Achieving meaningful participation of people who use drugs and their peer organizations in a strategic research partnership

Political constructions of people who use drugs in the Philippines: A qualitative content analysis

BACKGROUND

This paper examines the political constructions of people who use drugs in the Philippines throughout the presidency of Rodrigo Duterte (2016-2022), during which the government engaged in a 'war on drugs' and promoted a punitive drug regime.

METHODS

Building on and drawing inspiration from the global drug policy scholarship that has looked at the ways in which drugs are framed and problematised in various domains, this study used qualitative content analysis to review 96 documents from national government agencies - including strategic action plans, directives, memorandums, guidelines, annual reports, and legislative measures.

RESULTS

Foremost, the study finds that various terms were interchangeably used to refer to 'drug users' - dependent, offender, personality, abuser - and all of them contributed to the problematisation of people who use drugs as a societal "menace". As "drug dependents", they were likewise portrayed as necessitating treatment or rehabilitation. Moreover, presented as victims or passive subjects, their agency and subjectivity are not acknowledged in the documents, even as counter-discourses, mainly from opposition lawmakers, challenge these portrayals and call for people-centered, harm reduction approaches.

CONCLUSION

Overall, these overlapping framings cast people who use drugs simultaneously as victims, criminals, deviants, and sick individuals to the detriment of their security, health, and well-being - and to the retrogression of drug policy in the country.

Engaging families and parent advocates in research on substance use and drug policy reform: Guiding principles from a Canadian community-academic partnership

Canada is in the midst of a public health emergency in drug poisoning (overdose) deaths. In this context parents, and especially mothers, of those who have died from drug poisoning have mobilised to advocate for urgent responses and drug policy reforms. To document this emerging women-led advocacy, we initiated a community-academic research partnership with three parent groups representing families in Canada bereaved by drug-related deaths. In this commentary, we describe four guiding principles we developed during the course of this project, to ensure an ethical and equitable approach to conducting our research partnership. In particular, we emphasise how we navigated parents' roles as vocal advocates for addressing drug stigma and expanding harm reduction while actively working to avoid eclipsing the need to centre the perspectives of people who use drugs. Meaningful and collaborative partnerships between academics and community groups may facilitate greater understandings of how families and communities can be allied in drug policy reforms urgently needed to prevent drug poisoning deaths.

Using digital technology to reduce drug-related harms: a targeted service users' perspective of the Digital Lifelines Scotland programme

BACKGROUND

Deaths due to drug overdose are an international issue, causing an estimated 128,000 global deaths in 2019. Scotland has the highest rate of drug-related deaths in Europe, with those in the most deprived areas at greater risk than those in affluent areas. There is a paucity of research on digital solutions, particularly from the perspective of those who use drugs who additionally access harm reduction and homelessness support services. The Digital Lifelines Scotland programme (DLS) provides vulnerable people who use/d drugs with digital devices to connect with services.

METHODS

This paper reports on the evaluation of the DLS from the perspective of service users who accessed services for those at risk of drug-related harms. A mixed methods approach was used including an online-survey (n = 19) and semi-structured interviews (n = 21). Survey data were analysed descriptively and interview data through inductive coding, informed by the Technology, People, Organisations and Macroenvironmental factors (TPOM) framework, to investigate the use, access, and availability of devices, and people's experiences and perceptions of them.

RESULTS

Most participants lived in social/council housing (63.2%, n = 12), many lived alone (68.4%, n = 13). They were mainly over 40 years old and lived in a city. Participants described a desire for data privacy, knowledge, and education, and placed a nascent social and personal value on digital devices. Participants pointed to the person-centred individuality of the service provision as one of the reasons to routinely engage with services. Service users experienced an increased sense of value and there was a palpable sense of community, connection and belonging developed through the programme, including interaction with services and devices.

CONCLUSIONS

This paper presents a unique perspective which documents the experiences of service users on the DLS. Participants illustrated a desire for life improvement and a collective and individual feeling of responsibility towards themselves and digital devices. Digital inclusion has the potential to provide avenues by which service users can safely and constructively access services and society to improve outcomes. This paper provides a foundation to further cultivate the insight of service users on digital solutions in this emerging area.

Introducing the Harm Reduction Collaboration Framework for Policy, Systems, and Environmental Change

A revised way of thinking is essential for promoting harm reduction strategies and reducing the negative implications of injection drug use (IDU). Despite the growth of harm reduction approaches in the United States, there is limited guidance for designing and implementing multi-sector efforts that address the external determinants that promote and facilitate IDU. Current frameworks fail to acknowledge the individual's role and influence in multi-sector change. To address the multifaceted nature of IDU, we must address the complex relationship between people who inject drugs (PWID) and their external environment. As part of a community-academic partnership, a framework was developed to address the gaps in current theoretical models and community practice. Our Harm Reduction Collaboration Framework (HRCF) accepts PWID as key stakeholders and presents a practical framework in which PWID and community organizations partner in decision making to influence policy, systems, and environmental change. We provide examples of two organizations that have made substantive changes in implementing harm reduction strategies in their communities by utilizing the HRCF.

