Practices of care among people who buy, use, and sell drugs in community settings

"If everyone knew about this, how many lives could we save?": Do drug suppliers have a role in reducing overdose risk?

Introduction

An unpredictable illicit drug supply is driving high levels of overdose death in North America. Prior research has demonstrated the importance of involving people who use drugs in harm reduction intervention design and implementation. The inclusion of people who supply drugs in these efforts has been scant. We explore this possibility by interviewing persons targeted by a harm reduction educational program designed specifically for people who supply drugs.

Methods

In-person interviews with people who use drugs were conducted in 2022 in Indianapolis, Indiana. We conducted a thematic analysis of data from six interviews with people who were either primarily or secondarily trained through this harm reduction training for people who supply drugs.

Results

Participants described a diverse array of harm reduction strategies, some gained through the targeted education program, which they regularly practiced as they consumed and/or supplied drugs to others. People who supply drugs were regularly identified as key actors capable of widely reducing risk across drug networks. Participants described being motivated by a moral imperative to protect community members, tying the previous loss of friends and loved ones to overdose to their commitments to the safety of others.

Conclusion

This article contributes to the scholarship on the role of people who supply drugs in implementing harm reduction interventions and reducing overdose risk. Better enabling grassroots harm reduction organizations to provide people who supply drugs with harm reduction training and access to harm reduction resources may help to reduce drug-related harms.

Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study

BACKGROUND

North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC.

METHODS

We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation.

RESULTS

Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure.

CONCLUSIONS

BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.

Incarceration history and opioid use among adults living with HIV and chronic pain: a secondary analysis of a prospective cohort study

BACKGROUND

Adults living with HIV have disproportionately high chronic pain, prescription opioid use, history of substance use, and incarceration. While incarceration can have long-lasting health impacts, prior studies have not examined whether distant (>1 year prior) incarceration is associated with opioid use for chronic pain, or with opioid misuse or opioid use disorder among people living with HIV and chronic pain.

METHODS

We conducted a secondary analysis of a prospective cohort study of adults living with HIV and chronic pain. The independent variables were any distant incarceration and drug-related distant incarceration (both dichotomous). Dependent variables were current long-term opioid therapy, current opioid misuse, and current opioid use disorder. A series of multivariate logistic regression models were conducted, adjusting for covariates.

RESULTS

In a cohort of 148 participants, neither distant incarceration nor drug-related incarceration history were associated with current long-term opioid therapy. Distant incarceration was associated with current opioid misuse (AOR 3.28; 95% CI: 1.41-7.61) and current opioid use disorder (AOR 4.40; 95% CI: 1.54-12.56). Drug-related incarceration history was also associated with current opioid misuse (AOR 4.31; 95% CI: 1.53-12.17) and current opioid use disorder (AOR 7.28; 95% CI: 2.06-25.71).

CONCLUSIONS

The positive associations of distant incarceration with current opioid misuse and current opioid use disorder could indicate a persistent relationship between incarceration and substance use in people living with HIV and chronic pain. Additional research on opioid use among formerly incarcerated individuals in chronic pain treatment is needed.

Towards a social harm approach in drug policy

In this paper, we explore how the social harm approach can be adapted within drug policy scholarship. Since the mid-2000s, a group of critical criminologists have moved beyond the concept of crime and criminology, towards the study of social harm. This turn proceeds decades of research that highlights the inequities within the criminal legal system, the formation of laws that protect the privileged and punish the disadvantaged, and the systemic challenge of the effectiveness of retribution and punishment at addressing harm in the community. The purpose of this paper is to first identify parallels between the social harm approach and critical drug scholarship, and second to advocate for the adoption of a social harm lens in drug policy scholarship. In the paper, we draw out the similarities between social harm and drug policy literatures, as well as outline what the study of social harm can bring to an analysis of drug policy. This includes a discussion on the ontology of drug crime, the myth of drug crime and the ineffective use of the crime control system in response to drug use. The paper then discusses how these conversations in critical criminology and critical drugs scholarship can be brought together to inform future drug policy research. This reflection details the link between social harm and the impingement of human flourishing, explores the role of decolonizing drug policy, advocates for the centralization of lived experience within the research process and outlines how this might align with harm reduction approaches. We conclude by arguing that the social harm approach challenges the idea that neutrality is the goal in drug policy and explicitly seeks to expand new avenues in activist research and social justice approaches to policymaking.

