Gendered violence and overdose prevention sites: a rapid ethnographic study during an overdose epidemic in Vancouver, Canada

Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review

ISSUES

Overdose prevention centres (OPC) are non-residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work.

APPROACH

We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs.

KEY FINDINGS

Our retroductive analysis identified a causal pathway that highlights the feeling of safety - and the immediate outcome of not dying - as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can - depending on the contexts in which they operate - generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection-related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities.

CONCLUSIONS

OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions.

The gendered violence of injecting-related stigma among relatively affluent, suburban women who inject drugs

INTRODUCTION

In honouring the legacy of Jude Byrne's life-long advocacy for women and mothers who use drugs, this paper presents a case study of a group of women about whom we know little about and hear even less from: women who inject drugs in relatively affluent suburbs.

METHODS

Based on a 2020 qualitative study of people who inject drugs in an affluent area of Sydney known as 'The Beaches', we use in-depth interview data to thematically explore the lived experiences of gendered stigma among women who inject drugs.

RESULTS

Even when women occupy the 'ideal' social position in terms of class (middle-class) and race (White) they remain subject to harmful forms of gendered stigma related to injecting drug use. Participants had internalised negative attitudes around injection drug use as a form of failed femininity and, despite being part of 'good' families and neighbourhoods, participants experienced forced child removal.

DISCUSSION AND CONCLUSIONS

Taking the lead from feminist intersectionality scholarship, our data illustrate how stigma and discrimination act as a form of structural violence against women who inject drugs in affluent communities. While the social relations of gender provide some degree of protection by 'performing proximity to Whiteness', gendered stigma and violence persist.

Experiences of stigma and subsequent reduced access to health care among women who inject drugs

INTRODUCTION

Research into stigma and injecting drug use has typically involved predominantly male participants, with limited research about the unique experience of women who inject drugs.

METHODS

This study used survey methods to assess reduced access to health care due to stigma among a sample of women who inject drugs. Women (n = 232) completed a survey as part of a broader national study of people who inject drugs.

RESULTS

Only 46 (19.9%) women reported that they had not experienced any injecting drug use-related stigma in the past year and most commonly noted 'sometimes' experiencing injecting-related stigma (36.8%) with more than 75% of women reporting that health workers had treated them negatively because of their injecting drug use. Most women undertook strategies to prevent experiencing stigma, such as not disclosing drug use to a health worker (81.3%), not attending follow-up appointments (76.7%) and delaying accessing health care (76.8%). Women with lower levels of personal wellbeing, who had experienced poorer treatment by health workers, had engaged in greater past month injecting, were employed and identified as lesbian, gay, bisexual, transgender or queer (LGBTQ) reported more reduced access to health care.

DISCUSSION AND CONCLUSIONS

Stigma has concerning health care implications for women who inject drugs and this research highlights the importance of understanding the impact of stigma in impeding health care access. Public health interventions should focus on addressing the systemic factors that reduce health care access for women who inject and take account of the impact of stigma in diminishing the quality and accessibility of health care for this group.

Co-designing an Outreach Intervention for Women Experiencing Street-Involvement and Gender-Based Violence: Community-Academic Partnerships in Action

Outreach is an important approach to improve health and social care for women experiencing street involvement (SI) or gender-based violence (GBV). Few studies have examined outreach approaches that incorporate SI and GBV. Drawing on feminist theories and principles of community-based research, we detail an inclusive co-design approach for an outreach intervention considering these interrelated contexts. Women with lived experience, researchers, and service leaders drew on research and experiential knowledge to define outreach engagement principles: tackling GBV, personhood and relational engagement, trauma-informed engagement, and harm reduction engagement. The resulting intervention integrates these principles to enable building and sustaining relationships to facilitate care.

Using drugs alone in single room occupancy housing: Understanding environmental drivers of overdose risk

BACKGROUND

Across North America most overdose deaths occur in housing, largely due to individuals using drugs alone. In cities, fatalities are disproportionately concentrated in low-income housing, including single room occupancy (SRO) housing. While research has highlighted how SROs operate as risk environments for various poor outcomes, there has been little attention to specific drug use practices (i.e., using alone) associated with overdose vulnerability in these spaces. This study explores how environmental contexts of SROs shape overdose risks, with specific attention to practices of using drugs alone.

METHODS

In-depth semi-structured interviews were conducted with 30 people who use drugs (PWUD) living in Vancouver SROs. Interviews covered topics such as social-structural environments of housing, drug use practices, and housing-based harm reduction. Thematic analysis drew on the intersectional risk environment framework.

RESULTS

Narratives positioned SROs as extensions of public space, with similar expectations of risks and behaviours as in public spaces. For some participants, using alone in their room was characterized as a practice in claiming privacy within the context of a public existence. Participants highlighted how certain features of SRO's social-structural environments were routinely leveraged against them (e.g., security cameras, staff surveillance), suggesting using alone as a tactic to minimize risks of hyper-surveillance and punitive policies. Further, participants discussed using alone as "safer," describing how this practice mitigated place-based risks of social-structural harms (e.g., violence, criminalization) in ways that eclipsed overdose risk.

CONCLUSION

Using drugs alone may be understood as a spatial negotiation of vulnerability to diverse harms produced by environmental contexts of SROs. Interventions accounting for broader contextual factors (e.g., improvements housing quality/quantity, providing a safer supply of drugs) that render using alone as instrumental to survival, and that reduce the implicit threat of punishment from intensive surveillance and control practices are critical to reduce vulnerability to overdose and other harms.

Acceptability of integrating mental health and substance use care within sexual health services among young sexual and gender minority men in Vancouver, Canada

BACKGROUND

Despite well-established evidence showing that young sexual and gender minority (SGM) men experience disproportionate mental health and substance use inequities, few sexual health services provide mental health and substance use care. This qualitative study examined the experiences and perspectives about integrated care models within sexual health services among young SGM men experiencing mental health and substance use challenges.

METHODS

Semi-structured interviews were conducted with 50 SGM men aged 18-30 years who reported using substances with sex in Vancouver, Canada. Interviews were analyzed using thematic analysis.

RESULTS

Three themes were identified: 1) participants asserted that their sexual health, mental health and substance use-related health needs were interrelated and that not addressing all three concurrently could result in even more negative health outcomes. These concurrent health needs were described as stemming from the oppressive social conditions in which SGM men live. 2) Although sexual health clinics were considered a safe place to discuss sexual health needs, participants reported not being invited by health providers to engage in discussions about their mental health and substance use health-related needs. Participants also perceived how stigmas associated with mental health and substance use limited their ability to express and receive support. 3) Participants identified key characteristics they preferred and wanted within integrated care, including training for health providers on mental health and SGM men's health and connections (e.g., referral processes) between services. Participants also recommended integrating social support programs to help them address SGM-related social challenges.

