Harm reduction in name, but not substance: a comparative analysis of current Canadian provincial and territorial policy frameworks

Beyond struggle: A strengths-based qualitative study of cannabis use among queer and trans youth in Québec

BACKGROUND

Queer and trans (QT) youth report higher rates of cannabis use than their cisgender and heterosexual peers. Explanations for this have overwhelmingly focused on the difficulties QT youth face, while little research has examined how cannabis use can relate to QT youth's strengths. We sought to explore how cannabis use could be involved in the experiences of QT youth from a strengths-based perspective.

METHODS

We conducted a QT youth-led, community-based study composed of 27 semi-structured interviews with QT young adults aged 21-25 years and living in Québec who use(d) cannabis regularly. Through reflexive thematic analysis (Braun & Clarke, 2019), we used a strengths-based lens informed by the Minority Strengths Model (Perrin et al., 2020) to explore how cannabis use featured in participants' efforts to survive and thrive.

RESULTS

We generated three themes representing how cannabis featured in participants' efforts to survive and thrive. First, cannabis was used to facilitate the production of an authentic QT self, a process that involved self-discovery, introspection, exploration, awareness, and expression. Cannabis supported, accompanied, and/or complicated this process. Second, cannabis use (and non-use) was involved in building QT community and connection, which constituted a crux of participants' wellbeing. Third, cannabis was used to face adversity, such as marginalization, QT oppression, mental health challenges, and structural under-resourcing. This adversity contrasted experiences of QT identities themselves, which were described as a source of joy and pride.

CONCLUSION

Our analysis illustrates many ways in which cannabis use (and non-use) features in QT youth's efforts to survive and thrive. As a result, we encourage loved ones, clinicians, researchers and policy makers to adopt a view of QT cannabis use that is expansive and inclusive of QT youth's strengths.

Empirical assessment of wounds among people who use substances

BACKGROUND

Wounds are a significant source of morbidity among people who use substances (PWUS). This project sought to identify the incidence and severity of wounds among PWUS in the South Bronx, a region of New York City with one of the highest morbidities of substance use disorder.

METHODS

This study recruited PWUS within the past 30 days. Research staff were trained to document the presence and severity of wounds. The primary outcome measure was the incidence of wounds. Acceptability of on-the-street wound care was assessed by the number of participants encountered. The association between participant characteristics and wounds was also evaluated.

RESULTS

In total, 586 PWUS were assessed (19.4 % female: 69 % Hispanic; 23 % Black; 5 % White). Heroin (65.7 %) and psychostimulants (58.3 %) were the most commonly used drugs. Approximately 23 % of outreach recipients disclosed a wound. Among those with a wound, 60.9 % reported one wound, 27.8 % had two wounds, and 11.3 % had three or more wounds. Small wounds (approximately the size of a cherry) were the most common (78.6 %). Recent use of stimulants or heroin, along with intravenous use of any substance were significantly associated with having a wound.

CONCLUSIONS

This study found that drug-related wounds were common among PWUS. Toxicology data from other sources indicate that xylazine was present in the NYC market at the time, though its prevalence among the current sample is difficult to determine. The occurrence and severity of substance-related wounds in NYC should continue to be monitored as a function of changes in the xylazine adulteration.

Structural violence and necropolitics among Indigenous Peoples living with HIV who use substances in the Prairie provinces during COVID-19

BACKGROUND

Within Manitoba and Saskatchewan, pre-existing health inequities amongst Indigenous groups were intensified during the COVID-19 pandemic. Service disruptions in the health and social service sector-combined with the effects of intersectional stigma-disproportionately impacted Indigenous peoples living with HIV (IPLH). IPLH experience structural violence and necropolitical exclusion through systemic forms of stigma situated within Canada's expansive colonial history. Utilizing the theoretical foundations of structural violence and necropolitics, this qualitative study examines how the COVID-19 pandemic amplified preceding states of inequity for IPLH.

METHODS

Semi-structured interviews were conducted with 60 participants. The sample comprised of those with lived experience (n = 45) as well as those who provided services for IPLH (n = 15). Indigenous Storywork guided the data collection and analysis process. Topics explored within each interview included access to health and social services, harm reduction, substance use, and experiences in providing services during COVID-19 pandemic. Thematic analysis was used to identify common themes throughout each story.

RESULTS

Our results indicate that the COVID-19 pandemic exposed and amplified pre-existing forms of structural violence and necropolitical logics for IPLH within Manitoba and Saskatchewan. Specifically, we describe how structural violence and necropolitics are manifested via three main avenues- (i) restrictions and removal of care, (ii) bureaucracy and institutional care politics, and (iii) discrimination and systemic racism within the Canadian healthcare system.

CONCLUSION

The COVID-19 pandemic within Manitoba and Saskatchewan sparked massive changes in service provision within settler-colonial and neoliberal institutions of care. For those services that remained open to IPLH, masking requirements, questionnaire requirements, scheduling requirements, and a lack of in-person services acted as only some of the barriers described by community members as detrimental to care access. Increased experiences of discrimination in health care on the basis of substance use or HIV status further limited access to needed services.