Walk With Me: reducing harm and confronting the toxic drug poisoning crisis in small British Columbia cities through community engaged research

In an era of escalating and intersectional crises, the toxic drug poisoning crisis stands out as a devastating and persistent phenomenon. Where we write from in British Columbia (BC), Canada, over 13,000 deaths have occurred in the eight years since the toxic drug poisoning crisis was declared a provincial health emergency. While many of these deaths have occurred in large urban centres, smaller rural communities in British Columbia are also grappling with the profound impacts of the toxic drug poisoning crisis and are struggling to provide adequate support for their vulnerable populations. In response to these challenges, the Walk With Me research project has emerged in the Comox Valley of Vancouver Island, BC, employing community-engaged methodologies grounded in pluralist knowledge production. Walk With Me seeks to understand the unique manifestations of the toxic drug poisoning crisis in small communities, identifying local harm reduction interventions that can foster community resilience, and aiming to catalyze sustainable change by amplifying the voices of those directly affected by the crisis to advocate for policy changes. This paper outlines the conceptual and methodological underpinnings of the Walk With Me project as a harm reduction initiative, which holds community partnerships and diverse ways of knowing at its heart. It presents the community-engaged research framework used by the project to address overlapping health and social crises, offering practical examples of its application in various research projects across sites and organizations. The paper concludes with a reflection on the impacts of Walk With Me to date, highlighting the lessons learned, challenges encountered, and opportunities for future research and action. Overall, this article captures the urgent need for community-engaged approaches to address the toxic drug poisoning crisis and other multidimensional crises facing society, particularly in smaller and rural communities, underscoring the potential for meaningful change through collaborative, grassroots efforts.

Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada

The ongoing overdose and drug toxicity crisis in North America has contributed momentum to the emergence of safer supply prescribing and programs in Canada as a means of providing an alternative to the highly volatile unregulated drug supply. The implementation and scale-up of safer supply have been met with a vocal reaction on the part of news media commentators, conservative politicians, recovery industry representatives, and some prominent addiction medicine physicians. This reaction has largely converged around several narratives, based on unsubstantiated claims and anecdotal evidence, alleging that safer supply programs are generating a "new opioid epidemic", reflecting an emerging alignment among key institutional and political actors. Employing situational analysis method, and drawing on the policy studies and social science scholarship on moral panics, this essay examines news media coverage from January to July 2023, bringing this into dialogue with other existing empirical sources on safer supply (e.g. Coroner's reports, program evaluations, debates among experts in medical journals). We employ eight previously established criteria delineating moral panics to critically appraise public dialogue regarding safer supply, diverted medication, and claims of increased youth initiation to drug use and youth overdose. In detailing the emergence of a moral panic regarding safer supply, we trace historic continuities with earlier drug scares in Canadian history mobilized as tools of racialized poverty governance, as well as previous backlashes towards healthcare interventions for people who use drugs (PWUD). The essay assesses the claims of moral entrepreneurs against the current landscape of opioid use, diversion, and overdose among youth, notes the key role played by medical expertise in this and previous moral panics, and identifies what the convergence of these narratives materialize for PWUD and healthcare access, as well as the broader policy responses such narratives activate.

Feeling safer: effectiveness, feasibility, and acceptability of continuous pulse oximetry for people who smoke opioids at overdose prevention services in British Columbia, Canada

BACKGROUND

Smoking is the most common mode of unregulated opioid consumption overall and implicated in fatal overdoses in British Columbia (BC). In part, perception of decreased risk (e.g., fewer who smoke carry naloxone kits) and limited smoking-specific harm reduction services contribute to overdose deaths. Overdose prevention services (OPS) offer supervised settings for drug use. Continuous pulse oximetry, common in acute care, allows real-time, remote oxygen monitoring. We evaluated the effectiveness of a novel continuous pulse oximetry protocol aimed at allowing physical distancing (as required by COVID-19, secluded spaces, and to avoid staff exposure to vaporized opioids), its feasibility, and acceptability at OPS for people who smoke opioids.

METHODS

This was a mixed methods survey study. We developed a continuous pulse oximetry protocol in collaboration with clinical experts and people with lived/living experience of substance use. We implemented our protocol from March to August 2021 at four OPS in BC permitting smoking. We included adults (≥ 18 years) presenting to OPS to smoke opioids. Peer researchers collected demographic, health, and substance use information, and conducted structured observations. OPS clients participating in our study, OPS staff, and peer researchers completed post-monitoring surveys. We analyzed responses using a thematic inductive approach and validated themes with peer researchers.

RESULTS

We included 599 smoking events. OPS clients participating in our study had a mean age of 38.5 years; 73% were male. Most (98%) reported using "down", heroin, or fentanyl; 48% concurrently used other substances (32% of whom reported stimulants); 76% reported smoking alone in the last 3 days; and 36% reported an overdose while smoking. Respondents reported that the protocol facilitated physical distancing, was easy to use, high satisfaction, improved confidence, improved sense of safety, and that they would use it again.

