Density of low-barrier opioid agonist clinics and risk of non-fatal overdose during a community-wide overdose crisis: A spatial analysis

Spatiotemporal epidemiology of substance-related accidental acute toxicity deaths in Canada from 2016 to 2017

OBJECTIVES

In Canada, substance-related accidental acute toxicity deaths (AATDs) continue to rise at the national and sub-national levels. However, it is unknown if, where, when, and to what degree AATDs cluster in space, time, and space-time across the country. The objectives of this study were to 1) assess for clusters of AATDs that occurred in Canada during 2016 and 2017 at the national and provincial/territorial (P/T) levels, and 2) examine the substance types detected in AATD cases within each cluster.

METHODS

Two years of person-level data on AATDs were abstracted from coroner and medical examiner files using a standardized data collection tool, including the decedent's postal code and municipality information on the places of residence, acute toxicity (AT) event, and death, and the substances detected in the death. Data were combined with Canadian census information to create choropleth maps depicting AATD rates by census division. Spatial scan statistics were used to build Poisson models to identify clusters of high rates (p < 0.05) of AATDs at the national and P/T levels in space, time, and space-time over the study period. AATD cases within clusters were further examined for substance types most present in each cluster.

RESULTS

Eight clusters in five regions of Canada at the national level and 24 clusters in 15 regions at the P/T level were identified, highlighting where AATDs occurred at far higher rates than the rest of the country. The risk ratios of identified clusters ranged from 1.28 to 9.62. Substances detected in clusters varied by region and time, however, opioids, stimulants, and alcohol were typically the most commonly detected substances within clusters.

CONCLUSION

Our findings are the first in Canada to reveal the geographic disparities in AATDs at national and P/T levels using spatial scan statistics. Rates associated with substance types within each cluster highlight which substance types were most detected in the identified regions. Findings may be used to guide intervention/program planning and provide a picture of the 2016 and 2017 context that can be used for comparisons of the geographic distribution of AATDs and substances with different time periods.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services. Thirty participants were recruited via posters placed throughout the building and semi-structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma-free care. Close proximity and convenience of drop-in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre-existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low-barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.

Availability and use of non-prescribed buprenorphine-naloxone in a Canadian setting, 2014-2020

BACKGROUND

Buprenorphine-naloxone (BUP-NX) is a first-line treatment for opioid use disorder and has a superior safety profile compared to other forms of opioid agonist therapy. In Canada, restrictions on BUP-NX prescribing were relaxed in 2016, which may have had an effect on rates of diversion and non-prescribed use. We sought to longitudinally examine the reported availability and use of non-prescribed BUP-NX among people who use drugs (PWUD) in an urban Canadian setting.

METHODS

We collected data from two linked prospective cohorts of PWUD in Vancouver, Canada, and examined self-reported availability and use of non-prescribed BUP-NX over time. We used a multivariable generalized estimating equations model to identify trends and factors associated with the immediate availability (i.e., within 10 min) of non-prescribed BUP-NX.

RESULTS

Among 1617 participants between 2014 and 2020, the immediate availability of non-prescribed BUP-NX increased from 16% to 63% (p<0.001). In the multivariable analysis, factors independently associated with immediate BUP-NX availability included calendar year (adjusted odds ratio = 1.19, 95% confidence interval: 1.15-1.23), along with a number of other variables suggestive of more severe substance use disorders. Only 17 participants ever reported use of non-prescribed BUP-NX.

CONCLUSIONS

We observed that BUP-NX has become increasingly available in the unregulated drug supply in recent years but its use has remained infrequent in this setting. These results suggest that relaxed restrictions on BUP-NX prescribing have not been a major driver of increased non-prescribed use in this population.

A spatiotemporal analysis of inequalities in life expectancy and 20 causes of mortality in sub-neighbourhoods of Metro Vancouver, British Columbia, Canada, 1990-2016

Spatially varying baseline data can help identify and prioritise actions directed to determinants of intra-urban health inequalities. Twenty-seven years (1990-2016) of cause-specific mortality data in British Columbia, Canada were linked to three demographic data sources. Bayesian small area estimation models were used to estimate life expectancy (LE) at birth and 20 cause-specific mortality rates by sex and year. The gaps in LE for males and females ranged from 6.9 years to 9.5 years with widening inequality in more recent years. Inequality ratios increased for almost all causes, especially for HIV/AIDS and sexually transmitted infections, maternal and neonatal disorders, and neoplasms.

Examining factors that shape use and access to diverted prescription opioids during an overdose crisis: A qualitative study in Vancouver, Canada

OBJECTIVE

Prescription opioid (PO) diversion is widely regarded as a driver of overdose mortality. However, less is known about the rationale for using diverted POs during an overdose epidemic and how contextual factors (e.g., poverty, drug policies) may affect this practice. Therefore, we sought to examine this phenomenon.

