Activism and scientific research: 20 years of community action by the Vancouver area network of drug users

Co-creating and implementing a novel pre-conference event to promote equity and inclusivity among academic researchers and people who use drugs

This commentary draws on our experience organising a targeted networking event at the 10th International Conference on Health and Hepatitis in Substance Users, in Glasgow, Scotland in October 2022. The event, held the day before the conference, brought together people with lived and living experiences of drug use and early- and mid-career researchers on an equitable basis. We offer reflections, focussing on how the event promoted community-academic engagement from members of the respective groups. We provide recommendations for how conferences can organise to engage with people who use drugs-both those with lived and living experience and foster greater inclusion for all attendees.

People who use drugs' prioritization of regulation amid decriminalization reforms in British Columbia, Canada: A qualitative study

BACKGROUND

North America and the province of British Columbia (BC), Canada, is experiencing an unprecedented number of overdose deaths. In BC, overdose has become the leading cause of death for people between the ages of 10-59 years old. In January 2023, BC decriminalized personal possession of a number of illegal substances with one aim being to address overdose deaths through stigma reduction and promoting access to substance use services.

METHODS

We conducted a qualitative study to understand people who use drugs' (PWUD) perceptions of the new decriminalization policy, immediately prior to its' implementation (October-December 2022). To contextualize decriminalization within broader drug policy, we also asked PWUD what they perceived as the priority issues drug policy ought to address and the necessary solutions. Our final sample included 38 participants who used illegal drugs in the past month.

RESULTS

We identified four themes: 1) The illicit drug supply as the main driver of drug toxicity deaths 2) Concerns about the impact of decriminalization on drug toxicity deaths 3) Views towards decriminalization as a policy response in the context of the drug toxicity crisis 4) Regulation as a symbol of hope for reducing drug toxicity deaths.

CONCLUSION

From our data it became clear that many anticipated that decriminalization would have minimal or no impact on the overdose crisis. Regulation was perceived as the necessary policy approach for effectively and candidly addressing the drivers of the ongoing overdose crisis. These findings are important as jurisdictions consider different approaches to moving away from prohibition-based drug policy.

Translating the lived experience of illicit drinkers into program guidance for cannabis substitution: Experiences from the Canadian Managed Alcohol Program Study

A small but growing body of research has suggested the potential for cannabis substitution to support Managed Alcohol Program (MAP) service users to reduce acute and chronic alcohol-related harms. In 2022, researchers from the Canadian Managed Alcohol Program Study (CMAPS) noted a dearth of accessible, alcohol-specific educational resources to support service users and program staff to implement cannabis substitution pilots at several MAP sites in Canada. In this essay, we draw on over 10-years of collaboration between CMAPS, and organizations of people with lived experience (the Eastside Illicit Drinkers Group for Education (EIDGE) and SOLID Victoria) to describe our experiences co-creating cannabis education resources where none existed to support MAP sites interested in beginning to provide cannabis to participants. The research team relied on the unique lived experiences and informal cannabis-related harm reduction strategies described by EIDGE and SOLID members to create cannabis education resources that were accurate and relevant to MAP sites. EIDGE was familiar with creating peer-oriented educational resources and convened meetings and focus groups to engage peers. CMAPS research team members created standard cannabis unit equivalencies to support program delivery, and clinical advisors ensured that the stated risks and benefits of cannabis substitution, as well as tapering guidance for withdrawal management, were safe and feasible. The collaboration ultimately produced tailored client-facing and provider-facing resources. Our experience demonstrates that the lived expertise of drinkers can play an integral role in creating alcohol harm reduction informational materials, specifically those related to cannabis substitution, when combined with data from rigorous, community-based programs of research like CMAPS. We close by listing additional considerations for cannabis substitution program design for MAP settings emerging from this process of collaboration between illicit drinkers, service providers, clinicians, and researchers for consideration by other programs.

Labeled as "drug-seeking": nurses use harm reduction philosophy to reflect on mending mutual distrust between healthcare workers and people who use drugs

Introduction

Over 50 years of approaching drug use from the "War on Drugs" has led to ignoring the systemic structural and social determinants of health, enforced drug use stigma, and damaging stereotypes of people who use drugs or are labeled as "drug-seeking," and sorely failed to support those needing assistance.