The impact of the COVID-19 pandemic on people who use drugs in three Canadian cities: a cross-sectional analysis

BACKGROUND

The COVID-19 pandemic had a disproportionate impact on the health and wellbeing of people who use drugs (PWUD) in Canada. However less is known about jurisdictional commonalities and differences in COVID-19 exposure and impacts of pandemic-related restrictions on competing health and social risks among PWUD living in large urban centres.

METHODS

Between May 2020 and March 2021, leveraging infrastructure from ongoing cohorts of PWUD, we surveyed 1,025 participants from Vancouver (n = 640), Toronto (n = 158), and Montreal (n = 227), Canada to describe the impacts of pandemic-related restrictions on basic, health, and harm reduction needs.

RESULTS

Among participants, awareness of COVID-19 protective measures was high; however, between 10 and 24% of participants in each city-specific sample reported being unable to self-isolate. Overall, 3-19% of participants reported experiencing homelessness after the onset of the pandemic, while 20-41% reported that they went hungry more often than usual. Furthermore, 8-33% of participants reported experiencing an overdose during the pandemic, though most indicated no change in overdose frequency compared the pre-pandemic period. Most participants receiving opioid agonist therapy in the past six months reported treatment continuity during the pandemic (87-93%), however, 32% and 22% of participants in Toronto and Montreal reported missing doses due to service disruptions. There were some reports of difficulty accessing supervised consumption sites in all three sites, and drug checking services in Vancouver.

CONCLUSION

Findings suggest PWUD in Canada experienced difficulties meeting essential needs and accessing some harm reduction services during the COVID-19 pandemic. These findings can inform preparedness planning for future public health emergencies.

"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America

BACKGROUND

Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs.

METHODS

From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs.

RESULTS

Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust.

CONCLUSION

While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

Unit costs of needle and syringe program provision: a global systematic review and cost extrapolation

BACKGROUND

Needle and syringe programs (NSPs) are effective at preventing HIV and hepatitis C virus (HCV) among people who inject drugs (PWID), yet global coverage is low, partly because governments lack data on the cost and cost-effectiveness of NSP in their countries to plan and fund their responses. We conducted a global systematic review of unit costs of NSP provision to inform estimation of cost drivers and extrapolated costs to other countries.

METHODS

We conducted a systematic review to extract data on the cost per syringe distributed and its cost drivers. We estimated the impact of country-level and program-level variables on the cost per syringe distributed using linear mixed-effects models. These models were used to predict unit costs of NSP provision, with the best performing model used to extrapolate the cost per syringe distributed for 137 countries. The total cost for a comprehensive NSP (200 syringes per PWID/year) was also estimated for 68 countries with PWID population size estimates.

RESULTS

We identified 55 estimates of the unit cost per syringe distributed from 14 countries. Unit costs were extrapolated for 137 countries, ranging from $0.08 to $20.77 (2020 USD) per syringe distributed. The total estimated spend for a high-coverage, comprehensive NSP across 68 countries with PWID size estimates is $5 035 902 000 for 10 887 500 PWID, 2.1-times higher than current spend.

CONCLUSION

Our review identified cost estimates from high-income, upper-middle-income, and lower-middle-income countries. Regression models may be useful for estimating NSP costs in countries without data to inform HIV/HCV prevention programming and policy.

Infectious diseases in Indigenous populations in North America: learning from the past to create a more equitable future

The COVID-19 pandemic, although a profound reminder of endured injustices by and the disparate impact of infectious diseases on Indigenous populations, has also served as an example of Indigenous strength and the ability to thrive anew. Many infectious diseases share common risk factors that are directly tied to the ongoing effects of colonisation. We provide historical context and case studies that illustrate both challenges and successes related to infectious disease mitigation in Indigenous populations in the USA and Canada. Infectious disease disparities, driven by persistent inequities in socioeconomic determinants of health, underscore the urgent need for action. We call on governments, public health leaders, industry representatives, and researchers to reject harmful research practices and to adopt a framework for achieving sustainable improvements in the health of Indigenous people that is both adequately resourced and grounded in respect for tribal sovereignty and Indigenous knowledge.

A qualitative study of professionals' perspectives on the ethics of medically-delivered safer injection education for people who inject drugs

BACKGROUND

In this qualitative analysis we aimed to explore addiction physicians' perspectives on safer injection education for people who inject drugs, especially: (1) on possible means of introducing safer injection education in the medical environment, (2) on the compatibility of safer injection education with each physician's core values and goals, and (3) on possible reasons for the ethical dilemma in safer injection education.

METHODS

We conducted semi-structured interviews with eleven physicians practicing addiction medicine in France in clinical and harm reduction settings.