CONCLUSION

Our findings highlight that SGM men's sexual health, mental health and substance use-related health needs and preferences are interrelated and should be addressed together. Tailored training and resources as well as structural adaptations to improve communication channels and collaborative connections between health providers are required to facilitate the development of integrated care for young SGM men.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study

BACKGROUND

In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges.

METHODS

We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants' emphasis that knowing the composition of one's drugs is a "right to know", particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men.

CONCLUSIONS

The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions.

Characterizing Use of Supervised Consumption Services among Street-involved Youth and Young Adults in the Context of an Overdose Crisis

In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.

Patterns of Socioeconomic Marginalization among People Who Use Drugs: A Gender-Stratified Repeated Measures Latent Class Analysis

Socioeconomic factors are important correlates of drug use behaviors and health-related outcomes in people who use drugs (PWUD) residing in urban areas. However, less is known about the complex overlapping nature of socioeconomic conditions and their association with a range of individual, drug use, and health-related factors in men and women who use drugs. Data were obtained from two community-recruited prospective cohorts of PWUD. Using a gender-stratified approach, we conducted repeated measures latent class analyses (RMLCA) to identify discrete latent socioeconomic subgroups. Multivariable generalized estimating equations were then used to identify correlates of class membership. Between June 2014 and December 2018, RMLCA of 9844 observations from 1654 participants revealed five distinct patterns of socioeconomic status for both men and women. These patterns were primarily distinguished by variations in income, material and housing security, income generation activity, exposure to violence, criminal justice involvement, and police contact. Across gender, progressive increases in exposure to multiple dimensions of socioeconomic disadvantage were found to be associated with frequent use of opioids and stimulants, accessing social services, and being hepatitis C virus antibody-positive. Similar but less congruent trends across gender were observed for age, binge drug use, engagement with opioid agonist therapy, and living with HIV. Gendered patterns of multiple and overlapping dimensions of socioeconomic adversity aligned with patterns of frequent drug use and health-related concerns, highlighting priority areas for gender-inclusive, multilevel responses to mitigate health disparities and meet the diverse socioeconomic needs of urban-dwelling men and women who use drugs.

"If you're strung out and female, they will take advantage of you": A qualitative study exploring drug use and substance use service experiences among women in Boston and San Francisco

BACKGROUND

Significant disparities in substance use severity and treatment persist among women who use drugs compared to men. Thus, we explored how identifying as a woman was related to drug use and treatment experiences.

METHODS

The study recruited participants for a qualitative interview study in Boston and San Francisco from January-November 2020. Self-identified women, age ≥ 18 years, with nonprescribed opioid use in the past 14 days were eligible for inclusion. The study team developed deductive codes based on intersectionality theory and inductive codes generated from transcript review, and identified themes using grounded content analysis.

RESULTS

The study enrolled thirty-six participants. The median age was 46; 58 % were White, 16 % were Black, 14 % were Hispanic, and 39 % were unstably housed. Other drug use was common with 81 % reporting benzodiazepine, 50 % cocaine, and 31 % meth/amphetamine use respectively. We found that gender (i.e., identifying as a woman) intersected with drug use and sex work practices and exacerbated experiences of marginalization. Violence was ubiquitous in drug use environments. Some women reported experiences of gender-based violence in substance use service settings that perpetuated cycles of trauma and reinforced barriers to care. Substance use services that were women-led, safe, and responsive to women's needs were valued and sought after.

CONCLUSION

Women reported a cycle of trauma and drug use exacerbated by oppression in substance use services settings. In addition to increasing access to gender-responsive care, our study highlights the need for greater research and examination of practices within substance use service settings that may be contributing to gender-based violence.

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.

Negative changes in illicit drug supply during COVID-19: Associations with use of overdose prevention and health services among women sex workers who use drugs (2020-2021)

BACKGROUND

Women sex workers are a highly criminalized population who are over-represented amongst people who use drugs (PWUD) and face gaps in overdose prevention and harm reduction services. British Columbia, Canada continues to face a pronounced drug poisoning crisis of the illicit drug supply, which has intensified during the COVID-19 pandemic. Our objective was to examine the prevalence and structural correlates of experiencing negative changes in illicit drug supply (e.g., availability, quality, cost, or access to drugs) amongst women sex workers who use drugs during the first year of the COVID-19 pandemic.

METHODS

Cross-sectional questionnaire data were drawn from a prospective, community-based cohort of women sex workers in Vancouver (AESHA) from April 2020 to 2021. Bivariate and multivariable logistic regression was used to investigate structural correlates of negative changes in drug supply during COVID-19 among sex workers who use drugs.

RESULTS

Among 179 sex workers who use drugs, 68.2% reported experiencing negative changes to drug supply during COVID-19, 54.2% recently accessed overdose prevention sites, and 44.7% reported experiencing recent healthcare barriers. In multivariable analysis adjusted for injection drug use, women who reported negative changes in illicit drug supply had higher odds of experiencing recent healthcare barriers (AOR 2.28, 95%CI 1.12-4.62); those recently accessing overdose prevention sites (AOR 1.75, 95%CI 0.86-3.54) faced marginally higher odds also.

CONCLUSIONS

Over two-thirds of participants experienced negative changes to illicit drug supply during the first year of the COVID-19 pandemic. The association between experiencing negative changes in the illicit drug supply and accessing overdose prevention services highlights the agency of women in taking measures to address overdose-related risks. Highly criminalized women who experience structural barriers to direct services are also vulnerable to fluctuations in the illicit drug supply. Attenuating health consequences requires interventions tailored to sex workers' needs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

"We just don't have the space for it": Geographies of survival and spatial triage in overdose prevention sites

This study explores the role of Overdose Prevention Sites (OPS) within the geographies of survival of vulnerably housed people who use drugs (PWUD) in Vancouver, British Columbia (BC), Canada. In BC, OPS are low-barrier spaces where people may use drugs under monitoring of trained staff. OPS have been established by people who use drugs, activists, and allied organizations as an emergency measure to prevent overdose deaths. However, OPS have other important uses for PWUD who are vulnerably housed and rely on public spaces for survival. Drawing on two years (2018-2020) of ethnographic fieldwork and interviews with fifty-five people who work at and/or use OPS, we explore how OPS operators negotiated multiple and at times competing uses of service space for everyday survival. Data analysis was guided by critical urban theory to explore the place of OPS within PWUD's geographies of survival, with attention to how different uses of space were negotiated within the context of an illicit drug poisoning crisis and urban control practices that displace and exclude unhoused and vulnerably housed PWUD from the city. We find that OPS accommodated other important potential uses of space for unhoused and vulnerably housed PWUD who relied on public space for survival and were routinely displaced by revanchist urban control strategies. Low-barrier approaches and facility enhancements to OPS improved program accessibility and enabled PWUD to use the sites more broadly to meet survival needs including for mutual-aid, sheltering, and income-generation. However, these secondary uses of OPS presented multiple operational challenges as service volumes increased. We observed processes of 'spatial triage' emerge within sites to manage these challenges, which we characterise as a pragmatic set of rules, procedures, and spatial practices that constrained broader uses of OPS within PWUD's geographies of survival. While spatial triage offered a pragmatic way of prioritizing service delivery to address the most acute survival threats of overdose fatality, these practices had unintended and inequitable impacts on service access. Our findings indicate the need for complementary structural changes as part of overdose responses to reduce the need for spatial triage (i.e., safe, affordable housing and drug decriminalisation) and service innovations to mitigate potential harms (e.g., Expanded drop-in and chill spaces, temporary storage spaces for service user).