On philosophy of harm reduction and power

People who use drugs are often disenfranchised and pathologized by being labeled as "a drug addict," which then serves as a rationalization for mistreatment by healthcare providers. This is in opposition to a harm-reduction approach. Harm reduction philosophy is an epistemic valuation necessary for drug use stigma and our moral obligation to reduce harm from interlocking systems of power that perpetuate harm.

On drug-seeking mistrust and human rights

We have encountered many clients who use drugs that report harmful interactions with healthcare providers. Harm reduction is an issue of health equity, social justice, and fundamental human rights. This paper presents three vignettes, the author's experiences of being labeled as-and advocating for family members labeled as "drug-seeking."

Discussion

To better serve as healthcare providers, workers must be equipped to work with people who use drugs and reinforce the social justice commitment against medical stigma, neglect, racism, and inadequate pain coverage and withdrawal treatment. Nurses and our epistemic lens can meet the challenge of complex intersectional issues affecting our use of power to develop more just and equitable health systems and advance our rebuilding of a trusting relationship with the people we serve.

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.

Vancouver's Alcohol Knowledge Exchange: lessons learned from creating a peer-involved alcohol harm reduction strategy in Vancouver's Downtown Eastside

Despite high rates of harm attributable to alcohol use itself and the associated marginalization of illicit drinkers in Vancouver's Downtown Eastside (DTES), alcohol-specific harm reduction services there are under-resourced and highly disconnected from one another. In response to these conditions and high rates of death amongst its membership, the Eastside Illicit Drinkers Group for Education, an affiliate group of the Vancouver Area Network of Drug Users, convened a regular meeting of stakeholders, termed a "community of practice" in 2019 to bring together peers who used beverage and non-beverage alcohol, shelter and harm reduction service providers, public health professionals, clinicians, and policymakers to improve system-level capacity to reduce alcohol-related harm. The discussions that followed from these meetings were transformed into the Vancouver Alcohol Strategy (VAS), a comprehensive, harm reduction-oriented policy framework for alcohol harm reduction in the DTES. This article highlights our experiences producing community-led alcohol policy through the VAS with specific attention to the ways in which people who use alcohol themselves were centred throughout the policy development process. We also provide summary overviews of each of the VAS document's 6 thematic areas for action, highlighting a sampling of the 47 total unique recommendations. Historically, people who use non-beverage alcohol and whose use of alcohol in public spaces is criminalized due to housing precarity and visible poverty have been excluded from the development of population-level alcohol policies that can harm this specific population. The process of policy development undertaken by the VAS has attempted to resist this top-down approach to public health policy development related to alcohol control by intentionally creating space for people with lived experience to guide our recommendations. We conclude by suggesting that a grassroots enthusiasm for harm reduction focused policy development exists in Vancouver's DTES, and requires resources from governmental public health institutions to meaningfully prevent and reduce alcohol-related and policy-induced harms.

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.

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.

The overdose epidemic: a study protocol to determine whether people who use drugs can influence or shape public opinion via mass media

BACKGROUND

We are currently witnessing an ongoing drug overdose death epidemic in many nations linked to the distribution of illegally manufactured potent synthetic opioids. While many health policy makers and researchers have focused on the root causes and possible solutions to the current crisis, there has been little focus on the power of advocacy and community action by people who use drugs (PWUDs). Specifically, there has been no research on the role of PWUDs in engaging and influencing mass media opinion.

METHODS

By relying on one of the longest and largest peer-run drug user advocacy groups in the world, the Vancouver Area Network of Drug Users (VANDU), newspaper articles, television reports, and magazines that VANDU or its members have been directly involved in will be identified via two data bases (the Canadian Newsstream & Google News). The news articles and videos related to the health of PWUDs and issues affecting PWUDs from 1997 to the end of 2020 will be analyzed qualitatively using Nvivo software.

DISCUSSION

As our communities are entering another phase of the drug overdose epidemic, acknowledging and partnering with PWUDs could play an integral part in advancing the goals of harm reduction, treatment, and human rights.

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.

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.