RESULTS

All participants were in favor of educational interventions for people who inject drugs. Nonetheless, these interventions varied from simple advice to injection supervision and they were seen as less acceptable when they concerned the practical and material aspects of injection. Some participants found that physicians practicing in clinical settings, where patients consult mostly to stop their drug use, should not practice safer injection education. On the contrary, other participants claimed that safer injection education was essential in all settings and was not a choice but rather a duty for addiction physicians. The ethical dilemma of such intervention when delivered by medical staff was viewed as a complex phenomenon, related to the representations of intravenous drug use and to societal expectations from physicians.

CONCLUSION

Physicians' views on safer injection education for people who inject drugs reveal an emotionally charged subject related to the structural organization of addiction management in France. Such education is marked by an arduous history of harm reduction policies in France. IRB REGISTRATION: #00011928.

"No Good Choice": What are the Issues of Having no Harm Reduction Strategies in Hospitals?

Background

Despite an increase in methamphetamine use and subsequent hospitalizations, the majority of Canadian hospitals currently lack harm reduction strategies for substance use. This can mean that people with lived experience of methamphetamine use are faced with a number of difficult decisions to make when admitted to hospital. Caring for people with lived experience of methamphetamine use can also be problematic with zero tolerance policies requiring abstinence to be maintained. This analysis set out to understand potential health care issues due to a lack of harm reduction strategies from the prospective of people with lived experience of methamphetamine use as well as health care/service professionals.

Methods

Based on a larger study, this secondary analysis explored issues discussed by people with lived experience of methamphetamine use and health care/service professionals regarding the challenges of providing harm reduction approaches in the hospital setting. A total of 108 individuals with lived experience of methamphetamine use completed a qualitative component of a mixed-method interview. In addition, 31 health care/service professionals participated in virtual focus groups and one-to-one interviews. Responses were analyzed using an ethnographic thematic approach.

Results

People with lived experience of methamphetamine use reported 3 choices upon admission: leave or avoid the hospital, stay but experience unsupported withdrawal, or stay but hide their substance usage from health care professionals. Health care/service professionals described 2 options: uphold zero tolerance that can lead to stigma and a lack of knowledge regarding addiction, or accept harm reduction but be unable to implement such strategies. This could lead to health being compromised due to policy and practice that requires abstinence. Neither group of participants described a good choice for them.

Conclusion

Current policy and education related to substance use needs to be revised.

Prescribing safe supply: ethical considerations for clinicians

The COVID-19 pandemic has exacerbated the drug poisoning epidemic in a number of ways: individuals use alone more often, there is decreased access to harm reduction services and there has been an increase in the toxicity of the unregulated drug supply. In response to the crisis, clinicians, policy makers and people who use drugs have been seeking ways to prevent the worst harms of unregulated opioid use. One prominent idea is safe supply. One form of safe supply enlists clinicians to prescribe opioids so that people have access to drugs of known composition and strength. In this paper, we assess the ethical case for clinicians providing this service. As we describe, there is much that is unknown about safe supply. However, given the seriousness of the overdose death epidemic and the current limited evidence for safe supply's efficacy, we argue that it is ethically permissible for clinicians to begin prescribing opioids for some select patients.

Kim H, Gratzer D, George TP, Le Foll B, Castle DJ. Marked Increase in Amphetamine-Related Emergency Department Visits and Inpatient Admissions in Toronto, Canada, 2014-2021

BACKGROUND

We report emergency department and inpatient amphetamine-related trends focusing on co-occurring substance use and psychiatric diagnoses at the Centre for Addiction and Mental Health, the largest mental health teaching hospital in Canada.

METHODS

We describe yearly trends in amphetamine-related Centre for Addiction and Mental Health emergency department visits and inpatient admissions out of all emergency department visits and inpatient admissions between 2014 and 2021, along with proportions of concurrent substance-related admissions and mental/psychotic disorders emergency department visits and inpatient admissions among amphetamine-related contacts; joinpoint regression analyses assessed changes in amphetamine-related emergency department visits and inpatient admissions.

RESULTS

Amphetamine-related emergency department visits rose from 1.5% in 2014 to 8.3% in 2021, with a peak of 9.9% in 2020. Amphetamine-related inpatient admissions rose from 2.0% to 8.8% in 2021, with a peak of 8.9% in 2020. Significant increasing trends in the percentage of amphetamine-related emergency department visits happened especially between the second and the fourth quarter of 2014 (quarterly percent change =  + 71.4, P <0.01). Similarly, the percentage of amphetamine-related inpatient admissions increased mostly between the second quarter of 2014 and the third quarter of 2015 (quarterly percent change  =  + 32.6, P <0.01). The proportion of concurrent opioid-related contacts among amphetamine-related emergency department visits and inpatient admission increased markedly between 2014 and 2021; psychotic disorders in amphetamine-related inpatient admissions more than doubled from 2015 to 2021.

DISCUSSION

Prevalence of amphetamine use, mostly from methamphetamine, has been increasing in Toronto as have co-occurring psychiatric disorders and opioid use. Our findings highlight the need for increases in accessible efficacious treatments for complex populations with polysubstance use and co-occurring disorders.