METHOD

We conducted qualitative interviews with 24 participants who accessed diverted POs in Vancouver, Canada. Participants were recruited from ongoing cohort studies of people who use drugs (PWUD).

RESULTS

Participants preferred a variety of POs due to their known contents and lower overdose risk compared to street drugs and used them for pain relief and pleasure. Participants reported barriers in accessing POs from physicians, with some being cut off or having insufficient prescriptions. Prices for diverted POs varied and affected access among impoverished participants. These access challenges led some to acquire fentanyl. Some participants reported concerns over the contents of counterfeit pills, while others relied on trusted sources or using visual cues to identify legitimate pills.

CONCLUSIONS

Our findings demonstrate that diverted POs are being used by PWUD with the goal of reducing opioid-related harms, although PO use comes with challenges associated with limited accessibility and risks posed by counterfeit pills. Poverty also limited PO accessibility, leading some to purchase more toxic, yet affordable, street drugs. Given the risks and barriers affecting people seeking to use diverted POs, our findings emphasize the need for the continued implementation and evaluation of safer drug supply initiatives, including those providing access to various drug types.

"People need them or else they're going to take fentanyl and die": A qualitative study examining the 'problem' of prescription opioid diversion during an overdose epidemic

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.

The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada

Introduction

Universal provision of effective antiretroviral medication has been essential to reduce mortality, increase longevity, and reduce onward transmission of HIV. This study aims to illuminate persistent threats to the health and longevity of under-served PLWH in British Columbia (BC), Canada.

Methods

Between 2007 and 2010, 1000 PLWH across BC were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study and completed a cross-sectional survey on their HIV-care experiences and healthcare engagement. The sample generally reflects an under-served population of PLWH. A linkage to the provincial Vital Statistics registry is used in this analysis in order to examine overall mortality and cause-specific mortality trends; probability of death was modeled using logistic regression for participants with ongoing clinical monitoring (n = 910).

Results

By June 2017, 208 (20.8%) participants had died. The majority of deaths 57 (27.4%) were attributed to drug-related complications or overdoses, 39 (18.8%) were attributed to HIV-related complications, and 36 (17.3%) to non-AIDS-defining malignancies. We observed elevated odds of death among PLWH who smoked tobacco (aOR: 2.11, 95% CI: 1.38, 3.23), were older (aOR: 1.06 per one-year increase, 95% CI: 1.04, 1.08), indicated heavy alcohol consumption (aOR: 1.57, 95% CI: 1.11, 2.22), and reported unstable housing (aOR: 1.96, 95% CI: 1.37, 2.80); while higher CD4 cell count was protective (aOR: 0.87 per 100-unit increase, 95% CI: 0.79, 0.94) as was male gender), though non-significant (aOR: 0.73, 95% CI: 0.49, 1.07).

Conclusions

Overdose is - the leading cause of mortality among a cohort of under-served PLWH in BC, Canada. Public health efforts to end the HIV epidemic and support the health and well-being of PLWH are being thwarted by persistent health inequities and the enormous and persistent risks facing people who use drugs. Integrated low-barrier primary care is essential for supporting under-served PLWH, and safe drug supply is needed to support PLWH who use drugs.

Correlates of recent nonfatal overdose among people who inject drugs in West Virginia

Aim

Experiencing a nonfatal overdose (NFOD) is a significant risk factor for a subsequent nonfatal or fatal overdose. Overdose mortality rates in rural Appalachian states are some of the highest in the USA, but little is known about correlates of overdose among rural populations of people who inject drugs (PWID). Our study aimed to identify correlates of experiencing a recent (past 6 months) NFOD among rural PWID in Cabell County, West Virginia.

Methods

Using data from a June–July 2018 cross-sectional survey that was designed to estimate the size and characteristics of the PWID population in Cabell County, West Virginia, we used log binomial regression to identify correlates (e.g., structural vulnerabilities and substance use) of NFOD in the past 6 months.

Results

The majority of our sample of 420 PWID were male (61.2%), White, non-Hispanic (83.6%), and reported recent heroin injection (81.0%). More than two-fifths (42.6%) experienced a recent NFOD. Independent correlates of NFOD included witnessing an overdose in the past 6 months (adjusted prevalence ratio [aPR] = 2.28; 95% CI 1.48–3.50), attempting to quit using drugs in the past 6 months (aPR = 1.54; 95% CI 1.11–2.14), and the number of drugs injected (aPR = 1.16; 95% CI 1.10–1.23)

Conclusions

A large proportion of rural PWID in Appalachia reported having recently overdosed. The associations between witnessing an overdose, attempting to quit using drugs, and number of drugs injected with recent nonfatal overdose underscore the need for expanded access to overdose prevention resources that are tailored to the needs of this population. Expanding access to evidence-based overdose prevention strategies—such as take-home naloxone programs, treatment with methadone or buprenorphine, and harm reduction services—may decrease overdose morbidity and mortality among rural PWID in Appalachia.