1
|
Chayama KL, Ng C, Ivsins A, Small W, Knight R, McNeil R. "Everybody looks at it as drug use instead of pain management": Experiences of chronic pain and its management among older people living with HIV who use drugs in Vancouver, British Columbia. Drug Alcohol Depend 2024; 262:111399. [PMID: 39029372 DOI: 10.1016/j.drugalcdep.2024.111399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 06/01/2024] [Accepted: 07/02/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Chronic pain is a common comorbidity among people living with HIV (PLHIV) who use drugs. However, in-depth understanding of how chronic pain is managed among PLHIV who use drugs remains limited, especially in the aging population. We sought to explore how older PLHIV who use drugs manage chronic pain and situate these experiences within their social and structural contexts. METHODS This study draws on semi-structured, in-depth interviews conducted with 27 PLHIV who use drugs and were living with chronic pain in Vancouver, Canada. Participants were recruited through outreach at an integrated HIV care facility and from an open prospective cohort study of PLHIV who use drugs. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using an inductive-deductive approach to coding. RESULTS Three themes emerged from our data analysis. First, chronic pain influenced daily life and functioning, including ability to manage HIV and other health conditions. Second, provider-related barriers, including anti-drug stigma and discrimination, impeded access to pain management. Third, illicit drugs were often used to self-manage pain. CONCLUSIONS This study advances our understanding of the everyday experiences of living with chronic pain among older PLHIV who use drugs. Inadequately managed pain may contribute to an array of health- and drug-related harms among this population. Our findings underscore the need for equitable access to pain care, and safer alternatives to the toxic illicit drug supply in the context of the illicit drug poisoning epidemic, to relieve suffering and improve quality of life for older PLHIV who use drugs.
Collapse
Affiliation(s)
- Koharu Loulou Chayama
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Cara Ng
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
| | - Will Small
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 ave du Parc, Montréal, QC H3N 1×9, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Internal Medicine, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06519, United States; Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, New Haven, CT 06520, United States.
| |
Collapse
|
2
|
Kolla G, Pauly B, Cameron F, Hobbs H, Ranger C, McCall J, Majalahti J, Toombs K, LeMaistre J, Selfridge M, Urbanoski K. "If it wasn't for them, I don't think I would be here": experiences of the first year of a safer supply program during the dual public health emergencies of COVID-19 and the drug toxicity crisis. Harm Reduct J 2024; 21:111. [PMID: 38849866 PMCID: PMC11157725 DOI: 10.1186/s12954-024-01029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model. METHODS This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study. RESULTS Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability. CONCLUSIONS Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets.
Collapse
Affiliation(s)
- Gillian Kolla
- Memorial University, St. John's, Canada.
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada.
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | | | - Corey Ranger
- AVI Health and Community Services, Victoria, Canada
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | - Kim Toombs
- AVI Health and Community Services, Victoria, Canada
| | | | - Marion Selfridge
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| |
Collapse
|
3
|
Fleming T, Boyd J, Gagnon M, Kerr T, McNeil R. Using drugs alone in single room occupancy housing: Understanding environmental drivers of overdose risk. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 128:104444. [PMID: 38754243 DOI: 10.1016/j.drugpo.2024.104444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/02/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Across North America most overdose deaths occur in housing, largely due to individuals using drugs alone. In cities, fatalities are disproportionately concentrated in low-income housing, including single room occupancy (SRO) housing. While research has highlighted how SROs operate as risk environments for various poor outcomes, there has been little attention to specific drug use practices (i.e., using alone) associated with overdose vulnerability in these spaces. This study explores how environmental contexts of SROs shape overdose risks, with specific attention to practices of using drugs alone. METHODS In-depth semi-structured interviews were conducted with 30 people who use drugs (PWUD) living in Vancouver SROs. Interviews covered topics such as social-structural environments of housing, drug use practices, and housing-based harm reduction. Thematic analysis drew on the intersectional risk environment framework. RESULTS Narratives positioned SROs as extensions of public space, with similar expectations of risks and behaviours as in public spaces. For some participants, using alone in their room was characterized as a practice in claiming privacy within the context of a public existence. Participants highlighted how certain features of SRO's social-structural environments were routinely leveraged against them (e.g., security cameras, staff surveillance), suggesting using alone as a tactic to minimize risks of hyper-surveillance and punitive policies. Further, participants discussed using alone as "safer," describing how this practice mitigated place-based risks of social-structural harms (e.g., violence, criminalization) in ways that eclipsed overdose risk. CONCLUSION Using drugs alone may be understood as a spatial negotiation of vulnerability to diverse harms produced by environmental contexts of SROs. Interventions accounting for broader contextual factors (e.g., improvements housing quality/quantity, providing a safer supply of drugs) that render using alone as instrumental to survival, and that reduce the implicit threat of punishment from intensive surveillance and control practices are critical to reduce vulnerability to overdose and other harms.
Collapse
Affiliation(s)
- Taylor Fleming
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Marilou Gagnon
- School of Nursing, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2, Canada; Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Avenue, Victoria, BC V8N 5M8, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, Yale School of Medicine, 367 Cedar Street, New Haven, CT 10001, USA; Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, New Haven, CT 10001, USA.
| |
Collapse
|
4
|
Russolillo A, Carter M, Guan M, Singh P, Kealy D, Raudzus J. Adult psychiatric inpatient admissions and length of stay before and during the COVID-19 pandemic in a large urban hospital setting in Vancouver, British Columbia. FRONTIERS IN HEALTH SERVICES 2024; 4:1365785. [PMID: 38807747 PMCID: PMC11130439 DOI: 10.3389/frhs.2024.1365785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/01/2024] [Indexed: 05/30/2024]
Abstract
Introduction During the COVID-19 pandemic individuals with mental illnesses faced challenges accessing psychiatric care. Our study aimed to describe patient characteristics and compare admissions and length of stay (LOS) for psychiatric-related hospitalizations before and during the COVID-19 pandemic. Methods We conducted a retrospective analysis using health administrative data comparing individuals with an acute psychiatric admission between two time periods: 1st March 2019 to 31st December 2019 (pre-COVID) and 1st March 2020 to 31st December 2020 (during-COVID). Multivariable negative binomial regression was used to model the association between most responsible diagnosis type and the two-time periods to hospital LOS, reporting the Rate Ratio (RR) as the measure of effect. Results The cohort comprised 939 individuals who were predominately male (60.3%) with a severe mental illness (schizophrenia or mood-affective disorder) (72.7%) and a median age of 38 (IQR: 28.0, 52.0) years. In the multivariable analysis, anxiety disorders (RR: 0.63, CI: 0.4, 0.99) and personality disorders (RR: 0.52, CI: 0.32, 0.85) were significantly associated with a shorter LOS when compared to individuals without those disorders. Additionally, when compared to hospital admissions for non-substance related disorders the LOS for patients with substance-related disorders were significantly shorter during the COVID period (RR: 0.45, CI: 0.30, 0.67) and pre-COVID period (RR: 0.31, CI: 0.21, 0.46). Conclusions We observed a significant difference in the type and length of admissions for various psychiatric disorders during the COVID-19 period. These findings can support systems of care in adapting to utilization changes during pandemics or other global health events.