Identifying barriers and facilitators for implementing harm reduction strategies for methamphetamine use into hospital settings

INTRODUCTION

Harm reduction strategies for substance use disorder are not currently offered in Canadian hospitals. Previous research has suggested that substance use may continue to occur which can lead to further complications such as new infections. Harm reduction strategies may be a solution to this issue. This secondary analysis aims to explore the current barriers and potential facilitators for implementing harm reduction into the hospital from the perspective of health care and service providers.

METHOD

Primary data was collected from 31 health care and service providers who participated in a series of virtual focus groups and one-to-one interviews regarding their perspectives on harm reduction. All staff were recruited from hospitals in Southwestern Ontario, Canada from February 2021 to December 2021. Health care and service professionals completed a one-time individual interview or a virtual focus group using an open-ended qualitative interview survey. Qualitative data was transcribed verbatim and analyzed using an ethnographic thematic approach. Themes and subthemes were identified and coded based on responses.

FINDINGS

Attitude and Knowledge, Pragmatics, and Safety/Reduction of Harm were identified as the core themes. Attitudinal barriers such as stigma and lack of acceptance were reported but education, openness and community support were regarded as potential facilitators. Cost, space, time and availability of substances on site were regarded as Pragmatic barriers but potential facilitators such as organizational support, flexible harm reduction services and a specialized team were identified. Policy and liability were perceived as both a barrier and a potential facilitator. Safety and impact of substances on treatment were considered as both a barrier and a potential facilitator but sharps boxes and continuity of care were regarded as potential facilitators.

DISCUSSION

Although barriers in implementing harm reduction in hospital settings exist, there are opportunities to facilitate change. As identified in this study, feasible and achievable solutions are available. Education on harm reduction for staff was considered to be a key clinical implication in facilitating harm reduction implementation.

Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting

BACKGROUND

Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada.

METHODS

Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis.

RESULTS

Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services.

CONCLUSIONS

Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.

Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study

BACKGROUND

Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD.

METHODS

The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings.

RESULTS

The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors.

CONCLUSIONS

Structural vulnerability is salient within Canadian policy actors' discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.

Safety and danger: Perceptions of the implementation of harm reduction programs in two communities in Nova Scotia, Canada

People who use substances (PWUS), and specifically individuals who use injection drugs and/or smoke crack cocaine, experience risks which harm reduction programmes can help reduce. Prior to implementing harm reduction programmes, however, it is critical to understand how programme users and others in the community perceive the programmes as their perceptions may influence implementation. A mixed-methods study asked PWUS and key informants about their perceptions of implementing five harm reduction programmes in their communities, including perceptions of the advantages of the programmes, where best to locate them, and community support. Questionnaires were administered to 160 PWUS, and qualitative interviews were conducted with 11 purposefully sampled key informants. Data were collected in one medium-size and one small-size community/municipality in Nova Scotia, Canada, during 2017-2018. SPSS was used to generate descriptive statistics and means from the quantitative data, and the qualitative data were analysed for key themes using thematic analysis. Both PWUS and key informants perceived numerous advantages of the harm reduction programmes, but some key informants suggested that there might be potential opposition to the implementation of additional needle distribution and disposal programmes in some locations and potential opposition to safer consumption sites. Further research is needed to understand why these programmes were viewed as potentially generating opposition, but findings suggest that a key factor is the association of the programmes with 'danger' because the programmes are directly linked with criminalized drug use. In contrast, the three other programmes are linked to 'safety' because naloxone saves lives, peer navigation programmes support access to existing programmes and detoxification programmes are associated with safety through the reduction/elimination of drug use. Legalization/decriminalization of drugs might help to change the association of some programmes with 'danger' and therefore help support the implementation of harm reduction programmes that appear to be perceived by some as linked to danger.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Policy Advocacy and Nursing Organizations: A Scoping Review

Policy advocacy is a fundamental component of nursing's social mandate. While it has become a core function of nursing organizations across the globe, the discourse around advocacy has focused largely on the responsibilities and accountabilities of individual nurses, with little attention to the policy advocacy work undertaken by nursing organizations. To strengthen this critical function, an understanding of the extant literature is needed to identify areas that require further research. We conducted a scoping review to examine the nature, extent, and range of scholarly work focused on nursing organizations and policy advocacy. A systematic search of six databases produced 4,731 papers and 68 were included for analysis and synthesis. Findings suggest that the literature has been increasing over the years, is largely non-empirical, and covers a broad range of topics ranging from the role and purpose of nursing organizations in policy advocacy, the identity of nursing organizations, the development and process of policy advocacy initiatives, the policy advocacy products of nursing organizations, and the impact and evaluation of organizations’ policy advocacy work. Based on the review, we identify several research gaps and propose areas for further research to strengthen the influence and impact of this critical function undertaken by nursing organizations.