Creativity, care and 'messy' drug use: A collective history of the early days of peer-led needle exchange in Dunedin, New Zealand

Established in 1988, the New Zealand Needle Exchange Program (NZNEP) was the first needle exchange programme in the world to operate nation-wide under legal sanction. As in other countries, the ground for legislative reform was laid by activist action among the affected communities and their allies. In context of growing HIV/AIDS notifications, the provision of injecting equipment was positioned as a necessary, albeit politically contentious, public health priority. The NZNEP operated under a unique organisational model, with a national network of peer organisations formalised and supported to provide 'user pays' needle exchange. Unlike many other programmes of community empowerment instigated in response to HIV/AIDS, the NZNEP has over the past thirty years retained a significant degree of community control. Not without tensions, this history requires commemoration. The body of this essay was originally written as a chapter, focusing on the history of DIVO (Dunedin Intravenous Organisation), for a book to commemorate thirty years of the NZNEP. Under the auspices of a 'secret Facebook group' seven peers who worked at DIVO in the late 1980s and early 90s contributed the memories that make up this piece. As one of these peers, the author collated, coded and thematised these remembrances to create the story of DIVOS early days. From strategic positioning as a drug user organisation 'under wraps' DIVO garnered enough community support and institutional confidence to be 'out and proud' in advocating for the human rights of PWID. Ingenuity and action necessitated 'bending the rules' to protect against hepatitis C, and a community of care was recreated in the warmth of reconnection among the Facebook peer group. Tensions are inevitable in a peer-based organisation innovating in a context of precarious legitimacy, and they weave throughout this essay. This collective history is, however, primarily celebratory - of the achievements and legacy of a network of peers who were instrumental in providing care for their communities and advocating publicly for the rights of PWID in New Zealand.

"It's a Bit of a Double-Edged Sword": Motivation and Personal Impact of Bereaved Mothers' Advocacy for Drug Policy Reform

North America's overdose crisis is an urgent public health issue that has resulted in thousands of deaths. As the crisis began to take hold across Canada in 2016, bereaved parents, mainly mothers, emerged as vocal advocates for drug policy reform and harm reduction, using their stories to challenge the stigma of drug-related death. In 2017, we launched a qualitative research partnership with leading family organizations in Canada, conducting interviews with 43 mothers whose children had died from substance use, to understand their experiences of drug policy advocacy. Our findings showed that participants' motivations for engaging in advocacy were rooted in their experiences of grief, and that advocacy led to feelings of empowerment and connection to others. Our research suggests that advocacy can be cathartic and associated with healing from grief, but that "going public" in sharing a family story of substance use death can also have a considerable personal cost.

Love & hate in the Downtown Eastside of Vancouver: features of an unusual drug scene

Purpose

According to conventional research and political conceptions, illicit drug scenes are often characterised by cultures of crime, violence and deceit and customarily met by repressive law enforcement. However, a growing body of research demonstrates the very diverse nature of drug subcultures. This paper aims to explore this diversity and thereby investigates the psychosocial and socio-spatial features people selling and/or using drugs in the Downtown Eastside of Vancouver (DTES) attribute to the local drug scene.

Design/methodology/approach

Qualitative in-depth interviews were conducted with 23 persons with drug selling and/or using experiences in the DTES. Interviews were analysed and interpreted according to grounded theory.

Findings

Participants represent the social fabric of the DTES drug scene as comprising complexly interwoven facets and structures including frequent, brutal violence on the one hand and sincere, heart-rending compassion, care and even love on the other.

Originality/value

Police and social and health services can cooperate constructively with the overriding aim of individual and social harm reduction. Thereby, the existing social network and prosocial orientations of a drug scene can be used in effective approaches such as participatory policy strategies and peer-driven interventions.

Identification and Reporting of Patient and Public Partner Authorship on Knowledge Syntheses: Rapid Review

BACKGROUND

Patient and public involvement (PPI) in health research is an area of growing interest. Several studies have examined the use and impact of PPI in knowledge syntheses (systematic, scoping, and related reviews); however, few studies have focused specifically on the patient or public coauthorship of such reviews.

OBJECTIVE

This study seeks to identify published systematic and scoping reviews coauthored by patient or public partners and examine the characteristics of these coauthored reviews, such as which journals publish them, geographic location of research teams, and terms used to describe patient or public partner authors in affiliations, abstracts, or article text.