Collapse
Affiliation(s)
- Angela Russolillo
- Department of Psychiatry, Providence Health Care, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Michelle Carter
- Department of Psychiatry, Providence Health Care, Vancouver, BC, Canada
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Mejiao Guan
- Statistics and Health Economics, Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | - Pulkit Singh
- Department of Psychiatry, Providence Health Care, Vancouver, BC, Canada
| | - David Kealy
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Julia Raudzus
- Department of Psychiatry, Providence Health Care, Vancouver, BC, Canada
| |
Collapse
|
5
|
Makarenko I, Minoyan N, Bordier Høj S, Udhesister S, Martel-Laferrière V, Jutras-Aswad D, Larney S, Bruneau J. Determinants of psychological distress during the COVID-19 pandemic among people who use drugs in Montreal, Canada. Drug Alcohol Rev 2024. [PMID: 38741361 DOI: 10.1111/dar.13862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Limited data exists on psychological impacts of the COVID-19 pandemic among people who use drugs (PWUD). This study aimed to determine the prevalence and correlates of severe psychological distress (PD) among PWUD in Montreal around the beginning of the pandemic. METHODS We conducted a rapid assessment study from May to December 2020 among PWUD recruited via a community-based cohort of people who inject drugs in Montreal (Hepatitis C cohort [HEPCO], N = 128) and community organisations (N = 98). We analysed self-reported data on changes in drug use behaviours and social determinants since the declaration of COVID-19 as a public health emergency, and assessed past-month PD using the Kessler K6 scale. Multivariable logistic regression was conducted to examine correlates of PD distress (score ≥13). RESULTS Of 226 survey participants, a quarter (n = 56) were screened positive for severe PD. In multivariable analyses, age (1-year increment) (adjusted odds ratio = 0.94, 95% confidence interval [0.90, 0.98]) and a decrease in non-injection drug use versus no change (0.26 [0.07, 0.92]) were protective against severe PD, while positive associations were found for any alcohol use in the past 6 months (3.73 [1.42, 9.78]), increased food insecurity (2.88 [1.19, 6.93]) and both moving around between neighbourhoods more (8.71 [2.63, 28.88]) and less (3.03 [1.18, 7.74]) often compared to no change. DISCUSSION AND CONCLUSIONS This study documented a high prevalence of severe PD among PWUD during the COVID-19 pandemic compared with pre-COVID-19 data. Social determinants such as food insecurity and mobility issues, alongside demographic and substance use-related factors, were linked to distress. Evidence-based risk mitigation strategies for this population could reduce negative consequences in future pandemics or disruptions.
Collapse
Affiliation(s)
- Iuliia Makarenko
- Department of Family Medicine, McGill University, Montreal, Canada
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Nanor Minoyan
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Canada
| | - Stine Bordier Høj
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Sasha Udhesister
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Canada
| | - Valérie Martel-Laferrière
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Microbiology and Infectiology, Université de Montréal, Montreal, Canada
| | - Didier Jutras-Aswad
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Psychiatry and Addictology, Université de Montréal, Montreal, Canada
| | - Sarah Larney
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Canada
| | - Julie Bruneau
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Canada
| |
Collapse
|
6
|
Min JE, Guerra-Alejos BC, Yan R, Palis H, Barker B, Urbanoski K, Pauly B, Slaunwhite A, Bach P, Ranger C, Heaslip A, Nosyk B. Opioid Coprescription Through Risk Mitigation Guidance and Opioid Agonist Treatment Receipt. JAMA Netw Open 2024; 7:e2411389. [PMID: 38748421 PMCID: PMC11096992 DOI: 10.1001/jamanetworkopen.2024.11389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/12/2024] [Indexed: 05/18/2024] Open
Abstract
Importance At the onset of the COVID-19 pandemic, the government of British Columbia, Canada, released clinical guidance to support physicians and nurse practitioners in prescribing pharmaceutical alternatives to the toxic drug supply. These alternatives included opioids and other medications under the risk mitigation guidance (RMG), a limited form of prescribed safer supply, designed to reduce the risk of SARS-CoV-2 infection and harms associated with illicit drug use. Many clinicians chose to coprescribe opioid medications under RMG alongside opioid agonist treatment (OAT). Objective To examine whether prescription of hydromorphone tablets or sustained-release oral morphine (opioid RMG) and OAT coprescription compared with OAT alone is associated with subsequent OAT receipt. Design, Setting, and Participants This population-based, retrospective cohort study was conducted from March 27, 2020, to August 31, 2021, included individuals from 10 linked health administrative databases from British Columbia, Canada. Individuals who were receiving OAT at opioid RMG initiation and individuals who were receiving OAT and eligible but unexposed to opioid RMG were propensity score matched at opioid RMG initiation on sociodemographic and clinical variables. Data were analyzed between January 2023 and February 2024. Exposure Opioid RMG receipt (≥4 days, 1-3 days, or 0 days of opioid RMG dispensed) in a given week. Main Outcome and Measures The main outcome was OAT receipt, defined as at least 1 dispensed dose of OAT in the subsequent week. A marginal structural modeling approach was used to control for potential time-varying confounding. Results A total of 4636 individuals (2955 [64%] male; median age, 38 [31-47] years after matching) were receiving OAT at the time of first opioid RMG dispensation (2281 receiving ongoing OAT and 2352 initiating RMG and OAT concurrently). Opioid RMG receipt of 1 to 3 days in a given week increased the probability of OAT receipt by 27% in the subsequent week (adjusted risk ratio, 1.27; 95% CI, 1.25-1.30), whereas receipt of opioid RMG for 4 days or more resulted in a 46% increase in the probability of OAT receipt in the subsequent week (adjusted risk ratio, 1.46; 95% CI, 1.43-1.49) compared with those not receiving opioid RMG. The biological gradient was robust to different exposure classifications, and the association was stronger among those initiating opioid RMG and OAT concurrently. Conclusions and Relevance This cohort study, which acknowledged the intermittent use of both medications, demonstrated that individuals who were coprescribed opioid RMG had higher adjusted probability of continued OAT receipt or reengagement compared with those not receiving opioid RMG.