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.

How do people who use opioids express their qualities and capacities? An assessment of attitudes, behaviors, and opportunities

People who nonmedically use drugs (PWUD) face intricate social issues that suppress self-actualization, communal integration, and overall health and wellness. "Strengths-based" approaches, an under-used pedagogy and practice in addiction medicine, underscore the significance of identifying and recognizing the inherent and acquired skills, attributes, and capacities of PWUD. A strengths-based approach engenders client affirmation and improves their capacity to reduce drug use-related harms by leveraging existing capabilities. Exploring this paradigm, we conducted and analyzed interviews with 46 PWUD who were clients at syringe services programs in New York City and rural southern Illinois, two areas with elevated rates of opioid-related morbidity and mortality, to assess respondents' perceived strengths. We located two primary thematic modalities in which strengths-based ethos is expressed: individuals (1) being and advocate and resource for harm reduction knowledge and practices and (2) engaging in acts of continuous self-actualization. These dynamics demonstrate PWUD strengths populating and manifesting in complex ways that both affirm and challenge humanist and biomedical notions of individual agency, as PWUD refract enacted, anticipated, and perceived stigmas. In conclusion, programs that blend evidence-based, systems-level interventions on drug use stigma and disenfranchisement with meso and micro-level strengths-based interventions that affirm and leverage personal identity, decision-making capacity, and endemic knowledge may help disrupt health promotion cleavages among PWUD.

Radical hospitality: Innovative programming to build community and meet the needs of people who use drugs at a government-sanctioned overdose prevention site in San Francisco, California

BACKGROUND

The Tenderloin Center (TLC), a multi-service center where people could receive or be connected to basic needs, behavioral health care, housing, and medical services, was open in San Francisco for 46 weeks in 2022. Within a week of operation, services expanded to include an overdose prevention site (OPS), also known as safe consumption site. OPSs have operated internationally for over three decades, but government-sanctioned OPSs have only recently been implemented in the United States. We used ethnographic methods to understand the ways in which a sanctioned OPS, situated in a multi-service center, impacts the lives of people who use drugs (PWUD).

METHODS

We conducted participant observation and in-depth interviews June-December 2022. Extensive field notes and 39 in-depth interviews with 24 TLC guests and 15 TLC staff were analyzed using an inductive analysis approach. Interviewees were asked detailed questions about their experiences using and working at the TLC.

RESULTS

TLC guests and staff described an atmosphere where radical hospitality-welcoming guests with extraordinary warmth, generosity, and unconditional acceptance-was central to the culture. We found that the co-location of an OPS within a multi-service agency (1) allowed for the culture of radical hospitality to flourish, (2) yielded a convenient one-stop shop model, (3) created a space for community building, and (4) offered safety and respite to guests.

CONCLUSIONS

The co-location of an OPS within a multi-service drop-in center is an important example of how such an organization can build positive sociality among PWUD while protecting autonomy and reducing overdose mortality. Overdose response and reversal is an act of relational accountability in which friends, peers, and even strangers intervene to protect and revive one another. This powerful intervention was operationalized as an anti-oppressive, horizontal activity through radical hospitality with a built environment that allowed PWUD to be both social and safe.

Beyond a spec: assessing heterogeneity in the unregulated opioid supply

BACKGROUND

Drug checking services aim to provide compositional information for the illicit drug supply and are being employed in public health responses to extreme rates of overdose associated with fentanyl within street opioids. The technologies used within these services range from basic qualitative tests, such as immunoassay test strips, to comprehensive quantitative analyses, such as mass spectrometry. In general, there is concern that heterogeneity of a drug mixture adds significant uncertainty when using drug checking results based on a small subsamples. The presence of hot spots of active drug components in this context is often termed the 'chocolate chip cookie effect'. Establishing the limitations of the service are essential for interpretation of the results.

METHODS

This study assesses the consequence of drug heterogeneity and sampling of consumer level opioid purchased in Victoria, British Columbia ( n = 21 , 50-100 mg each) on quantitative fentanyl results determined from testing with paper spray mass spectrometry.