METHODS

We searched CAB Direct, CINAHL, Cochrane Database of Systematic Reviews (Ovid), Embase (Ovid), MEDLINE (Ovid), and PsycInfo from 2011 to May 2019, with a supplementary search of several PPI-focused databases. We refined the Ovid MEDLINE search by examining frequently used words and phrases in relevant search results and searched Ovid MEDLINE using the modified search strategy in June 2020.

RESULTS

We screened 13,998 results and found 37 studies that met our inclusion criteria. In line with other PPI research, we found that a wide range of terms were used for patient and public authors in author affiliations. In some cases, partners were easy to identify with titles such as patient, caregiver or consumer representative, patient partner, expert by experience, citizen researcher, or public contributor. In 11% (n=4) of studies, they were identified as members of a panel or advisory council. In 27% (n=10) of articles, it was either impossible or difficult to tell whether an author was a partner solely from the affiliation, and confirmation was found elsewhere in the article. We also investigated where in the reviews the partner coauthors' roles were described, and when possible, what their specific roles were. Often, there was little or no information about which review tasks the partner coauthors contributed to. Furthermore, only 14% (5/37) of reviews mentioned patient or public involvement as authors in the abstract; involvement was often only indicated in the author affiliation field or in the review text (most often in the methods or contributions section).

CONCLUSIONS

Our findings add to the evidence that searching for coproduced research is difficult because of the diversity of terms used to describe patient and public partners, and the lack of consistent, detailed reporting about PPI. For better discoverability, we recommend ensuring that patient and public authorships are indicated in commonly searched database fields. When patient and public-authored research is easier to find, its impact will be easier to measure.

Appreciating contributions more than celebrating resilience: Reflections on the disclosure of substance use in Appalachia

Disclosure of personal substance use often places people who use drugs (PWUD) at risk, both personally and professionally. Yet disclosure can positively influence governmental and organizational policies as well as improve programs meant to serve PWUD. Through numerous autobiographical conversations, six researchers and professionals in their thirties and forties who live in the Appalachian region of the United States examined what it meant for us to discuss our illicit substance use publicly. We examined the limitations of the term "lived experience" and detailed our non-problematic use. Most of us have, at times, experienced negative consequences of substance use, but these consequences are as tied to society's negative responses to substance use as to use itself. When disclosing use, we have often found that others are keen to portray PWUD as resilient, but are less willing to highlight the contributions of PWUD while they are using. We agree that making disclosure more acceptable as well as acknowledging the positive aspects of drug use would alter societal responses to use to be more effective at preventing harm. We conclude by highlighting societal and institutional policy changes that will increase the ability of PWUD to openly disclose use.

Practising critical resilience as an advanced peer support worker in London: A qualitative evaluation of a peer-led hepatitis C intervention amongst people experiencing homelessness who inject drugs

BACKGROUND

Peer support has been used as a mechanism to facilitate active engagement with healthcare amongst underserved populations. The HepCare project upskilled experienced peer support workers (PSWs) to become equal members of a service provider team, taking on advanced clinical roles normally carried out by medical or nursing specialists.

METHOD

A participatory case study approach was taken to the study following the methodological guidance of Merriam (1998). The subject of the case in our study is the advanced peer support workers (APSWs) functioning in the HepCare project as service providers. The object of the case is an exploration of their transition to service provider in the HCV screening and treatment support service. Five peer led in-depth interviews with APSWs were supplemented by a survey of health professionals, interviews with service users, documentary evidence in the form of job descriptions, observational notes and a blog from the field. Thematic analysis of the data was conducted, refined and finalised in a workshop with the research team and APSW participants.

RESULTS

Three themes were generated from the data that explore the peer support worker's transition to APSW in the programme: Transition to Integration, Retaining 'Peerness', and Practising Critical Resilience. The advocacy and support enacted by the APSWs through the HepCare project, offer purpose and meaning alongside integration into a new social group. This is buffered by the supportive context of the programme and facilitates a motivating sense of worth.

CONCLUSION

The programme offers policy guidance for the structured career development of APSWs and a platform for enactment of critical resilience as they transition to their advanced role, in the healthcare provider team.

