On Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Division of Infectious Diseases & Global Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92023, USA
| | - Thomas Kerr
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, , Vancouver, BC, V6Z 1Y6, Canada
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Foreman-Mackey A, Pauly B, Ivsins A, Urbanoski K, Mansoor M, Bardwell G. Moving towards a continuum of safer supply options for people who use drugs: A qualitative study exploring national perspectives on safer supply among professional stakeholders in Canada. Subst Abuse Treat Prev Policy 2022; 17:66. [PMID: 36209227 PMCID: PMC9547673 DOI: 10.1186/s13011-022-00494-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/30/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Novel public health interventions are needed to address the toxic drug supply and meet the needs of people who use drugs amidst the overdose crisis. Safer supply - low-barrier distribution of pharmaceutical grade substances - has been implemented in some jurisdictions to provide safer alternatives to the unregulated drug supply, yet no studies to date have explored professional stakeholder perspectives on this approach. METHODS We used purposive sampling to recruit professional stakeholders (n = 17) from four locations in British Columbia, Ontario, and Nova Scotia, including program managers, executive directors, political and health authority representatives, and healthcare providers involved in the design, implementation, and/or operation of safer supply programs in their communities. Semi-structured, one-to-one interviews were conducted, and interview data were coded and analyzed using thematic analyses. RESULTS Participants defined safer supply as low-barrier access to substances of known quality and quantity, offered on a continuum from prescribed to a legal, regulated supply, and focused on upholding autonomy and liberation of people who use drugs. Stakeholders expressed support for safer supply but explained that current iterations do not meet the needs of all people who use drugs and that implementation is limited by a lack of willing prescribers, stigma towards people who use drugs, and precarity of harm reduction programs to political ideology. Stakeholders expressed strong support for wider-reaching approaches such as decriminalization, legalization, and regulation of substances as a way to fully realize a continuum of safer supply, directly address the overdose crisis and toxic drug supply, and ensure equity of access nationally. CONCLUSION The results of this study highlight the need for innovative strategies to address the overdose crisis and that safer supply has the potential to benefit certain people who use drugs. A one-size-fits-all approach is not sufficient and the perspectives of professional stakeholders should be considered alongside those of people who use drugs when designing and implementing future safer supply.
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Affiliation(s)
- Annie Foreman-Mackey
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081, V6Z 1Y6 Burrard Street, Vancouver, BC Canada
| | - Bernie Pauly
- grid.143640.40000 0004 1936 9465Canadian Institute on Substance Use Research, University of Victoria, 2300 McKenzie Avenue, V8P 5C2 Victoria, BC Canada ,grid.143640.40000 0004 1936 9465School of Nursing, University of Victoria, Box 1700 STN CSC, V8W 2Y2 Victoria, BC Canada
| | - Andrew Ivsins
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081, V6Z 1Y6 Burrard Street, Vancouver, BC Canada
| | - Karen Urbanoski
- grid.143640.40000 0004 1936 9465Canadian Institute on Substance Use Research, University of Victoria, 2300 McKenzie Avenue, V8P 5C2 Victoria, BC Canada ,grid.143640.40000 0004 1936 9465School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Road, V8P 5C2 Victoria, BC Canada
| | - Manal Mansoor
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada
| | - Geoff Bardwell
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081, V6Z 1Y6 Burrard Street, Vancouver, BC Canada ,grid.46078.3d0000 0000 8644 1405School of Public Health Sciences, University of Waterloo, 200 University Ave. West, N2L 3G1 Waterloo, ON Canada ,grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 1Y6 Vancouver, BC Canada
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11
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Ferguson M, Parmar A, Papamihali K, Weng A, Lock K, Buxton JA. Investigating opioid preference to inform safe supply services: A cross sectional study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 101:103574. [PMID: 35007878 DOI: 10.1016/j.drugpo.2021.103574] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The drug toxicity crisis continues to be a significant cause of death. Over 24,600 people died from opioid toxicity in Canada over the last 5 years. Safe supply programs are required now more than ever to address the high rate of drug toxicity overdose deaths caused by illicit fentanyl and its analogues. This study aims to identify opioid preferences and associated variables to inform further phases of safe supply program implementation. METHODS The Harm Reduction Client Survey, an annual cross-sectional survey of people who use drugs (PWUD), was administered at harm reduction supply distribution sites in BC in October-December 2019. The survey collects information on substance use patterns, associated