Collapse
Affiliation(s)
- Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | | | - Ruyu Yan
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - Heather Palis
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Brittany Barker
- First Nations Health Authority, Vancouver, British Columbia, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Karen Urbanoski
- School of Public Health and Social Policy, University of Victoria, Victoria, British Columbia, Canada
- Canadian Institute for Substance Use Research, Victoria, British Columbia, Canada
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, Victoria, British Columbia, Canada
- Department of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Amanda Slaunwhite
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Corey Ranger
- AVI Health and Community Services, Victoria, British Columbia, Canada
| | - Ashley Heaslip
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Island Medical Program, University of Victoria, Victoria, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
7
|
Michaud L, Kolla G, Rudzinski K, Guta A. Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104423. [PMID: 38642543 DOI: 10.1016/j.drugpo.2024.104423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/26/2024] [Accepted: 04/06/2024] [Indexed: 04/22/2024]
Abstract
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.
Collapse
Affiliation(s)
- Liam Michaud
- Graduate Program in Socio-Legal Studies, York University, Toronto, ON, Canada; Nathanson Centre on Transnational Human Rights, Crime and Security, York University, Toronto, ON, Canada.
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada; Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | | | - Adrian Guta
- School of Social Work, University of Windsor, ON, Canada
| |
Collapse
|
8
|
Ledlie S, Juurlink DN, Tadrous M, Mamdani M, Paterson JM, Gomes T. Opioid-related deaths between 2019 and 2021 across 9 Canadian provinces and territories. CMAJ 2024; 196:E469-E476. [PMID: 38621782 PMCID: PMC11019600 DOI: 10.1503/cmaj.231339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND The drug toxicity crisis continues to accelerate across Canada, with rapid increases in opioid-related harms following the onset of the COVID-19 pandemic. We sought to describe trends in the burden of opioid-related deaths across Canada throughout the pandemic, comparing these trends by province or territory, age, and sex. METHODS We conducted a repeated cross-sectional analysis of accidental opioid-related deaths between Jan. 1, 2019, and Dec. 31, 2021, across 9 Canadian provinces and territories using aggregated national data. Our primary measure was the burden of premature opioid-related death, measured by potential years of life lost. Our secondary measure was the proportion of all deaths attributable to opioids; we used the Cochrane-Armitage test for trend to compare proportions. RESULTS Between 2019 and 2021, the annual number of opioid-related deaths increased from 3007 to 6222 and years of life lost increased from 126 115 to 256 336 (from 3.5 to 7.0 yr of life lost per 1000 population). In 2021, the highest number of years of life lost was among males (181 525 yr) and people aged 30-39 years (87 045 yr). In 2019, we found that 1.7% of all deaths among those younger than 85 years were related to opioids, rising to 3.2% in 2021. Significant increases in the proportion of deaths related to opioids were observed across all age groups (p < 0.001), representing 29.3% and 29.0% of deaths among people aged 20-29 and 30-39 years in 2021, respectively. INTERPRETATION Across Canada, the burden of premature opioid-related deaths doubled between 2019 and 2021, representing more than one-quarter of deaths among younger adults. The disproportionate loss of life in this demographic group highlights the critical need for targeted prevention efforts.
Collapse
Affiliation(s)
- Shaleesa Ledlie
- Li Ka Shing Knowledge Institute (Ledlie, Mamdani, Gomes), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Ledlie, Tadrous, Mamdani, Gomes), University of Toronto; ICES (Ledlie, Juurlink, Tadrous, Paterson, Gomes); Institute for Health Policy, Management and Evaluation (Juurlink, Mamdani, Paterson, Gomes), University of Toronto; Sunnybrook Research Institute (Juurlink), Toronto, Ont
| | - David N Juurlink
- Li Ka Shing Knowledge Institute (Ledlie, Mamdani, Gomes), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Ledlie, Tadrous, Mamdani, Gomes), University of Toronto; ICES (Ledlie, Juurlink, Tadrous, Paterson, Gomes); Institute for Health Policy, Management and Evaluation (Juurlink, Mamdani, Paterson, Gomes), University of Toronto; Sunnybrook Research Institute (Juurlink), Toronto, Ont
| | - Mina Tadrous
- Li Ka Shing Knowledge Institute (Ledlie, Mamdani, Gomes), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Ledlie, Tadrous, Mamdani, Gomes), University of Toronto; ICES (Ledlie, Juurlink, Tadrous, Paterson, Gomes); Institute for Health Policy, Management and Evaluation (Juurlink, Mamdani, Paterson, Gomes), University of Toronto; Sunnybrook Research Institute (Juurlink), Toronto, Ont
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute (Ledlie, Mamdani, Gomes), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Ledlie, Tadrous, Mamdani, Gomes), University of Toronto; ICES (Ledlie, Juurlink, Tadrous, Paterson, Gomes); Institute for Health Policy, Management and Evaluation (Juurlink, Mamdani, Paterson, Gomes), University of Toronto; Sunnybrook Research Institute (Juurlink), Toronto, Ont
| | - J Michael Paterson
- Li Ka Shing Knowledge Institute (Ledlie, Mamdani, Gomes), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Ledlie, Tadrous, Mamdani, Gomes), University of Toronto; ICES (Ledlie, Juurlink, Tadrous, Paterson, Gomes); Institute for Health Policy, Management and Evaluation (Juurlink, Mamdani, Paterson, Gomes), University of Toronto; Sunnybrook Research Institute (Juurlink), Toronto, Ont
| | - Tara Gomes
- Li Ka Shing Knowledge Institute (Ledlie, Mamdani, Gomes), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Ledlie, Tadrous, Mamdani, Gomes), University of Toronto; ICES (Ledlie, Juurlink, Tadrous, Paterson, Gomes); Institute for Health Policy, Management and Evaluation (Juurlink, Mamdani, Paterson, Gomes), University of Toronto; Sunnybrook Research Institute (Juurlink), Toronto, Ont.