Supporting the full participation of people who use drugs in policy fora: Provision of a temporary, conference-based overdose prevention site

The overdose epidemic in North America remains acute and interventions are needed to mitigate harm and prevent death. People who use/d drugs (PWUD) hold essential knowledge to guide the development of these interventions and conferences are vital fora for hearing their perspectives and building support for new policies and programs. However, little guidance exists on how to best ensure the safety of PWUD during conferences. In October 2018, a low-threshold overdose prevention site (OPS) was implemented at a national drug policy and harm reduction conference in Edmonton, Canada. The OPS provided delegates with a monitored space to consume drugs and access drug consumption supplies. This commentary describes the implementation of the OPS with the aim of providing practical guidance for organizers of future substance use-related conferences, meetings, and other events.

The Opioid Epidemic: Task-Shifting in Health Care and the Case for Access to Harm Reduction for People Who Use Drugs

We are sadly experiencing unprecedented levels of overdose mortalities attributed to the increased availability of synthetic opioids in illegal markets. While the majority of attention in North America has focused on preventing drug overdose cases through the distribution and administration of naloxone, in addition to stricter regulations of opioid prescriptions and greater law enforcement in illegal markets, little attention has been given to other alternative models and treatments for people who use drugs that are tailored specifically to the health care needs of this marginalized population. Through this analysis, the implications of task-shifting in health care via the distribution of naloxone for an already marginalized population are discussed. Alternatively, the role of pioneering harm-reduction programs - such as supervised injection/consumption sites, a variety of opioids maintenance therapies, and social-structural interventions - are highlighted as crucial interventions in the current ongoing opioid crisis. Moreover, people with lived experiences of illegal drug use are discussed as having a pivotal role but being ultimately overshadowed by public health partners.

One opioid user saving another: the first study of an opioid overdose-reversal and naloxone distribution program addressing hard-to-reach drug scenes in Denmark

Background

Overdose education and naloxone distribution programs decrease opioid overdose deaths. However, no studies of such programs have been carried out in Denmark. The aim of this study was to evaluate the feasibility and the effect of a broader “training-the-trainers” model in low-threshold settings after participation in the “Danish Save Lives” [SL] program.

Methods

Between May 2013 and November 2015, 552 participants from four municipalities took part in the SL program. The program is built on the train-the-trainers model where a central trainer trains others (trainers), who in turn train others (helpers). Participants were 30 police officers (5%), 188 people who use opioids (34%), 23 significant others (4%), and 217 social workers (39%). Ninety-four participants could not be classified (17%). At follow-up, participants were interviewed to determine the number and outcomes of opioid overdoses. Logistic regression was used to assess predictors of treating an overdose.

Results

In all, 37 (7%) participants had intervened in 45 opioid overdose events (two trainers and 35 helpers). Detailed descriptions of the overdose event were available from 32 follow-up interviews (70%). In 16 cases, the person who intervened was already present at the site when the overdose occurred, and in 17 cases, the overdose victim recovered without complications. All overdose victims survived except one. People who used opioids were more likely to have treated an overdose than other participants (adjusted odds ratio [AOR] = 8.50, p = 0.001), and the likelihood of treating and overdose declined over time AOR = 0.37 (0.13, 0.93), p = 0.034).

Conclusions

Prevention programs that target people who use opioids are more likely to be effective than programs that target professionals, especially in high-risk settings that can be hard for paramedics to reach. A future goal is to explore how prevention programs can be adapted to new user groups.

Trial registration

The Danish Data Protection Agency, 2015-57-0002, Aarhus University, 2016-051-000001, 184, retrospectively registered

"They're always there": resident experiences of living with rats in a disadvantaged urban neighbourhood

Background

The presence of urban rats in the neighbourhood environment may negatively impact the physical and mental health of residents. Our study sought to describe the experiences with, perceptions of, and feelings towards rats and rat control efforts among a group of disadvantaged urban residents in Vancouver, Canada.

Methods

Semi-structured interviews were held with 20 members of the Vancouver Area Network of Drug Users (VANDU) recruited by VANDU staff. Interviews were audio recorded, transcribed, and analyzed using thematic analysis.