Supervised Injection Facilities as Harm Reduction: A Systematic Review

CONTEXT

Supervised injection facilities are harm reduction interventions that allow people who inject drugs to use previously obtained substances under the supervision of health professionals. Although currently considered illegal under U.S. federal law, several U.S. cities are considering implementing supervised injection facilities anyway as a response to the escalating overdose crisis. The objective of this review is to determine the effectiveness of supervised injection facilities, compared with that of control conditions, for harm reduction and community outcomes.

EVIDENCE ACQUISITION

Studies were identified from 2 sources: a high-quality, broader review examining supervised injection facility-induced benefits and harms (from database inception to January 2014) and an updated search using the same search strategy (January 2014‒September 2019). Systematic review methods developed by the Guide to Community Preventive Services were used (screening and analysis, September 2019‒December 2020).

EVIDENCE SYNTHESIS

A total of 22 studies were included in this review: 16 focused on 1 supervised injection facility in Vancouver, Canada. Quantitative synthesis was not conducted given inconsistent outcome measurement across the studies. Supervised injection facilities in the included studies (n=number of studies per outcome category) were mostly associated with significant reductions in opioid overdose morbidity and mortality (n=5), significant improvements in injection behaviors and harm reduction (n=7), significant improvements in access to addiction treatment programs (n=7), and no increase or reductions in crime and public nuisance (n=7).

CONCLUSIONS

For people who inject drugs, supervised injection facilities may reduce the risk of overdose morbidity and mortality and improve access to care while not increasing crime or public nuisance to the surrounding community.

Public support for harm reduction: A population survey of Canadian adults

We described public views toward harm reduction among Canadian adults and tested a social exposure model predicting support for these contentious services, drawing on theories in the morality policy, intergroup relations, addiction, and media communication literatures. A quota sample of 4645 adults (18+ years), randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across Canadian provinces, was recruited in June 2018. Participants completed survey items assessing support for harm reduction for people who use drugs (PWUD) and for seven harm reduction interventions. Additional items assessed exposure to media coverage on harm reduction, and scales assessing stigma toward PWUD (α = .72), personal familiarity with PWUD (α = .84), and disease model beliefs about addiction (α = .79). Most (64%) Canadians supported harm reduction (provincial estimates = 60% - 73%). Five of seven interventions received majority support, including: outreach (79%), naloxone (72%), drug checking (70%), needle distribution (60%) and supervised drug consumption (55%). Low-threshold opioid agonist treatment and safe inhalation interventions received less support (49% and 44%). Our social exposure model, adjusted for respondent sex, household income, political views, and education, exhibited good fit and accounted for 17% of variance in public support for harm reduction. Personal familiarity with PWUD and disease model beliefs about addiction were directly associated with support (βs = .07 and -0.10, respectively), and indirectly influenced public support via stigmatized attitudes toward PWUD (βs = 0.01 and -0.01, respectively). Strategies to increase support for harm reduction could problematize certain disease model beliefs (e.g., "There are only two possibilities for an alcoholic or drug addict-permanent abstinence or death") and creating opportunities to reduce social distance between PWUD, the public, and policy makers.

Careful Practices: Ethics and the Anethical in Canadian Addiction Trajectories

A drug overdose epidemic in North America has sped the expansion of harm reduction services. Drawing on fieldwork in Ottawa, Ontario, we examine forms of care among people offering and accessing these resources. Notably, our interlocutors do not always characterize harm reduction as caring for oneself. Thus, we differentiate between the ethics of care through which one enters desired subject positions, and anethical careful practices. Harm reduction is sometimes anethical, enacted through minor gestures that do not constitute ethical work but allow for its future realization.

Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies

BACKGROUND

Harm reduction services, which typically provide overdose education and prevention with distribution of naloxone and other supplies related to safer drug use, help reduce opioid-related overdose and infectious disease transmission. However, structural stigma and the ongoing criminalization of drug use have limited the expansion of harm reduction services into many non-urban communities in the United States that have been increasingly affected by the health consequences of opioid and polysubstance use.

METHODS

We conducted qualitative interviews with 22 professionals working with people who use drugs in cities and towns across Rhode Island and Massachusetts to understand challenges and strategies for engaging communities in accepting harm reduction perspectives and services.

RESULTS

Our thematic analysis identified several interrelated challenges to implementing harm reduction services in non-urban communities, including: (1) limited understandings of harm reduction practice and preferential focus on substance use treatment and primary prevention, (2) community-level stigma against people who use drugs as well as the agencies supporting them, (3) data reporting and aggregating leading to inaccurate perceptions about local patterns of substance use and related health consequences, and (4) a "prosecutorial mindset" against drug use and harm reduction. From key informants' narratives, we also identified specific strategies that communities could use to address these challenges, including: (1) identifying local champions to advocate for harm reduction strategies, (2) proactively educating communities about harm reduction approaches before they are implemented, (3) improving the visibility of harm reduction services within communities, and (4) obtaining "buy-in" from a wide range of local stakeholders including law enforcement and local government.