| |
Collapse
|
9
|
Schneider KE, Martin EM, Allen ST, Morris M, Haney K, Saloner B, Sherman SG. Volatile drug use and overdose during the first year of the COVID-19 pandemic in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104371. [PMID: 38447262 PMCID: PMC11056297 DOI: 10.1016/j.drugpo.2024.104371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Overdose deaths in the United States rose substantially during the COVID-19 pandemic. Disruptions to the drug supply and service provision introduced significant instability into the lives of people who use drugs (PWUD), including volatility in their drug use behaviors. METHODS Using data from a multistate survey of PWUD, we examined sociodemographic and drug use correlates of volatile drug use during COVID-19 using multivariable linear regression. In a multivariable logistic regression model, we assessed the association between volatile drug use and past month overdose adjusting for sociodemographic and other drug use characteristics. RESULTS Among participants, 52% were male, 50% were white, 29% had less than a high school education, and 25% were experiencing homelessness. Indicators of volatile drug use were prevalent: 53% wanted to use more drugs; 45% used more drugs; 43% reported different triggers for drug use, and 23% used drugs that they did not typically use. 14% experienced a past-month overdose. In adjusted models, hunger (β=0.47, 95% CI: 0.21-0.72), transactional sex (β=0.50, 95% CI: 0.06-0.94), and the number of drugs used (β=0.16, 95% CI: 0.07-0.26) were associated with increased volatile drug use. Volatile drug use was associated with increased overdose risk (aOR=1.42, 95% CI: 1.17-1.71) in the adjusted model. CONCLUSIONS Volatile drug use during the COVID-19 pandemic was common, appeared to be driven by structural vulnerability, and was associated with increased overdose risk. Addressing volatile drug use through interventions that ensure structural stability for PWUD and a safer drug supply is essential for mitigating the ongoing overdose crisis.
Collapse
Affiliation(s)
- Kristin E Schneider
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Emily M Martin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Miles Morris
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Katherine Haney
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| |
Collapse
|
10
|
Nielsen S, Stowe MJ, Ritter A. In pursuit of safer supply: An emerging evidence base for medical and nonmedical models. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104365. [PMID: 38417226 DOI: 10.1016/j.drugpo.2024.104365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/01/2024]
Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Peninsula Campus Rm 205A, Level 2, Building D, 47-49 Moorooduc Hwy, Frankston 3199, Victoria, Australia.
| | - M J Stowe
- The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Alison Ritter
- The Drug Policy Modelling Program, UNSW Sydney, Australia
| |
Collapse
|
11
|
Henderson N, Marris J, Woodend K. "And this is the life jacket, the lifeline they've been wanting": Participant perspectives on navigating challenges and successes of prescribed safer supply. PLoS One 2024; 19:e0299801. [PMID: 38517923 PMCID: PMC10959334 DOI: 10.1371/journal.pone.0299801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/04/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND In 2021, 43% of drug toxicity deaths in Ontario were reported by public health units serving medium-sized urban and rural communities. Safer supply programs (SSPs) have been primarily established in large urban centres. Given this, the current study is based on an evaluation of a SSP based in a medium-sized urban centre with a large catchment area that includes rural and Indigenous communities. The aim of this research paper is to understand the challenges and successes of the nurse practitioner-led SSP from the perspective of program participants. METHODS Interpretive description was used to understand the experiences of 14 participants accessing a SSP. Each participant was interviewed using a semi-structured approach, and 13 of the interviewees also completed surveys accessed through Qualtrics. An iterative process using NVivo software was used to code interviews, and a constant comparative data analysis approach was used to refine and categorize codes to themes. FINDINGS Three overarching themes were the result of this analysis: feeling better, renewed hope, and safety. These three themes capture the experiences of participants in the SSP, including both the challenges and successes they faced. CONCLUSION The findings and subsequent discussion focus on both the key best practices of the program, and areas for future development and improvement. Despite barriers to services, prescribed SSPs are improving the lives of people who use drugs, and the current outcomes align with reports and evaluations from other SSPs across Canada.
Collapse
Affiliation(s)
- Nancy Henderson
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - John Marris
- John Marris Consulting, Peterborough, ON, Canada
| | - Kirsten Woodend
- School of Nursing, Trent University, Peterborough, ON, Canada
| |
Collapse
|
12
|
McCall J, Hobbs H, Ranger C, Cameron F, Stuart H, Nelken J, Majalahti J, Urbanoski K, Kolla G, LeMaistre J, Toombs K, Herriot R, Pauly B. Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation. Subst Abuse Treat Prev Policy 2024; 19:19. [PMID: 38444035 PMCID: PMC10913403 DOI: 10.1186/s13011-024-00598-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Within North America and worldwide, drug related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply to replace unregulated substances and to reduce toxicity and overdoses. Service providers play an integral role in the delivery of safer supply but there is little empirical evidence that conceptualizes effective safer supply from their perspectives. This study explored early implementation and impacts of a safer supply program, capturing the perspectives of an interdisciplinary team of service providers on tensions and issues encountered in the development of the SAFER program. METHODS Using a community-based participatory approach, we conducted individual interviews with program providers (n = 9). The research team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The Consolidated Framework for Implementation Research (CFIR) informed the interview guide. Data was analyzed using thematic analysis. RESULTS There are six themes describing early implementation: (1) risk mitigation prescribing as context for early implementation; (2) developing SAFER specific clinical protocols; (3) accessibility challenges and program innovations; (4) interdisciplinary team and wraparound care; (5) program tensions between addiction medicine and harm reduction; (6) the successes of safer supply and future visions. CONCLUSION Early implementation issues and tensions included prescriber concerns about safer supply prescribing in a highly politicized environment, accessibility challenges for service users such as stigma, encampment displacement, OAT requirements, program capacity and costs, and tensions between addiction medicine and harm reduction. Navigating these tensions included development of clinical protocols, innovations to reduce accessibility challenges such as outreach, wraparound care, program coverage of medication costs and prescribing safer supply with/without OAT. These findings contribute important insights for the development of prescribed safer supply programs.