harms, stigma, and utilization of harm reduction services. Eligibility criteria for survey participation included aged 19 years or older; self-reported substance use of any illicit substance in the past six months, and ability to provide verbal informed consent. We conducted multivariate logistic regression to investigate associations with opioid preference. We used the dichotomized preference for either heroin or fentanyl as an outcome variable. Explanatory variables of interest included: geographic region, urbanicity, gender, age category, Indigenous identity, housing, employment, witnessing or experiencing an overdose, using drugs alone, using drugs at an observed consumption site, injection as preferred mode of use, injecting any drug, frequency of use, and drugs used in last 3 days. RESULTS Of the 621 survey participants, 405 reported a preferred opioid; of these 57.8% preferred heroin, 32.8% preferred fentanyl and 9.4% preferred prescription opioids. The proportion of participants who preferred heroin over fentanyl significantly increased with age. The adjusted odds of a participant 50 or older preferring heroin was 6.76 (95% CI: 2.78-16.41, p-value: < 0.01) times the odds of an individual 29 or under. The adjusted odds of an Indigenous participant reporting a preference for heroin compared to fentanyl was 1.75 (95% CI: 1.03-2.98, p-value: 0.04) the odds of a non-Indigenous participant reporting the same. Adjusted odds of heroin preference also differed between geographic regions within British Columbia, Canada. CONCLUSION Opioid preference differs by age, geographic area, and Indigenous identity. To create effective safe supply programs, we need to engage PWUD about their drugs of choice.
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Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Amrit Parmar
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Anita Weng
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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The use of diverted pharmaceutical opioids is associated with reduced risk of fentanyl exposure among people using unregulated drugs in Vancouver, Canada. Drug Alcohol Depend 2021; 228:109109. [PMID: 34601278 PMCID: PMC8595770 DOI: 10.1016/j.drugalcdep.2021.109109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although non-medical use of pharmaceutical opioids (POs) is associated with a number of risks, in the context of the opioid-overdose crisis, it may have the secondary benefit of decreasing the risk of exposure to more potent opioids from unregulated sources. The aim of this study was to assess the effects of using diverted POs on fentanyl exposure. METHODS Using data from two prospective community-recruited cohorts of people who use drugs (PWUD) in Vancouver, Canada, we estimated the independent relationship between using diverted POs and fentanyl exposure (assessed through urine drug test [UDT]) between 2016 and 2018. We also explored if participant characteristics modified this relationship. RESULTS Over the study period, among 1150 participants, 241 (21.0%) reported using diverted POs in 292 (12.8%) occasions. In adjusted analyses, PWUD using diverted POs had decreased odds of fentanyl exposure (Adjusted odds ratio [AOR] = 0.70, 95% CI: 0.52-0.94). The reduced odds of fentanyl exposure persisted among participants with morphine positive UDT (AOR = 0.57, 95% CI: 0.40-0.82), but not among those with negative morphine UDT (AOR = 0.91, 95% CI: 0.54-1.55). CONCLUSION PWUD using diverted POs in our sample were 30% less likely to be exposed to fentanyl. This reduced likelihood was primarily observed among PWUD with morphine positive UDT, which could partially be explained by longer duration of action and lower street cost of slow-release oral morphine relative to other POs and fentanyl. Findings suggest that access to a regulated supply of pharmaceutical-grade opioids may serve to reduce fentanyl-related harms.
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Biggar E, Papamihali K, Leclerc P, Hyshka E, Graham B, Taylor M, Payer D, Maloney-Hall B, Buxton JA. Towards cross-Canada monitoring of the unregulated street drug supply. BMC Public Health 2021; 21:1678. [PMID: 34525994 PMCID: PMC8441944 DOI: 10.1186/s12889-021-11757-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions. Methods The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018–March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use. Results The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal. Conclusions This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.
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Affiliation(s)
- Emily Biggar
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada.
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Pascale Leclerc
- Direction régionale de santé publique, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal, 1301 rue Sherbrooke est, Montreal, QC, H2L 1M3, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, 3-300 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Brittany Graham
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Marliss Taylor
- Streetworks, Boyle Street Community Services, 10116-105 Ave, Edmonton, Alberta, T5H 0K2, Canada
| | - Doris Payer
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Bridget Maloney-Hall
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
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