RESULTS

Using descriptive statistics, such as relative standard deviation and interquartile range, the results demonstrate varied distributions of fentanyl concentrations within a single drug batch. However, the presence of hot spots, defined as outliers, were relatively rare.

CONCLUSIONS

This study found that the variability in fentanyl concentration from drug heterogeneity and sampling is greater than that attributed to the analytical technique. On a practical level, this provides data to help guide communication of limitations of drug checking services, supporting the aim of trust and transparency between services and people who use drugs. However, if drug checking services continue to be restricted from fully engaging with the reality of manufacturing, buying, selling, mixing and dosing practices, the accuracy, usefulness, and impact will always be limited.

Planning and implementing community-based drug checking services in Scotland: a qualitative exploration using the consolidated framework for implementation research

BACKGROUND

Drug checking services (DCS) provide harm reduction support and advice to individuals based on chemical analysis of submitted substances of concern. Whilst there are currently no DCS in Scotland, community-based services are being planned in three cities.

METHODS

In this paper, we report qualitative findings based on interviews with 43 participants, focused on perceptions of DCS and their implementation. Participants were relevant professionals, those with experience of drug use, and family members of those with experience of drug use. The Consolidated Framework for Implementation Research (CFIR) was used to inform data collection and analysis. We report findings under nine constructs/themes across the five CFIR domains.

RESULTS

Participants noted the importance of DCS being implemented in low-threshold, trusted services with a harm reduction ethos, and outlined a range of further service design considerations such as speed of testing, and information provided through the analysis process. In relation to the 'inner setting', a key finding related to the potential value of leveraging existing resources in order to expand both reach and effectiveness of drug trend communication. The approach of local and national police to DCS, and the attitudes of the public and local community, were described as important external factors which could influence the success (or otherwise) of implementation. Bringing together a range of stakeholders in dialogue and developing tailored communication strategies were seen as ways to build support for DCS. Overall, we found high levels of support and perceived need for DCS amongst all stakeholder groups.

CONCLUSIONS

Our findings present initial implementation considerations for Scotland which could be further explored as DCS are operationalised. Further, our focus on implementation contexts is relevant to research on DCS more generally, given the minimal consideration of such issues in the literature.

"It would really support the wider harm reduction agenda across the board": A qualitative study of the potential impacts of drug checking service delivery in Scotland

Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures.

Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis

BACKGROUND AND AIMS

Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections.

METHODS

We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes.

RESULTS

We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission).

CONCLUSIONS

Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.

Reducing the harms of xylazine: clinical approaches, research deficits, and public health context

OBJECTIVES

Xylazine has emerged as a consistent part of the unregulated drug supply in recent months. We discuss major domains of xylazine's harm, current knowledge deficits, clinical and harm reduction strategies for minimizing harm, and xylazine's public health and policy context. As an interdisciplinary team from across the USA, we have pooled our knowledge to provide an overview of xylazine's current and emerging contexts.

METHODS

To inform this essay, the pertinent literature was reviewed, clinical knowledge and protocols were shared by multiple clinicians with direct expertise, and policy and public health context were added by expert authors.

RESULTS

We describe xylazine's major harm domains-acute poisoning, extended sedation, and wounds, along with anemia and hyperglycemia, which have been reported anecdotally but lack as clear of a connection to xylazine. Current successful practices for xylazine wound care are detailed. Understanding xylazine's epidemiology will also require greater investment in drug checking and surveillance. Finally, approaches to community-based wound care are discussed, along with an orientation to the larger policy and public health context.

CONCLUSIONS

Addressing the harms of xylazine requires interdisciplinary participation, investment in community-based harm reduction strategies, and improved drug supply surveillance. The relatively unique context of xylazine demands buy-in from public health professionals, harm reduction professionals, clinicians, basic science researchers, policymakers and more.

