Organizational support for frontline harm reduction and systems navigation work among workers with living and lived experience: qualitative findings from British Columbia, Canada

"A little bit of hope goes a long way": Exploring the role of peer workers in alcohol and other drug rehabilitation services

INTRODUCTION

Peer workers operating within health care settings can offer unique perspectives based on their own lived experience. Within alcohol and other drug (AOD) rehabilitation services, the potential value of peer work is becoming increasingly recognised. This qualitative study aimed to evaluate a newly implemented peer worker program located across three rehabilitation services in Tasmania, Australia.

METHODS

Online interviews were conducted with eight clients, seven peer workers, and five non-peer worker employees with varied experience with peer worker programs. All interviews were audio-recorded and transcribed verbatim.

RESULTS

Guided by an overarching exploratory-descriptive methodological framework, thematic analysis generated three overarching themes: 1) Enhancing and supporting client experiences (what peer workers did in their role to improve client experiences, 2) Changing experiences with AOD rehabilitation (the unique benefits and changes that peer work brings to AOD rehabilitation services) and 3) Finding organizational value (how defining peer work and the feasibility of the peer worker role was challenged by different organizational factors). Overall, peer work was viewed as a positive addition to all rehabilitation services that was able to enhance client experiences through various mechanisms, such as by sharing their own stories, assisting with understanding, and creating safety. Peer work was also able to create change in AOD services, by instilling hope and reducing stigma. However, ongoing challenges with defining the peer worker role in a way that offers organizational recognition and financial security remain.

CONCLUSION

Peer workers offer a unique and valuable perspective when working within rehabilitation services. Through their own lived experience peer workers were able to support clients and assist them in their recovery. These findings highlight the potential benefit of peer work programs within AOD rehabilitation services.

"Everybody is impacted. Everybody's hurting": Grief, loss and the emotional impacts of overdose on harm reduction workers

BACKGROUND

The emotional impacts of witnessing and responding to overdose and overdose-related deaths have been largely overlooked during the drug toxicity overdose crisis in North America. Scarce research has analyzed these impacts on the health and well-being of harm reduction workers, and the broader determinants of harm reduction work. Our study investigates the experiences and impacts of witnessing and responding to frequent and escalating rates of overdose on harm reduction workers in Toronto, Canada.

METHODS

Using semi-structured interviews, 11 harm reduction workers recruited from harm reduction programs with supervised consumption services in Toronto, Canada, explored experiences with and reactions to overdose in both their professional and personal lives. They also provided insights on supports necessary to help people cope with overdose-related loss. We used thematic analysis to develop an initial coding framework, subsequent iterations of codes and emergent themes.

RESULTS

Results revealed that harm reductions workers experienced physical, emotional, and social effects from overdose-related loss and grief. While some effects were due to the toll of overdose response and grief from overdose-related losses, they were exacerbated by the lack of political response to the scale of the drug toxicity overdose crisis and the broader socio-economic-political environment of chronic underfunding for harm reduction services. Harm reduction workers described the lack of appropriate workplace supports for trauma from repeated overdose response and overdose-related loss, alongside non-standard work arrangements that resulted in a lack of adequate compensation or access to benefits.

CONCLUSIONS

Our study highlights opportunities for organizational practices that better support harm reduction workers, including formal emotional supports and community-based supportive care services. Improvement to the socio-economic-political determinants of work such as adequate compensation and access to full benefit packages are also needed in the harm reduction sector for all workers.

Operationalizing the Consolidated Framework for Implementation Research to build and support the lived experience workforce in direct health service provision

BACKGROUND

The involvement of people with lived experience (LEX) workers in the development, design, and delivery of integrated health services seeks to improve service user engagement and health outcomes and reduce healthcare gaps. Yet, LEX workers report feeling undervalued and having limited influence on service delivery. There is a need for systematic improvements in how LEX workforces are engaged and supported to ensure the LEX workforce can fully contribute to integrated systems of care.

OBJECTIVE

This study aimed to operationalize the Consolidated Framework for Implementation Research (CFIR) using a rigorous scoping review methodology and co-creation process, so it could be used by health services seeking to build and strengthen their LEX workforce.

SEARCH STRATEGY

A systematic literature search of four databases was undertaken to identify peer-reviewed studies published between 2016 and 2022 providing evidence of the inclusion of LEX workers in direct health service provision.