Socioeconomic marginalization and risk of overdose in a community-recruited cohort of people who use drugs: A longitudinal analysis

BACKGROUND

Poverty and socioeconomic disadvantage are important contributors to drug-related harm, but their precise role in overdose risk remains poorly understood. We sought to examine linkages between socioeconomic marginalization and non-fatal overdose risk in a community deeply affected by the ongoing drug poisoning crisis.

METHODS

This observational study used data derived from two community-recruited prospective cohorts of people who use drugs (PWUD) in Vancouver, British Columbia, Canada. Generalized linear mixed-effects models were used to assess longitudinal associations between multiple dimensions of socioeconomic disadvantage and self-reported non-fatal overdose.

RESULTS

Between 2014 and 2020, 1,493 participants (38.2% women; 59.6% white; 35.7% Indigenous) provided 9,968 interviews. Non-fatal overdose was reported by 32.5% of participants over the study period. In multivariable analyses, non-fatal overdose was independently associated with incarceration (adjusted odds ratios [AOR]: 1.42, 95% confidence interval [CI]: 1.08-1.88, p=0.012), homelessness (AOR: 1.57, 95%CI: 1.27-1.93, p<0.001), increased monthly income (AOR: 1.01, 95%CI: 1.00-1.01, p=0.029), and lower material security (AOR: 0.76, 95%CI: 0.67-0.88, p<0.001). We also observed differing strengths of association between illegal income generation and overdose in men (AOR: 1.84, 95%CI: 1.46-2.32, p<0.001) compared to women (AOR: 1.37, 95%CI: 1.06-1.78, p=0.016).

CONCLUSION

Non-fatal overdose was positively associated with incarceration, homelessness, higher monthly income, material insecurity, and engagement illegal income generating activities, underscoring the importance of addressing the socioeconomic production of overdose risk. These initiatives may include supportive housing interventions, alternative economic supports, and broader drug policy reform.

Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada

BACKGROUND

Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT.

METHODS

Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes.

RESULTS

Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment.

CONCLUSION

This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.

Intersections between syndemic conditions and stages along the continuum of overdose risk among women who inject drugs in Mexicali, Mexico

BACKGROUND

Research on women who inject drugs is scarce in low- and middle-income countries. Women experience unique harms such as sexism and sexual violence which translate into negative health outcomes. The present work aims to provide insight into the experiences of women who inject drugs at the US-Mexico border to identify social and health-related risk factors for overdose to guide harm reduction interventions across the Global South.

METHODS

We recruited 25 women ≥ 18 years of age accessing harm reduction and sexual health services at a non-governmental harm reduction organization, "Verter", in Mexicali, Mexico. We employed purposeful sampling to recruit women who inject drugs who met eligibility criteria. We collected quantitative survey data and in-depth interview data. Analyses of both data sources involved the examination of descriptive statistics and thematic analysis, respectively, and were guided by the syndemic and continuum of overdose risk frameworks.

RESULTS

Survey data demonstrated reports of initiating injection drug use at a young age, experiencing homelessness, engaging in sex work, being rejected by family members, experiencing physical violence, injecting in public spaces, and experiencing repeated overdose events. Interview data provided evidence of stigma and discrimination toward women, a lack of safe spaces and support systems, risk of overdose-related harms, sexual violence, and the overall need for harm reduction services.

CONCLUSION

Women who inject drugs in Mexicali describe experiences of violence, overdose, and public injecting. Women are particularly vulnerable in the Mexicali context, as this area faces a noticeable lack of health and social services. Evidenced-based harm reduction strategies such as safe consumption sites and overdose prevention strategies (e.g., naloxone distribution and training) may benefit this population. Evidence from local organizations could help close the gap in service provision in low-resource settings like Mexico, where government action is almost nonexistent.

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.

Experiences of violence during the COVID-19 pandemic among people who use drugs in a Canadian setting: a gender-based cross-sectional study

OBJECTIVES

People who use drugs (PWUD) experience disproportionately high rates of violent victimization. Emerging research has demonstrated that the COVID-19 pandemic has exacerbated violence against some priority populations (e.g., women), however there is limited research examining the impact of the pandemic on the experiences of violence of PWUD.

METHODS

Using data collected between July and November 2020 from three prospective cohort studies of PWUD in Vancouver, Canada, we employed multivariable logistic regression stratified by gender to identify factors associated with recent experiences of violence, including the receipt of COVID-19 emergency income support.

RESULTS

In total, 77 (17.3%) of 446 men, and 54 (18.8%) of 288 women experienced violence in the previous six months. Further, 33% of men and 48% of women who experienced violence reported that their experience of violence was intensified since the COVID-19 pandemic began. In the multivariable analyses, sex work (Adjusted Odds Ratio [AOR] = 2.15, 95% confidence interval [CI]: 1.06-4.35) and moderate to severe anxiety or depression (AOR = 3.00, 95% CI: 1.37-6.57) were associated with experiencing violence among women. Among men, drug dealing (AOR = 1.93, 95%CI: 1.10-3.38), street-based income sources (AOR = 1.93, 95%CI: 1.10-3.38), homelessness (AOR = 2.54, 95%CI: 1.40-4.62), and regular employment (AOR = 2.97, 95% CI: 1.75-5.04) were associated with experiencing violence.

CONCLUSION

Our study results suggest economic conditions and gender were major factors associated with experiencing violence among our sample of PWUD during COVID-19. These findings highlight criminalization of drug use and widespread socioeconomic challenges as barriers to addressing violence among PWUD during periods of crisis.