CONCLUSION

These findings carry important implications for expanding harm reduction services, including syringe service programs and safe injection sites, into non-urban communities that have a demonstrated need for evidence-based interventions to reduce drug-related overdose and infectious disease transmission.

Patterns of substance use before and after hospitalization among patients seen by an inpatient addiction consult service: A latent transition analysis

BACKGROUND AND AIMS

Polysubstance use is common and contributes to morbidity and mortality of hospitalized patients, and yet little is known about patterns of substance use among hospitalized patients, or how an addiction consult service (ACS) might impact polysubstance use after discharge. The objective of this study was to identify patterns of substance use at admission and after discharge among hospitalized patients with substance use disorders who saw an ACS.

DESIGN

Prospective cohort study. We used latent transition analysis of substance use scores at the time of hospital admission and 30 to 90 days posthospitalization.

SETTING

Single, academic health center with an ACS in Portland, Oregon, from 2015 to 2018.

PARTICIPANTS/CASES

Patients were eligible if they received a consult to the inpatient ACS.

MEASUREMENTS

We used Addiction Severity Index-Lite scores to capture self-reported substance use at baseline and follow-up for heroin, other opioid, alcohol, amphetamine, and cocaine.

FINDINGS

From 2015 to 2018, 486 individuals consented to participate. More than half of patients used more than one substance at baseline. Of those reporting any baseline opioid use, nearly three-quarters (n=187, 69.5%) had polysubstance use in the previous 30 days, including alcohol (n=80, 29.7%), cocaine (n=25, 9.3%), or amphetamine use (n=142, 52.8%). We identified three patterns of substance use at baseline: 1) alcohol use dominant, 2) polysubstance use dominant, and 3) heroin and other opioid use dominant. Patients transitioned along five trajectories to three different follow-up profiles that showed lower endorsement of all substances used. Slightly more than 40% (40.1%) of patients newly endorsed abstinence of at least one substance at follow-up.

CONCLUSIONS

Polysubstance use is common in hospitalized patients with substance use disorders and identifying patterns of polysubstance use can guide clinical management. Hospital providers should prepare to manage polysubstance use during hospitalization and hospitals should broaden care beyond interventions for opioid use disorder.

Harm Reduction Works: Evidence and Inclusion in Drug Policy and Advocacy

One of harm reduction's most salient features is its pragmatism. Harm reduction purports to distinguish itself from dominant prohibitionist and abstinence-based policy paradigms by being grounded in what is realistic, in contrast with the moralism or puritanism of prohibition and abstention. This is reflected in the meme "harm reduction works", popular both in institutional and grassroots settings. The idea that harm reduction is realistic and effective has meant different things among the main actors who seek to shape harm reduction policy. Drawing on scholarly literature about harm reduction, as well as examples from recent harm reduction advocacy efforts in relation to drug policy in Canada, this paper argues that harm reduction distinguishes itself through a unique "way of knowing". Grassroots harm reduction advocates, particularly as they argue through human rights frameworks, do more than simply make claims for the provision of particular services-like needle exchange, safe consumption sites, safe supply and the like-on the basis that these are realistic paths toward the health and well-being of people who use drugs. Rather, as they marshal lived experience in support of these policy changes through peer-driven initiatives in contexts of prohibition, they make particular claims about what constitute valid, methodologically rigorous evidence bases for action in contexts where policies to date have been driven by ideology and have developed in ways that have excluded and marginalized those most affected from policymaking. In doing so, they advocate for the centrality of people who use drugs not only in policy-making processes, but in evidence production itself.

'Small communities, large oversight': The impact of recent legislative changes concerning supervised consumption services on small communities in Ontario, Canada

The opioid epidemic continues to exert a large toll on public health across Canada, with the province of Ontario specifically experiencing exceptionally high opioid-related hospitalizations and overdoses in 2019. As a key evidence-based public health intervention to reduce these harms, over the past few years supervised consumption services (SCS), including temporary and flexible unsanctioned models, have been implemented in select cities across the province. However, in March 2019, the newly elected Ontario provincial government replaced SCS regulations with a 'streamlined' model that introduced additional bureaucratic and administrative requirements for application approval and funding, while placing a cap on the number of sites allowed. Only a select few sites were approved, despite the ability of numerous cities across the province to demonstrate a need for SCS in their community. Importantly, many small communities throughout Ontario have been experiencing opioid-related harms at rates which far outpace those of larger cities. Several of these communities have been actively working towards securing SCS sites, but have been unable to do so as they do not have the resources to meet stringent application requirements. These regulatory changes therefore hinder the feasibility of small communities to implement necessary and life-saving SCS, which will affect lives. This is a major oversight.