Collapse
Affiliation(s)
- J McCall
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - H Hobbs
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - C Ranger
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - F Cameron
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - H Stuart
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - J Nelken
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - J Majalahti
- SOLID Outreach, 1056 North Park St, Victoria, BC, Canada
| | - K Urbanoski
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - G Kolla
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - J LeMaistre
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - K Toombs
- AVI Health and Community Services, 713 Johnson Street, Victoria, BC, V8W 1M8, Canada
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - R Herriot
- Victoria SAFER Program, 1806 Cook Street, Victoria, BC, V8W 1M8, Canada
| | - Bernie Pauly
- University of Victoria, PO Box 1700, Stn CSC, Victoria, BC, V8W 2Y2, Canada.
- Canadian Institute of Substance Use Research, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada.
| |
Collapse
|
13
|
Mars S, Ondocsin J, Holm N, Ciccarone D. The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States. Harm Reduct J 2024; 21:57. [PMID: 38443903 PMCID: PMC10913463 DOI: 10.1186/s12954-024-00976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Co-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality. METHOD We recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant. RESULTS A clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand. CONCLUSION Transformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs' market dominance at this location and possible interventions.
Collapse
Affiliation(s)
- Sarah Mars
- University of California, San Francisco, USA.
| | | | - Nicole Holm
- University of California, San Francisco, USA
| | | |
Collapse
|
14
|
Xavier JC, McDermid J, Buxton J, Henderson I, Streukens A, Lamb J, Greer A. People who use drugs' prioritization of regulation amid decriminalization reforms in British Columbia, Canada: A qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 125:104354. [PMID: 38402802 DOI: 10.1016/j.drugpo.2024.104354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/27/2024]
Abstract
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.
Collapse
Affiliation(s)
- Jessica C Xavier
- School of Criminology, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, V5A 1S6, Canada; British Columbia Centre for Disease Control, 655W 12th Avenue, Vancouver, British Columbia, V5Z 4R4, Canada
| | - Jennifer McDermid
- School of Criminology, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, V5A 1S6, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, V6T 1Z8, Canada
| | - Iesha Henderson
- Professionals for the Ethical Engagement of Peers (PEEP), British Columbia Centre for Disease Control, 655W 12th Avenue, Vancouver, British Columbia, V5Z 4R4, Canada
| | - Amber Streukens
- Professionals for the Ethical Engagement of Peers (PEEP), British Columbia Centre for Disease Control, 655W 12th Avenue, Vancouver, British Columbia, V5Z 4R4, Canada
| | - Jessica Lamb
- Professionals for the Ethical Engagement of Peers (PEEP), British Columbia Centre for Disease Control, 655W 12th Avenue, Vancouver, British Columbia, V5Z 4R4, Canada
| | - Alissa Greer
- School of Criminology, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, V5A 1S6, Canada.
| |
Collapse
|
15
|
Ledlie S, Garg R, Cheng C, Kolla G, Antoniou T, Bouck Z, Gomes T. Prescribed safer opioid supply: A scoping review of the evidence. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 125:104339. [PMID: 38335867 DOI: 10.1016/j.drugpo.2024.104339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Safer opioid supply programs provide prescription pharmaceutical opioids, often with supportive services, to people at high risk of experiencing harms related to substance use. However, questions regarding the effectiveness and safety of this practice remain. We conducted a scoping review of literature describing client outcomes from formal opioid supply programs providing prescriptions for pharmaceutical opioids, and the perceptions of involved clients/providers. METHODS We performed a scoping review of peer-reviewed studies and grey literature published between January 1, 2012, to September 12, 2023. We included articles reporting either safer opioid supply client outcomes or clients/providers perspectives. Extracted data included study objectives, substance use patterns, client outcomes, client/provider perspectives, and estimates of effectiveness and/or harm. RESULTS Our search yielded 1,597 articles. Following removal of duplicates and application of exclusion criteria, 24 publications comprising 17 peer-reviewed and seven grey literature publications were included in our study. We generated eight themes summarizing topics in the available literature: opioid-related toxicities, infectious complications, other clinical outcomes, client-reported outcomes, program access barriers, diversion, program retention, and costs to the healthcare system. Specific findings included low rates of opioid toxicities, improved physical and mental health, and improved quality of life among clients. A lack of access to adequate opioid doses and the limited range of opioid options offered within safer opioid supply programs was described by clients and providers as a potential reason for diversion and a barrier to program access. CONCLUSIONS Generally, evidence suggests that safer opioid supply programs are beneficial to clients through measurable outcomes. However, the available literature has important limitations, including limited inferences about the effectiveness, safety, and potential for diversion within safer opioid supply programs. Further research is needed to support the ongoing evaluation of safer opioid supply programs as one component of a multifactorial response to escalating rates of substance-related harms.
Collapse
Affiliation(s)
- Shaleesa Ledlie
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Ria Garg
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Clare Cheng
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
| | - Gillian Kolla
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada; Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - Tony Antoniou
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Family and Community Medicine, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Zachary Bouck
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
16
|
Fleming T, Ivsins A, Barker A, Mansoor M, Mayer S, Vakharia S, McNeil R. Perceptions of prospective pharmaceutical stimulant substitution treatments among people who use illicit stimulants in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 125:104336. [PMID: 38281384 PMCID: PMC11045237 DOI: 10.1016/j.drugpo.2024.104336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/20/2023] [Accepted: 01/22/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Stimulant-involved overdose deaths are increasing, driven by polysubstance use and adulteration of the illicit drug supply. While emerging evidence for prescription stimulant substitution is promising, there are no approved treatment options for stimulant use disorder that address the realities of an unpredictable drug supply. This study explores treatment experiences of people who use illicit stimulants (PWUS) to identify gaps and perceptions of prospective pharmaceutical stimulant substitution treatments (SST). METHODS In-depth qualitative interviews were conducted with 86 PWUS in Vancouver, Canada. Thematic analysis focused on experiences of available treatment options for stimulant use and perceptions of prospective SST. RESULTS Participants identified how primarily behavioral treatment approaches do not meet the unique needs of PWUS, in contrast with the range of medical treatments available for opioid use disorder. Participants anticipated health and social benefits if they were able to access SST, including avoiding the toxic illicit stimulant supply, reduced engagement in criminalized activities, and greater economic security. Perceptions of prospective SST were informed by knowledge of existing opioid treatments. This led some participants to be unsupportive of SST, citing concerns around agency and highly regulated operational contexts that do not align with the lived realities of stimulant use. CONCLUSION Findings demonstrate the need for SST pilot programs in real-world settings and underscore the health and social advantages SST may offer; although drawing on existing opioid treatment models to implement SST pilots may limit success. Thus, any novel treatments for stimulant use must centre the lived realities of PWUS.