"The trauma machine expands faster than our services": Health risks for unhoused people in an early-stage gentrifying area

While homelessness continues to be a prevalent problem throughout the United States, many urban neighborhoods are also concurrently experiencing an influx of affluent neighbors through gentrification, exposing the stark inequalities in housing access nationwide. Gentrification-induced changes in neighborhood dynamics have also been shown to affect the health of low-income and non-white groups, with high risks of trauma from displacement and exposure to violent crime and criminalization. This study addresses risk factors for health among the most vulnerable, unhoused individuals, and provides a detailed case study on the potential exposures to emotional and physical traumas for unhoused people in early-stage gentrifying areas. By conducting 17 semi-structured interviews with people who work with the unhoused community - health providers, nonprofit employees, neighborhood representatives, and developers - in Kensington, Philadelphia, we analyze how early-stage gentrification impacts the risks for negative health consequences among unhoused groups. Results show that gentrification impacts the health of unhoused people in four main areas that, all together, create what we identify as a "trauma machine" - that is compounding traumas for unhoused residents by 1) reducing and compromising spaces of safety from violent crime, 2) decreasing public services, 3) threatening the quality of healthcare, and 4) increasing the likelihood of displacement and associated trauma.

What's in Stock? Drug drought anticipation during COVID-19 among people who use drugs and service providers

BACKGROUND

As with other areas of life, drug markets have been impacted by the COVID-19 pandemic and related restrictions. This article examines how structurally vulnerable people who use drugs (PWUD) experienced and adapted to changes in street drug markets caused by lockdown measures.

METHODS

The article builds on ethnographic fieldwork in two Danish cities in 2020, including in-depth interviews with 22 PWUD, and interviews with 20 service providers, including low-threshold service providers and outreach workers.

RESULTS

The most consistently reported effect of lockdown measures on local drug markets related to increases in cannabis prices. Accounts of changes in drug availability varied greatly, with some participants reporting changing availability while others described the situation as similar to pre-lockdown conditions. Rather than a long-term drug shortage, changes reported by participants related to the anticipated disruption of local markets and drug scarcity, restrictions in access to cash and sellers seeking to capitalize on the crisis.

CONCLUSION

Although no long-term drug scarcity was seen, the anticipation of a shortage was sufficient to impact on local drug market dynamics. Heterogeneity in PWUDs' experiences of access to drug markets during lockdown can to some degree be explained in terms of their varied embeddedness in social networks. While local markets proved resilient to lockdown measures, PWUD less embedded in social networks were more vulnerable to shifts in drug availability and to sellers' over-pricing of drugs.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies

Across North America, overlapping overdose and COVID-19 emergencies have had a substantial impact on young people who use drugs (YPWUD). New risk mitigation guidance (RMG) prescribing practices were introduced in British Columbia, Canada, in 2020 to allow people to decrease risk of overdose and withdrawal and better self-isolate. We examined how the prescribing of hydromorphone tablets specifically impacted YPWUD's substance use and care trajectories. Between April 2020 and July 2021, we conducted virtual interviews with 30 YPWUD who had accessed an RMG prescription of hydromorphone in the previous six months and 10 addiction medicine physicians working in Vancouver. A thematic analysis was conducted. YPWUD participants highlighted a disjuncture between risk mitigation prescriptions and the safe supply of unadulterated substances such as fentanyl, underscoring that having access to the latter is critical to reducing their reliance on street-based drug markets and overdose-related risks. They described re-appropriating these prescriptions to meet their needs, stockpiling hydromorphone so that it could be used as an “emergency backup” when they were unable to procure unregulated, illicit opioids. In the context of entrenched poverty, hydromorphone was also used to generate income for the purchase of drugs and various necessities. For some YPWUD, hydromorphone prescriptions could be used alongside opioid agonist therapy (OAT) to reduce withdrawal and cravings and improve adherence to OAT. However, some physicians were wary of prescribing hydromorphone due to the lack of evidence for this new approach. Our findings underscore the importance of providing YPWUD with a safe supply of the substances they are actively using alongside a continuum of substance use treatment and care, and the need for both medical and community-based safe and safer supply models.