Exploring Primary Healthcare Experiences and Interest in Mobile Technology Engagement Amongst an Urban Population Experiencing Barriers to Care

Mobile phone-based engagement approaches provide potential platforms for improving access to primary healthcare (PHC) services for underserved populations. We held two focus groups (February 2020) with residents (n = 25) from a low-income urban neighbourhood (downtown Vancouver, Canada), to assess recent healthcare experiences and elicit interest in mobile phone-based healthcare engagement for underserved residents. Note-based analysis, guided by interpretative description, was used to explore emerging themes. Engagement in PHC was complicated by multiple, intersecting personal-level and socio-structural factors, and experiences of stigma and discrimination from care providers. Perceived inadequacy of PHC services and pervasive discrimination reported by participants indicate a significant and ongoing need to improve client-provider relationships to address unmet health needs. Mobile phone-based engagement was endorsed, highlighting phone ownership and client-provider text-messaging, facilitated by non-clinical staff such as peers, as helpful to strengthening retention and facilitating care team connection. Concerns raised included reliability, cost, and technology and language accessibility.

Women who use drugs: engagement in practices of harm reduction care

BACKGROUND

Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada.

METHODS

Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction.

FINDINGS

Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection.

CONCLUSION

The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

Increasing trends and incidence of nonfatal overdose among women sex workers who use drugs in British Columbia: The role of criminalization-related barriers to harm reduction

BACKGROUND

Structurally marginalized women who use drugs experience disproportionately elevated health and social inequities that require specialized responses to mitigate risk of overdose. This study aimed to longitudinally investigate incidence and predictors of first nonfatal overdose among women sex workers who use drugs.

METHODS

Data (2010-2019) were drawn from AESHA (An Evaluation of Sex Workers Health Access), a community-based, prospective, open cohort of > 900 women sex workers in Metro Vancouver, Canada. Incidence was examined and Cox regression modelled time-updated predictors of first nonfatal overdose. Time series analysis examined annual trends.

RESULTS

Among 273 eligible participants, 23% (n = 63) reported a first nonfatal overdose over follow-up with an incidence density of 5.87/100 person-years. In multivariable analysis, independent predictors of time to nonfatal overdose were police-related barriers to harm reduction (Adjusted Hazard Ratio [AHR]=2.62; 95% confidence interval [CI] 1.51-4.54), binge alcohol use (AHR=2.28; 95%CI 1.16-4.45), opioid use (AHR=2.23; 95%CI 1.15-4.33), and crystal methamphetamine use (AHR=2.07; 95%CI 1.27-3.39). Time series analysis demonstrated a significantly increasing trend in first nonfatal overdose, with annual proportions increasing 0.59% (95%CI 0.39-0.78%) every year, on average.

CONCLUSIONS

This study provides strong longitudinal evidence from the longest-standing cohort of sex workers in North America. Nonfatal overdose in this setting is a critical public health concern. Criminalization-related barriers to harm reduction strongly predicted nonfatal overdose. Structural changes to legal and policing practices alongside gender-sensitive addiction services are urgently needed.

Prevalence and Social-Structural Correlates of Gender-Based Violence Against Women Living With HIV in Metro Vancouver, Canada

Violence experienced by cisgender (cis) and gender minority women living with HIV is known to be high. More work is needed to better understand how to support women living with HIV who have experienced violence. The objectives of this study are therefore to identify the prevalence and correlates of violence by any perpetrator among women living with HIV in a Canadian setting. Data were drawn from 9 years (January, 2010 to February, 2019) of a longitudinal community-based open cohort study of 350+ cis and trans women living with HIV who were living and/or accessed care in Metro Vancouver, Canada (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment "SHAWNA"). Participants completed baseline and biannual follow-up interviews. Bivariate and multivariable logistic regression with generalized estimating equations (GEE) were performed to identify correlates of recent (last 6 months) violence (physical and/or sexual) by any perpetrator. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CIs) are presented. At baseline, prevalence of violence was high: 95.5% (recent = 19.4%) of participants reported lifetime physical and/or sexual violence, 94.8% (recent = 17.9%) reported lifetime physical violence, and 84.5% (recent = 5.7%) reported lifetime sexual violence. In multivariable logistic regression with GEE, the following variables were associated with higher odds of recent physical/sexual violence: youth (<30 years) (AOR: 1.60, 95% CI [1.15, 2.22]), recent unstable housing/homelessness (AOR: 1.96, 95% CI [1.30, 2.97]), recent food insecurity (AOR: 1.57, 95% CI [1.13, 2.17]), recent incarceration (AOR: 1.85, 95% CI [1.18, 2.91]), recent opioid use (AOR: 1.38, 95% CI [1.04, 1.82]), recent stimulant use (AOR: 2.48, 95% CI [1.72, 3.56]), and lifetime HIV status disclosure without consent (AOR: 1.59, 95% CI [1.13, 2.24]). Trauma- and violence-informed (TVI) policies that include a focus on confidentiality and safe disclosure practices should be integrated into existing housing, incarceration, and harm reduction programs, and HIV care and practice for women living with HIV. Programs and policies that address high levels of violence remain critical.

Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis

PURPOSE

This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs.

METHODS

We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach.

RESULTS

The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1).

CONCLUSION

SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.

Association of sex work and social-structural factors with non-fatal overdose among women who use drugs in Vancouver, Canada

BACKGROUND

Women who use drugs (WWUD) and engage in sex work experience disproportionate sex- and drug-related harms, such as HIV, however comparatively little is known about their overdose risk. Therefore, we examined the association between sex work and overdose and secondarily explored the association of social-structural factors, such as policing and gendered violence, with overdose.

METHODS

Data were derived from two community cohort studies based in Vancouver, Canada between 2005 to 2018. We used logistic regression with GEE to examine the associations between a) sex work and nonfatal overdose and b) social-structural and individual variables with overdose among WWUD who engaged in sex work during the study. Sex work, overdose, and other variables were time-updated, captured every six months.

RESULTS

Among 857 WWUD included, 56% engaged in sex work during the study. Forty-three percent of WWUD engaged in sex work had at least one overdose compared to 26% of WWUD who did not. Sex work was not significantly associated with an increased odds of overdose (AOR = 1.14, 95% CI: 0.93-1.40). In the exploratory analysis amongst 476 WWUD engaged in sex work, social-structural variables associated with overdose in the multivariable model included exposure to: punitive policing (OR = 1.97, 95% CI: 1.30-2.96) and physical or sexual violence (OR = 2.55, 95% CI: 1.88-3.46).

CONCLUSIONS

WWUD engaged in sex work had an increased overdose burden that may be driven by social-structural factors rather than sex work itself. Interventions that address policing and gendered violence represent potential targets for effective overdose prevention.

A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services

A substantial body of evidence demonstrates that supervised consumption services (SCS) mitigate a variety of drug-related harms, including decreasing overdose deaths, infectious disease transmission, and connecting people who use drugs (PWUD) to various health and social services. Research on SCS has predominantly been quantitative, though qualitative research on these services has increased substantially over the last decade. Qualitative methods provide a framework for developing a richer and more nuanced understanding of meanings and contexts associated with drug use, health service implementation, and experience. We present findings from a scoping review of qualitative studies on experiences of PWUD with SCS published between 1997 and 2022. In total, forty-two papers were included in this analysis. Four primary themes emerged from our analysis: 1) Influence of SCS on health and wellbeing among PWUD, 2) the physical environment of SCS can be both a facilitator and barrier to use, 3) social resources can shape and reshape the context within which PWUD benefit from SCS, and 4) various intersecting forces at play both support and harm PWUD in relation to their experiences with SCS. We discuss the primary facilitators and barriers of SCS use and conclude with suggestions to inform future qualitative research, SCS implementation, and PWUD-centered approaches to drug policy.