Collapse
Affiliation(s)
- Taylor Fleming
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Allison Barker
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Manal Mansoor
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Samara Mayer
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Sheila Vakharia
- Drug Policy Alliance, 131 West 33rd Street, 15th Floor, New York, NY 10001, USA
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, Yale School of Medicine, 367 Cedar Street, New Haven, CT 10001, USA; Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, New Haven, CT 10001, USA.
| |
Collapse
|
17
|
Nguyen HV, Mital S, Bugden S, McGinty EE. British Columbia's Safer Opioid Supply Policy and Opioid Outcomes. JAMA Intern Med 2024; 184:256-264. [PMID: 38227344 PMCID: PMC10792500 DOI: 10.1001/jamainternmed.2023.7570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/13/2023] [Indexed: 01/17/2024]
Abstract
Importance In March 2020, British Columbia, Canada, became the first jurisdiction globally to launch a large-scale provincewide safer supply policy. The policy allowed individuals with opioid use disorder at high risk of overdose or poisoning to receive pharmaceutical-grade opioids prescribed by a physician or nurse practitioner, but to date, opioid-related outcomes after policy implementation have not been explored. Objective To investigate the association of British Columbia's Safer Opioid Supply policy with opioid prescribing and opioid-related health outcomes. Design, Setting, and Participants This cohort study used quarterly province-level data from quarter 1 of 2016 (January 1, 2016) to quarter 1 of 2022 (March 31, 2022), from British Columbia, where the Safer Opioid Supply policy was implemented, and Manitoba and Saskatchewan, where the policy was not implemented (comparison provinces). Exposure Safer Opioid Supply policy implemented in British Columbia in March 2020. Main Outcomes and Measures The main outcomes were rates of prescriptions, claimants, and prescribers of opioids targeted by the Safer Opioid Supply policy (hydromorphone, morphine, oxycodone, and fentanyl); opioid-related poisoning hospitalizations; and deaths from apparent opioid toxicity. Difference-in-differences analysis was used to compare changes in outcomes before and after policy implementation in British Columbia with those in the comparison provinces. Results The Safer Opioid Supply policy was associated with statistically significant increases in rates of opioid prescriptions (2619.6 per 100 000 population; 95% CI, 1322.1-3917.0 per 100 000 population; P < .001) and claimants (176.4 per 100 000 population; 95% CI, 33.5-319.4 per 100 000 population; P = .02). There was no significant change in prescribers (15.7 per 100 000 population; 95% CI, -0.2 to 31.6 per 100 000 population; P = .053). However, the opioid-related poisoning hospitalization rate increased by 3.2 per 100 000 population (95% CI, 0.9-5.6 per 100 000 population; P = .01) after policy implementation. There were no statistically significant changes in deaths from apparent opioid toxicity (1.6 per 100 000 population; 95% CI, -1.3 to 4.5 per 100 000 population; P = .26). Conclusions and Relevance Two years after its launch, the Safer Opioid Supply policy in British Columbia was associated with higher rates of safer supply opioid prescribing but also with a significant increase in opioid-related poisoning hospitalizations. These findings will help inform ongoing debates about this policy not only in British Columbia but also in other jurisdictions that are contemplating it.
Collapse
Affiliation(s)
- Hai V. Nguyen
- School of Pharmacy, Memorial University, St John’s, Newfoundland and Labrador, Canada
| | - Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- School of Pharmacy, Memorial University, St John’s, Newfoundland and Labrador, Canada
| | | |
Collapse
|
18
|
Fischer B, Robinson T, Jutras-Aswad D. Three noteworthy idiosyncrasies related to Canada's opioid-death crisis, and implications for public health-oriented interventions. Drug Alcohol Rev 2024; 43:562-566. [PMID: 38098180 DOI: 10.1111/dar.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/25/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023]
Abstract
Canada has been experiencing a prolonged public health-crisis of high rates of overdose deaths caused by exceptionally potent/toxic, illicit opioid use. While many key features of this drug death epidemic are well-documented, several idiosyncratic aspects with relevance for public health-oriented interventions are not adequately recognised. These include: (i) the discrepant opioid patterns pan-Canada, with large majorities of opioid deaths caused by illicit fentanyl drugs in Western, but not Eastern regions where prescription-type opioid prevail; (ii) the environments of overdose deaths, where vast majorities occur in 'residential' or other shelter-type settings, presenting barriers for emergency interventions rather than health protection; and (iii) shifting drug use modes, where now majorities of overdose deaths are associated with drug 'inhalation' (instead of 'injection') in contexts of potent/toxic drug supply. We briefly describe these factors and related implications for intervention programming towards an improved response to the drug death-crisis.
Collapse
Affiliation(s)
- Benedikt Fischer
- Research & Graduate Studies, University of the Fraser Valley, Abbotsford, Canada
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, Canada
| |
Collapse
|
19
|
Slaunwhite A, Min JE, Palis H, Urbanoski K, Pauly B, Barker B, Crabtree A, Bach P, Krebs E, Dale L, Meilleur L, Nosyk B. Effect of Risk Mitigation Guidance opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study. BMJ 2024; 384:e076336. [PMID: 38199614 PMCID: PMC10777271 DOI: 10.1136/bmj-2023-076336] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE To determine the effect of opioid and stimulant Risk Mitigation Guidance (RMG) dispensations on mortality and acute care visits during the dual public health emergencies of overdose and covid-19. DESIGN Population based retrospective cohort study. SETTING British Columbia, Canada. PARTICIPANTS 5882 people with opioid or stimulant use disorder who received RMG prescriptions for opioids (n=5356) and/or stimulants (n=1061) (535 received both) from 27 March 2020 to 31 August 2021. MAIN OUTCOME MEASURES All cause and overdose specific mortality and acute care visits in the week after RMG opioid or stimulant dispensation. RMG recipients were matched 1:1 with controls through use of high dimensional propensity score matching. Marginal structural models, executed on weekly time steps, were used to measure the effect of dispensations on outcomes. RESULTS RMG opioid dispensations of one day or more were associated with reduced all cause mortality (adjusted hazard ratio 0.39, 95% confidence interval 0.25 to 0.60) and overdose related mortality (0.45, 0.27 to 0.75) in the subsequent week. Dispensations of RMG stimulants (≥1 days) were not significantly associated with reduced all cause mortality (adjusted hazard ratio 0.50, 0.20 to 1.23) or overdose related mortality (0.53, 0.18 to 1.56). The protective effect of RMG opioid dispensations increased with the number of days the medications were dispensed in a given week. People who received four or more days of RMG opioid dispensations had reduced all cause mortality (adjusted hazard ratio 0.09, 0.04 to 0.21) and overdose related mortality (0.11, 0.04 to 0.32) compared with the control group. Opioid RMG dispensations did not significantly modify the odds of all cause or overdose related acute care visits. Dispensations of RMG stimulants were associated with a significant decrease in the odds of acute care visits for any cause but did not affect the odds of overdose related acute care visits. CONCLUSIONS RMG opioid dispensations were associated with reduced overdose related and all cause mortality among a sample of people with opioid use disorder. Pharmaceutical alternatives to the illegal drug supply are promising interventions to reduce mortality in people with opioid use disorder.