Results

Participants reported daily sightings of rats and close contact during encounters. Participants generally disliked encountering rats, raising issues of health and safety for themselves and the community due to the belief that rats carry disease. Fear of rats was common, and in some cases resulted in avoidance of rats. Effects of rats on participants were particularly pronounced for those living with rats in the home or for homeless participants who described impacts on sleep due to the sounds made by rats. Although rats were viewed as more problematic in their neighbourhood than elsewhere in Vancouver, participants believed there to be a lack of neighbourhood-level control initiatives that angered and disheartened participants. In combination with other community-level concerns (e.g., housing quality and availability), the presence of rats was viewed by some to align with a general disregard for the community and its residents.

Conclusions

This study suggests that the presence of rats in urban centres may have several consequences on the physical and mental health of residents living in close contact with them. These effects may be exacerbated with continued contact with rats and when residents perceive a lack of initiative to control rats in their neighbourhood. As such, research and policies aimed at mitigating the health risks posed by rats should extend beyond disease-related risk and incorporate diverse health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7202-6) contains supplementary material, which is available to authorized users.

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

Background

Peer-led programs with people who use drugs (PWUD) have been a key characteristic of the harm reduction in many countries, including their involvement in research. However, peer involvement in research is often limited to recruitment, consultation, and reporting back, rather than a genuine collaboration in the priority setting, design, and conduct of research. PWUD peer organizations face ongoing challenges to demonstrate the depth of their knowledge of current and emerging issues within drug-using networks and the value of their peer insights for effective research and policy. The identification of benefits, barriers, and enablers for meaningful participation of PWUD in research has often been limited to methodological rather than system level factors.

Methods

This paper draws on the experiences and findings of the What Works and Why (W3) Project, a 5-year collaborative study with peer organizations. The study drew on systems thinking methods to develop a framework to demonstrate the role of peer organizations within their community and policy systems. The study required peer staff and researchers to undertake the simultaneous role of drivers, participants, and analysts in the research. To identify the learnings in relation to meaningful participation of PWUD peer organizations in research, we drew together the insights and experiences of peer staff and researchers across the 5 years of the study

Results

The W3 Project provided insights into the nuances of community-engaged research practice and the ongoing benefits, barriers, and enablers to the meaningful participation of PWUD and their peer organizations. These included system-level barriers and enablers beyond individual research projects or methodology. The capacity of research and peer organizations to maintain meaningful peer participation in research can be restricted or enhanced by the systems in which they are embedded.

Conclusions

Recognizing peer organizations as active participants and drivers within community and policy systems can help clarify their unique and critical role in research. Achieving meaningful collaboration with PWUD peer organizations requires looking beyond good practice methods to the system-level factors with attention to the system-level benefits, barriers, and enablers.

Characterising the policy influence of peer-based drug user organisations in the context of hepatitis C elimination

BACKGROUND

Achieving hepatitis C (HCV) elimination goals will require major policy and health service reorientation to scale up testing and treatment among people who inject drugs (PWID). To achieve this, a close partnership with peer-based drug user organisations is required. However, peer organisations have historical and ongoing difficulties in articulating the validity of their service delivery and policy advice, leading to some policy and health services resisting partnership and advice from peer-based drug user organisations.

METHODS

To develop a deeper understanding of the role of peer-based drug user organisations in the HCV response, we analysed data from the W3 Project which used systems thinking methods to draw together the insights of over 90 peer staff from 10 Australian community and peer organisations in HCV and HIV. The resulting system maps were analysed to identify system dynamics and functions that need to be fulfilled for peer organisations to be influential within their community and policy system.

RESULTS

We identified the interactions at a system level which can enhance or constrain the quality and influence of policy advice from peer-based drug user organisations. We found the strength of Peer-based drug user organisations to support the scale up of HCV testing and treatment was their capacity to mediate between, and navigate within, the complex community and policy/health service systems. While peer-based drug user organisations endeavour to demonstrate their capacity and credibility in terms of engagement, alignment, adaptation and influence, policy and service organisations also need recognise their own system role to value and enable peer-based drug user organisations to achieve their potential.

CONCLUSION

If the HCV prevention and treatment system is to reach PWID living with HCV and achieve HCV elimination goals, then policy and health services need to invest in strengthening peer-based drug user organisations as well as recognise, value and act on quality policy advice from PWID peer leadership.