DATA EXTRACTION AND SYNTHESIS

A descriptive-analytical method was used to map current evidence of LEX workers onto the CFIR. Then, co-creation sessions with LEX workers (n = 4) and their counterparts-nonpeer workers (n = 2)-further clarified the structural policies and strategies that allow people with LEX to actively participate in the provision and enhancement of integrated health service delivery.

MAIN RESULTS

Essential components underpinning the successful integration of LEX roles included: the capacity to engage in a co-creation process with individuals with LEX before the implementation of the role or intervention; and enhanced representation of LEX across organizational structures.

DISCUSSION AND CONCLUSION

The adapted CFIR for LEX workers (CFIR-LEX) that was developed as a result of this work clarifies contextual components that support the successful integration of LEX roles into the development, design, and delivery of integrated health services. Further work must be done to operationalize the framework in a local context and to better understand the ongoing application of the framework in a health setting.

PATIENT OR PUBLIC CONTRIBUTION

People with LEX were involved in the operationalization of the CFIR, including contributing their expertise to the domain adaptations that were relevant to the LEX workforce.

The joy and pain of being a harm reduction worker: a qualitative study of the meanings about harm reduction in Brazil

BACKGROUND

Although harm reduction is highlighted as an effective intervention for alcohol and drug use, a funding gap for harm reduction interventions has been identified, mainly in low- and middle-income countries. In these countries, tensions between abstinence and harm reduction models have impaired the shift from punitive practices to evidence-based interventions committed to guaranteeing the human rights of people who use drugs. Since 2015, the Brazilian government has adopted a more punitive and abstinence-focused drug policy that jeopardizes the care of people who use alcohol and other drugs and the comprehension of the harm reduction workers' perspective in relation to their practice. Therefore, this study aimed to comprehend the meanings constructed by Brazilian harm reduction workers regarding their practices with vulnerable populations amidst a context of political tension.

METHODS

We conducted 15 in-depth semi-structured qualitative interviews with harm reduction workers employed in public health services for at least 6 months. Data were analyzed using thematic analysis.

RESULTS

The thematic axis "The joy and pain of being a harm reduction worker in Brazil" was constructed and divided into four major themes: (1) Invisibility of harm reduction work; (2) Black, poor, and people who use drugs: identification with the service users; (3) Between advocacy and profession: harm reduction as a political act; (4) Small achievements matter. Despite the perceived invisibility of harm reduction workers in the public health and alcohol and drug fields, valuing small achievements and advocacy were important resources to deal with political tension and punitive strategies in Brazil. The findings also highlight the important role of harm reduction workers due to their personal characteristics and understanding of drug use behavior, which bring the target audience closer to actions within the public health system.

CONCLUSION

There is an urgent need to acknowledge harm reduction based on peer support as a professional category that deserves adequate financial support and workplace benefits. Additionally, expanding evidence-based harm reduction interventions and community-based voluntary drug use treatment centers should be prioritized by public policies to address the human rights violations experienced by people who use drugs.

Changes in harm reduction service providers professional quality of life during dual public health emergencies in Canada

BACKGROUND

Harm reduction (HR) is a critical response to the pronounced toxicity deaths being experienced in Canada. HR providers report many benefits of their jobs, but also encounter chronic stress from structural inequities and exposure to trauma and death. This research study sought to quantify the emotional toll the toxicity emergency placed on HR providers (Cycle One; 2019). Study objectives were later expanded to determine the impact of the ongoing toxicity as well as the pandemic's impact on well-being (Cycle Two; 2021).

METHODS

Standardized measures of job satisfaction, burnout, secondary traumatic stress, and vulnerability to grief were used in an online national survey. Open-ended questions addressed resources and supports. HR partners across Canada validated the findings and contributed to alternative interpretations and implications.

RESULTS

651 respondents in Cycle One and 1,360 in Cycle Two reported moderately high levels of job satisfaction; they reported finding great meaning in their work. Yet, mean levels of burnout and secondary traumatic stress were moderate, with the latter significantly increasing in Cycle Two. Reported vulnerability to grief was moderate but increased significantly during COVID. When available, supports lacked the quality necessary to respond to the complexities of HR workers' experiences, or an insufficient number of sessions were covered through benefits. Respondents shared that their professional quality of life was affected more by policy failures and gaps in the healthcare system than it was by the demands of their jobs.