(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.

Approaches to enabling rapid evaluation of innovations in health and social care: a scoping review of evidence from high-income countries

OBJECTIVE

The COVID-19 pandemic increased the demand for rapid evaluation of innovation in health and social care. Assessment of rapid methodologies is lacking although challenges in ensuring rigour and effective use of resources are known. We mapped reports of rapid evaluations of health and social care innovations, categorised different approaches to rapid evaluation, explored comparative benefits of rapid evaluation, and identified knowledge gaps.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, EMBASE and Health Management Information Consortium (HMIC) databases were searched through 13 September 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included publications reporting primary research or methods for rapid evaluation of interventions or services in health and social care in high-income countries.

DATA EXTRACTION AND SYNTHESIS

Two reviewers developed and piloted a data extraction form. One reviewer extracted data, a second reviewer checked 10% of the studies; disagreements and uncertainty were resolved through consensus. We used narrative synthesis to map different approaches to conducting rapid evaluation.

RESULTS

We identified 16 759 records and included 162 which met inclusion criteria.We identified four main approaches for rapid evaluation: (1) Using methodology designed specifically for rapid evaluation; (2) Increasing rapidity by doing less or using less time-intensive methodology; (3) Using alternative technologies and/or data to increase speed of existing evaluation method; (4) Adapting part of non-rapid evaluation.The COVID-19 pandemic resulted in an increase in publications and some limited changes in identified methods. We found little research comparing rapid and non-rapid evaluation.

CONCLUSIONS

We found a lack of clarity about what 'rapid evaluation' means but identified some useful preliminary categories. There is a need for clarity and consistency about what constitutes rapid evaluation; consistent terminology in reporting evaluations as rapid; development of specific methodologies for making evaluation more rapid; and assessment of advantages and disadvantages of rapid methodology in terms of rigour, cost and impact.

The "goldfish bowl": a qualitative study of the effects of heightened surveillance on people who use drugs in a rural and coastal Canadian setting

BACKGROUND

A growing body of research has focused on contextual factors that shape health and well-being of people who use drugs (PWUD). However, most of this research focuses on large cities and less is known about the effects of social and structural contexts on drug use and associated risks in rural Canadian settings. Therefore, we undertook this study to examine rural-specific contextual factors that affect the day-to-day experiences of PWUD.

METHODS

Twenty-seven qualitative semi-structured interviews were conducted with PWUD in a rural and coastal setting in British Columbia, Canada. Participants had to be ≥ 19 years old, used illegal opioids and/or stimulants regularly, and lived in the qathet region. Interview transcripts were coded based on themes identified by the research team.

RESULTS

Participants described progressive shifts in politics and culture in the qathet region while also identifying resource scarcity, homelessness, and changes in the drug supply, where illicit drug contents have become highly toxic and unpredictable. Participants discussed the qualities of a small community where everyone knows each other and there is a lack of privacy and confidentiality around drug use, which resulted in experiences of stigma, discrimination, and surveillance. Participants also reported rural-specific policing issues and experiences of surveillance on ferries when traveling to larger cities to purchase drugs. This led to significantly higher drug prices for PWUD due to the time dedication and criminalized risks associated with drug possession and trafficking.

CONCLUSIONS

Our findings illustrate the unique experiences faced by PWUD in a rural and coastal setting. The "goldfish bowl" effect in this rural community created heightened social and structural surveillance of PWUD, which led to a variety of negative consequences. There is a clear need for interventions to address the larger contextual drivers affecting people who use drugs in rural settings, including decriminalization and peer-led anti-stigma strategies, in order to improve the lives of PWUD.

Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection

BACKGROUND AND AIMS

Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID).

DESIGN

A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews.

SETTING

Baltimore City, MD, USA.

PARTICIPANTS

Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021).

MEASUREMENTS

Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone.

FINDINGS

Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces.

CONCLUSIONS

WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Day-to-day impact of COVID-19 and other factors associated with risk of nonfatal overdose among people who use unregulated drugs in five cities in the United States and Canada

BACKGROUND

The COVID-19 pandemic has compounded the longstanding drug poisoning crisis in Canada and the United States (US). Research is needed to understand the contributions of COVID-19 and subsequent infection control measures. We sought to estimate the prevalence of and factors associated with nonfatal overdose among participants in nine prospective cohorts of people who use unregulated drugs (PWUD) in Canada and the US.

METHODS

Data were derived from nine cohorts of PWUD in urban centres in Canada (Vancouver, BC) and the US (Baltimore, MD; Miami, FL; Chicago, IL; Los Angeles, CA) between May, 2020 and April, 2021. Multivariable logistic regression was used to identify factors associated with nonfatal overdose among participants who used unregulated drugs in the past month.

RESULTS

Among 885 participants (including 253 females), 41 (4.6 %) experienced a non-fatal overdose in the past month, and 453 (51.2 %) reported being highly impacted day-to-day by the pandemic. In multivariable analyses, people who experienced a non-fatal overdose were more likely to be female (Adjusted Odds Ratio [AOR]=2.18;95 % Confidence Interval [CI]=1.10-4.30); unstably housed/homeless (AOR=2.16;95 % CI=1.11-4.26); engaged in medications for opioid use disorder (AOR=2.45;95 % CI=1.19-4.97); and highly impacted day-to-day (AOR=2.42;95 % CI=1.22-5.10).

CONCLUSION

Our findings may reflect characteristics of participants who experienced a compounding of vulnerabilities during the pandemic and thus are vulnerable to overdose, including women, those unstably housed/homeless, and those who perceived their daily lives were highly impacted by the pandemic. Multi-level interventions are needed to remediate the vulnerabilities and address the main driver of poisoning crisis.