"You need to just provide health services:" navigating the politics of harm reduction in the twin housing and overdose crises in Vancouver, BC

BACKGROUND

Since harm reduction's origins as a grassroots, activist movement, cooperation and compromise among people who use drugs, bureaucrats, politicians, and other actors have been critical to its advancement in Canada. Critics have argued, however, that the institutionalization of harm reduction practice within the context of a politically sensitive environment has eroded its radical potential. The overdose crisis in Vancouver's Downtown Eastside (DTES) community has led to innovative harm reduction organizing that has been replicated globally. In this paper, we explore how one such intervention, the Tenant Overdose Response Organizers (TORO) program, has supported a resurgence in tenant-led harm reduction organizing in Single Room Occupancy (SRO) buildings in the DTES.

METHODS

We draw on 15 months of ethnographic fieldwork conducted between May 2017 and August 2018, over 100 hours of participant observation of TORO activities, and 15 semi-structured interviews with key stakeholders in the program.

RESULTS

TORO's leaders attempted to mobilize harm reduction intervention towards collective action on SRO risk environments underlying drug-related harms, but their efforts were constrained by the necessity of meeting practical expectations of funders regarding health education and supply distribution. Navigating these constraints ultimately shaped the development of the TORO program, helping to secure its longevity but also limiting its ability to organize a coordinated harm reduction and tenants' rights response to the dual housing and overdose crises.

CONCLUSION

Our examination of TORO demonstrates how the harm reduction movement continues to be shaped by conflict, cooperation, and compromise between the state and grassroots groups. Even as actors strive to work collaboratively, the unequal distribution of power inherent in this relationship may contribute to the reinscription of a depoliticized harm reduction approach. We discuss the potential role of the risk environment framework in lending political legitimacy to grassroots harm reduction initiatives.

Impact of overdose prevention sites during a public health emergency in Victoria, Canada

The primary objective of this study was to examine the impacts associated with implementation of overdose preventions sites (OPSs) in Victoria, Canada during a declared provincial public health overdose emergency. A rapid case study design was employed with three OPSs constituting the cases. Data were collected through semi-structured interviews with 15 staff, including experiential staff, and 12 service users. Theoretically, we were informed by the Consolidated Framework for Implementation Research. This framework, combined with a case study design, is well suited for generating insight into the impacts of an intervention. Zero deaths were identified as a key impact and indicator of success. The implementation of OPSs increased opportunities for early intervention in the event of an overdose, reducing trauma for staff and service users, and facilitated organizational transitions from provision of safer supplies to safer spaces. Providing a safer space meant drug use no longer needed to be concealed, with the effect of mitigating drug related stigma and facilitating a shift from shame and blame to increasing trust and development of relationships with increased opportunities to provide connections to other services. These impacts were achieved with few new resources highlighting the commitment of agencies and harm reduction workers, particularly those with lived experience, in achieving beneficial impacts. Although mitigating harms of overdose, OPSs do not address the root problem of an unsafe drug supply. OPSs are important life-saving interventions, but more is needed to address the current contamination of the illicit drug supply including provision of a safer supply.

How Do Nursing Organizations Measure Up on Harm Reduction? An Environmental Scan

BACKGROUND

In the past five years, we have seen a rapid expansion of harm reduction approaches, programs, and policies in Canada. To keep up with the changing policy landscape, a number of Canadian researchers have undertaken projects that seek to analyze policy documents published by provincial and territorial governments. Building on this important body of work, we undertook a similar analysis using documents published by nursing organizations.

PURPOSE

To present key findings and propose ways that nursing organizations can strengthen their position on harm reduction.

METHODS

We conducted an environmental scan with a two-part analysis. To complete the first part, we used the 17 quality indicators. To complete the second part, we analyzed the documents for specific harm reduction interventions.

RESULTS

A total of 39 documents were collected across 76 nursing organizations. The majority of the documents were press or public statements (n = 22), and the most frequently mentioned intervention was supervised injection services (n = 31). On average, documents met 5.6 quality indicators. Documents scored highest on indicator 12 (discuss low-threshold approaches to service provision) and lowest on indicator 3 (acknowledge that not all substance use is problematic).

CONCLUSIONS

Six areas were identified to strengthen nursing organizations' position on harm reduction.

EVALUATION OF HARM REDUCTION STRATEGIES IN THE PSYCHOSOCIAL CARE NETWORK

ABSTRACT Objective: to evaluate harm reduction strategies in the Psychosocial Care Network of a small city in the southern region of Brazil. Method: qualitative study, using the methodological assumptions of the Empowerment Evaluation. The research was carried out in the Psychosocial Care Network of a small city in Rio Grande do Sul, Brazil, from March to December 2017. Forty-two managers and workers of the psychosocial care network services and the intersectoral network for drug users participated in the study. Thematic analysis was used for data analysis. Results: the mission of the network under study involved a work proposal aimed at harm reduction. In the knowledge of the current situation, the integrated action of the harm reduction team to the other services in the network was identified and the need for greater understanding of the specifics of this work. Concerning the perspectives for the future of the network, efforts were made to strengthen harm reduction strategies that redeem the potential of individuals and investments in human and structural resources in damage reduction teams. Conclusion: the study presents support for the construction of harm reduction proposals integrated into the psychosocial care network, which can guide the prioritization of investments and improvements in the decision making of network managers and workers.