CONCLUSION

Both the benefits and the strain of providing harm reduction services cannot be underestimated. For HR providers, these impacts are compounded by the drug toxicity emergency, making the service gaps experienced by them all the more critical to address. Implications highlight the need for integration of HR into the healthcare system, sustainable and reliable funding, sufficient counselling supports, and equitable staffing models. Support for this essential workforce is critical to ensuring the well-being of themselves, the individuals they serve, and the health of the broader healthcare system.

Workforce outcomes among substance use peer supports and their contextual determinants: A scoping review protocol

Background

Peer recovery support services are a promising approach for improving harm reduction, treatment, and recovery-related outcomes for people who have substance use disorders. However, unique difficulties associated with the role may put peer recovery support staff (i.e., peers) at high risk for negative workforce outcomes, including burnout, vicarious trauma, and compassion fatigue, which impact one's personal recovery journey. Little is known about the extent to which peers experience such negative outcomes or the influence the service setting context has upon them. This scoping review aims to describe the nature and extent of research evidence on peers' workforce outcomes and how these outcomes might differ across service settings.

Methods

A scoping review will be conducted with literature searches conducted in PsycINFO®, (EBSCO), Embase® (EBSCO), CINAHL® (EBSCO), Web of Science™ (Clarivate), and Google Scholar databases for relevant articles discussing US-based research and published in English from 1 January 1999 to 1 August 2023. The study will include peer-reviewed and grey-literature published materials describing the experiences of peers participating in recovery support services and harm reduction efforts across a variety of service settings. Two evaluators will independently review the abstracts and full-text articles. We will perform a narrative synthesis, summarizing and comparing the results across service settings.

Conclusions

This review will assess the state of the literature on peer workforce-related outcomes and how outcomes might vary by service setting context. Exploration will include individual characteristics of peers that moderate workforce outcomes, and workforce outcomes that mediate personal recovery outcomes. Results will inform the field regarding future directions for research in this area.

Systematic review registration

Submitted to Open Science Framework, August 22nd, 2023.

Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey

BACKGROUND

With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply.

METHODS

Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply.

RESULTS

A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00-2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20-3.60)) of prescribed safer supply access, compared to people who did not access these services.

CONCLUSIONS

Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.

Meaningful inclusion of people living with HIV as a model for workplace policies: Key findings from the project PEER study

BACKGROUND

As a large number of people live with HIV, it is worthwhile to examine the integration of this group in the workplace.

OBJECTIVE

To investigate how the operationalization of GIPA/MEPA supports workplace policies and practices for PLHIV. The study aims to explore what is being offered to support PLHIV in community-based agencies and what can be done to enhance the offerings.

METHODS

For this community-based research, 2 bilingual online surveys were sent to 150 Canadian organizations that work closely with PLHIV or offer support to them. One of the surveys was for Executive Directors of these organizations while the other was sent to peers; i.e. PLHIV whose job is to offer services to PLHIV. Questions in the surveys varied between open-ended, binary, and Likert.

RESULTS

GIPA/MEPA are implemented in most organizations and Executive Directors affirmed that PLHIV and their impacts on the workplace are valued. There is a consensus among Executive Directors that formal support is provided but most respondents argued that this support is not specific for PLHIV. More than half of respondents were either unaware or uncertain about the existence of informal support. Peer-employees claimed that one of the challenges of disclosing HIV to receive peer support is that they may face stigma.

CONCLUSION

The application of GIPA/MEPA results in positive outcomes in the workplace. The study emphasizes the need to facilitate access to informal support.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

BACKGROUND

The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements.

METHODS

Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis.

RESULTS

An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care.

CONCLUSIONS

To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

(Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada

Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of supportive environments and team-based approaches for overdose response; and the benefits of community-driven training that extends beyond technical skills of overdose identification and naloxone administration.

Core competencies of peer workers who use pulse oximeters to supplement their overdose response in British Columbia

Introduction

Peer workers (those with lived/living experience of substance use) are at the forefront of overdose response initiatives in British Columbia, Canada. The onset of the coronavirus disease pandemic has significantly compounded the impact of the overdose crisis. Peer workers are integral in supporting people who use substances. However, despite the important work they do, peer workers often lack formalized credibility and do not have the same resources available to them as service providers without lived experience. The peer-led project titled the Peer2Peer Project implemented several support programs for peer workers, including providing pulse oximeters to peer workers to supplement their overdose response procedures.