Beyond co-production: The construction of drug checking knowledge in a Canadian supervised injection facility

Drug-checking is an ensemble of different harm reduction techniques providing people the ability to test illegally purchased drugs for strength, the presence of particular substances, and possible adulterants. Drug-checking research has primarily focused on nightlife and festival communities of people who use drugs and has overlooked how it functions as a knowledge forming process, particularly by people whose drug use is more stigmatized. The implementation of Fourier-Transform Infrared Spectroscopy (FTIR) in Vancouver, Canada's Downtown Eastside in response to the overdose crisis has made it possible for people who use drugs to receive information about the drugs that they are consuming. Using insights developed from the 'ontological turn' and approaches to co-production from public health and science and technology studies, we explore the multiple relations that come to produce and contest drug-checking knowledge in this setting. We look at how knowledge is produced by and for people who use drugs, including people who use drugs operating the FTIR. Using rapid ethnographic assessment and semi-structured interviews, participants were recruited from a low-barrier supervised injection facility to explore their experience of drug-checking. Data were coded in NVivo 12 using an initial coding scheme, as well as an iterative coding scheme as the data were explored. We find that the traditional demarcation between lay and expert, or peer and professional, which co-production idioms often rely on, creates barriers to seeing the different knowledge formations of drug-checking knowledge, and instead offer up a new idiom, trans-production, to explore how knowledge and harm reduction services are mutually enacted.

Negotiating an Illicit Economy in the Time of COVID-19: Selling and Buying Dilemmas in the Lives of People Who Use Drugs in Scotland

The impact of COVID-19 itself and societal responses to it have affected people who use drugs and the illicit drug economy. This paper is part of a project investigating the health impacts of COVID-19 related control measures on people who use drugs in Scotland. It examines their roles and decisions as economically situated actors. It does this within a moral economy perspective that places economic decisions and calculations within a context of the network of social obligations and moral decisions. The paper uses a mixed methods approach, reporting on a drug trend survey and in-depth interviews with people who use drugs. It finds they were affected by restrictions in the drug consumption context and changes in the supply context, both in terms of what was supplied and changes in the relationship between sellers and buyers. Face to face selling became more fraught. Participants in more economically precarious circumstances were faced with dilemmas about whether to move into drug selling. The double impact of loss of income and reduced access to support networks were particularly difficult for them. Despite the perception that the pandemic had increased the power of sellers in relation to their customers, many full-time sellers were reported to be keeping their prices stable in order to maintain their relationships with customers, instead extending credit or adulterating their products. The effect of spatial controls on movement during the pandemic also meant that the digital divide became more apparent. People with good access to digital markets and easy drug delivery through apps were in a better position to manage disruption to drug sales contexts. We make recommendations in relation to how policy can respond to the interests of people who use drugs in a pandemic.

People engaged in opioid agonist treatment as a counterpublic during the COVID-19 pandemic in Australia: A qualitative study

INTRODUCTION

People receiving opioid agonist treatment (OAT) are at higher risk of comorbidities, poverty and discrimination, which Big Events like the COVID-19 pandemic may exacerbate. The behaviours of people receiving OAT do not always align with normative behaviours as conceived by ruling institutions and laws, and so the group becomes a counterpublic, not imagined in mainstream public discourse. The aim of this study was to understand how people receiving OAT, as a counterpublic, implemented practises of care to mitigate negative health outcomes during COVID-19.

METHODS

Participants were recruited via eight peer-led organisations across Australia. In-depth, semi-structured interviews were completed between August and December 2020 with 40 people receiving OAT. The analysis centres practises of care, allowing interactions that influence the health of participants, to be understood in their unique contexts.

RESULTS

Aspects of the COVID-19 state response were designed for an idealised public, demonstrated by the increased policing that accompanied enforcement of restrictions which was detrimental to the wellbeing of people receiving OAT. Counterpublic health strategies employed by people receiving OAT were disrupted, but participants were often able to adapt to the changing context.

DISCUSSION AND CONCLUSION

This study elucidates how practises of care among people receiving OAT are enacted and disrupted during a Big Event, with implications beyond the COVID-19 pandemic for future Big Events. The study findings evidence the need for policies that mitigate the impact of Big Events such as supporting re-groupment within the counterpublic, legitimising counterpublic health strategies and stopping the criminalisation of people who use drugs.