Peer worker involvement in low-threshold supervised consumption facilities in the context of an overdose epidemic in Vancouver, Canada

Overdose prevention sites (OPS) are a form of supervised consumption facility that have been implemented in Vancouver, Canada as an innovative response to an ongoing overdose epidemic. OPS are primarily staffed by peers - people who use(d) drugs (PWUD) - trained in overdose response. We sought to characterize peer worker involvement in OPS programming, including how this shapes service dynamics and health outcomes among PWUD. Data were drawn from a rapid ethnographic study examining the implementation, operations and impacts of OPS in Vancouver from December 2016 to April 2017. We conducted approximately 185 h of observational fieldwork at OPS and 72 in-depth qualitative interviews with PWUD. Data were analyzed thematically, with a focus on peer worker involvement at OPS and related outcomes. OPS implementation and operations depended on peer worker involvement and thus allowed for recognition of capacities developed through roles that peers were already undertaking through local programming for PWUD. Peer involvement at OPS enhanced feelings of comfort and facilitated engagement with OPS among PWUD. These dynamics and appreciation of peer worker expertise enabled communication with staff in ways that fostered harm reduction practices and promoted health benefits. However, many peer workers received minimal financial compensation and experienced considerable grief due to the emotional toll of the epidemic and lack of supports, which contributed to staff burnout. Our findings illustrate the specific contributions of task shifting OPS service delivery to peer workers, including how this can enhance service engagement and promote the reduction of harms among PWUD. Amidst an ongoing overdose epidemic, expanding formalized peer worker involvement in supervised consumption programming may help to mitigate overdose-related harms, particularly in settings where peers are actively involved in existing programming. However, efforts are needed to ensure that peer workers receive adequate financial support and workplace benefits to promote the sustainability of this approach.

An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada

BACKGROUND

Nonmedical prescription opioid use (NMPOU) is a serious public health problem in North America. At a population-level, previous research has identified differences in the prevalence and correlates of NMPOU among younger versus older age groups; however, less is known about age-related differences in NMPOU among people who use illegal drugs.

METHODS

Data were collected between 2013 and 2015 from two linked prospective cohort studies in Vancouver, Canada: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Factors independently associated with NMPOU among younger (ARYS) and older (VIDUS) participants were examined separately using bivariate and multivariate generalized estimating equations.

RESULTS

A total of 1162 participants were included. Among 405 eligible younger participants (Median age = 25; Inter-Quartile Range [IQR]: 22-28), 40% (n = 160) reported engaging in NMPOU at baseline; among 757 older participants (Median age = 48, IQR: 40-55), 35% (n = 262) reported engaging in NMPOU at baseline. In separate multivariate analyses of younger and older participants, NMPOU was positively and independently associated with heroin use (younger: Adjusted Odds Ratio [AOR] = 3.12, 95% Confidence Interval [CI]: 2.08-4.68; older: AOR = 2.79, 95% CI: 2.08-3.74), drug dealing (younger: AOR = 2.22, 95% CI: 1.58-3.13; older: AOR = 1.87, 95% CI: 1.40-2.49), and difficulty accessing services (younger: AOR = 1.47, 95% CI: 1.04-2.09; older: AOR = 1.74, 95% CI: 1.32-2.29). Among the youth cohort only, NMPOU was associated with younger age (AOR = 1.12, 95% CI: 1.05-1.19), crack use (AOR = 1.56, 95% CI: 1.06-2.30), and binge drug use (AOR = 1.41, 95% CI: 1.00-1.97); older participants who engaged in NMPOU were more likely to report crystal methamphetamine use (AOR = 1.97, 95% CI: 1.46-2.66), non-fatal overdose (AOR = 1.76, 95% CI: 1.20-2.60) and sex work (AOR = 1.49, 95% CI: 1.00-2.22).

DISCUSSION

The prevalence of NMPOU is similar among younger and older people who use drugs, and independently associated with markers of vulnerability among both age groups. Adults who engage in NMPOU are at risk for non-fatal overdose, which highlights the need for youth and adult-specific strategies to address NMPOU that include better access to health and social services, as well as a range of addiction treatment options for opioid use. Findings also underscore the importance of improving pain treatment strategies tailored for PWUD.