Media coverage of harm reduction, 2000-2016: A content analysis of tone, topics, and interventions in Canadian print news

BACKGROUND

Harm reduction interventions reduce mortality and morbidity for people who use drugs (PWUD), but are contentious and haphazardly implemented. This study describes volume and content of Canadian newspaper coverage of harm reduction produced from 2000 to 2016.

METHODS

Searches of 54 English-language newspapers identified 5681 texts, coded for type (news reports, opinion pieces), tone (positive, negative, or neutral/balanced coverage), topic (health, crime, social welfare, and political perspectives on harm reduction), and seven harm reduction interventions.

RESULTS

Volume of coverage doubled in 2008 (after removal of harm reduction from federal drug policy and legal challenges to Vancouver's supervised consumption program) and quadrupled in 2016 (tracking Canada's opioid emergency). Health perspectives on harm reduction were most common (39% of texts) while criminal perspectives were rare (3%). Negative coverage was over 10 times more common in opinion pieces (31%) compared to news reports (3%); this trend was more pronounced in British Columbia and Alberta, a region particularly affected by Canada's opioid emergency. Supervised drug consumption accounted for 49% of all newspaper coverage.

CONCLUSIONS

Although federal policy support for harm reduction waxed and waned over 17 years, Canadian newspapers independently shaped public discourse, frequently characterizing harm reduction positively/neutrally and from a health perspective. However, issue framing and agenda setting was also evident: supervised drug consumption offered in a single Canadian city crowded out coverage of all other harm reduction services, except for naloxone. This narrow sense of 'newsworthiness' obscured public discourse on the full spectrum of evidence-based harm reduction services that could benefit PWUD.

The ever-changing narrative: Supervised injection site policy making in Ontario, Canada

BACKGROUND

We analyze the ongoing debate surrounding supervised injection sites in Ontario, Canada and changing policies that impact host communities. Despite a plethora of evidence proving the effectiveness of supervised injection sites on harm reduction strategy, the topic remains highly controversial with constantly changing rhetoric in the Ontario drug policy landscape.

METHODS

We reviewed government reports, policies, and media sources spanning from prior to the establishment of the first Canadian supervised injection site in 2000 to early 2019, adopting an advocacy coalition framework approach to this policy analysis. Various advocacy coalitions emerge from this analysis, including all three levels of government, law enforcement, health practitioners, and community groups. We describe the narratives constructed by these coalitions, analyzing the supervised injection site model as a harm reduction strategy within a continually shifting socio-political landscape.

RESULTS

Emerging from the analysis are competing narratives put forward by various stakeholders within the policy subsystem. We find policy-makers tend to leverage scientific uncertainty as a tool to defend the interests of the most powerful actor in the subsystem. Despite an increase in the number of deaths due to the opioid crisis and evidence highlighting the efficacy of supervised injection sites as a harm reduction tool, various stakeholders are locked in a battle of claims and counter-claims about the appropriate policy response to opioids.

CONCLUSIONS

These findings have broad implications for drug policy in other contexts. Our case study demonstrates the strength of stopgap measures, like supervised injection, to reduce harm from controlled substances.

The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency

BACKGROUND

Drug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use.

METHODS

A multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents.

RESULTS

The legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency.

CONCLUSION

The rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments' restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.

A policy analysis exploring hepatitis C risk, prevention, testing, treatment and reinfection within Australia's prisons

Background

Hepatitis C (HCV) is a global public health concern. There is a global prevalence of 15% among the world’s prisoner population, suggesting the need for priority HCV treatment among this population group. New highly efficacious therapies with low side effects, known as directing-acting antivirals, became available under Australia’s universal healthcare scheme on 1 March 2016. This creates an opportune time to trial treatment as prevention as an elimination strategy for HCV in prison settings. This paper examines whether policies in Australian jurisdictions support treatment scale-up to achieve elimination among this priority population.

Methods

A comprehensive search was conducted using Google and other web-based search functions to locate all publicly available policies in each Australian state and territory related to HCV health and HCV-related prison health. Ministers (corrections and health) were contacted from each jurisdiction to identify any additional policies. Inductive and deductive analyses were conducted for each jurisdiction, with documents being assessed against a set of four a priori criteria. Documents included in the analysis were current at 1 September 2017, or 18 months following treatment availability.

Results

A total of 18 documents were located, including both health (n = 12) and corrections/prison health (n = 6) documents relevant to HCV. Jurisdictions ranged in their commitments for delivering HCV harm reduction strategies and treatment availability within the prison setting.

Conclusion

Few jurisdictions have updated or published HCV-related health or prisoner health policies following availability of directing-acting antivirals. Current policies do not provide effective support for implementing treatment scale-up that could be possible under universal access to HCV treatment among this priority population.