Association Between Multiple Experiences of Violence and Drug Overdose Among Black Women in Community Supervision Programs in New York City

Research has documented associations between all types of violence and substance misuse among Black women. However, research has yet to examine how different experiences of violence may be contributing to the surging epidemic of drug overdose among Black women. This study was conducted between 2015 and 2018 among 296 Black women who were mandated to community supervision programs (CSPs) in New York City (NYC). We used generalized linear modeling (GLM) to estimate associations of the adjusted relative risk (aRR) of experiencing a non-fatal overdose based on exposure to each type of violence after controlling for potentially confounding variables. Lifetime prevalence of a non-fatal drug overdose was 13.9% (n = 41). Lifetime severe physical/sexual violence by a male intimate partner (prevalence rate = 61.8%, n = 181) was associated with an overdose (aRR = 3.41, 95%CI = 1.19, 9.73). Severe violence by a female partner (prevalence rate = 7.4%, n = 22) was also associated with an overdose (aRR = 2.61, 95%CI = 1.46, 4.65). Lifetime sexual violence by a non-intimate partner (prevalence rate: 29.1%, n = 86) was associated with an overdose (aRR = 2.23, 95%CI = 1.32, 3.77). Sexual abuse by police/CSP staff (prevalence rate: 14.9%, n = 44) was associated with an overdose (aRR = 2.29, 95%CI = 1.27, 4.12). For each increase in the number of types of violence experienced, there was a 27% increase in the risk for an overdose (aRR = 1.27, 95%CI = 1.14, 1.42). This study found high rates of multiple types of violence that are associated with drug overdose among this sample of Black women in CSPs. These findings highlight the urgent public health need to address violence associated with overdose in this population.

Difficulty accessing supervised consumption services during the COVID-19 pandemic among people who use drugs in Vancouver, Canada

BACKGROUND

The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS.

RESULTS

Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42-58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28-5.30), active injection drug use (AOR = 4.06; 95% CI 1.38-11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24-4.85), and unstable housing (AOR = 2.14; 95% CI 1.08-4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93-0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%).

CONCLUSIONS

We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

Injecting drugs alone during an overdose crisis in Vancouver, Canada

BACKGROUND

Settings throughout Canada and the USA continue to experience crises of overdose death due to the toxic unregulated drug supply. Injecting drugs alone limits the potential for intervention and has accounted for a significant proportion of overdose deaths, yet the practice remains understudied. We sought to examine the practice of injecting alone among people who inject drugs (PWID) in Vancouver, Canada.

METHODS

Data were derived from two prospective cohorts of people who use drugs between June 2016 and November 2018. This analysis was restricted to participants who, in the previous 6 months, reported any injection drug use. Rates of injecting alone were categorized as always, usually, sometimes, or occasionally. We fit a multivariable generalized linear mixed model to identify factors associated with injecting drugs alone.

RESULTS

Among 1070 PWID who contributed 3307 observations, 931 (87%) reported injecting alone at least once during the study period. In total, there were 729 (22%) reports of always injecting alone, 722 (21.8%) usually, 471 (14.2%) sometimes, 513 (15.5%) occasionally, and 872 (26.4%) never. In a multivariable model, factors positively associated with injecting drugs alone included male sex (adjusted odds ratio [AOR] 1.69; 95% confidence interval [CI] 1.20-2.37), residence in the Downtown Eastside neighbourhood (AOR 1.43; 95% CI 1.08-1.91), binge drug use (AOR 1.36; 95% CI 1.08-1.72), and experiencing physical or sexual violence or both (AOR 1.43; 95% CI 1.00-2.03). Protective factors included Indigenous ancestry (AOR 0.71; 95% CI 0.52-0.98) and being in a relationship (AOR 0.30; 95% CI 0.23-0.39).

CONCLUSION

We observed that injecting alone, a key risk for overdose mortality, was common among PWID in Vancouver. Our findings underline the need for additional overdose prevention measures that are gender-specific, culturally appropriate, violence- and trauma-informed, and available to those who inject alone.

Overdose Prevention and Housing: a Qualitative Study Examining Drug Use, Overdose Risk, and Access to Safer Supply in Permanent Supportive Housing in Vancouver, Canada

The majority of overdose deaths in British Columbia (BC) occur among people using illicit substances alone in private residences. Some supportive housing in BC includes on-site access to a variety of health and substance use-related services. More recently, a number of supportive housing locations have started offering prescribed safer supply medications to people at high overdose risk, though these remain limited and under-evaluated. In this study, we describe the drug use practices - including access to and use of on-site supervised consumption, OAT, and prescribed safer supply medications - of study participants living in permanent supportive housing with integrated primary care, substance use treatment services, and supervised consumption spaces. Qualitative interviews were conducted with 30 residents of a permanent supportive housing site in Vancouver, Canada. Data were analyzed using a sequential process to identify both a priori (e.g., low-barrier substance use treatment, pandemic effects on service access) and emerging themes (e.g., using alone). Most (N = 27) study participants reported using alone in their rooms, despite having access to an on-site supervised consumption area. Reasons for using alone include the following: preference for being alone, discretion/stigma, and restrictive housing policies. Less than half (N = 12) of the study participants accessed on-site prescribed safer supply medications. Participants receiving on-site prescribed safer supply described positive benefits including reduced use of illicit opioids, and less reliance on illicit income generation activities. On-site prescribed safer supply programs within supportive housing environments are an important tool in addressing overdose risk.

Harm reduction in the hospital: An overdose prevention site (OPS) at a Canadian hospital

BACKGROUND

Substance use management in hospitals can be challenging. In response, a Canadian hospital opened an overdose prevention site (OPS) where community members and hospital inpatients can inject pre-obtained illicit drugs under supervision. This study aims to: (1) describe program utilization patterns; (2) characterize OPS visits; and (3) evaluate overdose events and related outcomes.

METHODS

A retrospective chart review was completed at one hospital in Vancouver, Canada. All community members and hospital inpatients who visited the OPS between May 2018 and July 2019 were included. Client measures included: hospital inpatient status, use of intravenous access line for drug injection, and substances used. Program measures included: number of visits (daily/monthly), overdose (fatal/non-fatal) events and overdose-related outcomes.

RESULTS

Overall, 11,673 OPS visits were recorded. Monthly visits increased from 306 to 1198 between May 2018 and July 2019 respectively. On average, 26 visits occurred daily. Among all visits, 20% reported being a hospital inpatient, and 5% reported using a hospital intravenous access line for drug injection. Opioids (56%) and stimulants (24%) were the most common substances used. Overall 39 overdose events occurred - 82% required naloxone reversal, 28% required transfer to the hospital's emergency department and none were fatal. Overdose events were more common among hospital inpatients compared to community clients (6.6 vs 2.2 per 1000 visits respectively; p value = 0.046).

CONCLUSIONS

This unique OPS is an example of a hospital-based harm reduction initiative. Use of the site increased over time among both groups with no fatal overdose events occurring.

The practice and embodiment of "goofballs": A qualitative study exploring the co-injection of methamphetamines and opioids

BACKGROUND

Polysubstance use is common among people who use drugs, including the co-use of stimulants and opioids. Research suggests the practice of simultaneous co-injection of methamphetamines and opioids, often referred to as "goofballs", is increasing. As a relatively unique drug use practice, little qualitative research currently exists on goofball injecting. This study explores the practice and embodied experiences of goofball injecting.