CONCLUSIONS

Continuous pulse oximetry allowed safe physical distancing, was feasible, and acceptable in monitoring people who smoke opioids at OPS.

"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.

Peer workers to address discrimination against women in psychiatry and mental health

Compared to the general population and to males with mental health disorders, women with these disorders face more obstacles in psychiatric and mental health care settings. This strongly encourages mental health policies and psychiatric care to consider specific strategies that prevent gender bias in treatment among women with mental health issues. A growing body of research demonstrates the benefits of having peer workers-professionals with a lived experience of mental health issues who use their own experiences of mental distress to support others with comparable experiences-in mental health services. We postulate that peer support can become an important and integrated aspect of preventing and addressing discrimination against women in psychiatry and mental health care. First, women peer workers may combine their lived experiences as service users and as women to provide unique, experience- and gender-based support to women users who experience discrimination. Non-women or women peer workers who did not experience gender discrimination in psychiatric settings may nevertheless benefit from the integration of gender education in their curriculum and, in turn, bring a feminist lens to their work to achieve this mission. Second, using their experience as service users, peer workers have the credible ability to communicate and translate women patients' needs to the medical staff, and thus facilitate concrete, need-based adjustments of services. Third, peer workers' involvement as instructors in medical schools could provide early awareness of injustices experienced by women in psychiatry and mental health care. Further research is required to test the effectiveness of peer workers in addressing discrimination against women in real-world clinical settings. More broadly, from a diversity perspective, we believe that peer workers are one of the critical elements in the fight against discrimination in psychiatry and mental health.

Community advisory board members' perspectives on their contributions to a large multistate cluster RCT: a mixed methods study

Background

Community advisory boards (CABs) are an established approach to ensuring research reflects community priorities. This paper examines two CABs that are part of the HEALing Communities Study which aims to reduce overdose mortality. This analysis aimed to understand CAB members' expectations, experiences, and perspectives on CAB structure, communication, facilitation, and effectiveness during the first year of an almost fully remote CAB implementation. Current literature exploring these perspectives is limited.

Methods

We collected qualitative and survey data simultaneously from members (n = 53) of two sites' CABs in the first 9 months of CAB development. The survey assessed trust, communication, and relations; we also conducted 32 semi-structured interviews. We analyzed the survey results descriptively. The qualitative data were analyzed using a deductive codebook based on the RE-AIM PRISM framework. Themes were drawn from the combined qualitative data and triangulated with survey results to further enrich the findings.

Results

CAB members expressed strong commitment to overall study goals and valued the representation of occupational sectors. The qualitative data described a dissonance between CAB members' commitment to the mission and unmet expectations for influencing the study within an advisory role. Survey results indicated lower satisfaction with the research teams' ability to create a mutually beneficial process, clear communication, and sharing of power.

Conclusion

Building a CAB on a remote platform, within a study utilizing a community engagement strategy, still presents challenges to fully realizing the potential of a CAB. These findings can inform more effective operationalizing of community-engaged research through enhanced CAB engagement.

A rapid review of current engagement strategies with people who use drugs in monitoring and reporting on substance use-related harms

BACKGROUND

The Canadian drug supply has significantly increased in toxicity over the past few years, resulting in the worsening of the overdose crisis. A key initiative implemented during this crisis has been data monitoring and reporting of substance use-related harms (SRH). This literature review aims to: (1) identify strategies used for the meaningful engagement of people who use drugs (PWUD) in local, provincial, and national SRH data system planning, reporting, and action and (2) describe data monitoring and reporting strategies and common indicators of SRH within those systems.

METHODS

We searched three academic and five gray literature databases for relevant literature published between 2012 and 2022. Team members who identify as PWUD and a librarian at Public Health Ontario developed search strings collaboratively. Two reviewers screened all search results and applied the eligibility criteria. We used Microsoft Excel for data management.

RESULTS

Twenty-two articles met our eligibility criteria (peer-reviewed n = 10 and gray literature reports n = 12); most used qualitative methods and focused on the Canadian context (n = 20). There were few examples of PWUD engaged as authors of reports on SRH monitoring. Among information systems involving PWUD, we found two main strategies: (1) community-based strategies (e.g., word of mouth, through drug sellers, and through satellite workers) and (2) public health-based data monitoring and communication strategies (e.g., communicating drug quality and alerts to PWUD). Substance use-related mortality, hospitalizations, and emergency department visits were the indicators most commonly used in systems of SRH reporting that engaged PWUD.

CONCLUSION

This review demonstrates limited engagement of PWUD and silos of activity in existing SRH data monitoring and reporting strategies. Future work is needed to better engage PWUD in these processes in an equitable manner. Building SRH monitoring systems in partnership with PWUD may increase the potential impact of these systems to reduce harms in the community.

Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report

BACKGROUND

People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs.

OBJECTIVE

This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges.

METHODS

Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges.

RESULTS

Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes.

CONCLUSIONS

While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

Doing community-based research during dual public health emergencies (COVID and overdose)

Meaningful engagement and partnerships with people who use drugs are essential to conducting research that is relevant and impactful in supporting desired outcomes of drug consumption as well as reducing drug-related harms of overdose and COVID-19. Community-based participatory research is a key strategy for engaging communities in research that directly affects their lives. While there are growing descriptions of community-based participatory research with people who use drugs and identification of key principles for conducting research, there is a gap in relation to models and frameworks to guide research partnerships with people who use drugs. The purpose of this paper is to provide a framework for research partnerships between people who use drugs and academic researchers, collaboratively developed and implemented as part of an evaluation of a provincial prescribed safer supply initiative introduced during dual public health emergencies (overdose and COVID-19) in British Columbia, Canada. The framework shifts from having researchers choose among multiple models (advisory, partnership and employment) to incorporating multiple roles within an overall community-based participatory research approach. Advocacy by and for drug users was identified as a key role and reason for engaging in research. Overall, both academic researchers and Peer Research Associates benefited within this collaborative partnerships approach. Each offered their expertise, creating opportunities for omni-directional learning and enhancing the research. The shift from fixed models to flexible roles allows for a range of involvement that accommodates varying time, energy and resources. Facilitators of involvement include development of trust and partnering with networks of people who use drugs, equitable pay, a graduate-level research assistant dedicated to ongoing orientation and communication, technical supports as well as fluidity in roles and opportunities. Key challenges included working in geographically dispersed locations, maintaining contact and connection over the course of the project and ensuring ongoing sustainable but flexible employment.

Rethinking urban-rural designations in public health surveillance of the overdose crisis and crafting an agenda for future monitoring

Rurality has served as a key concept in popular and scientific understandings of the US overdose crisis, with White, rural, and low-income areas thought to be most heavily affected. However, we observe that overdose trends have risen nearly uniformly across the urban-rural designations employed in most research, implying that their importance has likely been overstated or incorrectly conceptualized. Nevertheless, urbanicity/rurality does serve as a key axis to understand inequalities in overdose mortality when assessed with more nuanced modalities-employing a more granular analysis of geography at the sub-county level, and intersecting rurality sociodemographic indices such as race/ethnicity. Using national overdose data from 1999-2021, we illustrate the intersectional importance of rurality for overdose surveillance. Finally, we offer recommendations for integrating these insights into drug overdose surveillance moving forward.

Addressing stigma within the dissemination of research products to improve quality of care for pregnant and parenting people affected by substance use disorder

Substance use disorders are a common and treatable condition among pregnant and parenting people. Social, self, and structural stigma experienced by this group represent a barrier to harm reduction, treatment utilization, and quality of care. We examine features of research dissemination that may generate or uphold stigmatization at every level for pregnant and parenting individuals affected by substance use disorder and their children. We explore stigma reduction practices within the research community that can increase uptake of evidence-based treatment programs and prevent potential harm related to substance use in pregnant and parenting people. The strategies we propose include: (1) address researcher stereotypes, prejudice, and misconceptions about pregnant and parenting people with substance use disorder; (2) engage in interdisciplinary and transdisciplinary collaborations that engage with researchers who have lived experience in substance use; (3) use community-based approaches and engage community partners, (4) address stigmatizing language in science communication; (5) provide contextualizing information about the social and environmental factors that influence substance use among pregnant and parenting people; and (6) advocate for stigma-reducing policies in research articles and other scholarly products.

From design to action: participatory approach to capacity building needs for local overdose response plans

BACKGROUND

In response to the rise in opioid-related deaths, communities across Ontario have developed opioid or overdose response plans to address issues at the local level. Public Health Ontario (PHO) leads the Community Opioid / Overdose Capacity Building (COM-CAP) project, which aims to reduce overdose-related harms at the community level by working with communities to identify, develop, and evaluate capacity building supports for local needs around overdose planning. The 'From Design to Action' co-design workshop used a participatory design approach to engage communities in identifying the requirements for capacity building support.

METHODS

A participatory approach (co-design) provided opportunity for collaborative discussion around capacity building needs at the community level. The co-design workshop included three structured collaborative activities to 1) prioritize scenarios that illustrated various challenges associated with community overdose response planning, 2) prioritize the challenges within each scenario and 3) prioritize the supports to address each of these challenges. It was conducted with fifty-two participants involved in opioid/overdose-related response plans in Ontario. Participatory materials were informed by the results of a situational assessment (SA) data gathering process, including survey, interview, and focus group data. A voting system, including dot stickers and discussion notes, was applied to identify priority supports and delivery mechanisms.

RESULTS

At the workshop, key challenges and top-priority supports were identified, for development and implementation. The prioritized challenges were organized into five categories of capacity building supports addressing: 1) stigma & equity; 2) trust-based relationships, consensus building & on-going communication; 3) knowledge development & on-going access to information and data; 4) tailored strategies and plan adaptation to changing structures and local context; and 5) structural enablers and responsive governance.