Tramadol in seized drugs containing non-pharmaceutical fentanyl: Crime lab data from Ohio, USA

Introduction

Non-pharmaceutical fentanyl and related drugs (NPF) have contributed to increases in drug-related overdose mortality in the U.S. More data are needed to track the shifting composition of fentanyl-containing drug mixtures. The key aims of the study are to characterize the crime lab data from Montgomery County, Ohio on the increased cases of seized drugs containing mixtures of NPF and tramadol.

Methods

Crime lab data on seized drugs in Montgomery County, Ohio (2015 - 2020) were analyzed to extract information on cases that tested positive for NPF and tramadol. Descriptive statistics are provided to characterize NPF/tramadol mixtures in terms of the quantity, weight, form of the drug seized (powder, tablet, capsule, residue), and the types of fentanyl analogs and other drugs identified.

Results

In December 2017, the first case of NPF/tramadol mixture was identified in the amount of 0.2 g. Sub-sequently, cases containing NPF/tramadol increased significantly to 149 cases in 2018, 102 in 2019, and 134 in 2020. The total yearly amounts of seized NPF/tramadol mixtures increased to 373.27 g in 2018, 2,601.82 g in 2019, and 13,487.62 g in 2020. The majority (72.6%) of the cases were in powder form. There were 15 other drugs identified along with fentanyl with tramadol mixtures, including heroin (38.8%), 5.7% cocaine (5.7%), and methamphetamine (4.9%).

Conclusions

The addition of tramadol to NPF may be viewed as a harm mitigation strategy but contributes to the overall unpredictability of the illicit drug supply. According to Ohio legal statutes, identification of schedule IV drugs such as tramadol with fentanyl (schedule II) may provide a reduction in drug-related charges from a felony to a misdemeanor. More research is needed to characterize potential sources of tramadol in NPF-containing drugs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Consuming illicit opioids during a drug overdose epidemic: Illicit fentanyls, drug discernment, and the radical transformation of the illicit opioid market

BACKGROUND

North America continues to face an opioid overdose epidemic, driven by persistent increases in illicit fentanyls and fluctuations in potency leading to uncertainty for consumers. This qualitative study was conducted to better understand how people who inject drugs (PWID) came to recognize fentanyl as a growing adulterant of heroin and the subsequent sensory discernment strategies they employed to continue injecting. Our main objective was to investigate how observations and knowledge are combined as homegrown techniques for detecting fentanyl and minimizing risk. Secondary objectives were to examine the impact of growing fentanyl adulteration on individual drug use behavior.

METHODS

Between April and May 2019, 28 PWID (18 men, 10 women; average age = 38.43 years, SD = 9.26) were purposely recruited from a needle services program in Greensboro, North Carolina. Study participants were interviewed in-person using a qualitative, semi-structured instrument. Interviews were analyzed with a general inductive approach using NVivo12.

RESULTS

Participants described methods for detecting fentanyl in illicit opioids. Sudden increases in the potency of the 'rush' and sharp decreases in the length of the 'high' were chief indicators along with changes in drug color and texture. Heavy sedation was associated with fentanyl use and histamine-releasing effects characterized as 'pins and needles' were ascribed to injecting fentanyl as a component of the rush. Fentanyl's short high helped explain higher injection frequency and heavy sedation was the leading reason for co-using fentanyl with cocaine/crack or methamphetamine.

CONCLUSION

PWID have the capacity to recognize changes to the illicit opioid supply. Study participants navigated unpredictable fluctuations in the illicit opioid market by employing homegrown discernment techniques, modifying drug use behavior, and co-using non-opioid drugs. Researchers and policymakers should involve PWID as subject matter experts to help modernize harm reduction for the fentanyl age with practical strategies to boost resiliency and save lives.

Third party drug checking: accessing harm reduction services on the behalf of others

BACKGROUND

Drug checking uses chemical analytical technologies to analyze drugs from the unregulated market to reduce substance use-related risks. We aim to examine the frequency of third party use of a community drug checking service to explore the potential for harm reduction to extend beyond the individual into the community, increase service accessibility, and to contribute to upstream interventions in the supply.

METHODS

Over 31 months, data were collected from a point-of-care drug checking service operated in Victoria, Canada. Through the implementation of survey questions at the intake of the service, data were collected about whether the drug check was for the individual, to sell, and/or for others.