METHODS

This article draws on in-depth interviews conducted across two qualitative studies undertaken in Vancouver, Canada's Downtown Eastside neighbourhood examining changing dynamics in relation to stimulant use and experiences with an overdose prevention site-based safer supply intervention, respectively. Interviews containing discussions of goofball use (n=29) were extracted from each study and merged into a single qualitative dataset. Data were analysed thematically and focused on the practices and embodied experiences of goofball injection.

RESULTS

Our analysis uncovered how goofball injection represented a complex drug use practice driven by the desire to achieve particular embodied experiences not attainable by using either drug individually. We identified three distinct practices of goofball use: 1) to alter or enhance the effects of opioids; 2) to alter or enhance the effects of methamphetamines; and 3) to balance out the effects of both drugs.

CONCLUSION

Our study fills an important gap in the polysubstance use literature specifically exploring the co-injection of methamphetamines and opioids. Our findings highlight the need to implement and expand interventions and services attentive to polysubstance use and the role of pleasure in drug taking practices, including expanding non-medicalized opioid and stimulant safer supply initiatives across North America.

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.

Interpersonal violence and other social-structural barriers associated with needing HIV treatment support for women living with HIV

Women living with HIV (WLWH), experience disproportionate rates of violence, along with suboptimal HIV health outcomes, despite recent advancements in HIV treatment, known as antiretroviral therapy (ART). The objectives of this study were to: (a) describe different types of support needed to take ART and (b) investigate the social and structural correlates associated with needing support for ART adherence among WLWH. Data are drawn from Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment, a community-based open research cohort with cisgender and transgender WLWH, aged 14+ who live or access HIV services in Metro Vancouver, Canada (2014-present). Baseline and semi-annual questionnaires are administered by community interviewers alongside a clinical visit with a sexual health research nurse. Bivariate and multivariable logistic regression using generalized estimating equations and an exchangeable working correlation matrix was used to model factors associated with needing supports for ART adherence. Among 276 WLWH, 51% (n = 142) reported needing support for ART adherence; 95% of participants reported lifetime gender-based violence and identified many interpersonal, structural, community, and clinical supports that would facilitate and support ART adherence. In multivariable logistic regression, participants who were Indigenous (adjusted odds ratio [AOR]: 1.70, 95% confidence intervals [CI]: 1.07-2.72), or otherwise racialized (AOR: 2.36, 95% CI : 1.09-5.12) versus white, experienced recent gender-based physical violence (AOR : 1.54, 95% CI : 1.03-2.31), lifetime post-traumatic stress disorder (AOR : 1.97, 95% CI : 1.22-3.18), and recent illicit drug use (AOR : 2.15, 95% CI : 1.43-3.22), had increased odds of needing support for ART adherence. This research suggests a need for trauma-informed, culturally safe and culturally responsive practice and services for WLWH along the HIV care continuum to support ART adherence. All services should be developed by, with, and for WLWH and tailored according to gender identity, taking into account history, culture, and trauma, including the negative impacts of settler colonialism for Indigenous people.

Requiring help injecting among people who inject drugs in Toronto, Canada: Characterising the need to address sociodemographic disparities and substance-use specific patterns

INTRODUCTION

Those requiring help injecting are at an elevated risk of injection-related injury and blood-borne infections and are thus a priority group for harm reduction programs. As supervised consumption services (SCS) are scaled-up across Canada, information on those who require help injecting is necessary to inform equitable service uptake. We characterised the sociodemographic, structural and drug use correlates of needing help injecting among a cohort of people who inject drugs in Toronto, Canada.

METHODS

A cross-sectional baseline survey was administered between November 2018 and March 2020. Unadjusted and multivariable logistic regression models examined associations with requiring help injecting in the past 6 months. A gender-stratified sub-analysis described characteristics of receiving help among those requiring it.

RESULTS

Of 701 participants (31.0% cisgender women), 294 (41.9%) needed recent help injecting. In unadjusted analyses, being a racialised, non-Indigenous person (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.13-2.86) or a cisgender woman (OR 1.72, 95% CI 1.24-2.39) were associated with needing help. In multivariable analyses, requiring assistance was associated with needing frequent help preparing drugs (adjusted OR [AOR] 9.52, 95% CI 4.78-21.28), fewer years since first injection (AOR for 1 year increase: 0.97, 95% CI 0.95-0.99) and injecting stimulants. Among those who required help, cisgender women reported needing assistance more often than cisgender men (P = 0.009).

DISCUSSION AND CONCLUSIONS

Over two-fifths of the sample required help injecting; requiring assistance was associated with sociodemographic indicators and substance use-specific patterns. Findings highlight the need to scale-up educational resources for those who receive or provide help injecting, as well as SCS that accommodate onsite injection assistance.

"There are solutions and I think we're still working in the problem": The limitations of decriminalization under the good Samaritan drug overdose act and lessons from an evaluation in British Columbia, Canada

BACKGROUND

Drug prohibition has been associated with increased risk of overdose. However, drug prohibition remains the dominant drug policy, including in Canada with the Controlled Drugs and Substances Act. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted, to encourage people to contact emergency medical services by providing bystanders at the scene of an overdose with legal protection for simple possession and conditions related to simple possession.

METHODS

We conducted an evaluation of the GSDOA in British Columbia, Canada that included one-on-one interviews with people who use illicit drugs (PWUD), to determine peoples' experiences and perceptions surrounding this form of decriminalization. We present findings from a thematic analysis of 37 interviews.

RESULTS

We identified limitations of the GSDOA at overdose events; key themes and concerns causing PWUD to hesitate to or avoid contacting emergency medical services included drug confiscation, the thin line between simple possession and drug trafficking, and enforcement of other charges and court ordered conditions that are not legally protected by the GSDOA. Moreover, participants discussed the GSDOA as inequitable; benefiting some while excluding PWUD with intersecting marginalized identities.

CONCLUSION

Our findings are pertinent in light of many jurisdictions across the world considering dejure decriminalization, including BC and Vancouver. The GSDOA and associated limitations that emerged in our evaluation can serve to guide jurisdictions implementing or amending dejure decriminalization policies.

Establishment and Enforcement of Operational Rules at an Unsanctioned Safe Drug Consumption Site in the United States, 2014-2020

Objectives. To examine how operational rules are established and enforced at an unsanctioned safe consumption site (SCS) operating in the United States. Methods. We conducted 44 qualitative interviews with people who use drugs, staff members, and volunteers at an unsanctioned SCS and analyzed them using an inductive thematic approach. Results. Rule-making processes were largely driven by concerns raised by service users rather than driven by external pressures, and iterated rapidly in response to changing needs. The unsanctioned nature of the site produced an environment where bottom-up rule-making was critical to generating a shared sense of ownership of the site and where enforcement was necessarily fluid. Conclusions. Removing external restrictions on operational rules for SCSs results in a flexible set of rules that are highly responsive to the social and public health needs of people who use drugs. Legislation and regulations of SCSs should aim to place as few hard limits on operating conditions as possible to maximize involvement of and responsiveness to people who use drugs. (Am J Public Health. 2022;112(S2):S166-S172. https://doi.org/10.2105/AJPH.2022.306714).