CONCLUSION

Using a participatory approach, the workshop provided an opportunity for sharing, generating, and mobilizing knowledge to address research-practice gaps at the community level for opioid response planning. The application of health design methods such as the 'From Design to Action' co-design workshop supports teams to gain a deeper understanding of needs for capacity building as well as illustrating the application of participatory approaches in identifying capacity building needs for complex public health issues such as the overdose crisis.

Trust and service engagement among people who inject drugs after release from prison

BACKGROUND

Compounding histories of injecting drug use and incarceration can marginalise people engaging with services, making it difficult for them to address their health and social welfare needs, particularly when they navigate community re-entry service supports. Drawing on Hall and colleagues' five components of trust, this paper seeks to understand how trust in service providers fosters (or inhibits) effective service engagement from the perspective of people who inject drugs during the prison post-release period.

METHODS

Between September 2018 and May 2020, qualitative in-depth interviews were completed with 48 adults (33 men, 15 women) recruited from SuperMIX (a longitudinal cohort study of people with a history of injection drug use in Victoria, Australia). Data relating to service engagement were coded against the five components of trust: competence, fidelity, honesty, global trust, and confidence.

RESULTS

Reflections of post-release service engagement frequently focused on interactions with community corrections (parole) officers. Depictions of trust were consistently portrayed within the context of negative experiences and deficits, whereby trusting provider relationships and interactions were rarely described. Most participants recounted a stark absence of fidelity (that is, "pursuing a [client's] best interests"), with some participants detailing circumstances in which their vulnerability was purposefully, almost strategically, exploited. These encounters nearly always had the consequence of impeding the participant's positive progression in the post-release integration period.

CONCLUSION

There is an urgent need to prioritise the client in health and social service delivery in the post-release transition-to-community period and recognise the importance of trust in delivering effective services to people whose life histories make them highly vulnerable to marginalisation.

Peer support and online cognitive behavioural therapy for substance use concerns: protocol for a randomised controlled trial

INTRODUCTION

Hazardous alcohol and drug use is associated with substantial morbidity, mortality and societal cost worldwide. Yet, only a minority of those struggling with substance use concerns receive specialised services. Numerous barriers to care exist, highlighting the need for scalable and engaging treatment alternatives. Online interventions have exhibited promise in the reduction of substance use, although studies to date highlight the key importance of patient engagement to optimise clinical outcomes. Peer support may provide a way to engage patients using online interventions. The goal of this study is to evaluate the efficacy and cost-effectiveness of Breaking Free Online (BFO), an online cognitive-behavioural intervention for substance use, delivered with and without peer support.

METHODS AND ANALYSIS

A total of 225 outpatients receiving standard care will be randomised to receive clinical monitoring with group peer support, with BFO alone, or with BFO with individual peer support, in an 8-week trial with a 6-month follow-up. The primary outcome is substance use frequency; secondary outcomes include substance use problems, depression, anxiety, quality of life, treatment engagement and cost-effectiveness. Mixed effects models will be used to test hypotheses, and thematic analysis of qualitative data will be undertaken.

ETHICS AND DISSEMINATION

The protocol has received approval by the Centre for Addiction and Mental Health Research Ethics Board. Results will help to optimise the effectiveness of structured online substance use interventions provided as an adjunct to standard care in hospital-based treatment programmes. Findings will be disseminated through presentations and publications to scholarly and knowledge user audiences.

TRIAL REGISTRATION NUMBER

NCT05127733.

Occupational roles and risks of community-embedded peer educators providing HIV, hepatitis C and harm reduction services to persons who inject drugs in Nairobi, Kenya

BACKGROUND

In Kenya, harm reduction organizations have adopted evidence-based peer educator (PE) programs, where former people who inject drugs (PWID) serve as community health liaisons to engage PWID in HIV, HCV and harm reduction services. While PEs play an integral role in healthcare delivery, little data exists on their roles, risks and experiences working with PWID, which may be used to inform local harm reduction policy.

METHODS

PE's from two harm reduction sites in Nairobi were randomly and purposively selected to participate in semi-structured in-depth interviews. Thematic analysis was conducted to characterize the expected versus actual roles that PEs employ while serving PWID, personal motivation and/or challenges and occupational health risks. Data was analyzed using Atlas.ti software.

RESULTS

Twenty PEs participated in the study. On average, PEs were 37 years of age, with 3 years of service. Female representation was 30%. Expected responsibilities included locating clients, establishing rapport, educating and escorting clients to addiction care facilities. Additional roles included attending to clients outside of work hours, escorting clients to medical appointments and facilitating patient-provider discussions. Occupational health risks included harassment by police and drug dealers, needle sticks, and close proximity to drug use environments that could prompt drug relapse. Despite these challenges and risks, PEs are motivated by their personal experiences of overcoming addiction with help from harm reduction programs.