RESULTS

Just over half (52%) of service users were checking for reasons that extended beyond individual use. When checking for others, friends were the most common response, representing 52% of responses, and outreach/support workers checking for others was the second most at 32%. Twelve percent of service users reported checking to sell or for a supplier.

CONCLUSIONS

Third party checking is a frequent, and important aspect of drug checking services, which through facilitating community engagement and increasing accessibility, has expanded the reach of interventions beyond individuals to reduce risks within the unregulated market. Therefore, drug checking as an overdose response should be responsive and accessible for those using the service on the behalf of others.

Consumer discernment of fentanyl in illicit opioids confirmed by fentanyl test strips: Lessons from a syringe services program in North Carolina

BACKGROUND

The United States (U.S.) continues to witness an unprecedented increase in opioid overdose deaths driven by precipitous growth in the supply and use of illicitly-manufactured fentanyls (IMF). Fentanyl's growing market share of the illicit opioid supply in the U.S. has led to seismic shifts in the composition of the country's heroin supply. The growth in fentanyl supply has transformed illicit opioid markets once offering heroin with fairly consistent purity and potency to a supply overpopulated with fentanyl(s) of inconsistent and unpredictable potency. In response, people who inject drugs (PWID) have developed a number of sensory strategies to detect fentanyl in illicit opioids. The current study examined the accuracy of sensory discernment strategies by measuring study participants' descriptions of the last opioid injected and checked with a fentanyl test strip (FTS) by that test's positive/negative result. The primary objective was to determine associations between FTS results and descriptions of the illicit opioid's physical appearance and physiological effects.

METHODS

Between September-October 2017, a total of 129 PWID were recruited from a syringe services program in Greensboro, North Carolina and completed an online survey about their most recent use of FTS. Participants were instructed to describe the appearance and effects associated with the most recent opioid they injected and tested with FTS. We conducted bivariate and multivariate analyses to determine differences in positive vs negative FTS results and the physical characteristics and physiological experiences reported. An exploratory analysis was also conducted to describe the types and bodily locations of unusual sensations experienced by PWID reporting positive FTS results.

RESULTS

For physical characteristics, 32% reported that the drug was white before adding water and 38% reported the solution was clear after adding water. For physiological effects compared to heroin, 42% reported a stronger rush, 30% a shorter high, 30% a shorter time to the onset of withdrawal symptoms, and 42% experienced unusual sensations. In the multivariable model adjusting for demographics and polydrug correlates, white color of drug before adding water, stronger rush, shorter time to withdrawal, and unusual sensations were significantly associated with a positive FTS result. The most common unusual sensations were pins and needles (51%), warming of the head and face (35%), and lightheadedness (30%), and the most common locations where sensations occurred were face and neck (61%), arms/legs (54%), and chest (37%).

CONCLUSION

We found positive FTS results were significantly associated with the physical characteristics and physiological effects described by PWID. Descriptions concerning physical appearance were consistent with law enforcement profiles of illicitly-manufactured fentanyl and physiological effects were concomitant with scientific and clinical medical literature on iatrogenic fentanyl use. Taken together, these findings suggest sensory strategies for detecting fentanyl in illicit opioids may be an effective risk reduction tool to help consumers navigate unpredictable markets more safely.

The potential impacts of community drug checking within the overdose crisis: qualitative study exploring the perspective of prospective service users

Background

As drug checking becomes more integrated within public health responses to the overdose crisis, and potentially more institutionalized, there is value in critically questioning the impacts of drug checking as a harm reduction response.

Methods

As part of a pilot project to implement community drug checking in Victoria, BC, Canada, in-depth interviews (N = 27) were held with people who use or have used substances, family or friends of people who use substances, and/or people who make or distribute substances. Critical harm reduction and social justice perspectives and a socioecological model guided our analysis to understand the potential role of drug checking within the overdose crisis, from the perspective of prospective service users.

Results

Participants provided insight into who might benefit from community drug checking and potential benefits. They indicated drug checking addresses a “shared need” that could benefit people who use substances, people who care for people who use substances, and people who sell substances. Using a socioecological model, we identified four overarching themes corresponding to benefits at each level: “drug checking to improve health and wellbeing of people who use substances”, “drug checking to increase quality control in an unregulated market”, “drug checking to create healthier environments”, and “drug checking to mediate policies around substance use”.