Materials and methods

This study was a component of a larger evaluation of the pulse oximeter program at two organizations in BC. The study aims to highlight the competencies of peer workers who use pulse oximeters. Telephone interviews were conducted with seven peer workers who were given pulse oximeters. The transcripts were thematically coded using Covert et al.’s framework of core competencies of community health workers to compare our sample with other widely recognized professions.

Findings

We found that peer workers who used pulse oximeters described several core competencies in their work and these were aligned with Covert et al.’s core competencies for community health workers, including assessment, community health practice, communication, diversity and inclusion, professional practice, and disease prevention and management.

Conclusion

By aligning peer workers’ skills to those of community health workers, we create awareness on the competencies of peer workers in using oximeters to supplement overdose response and advocate for them to receive more recognition and respect within the workplace. Further, our findings act as groundwork for future research in identifying the professional proficiencies of peer workers.

A scoping review of opioid harm reduction interventions for equity-deserving populations

Background

Morbidity and mortality associated with opioid use has become a North American crisis. Harm reduction is an evidence-based approach to substance use. Targeted harm reduction strategies that consider the needs of specific populations are required. The objective of this scoping review was to document the range of opioid harm reduction interventions across equity-deserving populations including racialized groups, Indigenous peoples, LGBTQIA2S+, people with disabilities, and women.

Methods

Ten databases were searched from inception to July 5th, 2021. Terms for harm reduction and opioid use formed the central concepts of the search. We included studies that: (1) assessed the development, implementation, and/or evaluation of harm reduction interventions for opioid use, and (2) reported health-related outcomes or presented perspectives that directly related to experiences receiving or administering harm reduction interventions, (3) were completed within an equity-deserving population and (4) were completed in New Zealand, Australia, Canada or the US. A knowledge map was developed a-priori based on literature outlining different types of harm reduction interventions and supplemented by the expertise of the research team.

Findings

12,958 citations were identified and screened, with 1373 reviewed in full-text screening. Of these, 15 studies were included in the final dataset. The most common harm reduction program was opioid agonist treatment (OAT) (n = 11, 73%). The remaining four studies included: overdose prevention; drug testing equipment; and outreach, peer support, and educational programs for safer use. Nine studies focused on women, primarily pregnant/post-partum women, three focused on Indigenous peoples, and three studies included racialized groups. No studies were identified that provided any information on persons with a disability or members of the LGBTQIA2S+ population.

Interpretation

The scant opioid specific harm reduction literature on equity-deserving populations to date has primarily focused on OAT programs and is focused primarily on women. There is a need for more targeted research to address the diverse social experiences of people who use drugs and the spectrum of harm reduction interventions that are needed. There is also a need to acknowledge the history of harm reduction as a drug-user activist movement aimed at challenging bio-medical paradigms of drug use. Further, there is a need to recognize that academic research may be contributing to health inequity by not prioritizing research with this lens.

Funding

This research was funded by the Canadian Institutes of Health Research.

Peer Support and Overdose Prevention Responses: A Systematic 'State-of-the-Art' Review

Overdose prevention for people who use illicit drugs is essential during the current overdose crisis. Peer support is a process whereby individuals with lived or living experience of a particular phenomenon provide support to others by explicitly drawing on these experiences. This review provides a systematic search and evidence synthesis of peer support within overdose prevention interventions for people who use illicit drugs. A systematic search of six databases (CINAHL, SocINDEX, PsycINFO, MEDLINE, Scopus, and Web of Knowledge) was conducted in November 2020 for papers published in English between 2000 and 2020. Following screening and full-text review, 46 papers met criteria and were included in this review. A thematic analysis approach was used to synthesize themes. Important findings include: the value of peers in creating trusted services; the diversity of peers' roles; the implications of barriers on peer-involved overdose prevention interventions; and the stress and trauma experienced by peers. Peers play a pivotal role in overdose prevention interventions for people who use illicit drugs and are essential to the acceptability and feasibility of such services. However, peers face considerable challenges within their roles, including trauma and burnout. Future interventions must consider how to support and strengthen peer roles in overdose settings.