CONCLUSIONS/RECOMMENDATIONS

PEs play a vital role in HIV, HCV and harm reduction service delivery in Kenya, often exceeding their job descriptions by offering additional support to PWID. Recommendations include (1) advocating for PEs to provide patient navigation services, (2) promoting the use of post-exposure prophylaxis (PEP), (3) providing occupational mental health services to prevent drug relapse, and (4) collaborating with law enforcement to address harassment, with the ultimate goal of reducing HIV and HCV incidence among PWID.

Buprenorphine Initiation in the Era of High-Potency Synthetic Opioids: A Call for Community-Based Participatory Research to Help Learning Health Systems Provide Precision Medicine for Opioid Use Disorder

High-potency synthetic opioids and adulterants have saturated the US opioid supply, heightening risk to people who use drugs and creating challenges to buprenorphine initiation. As buprenorphine is an essential component of a response to the opioid crisis, a robust evidence base is urgently needed. Rapid research, in partnership with people who use drugs and using community-based participatory research practices to ensure trust, shared goals, and an absence of adverse consequences, should be conducted to help identify the factors associated with successful and failed inductions. Among factors to be considered include detailed assessment of substances used, amount of substances used, time between last use and buprenorphine induction, withdrawal severity at time of buprenorphine induction, dose of buprenorphine, impact of buprenorphine on withdrawal severity, and perhaps even genotypic information. Successful conduct of these efforts in learning health systems can help us move toward precision medicine for opioid use disorder.

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.

Applicability of a national strategy for patient-oriented research to people who use(d) substances: a Canadian experience

BACKGROUND

Europe and North America are in the grips of a devastating overdose crisis. People who use substances often feel unsafe to access healthcare due to fears of stigma, blame, judgement, poor treatment, or other repercussions. As a result, they often avoid, delay, or leave care, resulting in premature death and missed opportunities for care. Internationally, there have been concerted efforts to move towards patient-engaged research to enhance the quality of health care systems and services. In Canada, the Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) initiative promotes engagement of patients as active partners in health care research. As part of a community based patient oriented research project, we critically analyze the SPOR framework to provide insights into what constitutes safer research with people who use(d) substances.

METHODS

We undertook a two-stage process that began with a review of community based research principles and the SPOR framework. At the second stage, we undertook a qualitative descriptive study employing focus groups to generate description of the adequacy and appropriateness of the SPOR framework for guiding research with people who use(d) substances on four key dimensions (patient engagement, guiding principles, core areas of engagement and benefits). The data were analyzed using qualitative content analysis to identify key issues and insights.

RESULTS

While the SPOR framework includes a range of patient roles, principles and areas for engagement, there are issues and gaps related to essential elements of safe patient-oriented research for people who use substances. These include an individualized focus on patients as partners, lack of recognition of community benefits, power imbalances and distrust due to systemic stigma, engagement as one way capacity building and learning, and lack of accountability for taking action on research findings.

CONCLUSIONS

Given the extent of stigma in health care and the ongoing illicit drug policy crisis, strategies for enhancing equitable Patient-Oriented Research (POR) include shifting language from patient partners to community researchers, recognizing power inequities and adding trust and equity as core POR principles including pay equity. Employing community based participatory research as a POR methodology allows the lead researchers to fully engage community throughout the research process, enhances community benefits and accountability for action.

A gender lens is needed in hepatitis C elimination research

The World Health Organisation has established a goal of eliminating the hepatitis C virus (HCV) as a public health threat by 2030. Considerable effort is being directed towards research to support and enhance HCV treatment uptake among people who inject drugs, but there is a distinct lack of attention given to gender in this work. We argue that a gender lens is needed to make visible the limitations of current HCV elimination research, and support the development of innovative, inclusive approaches to HCV treatment. Partnerships between researchers and people who inject drugs are essential in this work, particularly in the development and evaluation of programs by and for women who inject drugs. Failure to acknowledge the gendered dimensions of HCV elimination risks entrenching gender disparities in access to treatment and cure.

Impact of health system engagement on the health and well-being of people who use drugs: a realist review protocol

BACKGROUND

Although community-level benefits of health system engagement (i.e., health service planning, delivery, and quality improvement, engaged research and evaluation, and collaborative advocacy) are well established, individual-level impacts on the health and well-being of community members are less explored, in particular for people who use or have used illegal drugs (PWUD). Capacity building, personal growth, reduced/safer drug use, and other positive outcomes may or may not be experienced by PWUD involved in engagement activities. Indeed, PWUD may also encounter stigma and harm when interacting with healthcare and academic structures. Our objective is to uncover why, how, and under what circumstances positive and negative health outcomes occur during health system engagement by PWUD.