Conclusions

Drug checking requires a universal approach to meet the needs of diverse populations who use substances, and must not be focused on abstinence based outcomes. As a harm reduction response, community drug checking has potential impacts beyond the individual level. These include increasing power and accountability within the illicit drug market, improving the health of communities, supporting safer supply initiatives and regulation of substances, and mitigating harms of criminalization. Evaluation of drug checking should consider potential impacts that extend beyond individual behaviour change and recognize lived realities and structural conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11243-4.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs

BACKGROUND

Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women's experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site.

METHODS

Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence.

RESULTS

Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women's specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose.

CONCLUSIONS

Findings demonstrate the ways in which gendered social and structural environments shape women's daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.

Women's multiple uses of an overdose prevention technology to mitigate risks and harms within a supportive housing environment: a qualitative study

Background

North America is amidst an opioid overdose epidemic. In many settings, particularly Canada, the majority of overdose deaths occur indoors and impact structurally vulnerable people who use drugs alone, making targeted housing-based interventions a priority. Mobile applications have been developed that allow individuals to solicit help to prevent overdose death. We examine the experiences of women residents utilizing an overdose response button technology within a supportive housing environment.

Methods

In October 2019, we conducted semi-structured qualitative interviews with 14 residents of a women-only supportive housing building in an urban setting where the overdose response button technology was installed. Data was analyzed thematically and framed by theories of structural vulnerability.

Results

While participants described the utility and disadvantages of the technology for overdose response, most participants, unexpectedly described alternate adoptions of the technology. Participants used the technology for other emergency situations (e.g., gender-based violence), rather than its intended purpose of overdose response.

Conclusions

Our findings highlight the limitations of current technologies while also demonstrating the clear need for housing-based emergency response interventions that address not just overdose risk but also gender-based violence. These need to be implemented alongside larger strategies to address structural vulnerabilities and provide greater agency to marginalized women who use drugs.

Having a voice and saving lives: a qualitative survey on employment impacts of people with lived experience of drug use working in harm reduction

Background

Ongoing legal and social discrimination, and stigmatization of people with lived experience of drug use (PWLE) continues to contribute to overdose-related deaths in Canada. The involvement of PWLE working in harm reduction services has proven effective in decreasing drug-related harms among PWLE; however, there exist unintended negative impacts. PWLE working in harm reduction services risk overextending themselves beyond employment parameters (e.g., emotional labor) with few systems in place (e.g., employment advocacy) for support. While meaningful participation of PWLE in harm reduction programs is critical to addressing the overdose crisis, their labor in Canada’s overdose response commands further investigation and recognition. This paper examines some of the benefits and negative aspects of working in harm reduction among PWLE.

Methods

Fifty qualitative surveys were completed by PWLE working in harm reduction services from across Canada at the National 2018 Stimulus conference held in Edmonton, Alberta. The surveys focused on the benefits and negatives of ‘peer’ employment and recommendations for organizational transformation through short answer written sections. Surveys were analyzed thematically using NVivo, informed by critical perspectives on substance use, with attention to key re-occurring themes on employment equity.

Results

While participants described multiple benefits of working in harm reduction services, such as the valuing of their expertise by fellow ‘peers,’ growing skill sets, countering stigma, and preventing overdose deaths, issues of workplace equity were significantly identified. Stigma, tokenism, workplace discrimination, including power and pay inequities, as well as lack of worker compensation and benefits were identified as key factors persisting in the everyday experiences of participants.

Conclusion

Continued exposure to stigma, workplace discrimination, and/or power imbalances, combined with the impact of high stakes employment (e.g., dealing with overdose deaths), can have significant consequences for PWLE working in harm reduction, including burn out. Policy recommendations include large-scale structural changes that address inequities of hierarchical ‘peer’ employment for PWLE, including increased leadership roles for diverse PWLE, pay equity and benefits, unionization, as well as more supportive working environments attentive to the intersecting social-structural factors (poverty, criminalization, racism, gendered violence) impacting the everyday lives of PWLE working in harm reduction.

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.