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Health impacts of a scale-up of supervised injection services in a Canadian setting: an interrupted time series analysis

BACKGROUND AND AIMS

In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed 'overdose prevention sites' (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID).

DESIGN

Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends.

SETTING

Vancouver, Canada.

PARTICIPANTS

Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline.

MEASUREMENTS

Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment.

FINDINGS

Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation.

CONCLUSIONS

Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.

Male partners of female sex workers: The intersectional risk environment of HIV/AIDS in a Kampala informal settlement

AIM

This study examined the context and drivers of HIV risk and vulnerability among male partners of female sex workers in Kampala, Uganda, using an "intersectional risk environment" framework.

METHODS

This research reports on findings from an ethnographic study (2016-2019) of men in one informal settlement in Kabalagala Parish in Kampala. This research included long-term participant observation in and around the study community. Thematic analysis was used to assess aspects of the risk environment and how it influences HIV/AIDS among male partners of female sex workers.

RESULTS

The informal settlement context where sex work takes place is conceptualized here as a "risk environment," or a social-physical space in which risk and harm are produced (Rhodes, 2002). Risk is situated within a broader social and political structure that constrains choices and facilitates HIV risk, particularly for young, low-income men facing matrices of domination on the basis of age, gender, residence, and income. These intersectionalities guide experiences of HIV vulnerability in the risk environment, including physical, social, economic, and policy risks. This includes physical risks (population density, bar density), social risks (sex work, bar groups), economic risks (informal and low wage work), and political risks (anti-poverty laws and legislation, urban policy).

CONCLUSION

These findings highlight how an intersectional risk environment is differentially experienced by young, low-income men to produce unequal HIV/AIDS outcomes. This research fills a gap in the literature on the context of HIV/AIDS among men, particularly high-risk men like male partners of female sex workers. Using this framework will improve understandings of HIV outcomes among male partners of female sex workers and will facilitate context-specific and adapted structural interventions for HIV/AIDS prevention and treatment.

Understanding the Perspectives of Women Who Use Intravenous Drugs and are Experiencing Homelessness in an Urban Centre in Canada: An Analysis of Ethnographic Data

Injection drug use has long been a topic of investigation, whether through a health or criminal justice lens. Whilst these bodies of literature offer important perspectives, missing from the extant literature is evidence, particularly involving women who use drugs, and more specifically evidence about the health beliefs of these women. To address this knowledge gap, we undertook an ethnographic study of homeless women in downtown Ottawa who inject drugs. This included interviews, observations, and artifact analyses. In this paper, we report on these ethnographic data to show the context and nature of the subjective lives of women who use injection drugs and their beliefs and perspectives on health. We use these data to make recommendations for nursing and healthcare practice moving forward.

Crystal methamphetamine use subgroups and associated addiction care access and overdose risk in a Canadian urban setting

OBJECTIVES

Methamphetamine use is rising globally and we have limited treatments for this. Subgroups within the diverse methamphetamine-using population may have distinct treatment needs. Among a community-recruited sample of people who use crystal methamphetamine, we aimed to identify subgroups and characterize their overdose risk and access to addiction care.

METHODS

Data from prospective cohorts of people who use drugs in Vancouver, Canada from 2014 to 2018 were used to conduct a repeated measures latent class analysis among participants who used crystal methamphetamine. Multivariable generalized estimating equations models were fit to determine the associated factors.

RESULTS

Among 824 eligible participants, a five-class model was identified as the best fit: (1) primary stimulant use (15.7%); (2) women engaged in sex work and opioid use (21.4%); (3) street income generation and opioid use (31.6%); (4) opioid agonist therapy (OAT) patients (22.3%); and (5) men who have sex with men (9.0%). In multivariable analyses, compared to the primary stimulant use group, non-fatal overdose was positively associated with street income generation (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI]=1.30-1.71), sex work (AOR = 1.38, 95% CI=1.20-1.59) and OAT (AOR = 1.22, 95% CI=1.06-1.41) subgroups; engagement in non-OAT addiction care was negatively associated with street income generation (AOR = 0.81, 95% CI=0.68-0.97) and sex work (AOR = 0.78, 95% CI=0.63-0.98) subgroups.

DISCUSSION

Socioeconomically marginalized subgroups with opioid and crystal methamphetamine co-use were at highest risk of non-fatal overdose and had poorer access to addiction care, highlighting the need for tailored interventions.

The Overdose Crisis and Using Alone: Perspectives of People Who Use Drugs in Rural and Semi-Urban Areas of British Columbia

Background: A significant rise in the rate of overdose deaths in British Columbia (BC), driven by fentanyl contamination of the illicit drug supply, led to the declaration of a public health emergency in 2016. Those at greatest risk of death are people who use alone. This community-based participatory action research study based in the Fraser East region of BC study aimed to overview underlying factors that contribute to unwitnessed overdoses in semi-urban and rural settings. Methods: This descriptive study used a community-based participatory action research model with peer research associates (PRAs) involved at various research stages. In total, 22 interviews were conducted with participants aged 19 and over who used illicit drugs in the Fraser East since the start of the public health emergency in 2016. A collaborative data analysis approach was taken for data interpretation, and content analysis was performed to explore themes surrounding using alone. Results: Among people who use drugs (PWUD), using alone was found to be influenced by (a) the availability of drugs and personal funds, (b) personal safety, (c) stigma and shame, (d) protecting privacy, (e) mental health conditions and addiction, and (f) the lack of engagement with harm reduction services. At times, using alone was due to unforeseen, episode-specific situations. Conclusion: A multi-dimentional and context-specific approach is needed in overdose prevention and response for people who use drugs alone. There is need for enhanced approaches that address or include support services for families to reduce stigma and isolation of those at risk of an overdose.

Research With Women Who Use Drugs: Applying a Trauma-informed Framework

Women who use drugs (WWUD) experience high rates of trauma. The complex impacts of trauma can act as a barrier to accessing substance use and harm reduction services, and to participation and representation within substance use research. Trauma-informed practice is an evidence-based approach for improved clinical care among WWUD, the principles of which can be applied to substance use research. Many researchers are integrating trauma-informed approaches across research settings, yet these principles are often not referenced specifically within publications, and there is a lack of comprehensive guidance regarding integration of trauma-informed methods across different research designs and methodologies. This commentary describes and discusses the merits of applying the 4 principles of trauma-informed practice - trauma awareness, safety and trustworthiness, choice collaboration and connection, and strengths-based and skills building - to promote safety and inclusion of WWUD in substance use research.