METHODS

We propose a realist review approach due to its explanatory lens. Through preliminary exploration of literature, lived experience input, and consideration of formal theories, an explanatory model was drafted. The model describes contexts, mechanisms, and health outcomes (e.g., mental health, stable/safer drug use) involved in health system engagement. The explanatory model will be tested against the literature and iteratively refined against formal theories. A participatory lens will also be used, wherein PWUD with lived experience of health system engagement will contribute throughout all stages of the review.

DISCUSSION

We believe this is the first realist review to explore the contextual factors and underlying mechanisms of health outcomes for PWUD who participate in health system engagement. A thorough understanding of the relevant literature and theoretical underpinnings of this process will offer insights and recommendations to improve the engagement processes of PWUD.

Peer- and community-led responses to HIV: A scoping review

INTRODUCTION

In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track.

METHODS

We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research.

FINDINGS

Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices.

CONCLUSIONS AND RECOMMENDATIONS

Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

Improving Treatment Together: a protocol for a multi-phase, community-based participatory, and co-design project to improve youth opioid treatment service experiences in British Columbia

Background

Opioid use is one of the most critical public health issues as highly potent opioids contribute to rising rates of accidental opioid-related toxicity deaths. This crisis has affected people from all age groups, including youth (ages 15–24) who are in a critical developmental period where the stakes of opioid use are especially high. Efforts to reduce the significant harms of opioid use have focused on the expansion of evidence-based treatments, including medications for opioid use disorder (e.g. buprenorphine). While these treatments are unequivocally life saving, recent evidence suggests that they may not align with youths’ needs. Accordingly, the ‘Improving Treatment Together’ (ITT) project has been designed with the aim to improve youths’ opioid treatment service experiences and outcomes by co-developing, implementing, and measuring youth-centred opioid use treatment service innovations. This manuscript describes the protocol for this multi-phase project.

Methods

The ITT project follows community-based participatory research (CBPR) and strategically integrates co-design processes throughout its four phases. Upon establishing a project partnership between national, provincial and community-based organizations, Phase 1 follows four core elements of human-centred co-design (empathy, needs identification, ideation, prototyping) in nine separate workshops. These workshops will be held in four diverse communities with youth, caregivers and service providers who have accessed or delivered opioid treatment services. Phase 1 will culminate in the co-production of opioid treatment service innovations to be considered by the project’s partners for further co-development, pilot testing, and wider implementation during the remaining phases of the project. Throughout each phase, the project will collect and analyse both qualitative and quantitative research and evaluation data to determine the project’s impact.

Discussion

This protocol provides a detailed description of the ITT project, with an emphasis on the project’s application of co-design and CBPR processes, the planned research and implementation procedures, and the establishment of a unique partnership. To our knowledge, this is one of the first projects to integrate these participatory processes to the design, implementation and measurement of youth-centred opioid treatment services. Embedding these processes throughout each phase of the project will strengthen the relevance and feasibility of the project’s service delivery innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00261-7.

We are the researched, the researchers, and the discounted: The experiences of drug user activists as researchers

In this commentary, activists from Urban Survivors Union, the United States national drug users union, discuss our experiences conducting research on methadone clinic adoption of relaxed SAMHSA guidelines during the COVID-19 epidemic. In particular, we focus on our interactions with academic researchers as a grassroots organization of criminalized people designing our own research. We describe the challenges we navigated to retain decision making powers over the research question, data analysis and interpretation, and dissemination. We find that our collaborations with academic researchers are often complicated by power imbalances and structural issues. In our experience as directly impacted people, even community based participatory research (CBPR) often sidelines us. Our eventual research approach demonstrates how our process transcends CBPR by becoming community driven research (CDR). We suggest several changes to the research process in order to propagate this model.

Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries

Introduction

Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic.

Methods

Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts.

Results

Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as ‘bridge’ and ‘role model’ processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and ‘bridge’ mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O).

Conclusion

Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.

Essential work, precarious labour: The need for safer and equitable harm reduction work in the era of COVID-19

This commentary highlights labour concerns and inequities within the harm reduction sector that hinder programs' ability to respond to converging public health emergencies (the overdose crisis and COVID-19), and potentially contribute to spread of the novel coronavirus. Many harm reduction programs continue to support people who use illicit drugs (PWUD) during the pandemic, yet PWUD working in harm reduction programs (sometimes termed 'peers') experience precarious labour conditions characterized by low wages, minimal employee benefits (such as paid sick leave) and high employment insecurity. Along with precarious labour conditions, PWUD face heightened vulnerabilities to COVID-19 and yet have been largely overlooked in global response to the pandemic. Operating under conditions of economic and legal precarity, harm reduction programs' reliance on precarious labour (e.g. on-call, temporary and unpaid work) renders some services vulnerable to staffing shortages and service disruptions during the pandemic, while also heightening the risk of virus transmission among workers, service users and their communities. We call for immediate policy and programmatic actions to strengthen working conditions within these settings with a priority on enhancing protections and supports for workers in peer roles.