Collapse
Affiliation(s)
- Amanda Slaunwhite
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- BC Centre for Disease Control, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | - Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | - Heather Palis
- BC Centre for Disease Control, Vancouver, BC, Canada
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
- Department of Nursing, University of Victoria, Victoria, BC, Canada
| | - Brittany Barker
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
- First Nations Health Authority, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Alexis Crabtree
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Paxton Bach
- BC Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Emmanuel Krebs
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
- BC Cancer, Vancouver, BC, Canada
| | - Laura Dale
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | | | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| |
Collapse
|
20
|
Crowther D, Curran J, Somerville M, Sinclair D, Wozney L, MacPhee S, Rose AE, Boulos L, Caudrella A. Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review. PLoS One 2023; 18:e0294804. [PMID: 38100469 PMCID: PMC10723714 DOI: 10.1371/journal.pone.0294804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings. METHODS A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature. FINDINGS The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives. CONCLUSION This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.
Collapse
Affiliation(s)
- Daniel Crowther
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Janet Curran
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | - Mari Somerville
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | - Doug Sinclair
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | - Lori Wozney
- Mental Health and Addictions Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Shannon MacPhee
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | | | - Leah Boulos
- The Maritime Strategy for Patient Oriented Research SUPPORT Unit, Halifax, NS, Canada
| | - Alexander Caudrella
- Mental Health and Addictions Service, St Michael’s Hospital, Toronto, Ontario, Canada
| |
Collapse
|
21
|
Edmundson C, Croxford S, Emanuel E, Njoroge J, Ijaz S, Hope V, Phipps E, Desai M. Recent increases in crack injection and associated risk factors among people who inject psychoactive drugs in England and Wales. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104262. [PMID: 38030466 DOI: 10.1016/j.drugpo.2023.104262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/03/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Crack use is higher in the United Kingdom (UK) than other European countries. Crack is a stimulant with a short half-life, requiring frequent injection to maintain its euphoric effects, thus increasing the risk of blood borne viruses (BBVs) and skin and soft tissue infections (SSTIs). We assessed trends in the prevalence of current crack injection among people who inject drugs (PWID) and investigated harms and other factors associated with its use. METHODS We used data from the annual Unlinked Anonymous Monitoring Survey of PWID, which recruits people who have ever injected psychoactive drugs through specialist services. Participants provide a biological sample and self-complete a questionnaire. We included participants from England and Wales who had injected in the past month. We examined trends in crack injection over time (2011-2021) and factors associated with crack injection using multivariable logistic regression (2019-2021). RESULTS The proportion of people self-reporting crack injection in the past month almost doubled between 2011-2020/21, from 34 % (416/1237) to 57 % (483/850). Crack injection was more frequently reported by males than females (adjusted odds ratio 1.46, 95 % confidence interval: 1.15-1.87) and injected alongside heroin (6.67, 4.06-10.97) more frequently than alone. Crack injection was independently associated with injecting equipment sharing (1.64, 1.30-2.07), groin injection (2.03, 1.60-2.56) in the past month, overdosing in the past year (1.90, 1.42-2.53), homelessness in the past year (1.42, 1.14-1.77) and ever having hepatitis C infection (1.64, 1.31-2.06). CONCLUSION Crack injection has increased significantly over the past decade in England and Wales. People injecting crack are more likely to engage in behaviours that increase the risk of BBV and SSTI acquisition, such as needle/syringe sharing, groin injection and polydrug use. Harm reduction and drug treatment services should adapt to support the needs of this growing population of people injecting stimulants.
Collapse
Affiliation(s)
- Claire Edmundson
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK.
| | - Sara Croxford
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK; St Helens and Knowsley Teaching Hospitals NHS Trust, Warrington Rd, Rainhill, Prescot, L35 5DR, UK
| | - Eva Emanuel
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Jacquelyn Njoroge
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Samreen Ijaz
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Vivian Hope
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK; Public Health Institute, Liverpool John Moores University, Henry Cotton Building 15-21 Webster St, Liverpool, L3 2ET, UK
| | - Emily Phipps
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Monica Desai
- National Infection Service, UK Health Security Agency, 61 Colindale Avenue, London, NW9 5EQ, UK
| |
Collapse
|
22
|
Fischer B, Robinson T. "Safer Drug Supply" Measures in Canada to Reduce the Drug Overdose Fatality Toll: Clarifying Concepts, Practices and Evidence Within a Public Health Intervention Framework. J Stud Alcohol Drugs 2023; 84:801-807. [PMID: 37796625 PMCID: PMC10765983 DOI: 10.15288/jsad.23-00195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/25/2023] [Indexed: 10/07/2023] Open
Abstract
North America has been home to an unprecedented crisis of drug overdose deaths, driven largely by drug users' exposure to highly potent and toxic, illicit opioid drugs (e.g., fentanyl). Although a large and diverse menu of interventions (e.g., targeted prevention or treatment measures) has been implemented or expanded in Canada, these have not effectively managed to revert and reduce this excessive death toll. Given the fact that these interventions do not directly aim to address toxic drug exposure as the primary vector and cause of acute overdose deaths, public health-oriented "safer drug supply" measures have been initiated in local settings across Canada. These safer supply initiatives provide users with prescribed, pharmaceutical-grade drug supply with the aim of reducing overdose and death risks. These measures have been criticized but also misconstrued from several angles, e.g., as representing inadequate medical or even unethical and harmful practice. Related concerns regarding "diversion" have been raised. In this Perspective, we briefly address some of these issues and clarify selected issues of elementary concepts, practices, and evidence related to safer supply measures within a public health-oriented intervention framework. These measures are also discussed in reference to other, comparable types of public health-oriented emergency health or survival care standards, while considering the extreme contexts of an ongoing, acute drug death crisis in Canada.