Bereaved mothers' engagement in drug policy reform: A multisite qualitative analysis

BACKGROUND

Globally, a tainted drug supply is claiming the lives of tens of thousands of people who use drugs and current measures are not quelling this crisis. Within this context, mothers who have lost a child to substance use have emerged as vocal advocates for drug policy changes. This paper explores mothers' experiences in drug policy advocacy to uncover how they are using their stories to drive policy change.

METHODS

Critical qualitative and narrative methods informed individual interviews with 43 mothers who had lost a child to substance use from across three regions in Canada: British Columbia, Prairie Provinces, and Eastern Provinces. Multisite qualitative analysis (MSQA) provided a rigorous analytical method to identify how social context informed participants' advocacy efforts within and across geographies, together with a theoretical lens from Haraway to understand mothers' activism as situated knowledge.

RESULTS

Mothers' drug policy advocacy was shaped by social context and norms, which influenced the types of advocacy targets pursued, within the constraints of the social and political ethos of each geographic region. Yet across regions, narratives of shared aims and experiences also emerged. Specifically, the notion that people of all backgrounds are dying and that losing a child to substance use can "happen to anyone" - though people who experience structural vulnerabilities are disproportionately impacted. Additionally, mothers' stories were identified as a particularly powerful tool for conveying emotional knowledge and prompting action that complements other forms of knowledge or evidence.

CONCLUSION

To date, efforts to address the drug poisoning epidemic have done little to curb casualties. Mothers whose child's death is related to substance use are one group who are bringing their experiences to advocacy efforts aimed at generating new solutions, including calls for decriminalization and legal regulation of drugs. This and other lived experience perspectives represent a critical voice in decision-making and hold the potential to inform more responsive and impactful drug policy.

A focused netnographic study exploring experiences associated with counterfeit and contaminated anabolic-androgenic steroids

Background

A primary consequence of illicit drug markets and the absence of regulation is the variable quality or purity of the final product. Analysis of anabolic-androgenic steroid seizures shows that these products can contain adulterated products, product not included on the label, or product of unsatisfactory standard. While the potential negative effects of counterfeit anabolic-androgenic steroids (AAS) use is a recognised risk associated with use, no study has explored personal experiences associated with use. The aim of the present study was to use online discussion forums to investigate and explore the experiences associated with the purchase and consumption of counterfeit AAS among consumers.

Methods

An online search was conducted to identify online forums that discussed counterfeit or contaminated AAS; three were deemed suitable for the study. The primary source of data for this study was the ‘threads’ from these online forums, identified using search terms including ‘counterfeit’, ‘tampered’, and ‘fake’. Threads were thematically analysed for overall content, leading to the identification of themes.

Results

Data from 134 threads (2743 posts from 875 unique avatars) was included. Two main themes were identified from the analysis: (1) experiences with counterfeit product and (2) harms and benefits associated with counterfeit product.

Conclusions

The use of counterfeit or contaminated substances represents a public health concern. Those who report using performance and image enhancing drugs such as AAS for non-medical purposes report consuming these substances and experiencing harm as a result. Consumers take steps to limit coming into contact with counterfeit or contaminated product, though recognise that many of these have limitations. The implementation of accessible drug safety checking services may provide an opportunity to provide consumers with information to assist them with making healthier choices.

Provision of peer support at the intersection of homelessness and problem substance use services: a systematic 'state of the art' review

Background

Peer support refers to a process whereby individuals with lived experience of a particular phenomenon provide support to others by explicitly drawing on their personal experience. It has been adopted in a variety of service contexts including homelessness, substance use, mental and physical health. Those who experience homelessness have some of the most complex intersecting health and social challenges. This ‘state of the art’ review provides a systematic search and synthesis of literature examining use of peer support models within services for people impacted by homelessness and problem substance use.

Methods

A systematic search using six databases (CINAHL, SocINDEX, PsycINFO, MEDLINE, Scopus and Web of Knowledge) was conducted in August 2019 and identified 2248 papers published in English after the year 2000. After de-duplication and scanning titles/abstracts, 61 papers were deemed relevant. Three more papers (including one grey literature report) were identified via references, but two papers were later excluded due to relevance. The final 62 papers included studies conducted in five countries. A thematic analysis approach was used to compare and contrast the study findings and provide a synthesis of the main learning points.

Results

In recent years there has been a substantial increase in research examining the utility of peer support yet there is significant variation across this field. Alongside profiling the range of settings, aims, populations, and main outcomes of these studies, this paper also provides an overview of overarching themes: the overall effectiveness and impact of peer-staffed or peer-led interventions; and challenges commonly faced in these roles. Five themes relating to the challenges faced by peers were identified: vulnerability, authenticity, boundaries, stigma, and lack of recognition.

Conclusions

While our findings provide support for current efforts to involve individuals with lived experience in providing peer support to those experiencing concurrent problem substance use and homelessness, they also urge caution because of common pitfalls that can leave those providing the support vulnerable. We conclude that peers should be respected, valued, supported, and compensated for their work which is often profoundly challenging. Suggested guidelines for the implementation of peer involvement in research studies and service delivery are presented.