Collapse
Affiliation(s)
- Benedikt Fischer
- Research and Graduate Studies, University of the Fraser Valley, Abbotsford, British Columbia, Canada
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
23
|
Schmidt RA, Kaminski N, Kryszajtys DT, Rudzinski K, Perri M, Guta A, Benoit AC, Bayoumi AM, Challacombe L, Hales J, Kenny K, Kolla G, O'Reilly E, Sereda A, Rai N, Strike C. 'I don't chase drugs as much anymore, and I'm not dead': Client reported outcomes associated with safer opioid supply programs in Ontario, Canada. Drug Alcohol Rev 2023; 42:1825-1837. [PMID: 37718646 DOI: 10.1111/dar.13745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/26/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION The ongoing opioid overdose crisis, which has killed over 30,000 people in Canada since 2016, is driven by the volatility of an unregulated opioid drug supply comprised primarily of fentanyl. The Canadian government has recently funded safer opioid supply (SOS) programs, which include off-label prescriptions of pharmaceutical-grade opioids to high risk individuals with the goal of reducing overdose deaths. METHODS In 2021, we examined the implementation and adaption of four SOS programs in Ontario. These programs use a primary care model and serve communities experiencing marginalisation. We conducted semi-structured interviews with program clients. We present the results of a thematic analysis with the aim of describing clients' self-reported impact of these programs on their health and well-being. RESULTS We interviewed 52 clients between June and October 2021 (mean age 47 years, 56% men, 17% self-identified Indigenous, 14% living with HIV). Our results indicate multifaceted pathways to improved self-reported health and well-being among clients including changes to drug use practices, fewer overdoses, reduced criminalised activity, improved trust and engagement in health care, and increased social stability (e.g., housing). DISCUSSION AND CONCLUSION Most clients reported that the intervention saved their life because of the reduced frequency of overdoses. Findings suggest that SOS programs improved clients' health outcomes and increase opportunities for engagement in health services. Our results provide insight into the mechanisms behind some of the emergent evidence on the impact of safer supply prescribing.
Collapse
Affiliation(s)
- Rose A Schmidt
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Nat Kaminski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - David T Kryszajtys
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Katherine Rudzinski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- School of Social Work, University of Windsor, Windsor, Canada
| | - Melissa Perri
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, Canada
| | - Anita C Benoit
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Health and Society, University of Toronto Scarborough, Scarborough, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Ahmed M Bayoumi
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | | | - Jessica Hales
- Regent Park Community Health Centre, Toronto, Canada
| | - Kathleen Kenny
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Emmet O'Reilly
- South Riverdale Community Health Centre, Toronto, Canada
| | | | - Nanky Rai
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Parkdale Queen West Community Health Centre, Toronto, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| |
Collapse
|
24
|
McCracken RK, Narayan S, Maclure M, Cooper I, Cui Z, Cullen W, Dormuth C, Hamilton MA, Nolan S, Singer J, Socías ME, Wong S, Klimas J. Evaluation of audit and feedback to family physicians on prescribing of opioid analgesics to opioid-naïve patients: A pragmatic randomized delay trial. Contemp Clin Trials 2023; 134:107354. [PMID: 37802223 DOI: 10.1016/j.cct.2023.107354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/29/2023] [Accepted: 10/01/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Exposure to opioid analgesics have historically raised concern for a risk of developing opioid use disorder. Prescriber audit-and-feedback interventions may reduce opioid prescribing, but some studies have shown detrimental effects for current users. We examined the effectiveness of an audit and feedback intervention, named Portrait, to reduce initiation of opioid analgesics among opioid-naïve patients experiencing pain. METHODS REDONNA was a single-blinded, two-arm (Early vs Delayed mailing) randomized trial of a portrait for eligible family physicians (FPs) in British Columbia (BC), Canada. The primary outcome was the change in the number of initiations of opioid analgesic prescriptions written by FPs for acute/chronic pain management. We compared outcomes for a 6-month window before vs. after each mailed intervention, using differences in percent differences (DPD) with 95% confidence intervals (CI) and odds ratios (OR) from logistic regressions adjusted for clustering of patients by FP. RESULTS In the Early (n = 2260) and Delayed (n = 2156) groups, opioid initiations per month were the same in the Before (2.10 Early; 2.06 Delayed) and After (1.94 Early; 1.95 Delayed) windows. The DPD was -2.1% (CI: -4.4% to 0.3%), and ORs were: 0.98 (CI: 0.96 to 1.01) for any opioid, 0.97 (CI: 0.94 to 1.01) for codeine (62% of initiations), and 1.0 (CI: 0.97 to 1.07) for tramadol (25% of initiations). There were no differences in mean quantity of tablets, mean milligrams of morphine equivalents (MME), or mean number of days. CONCLUSION Portrait had no impact on FPs' rates of prescribing opioid analgesics to opioid-naïve patients experiencing pain. TRIAL REGISTRATION The study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).
Collapse
Affiliation(s)
- Rita K McCracken
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, University of British Columbia, 570-1081 Burrard Street St. Paul's Hospital, Vancouver, BC V6Z IY6, Canada.
| | - Shawna Narayan
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada
| | - Malcolm Maclure
- Therapeutics Initiative, Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Ian Cooper
- Cummings School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Zishan Cui
- British Columbia Center on Substance Use, 400-1045 Howe St, Vancouver, BC V6Z 2A9, Canada
| | - Walter Cullen
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - Colin Dormuth
- Therapeutics Initiative, Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Michee-Ana Hamilton
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada
| | - Seonaid Nolan
- British Columbia Center on Substance Use, 400-1045 Howe St, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1 M9, Canada
| | - Joel Singer
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, 570-1081 Burrard Street St. Paul's Hospital, Vancouver, BC V6Z IY6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - M Eugenia Socías
- British Columbia Center on Substance Use, 400-1045 Howe St, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1 M9, Canada
| | - Sabrina Wong
- Centre for Health Services and Policy Research, University of British Columbia, 201-2206 East Mall, Vancouver, BC V6T 1Z3, Canada; School of Nursing, University of British Columbia, 211 Wesbrook Mall T201, Vancouver, BC V6T 2B5, Canada
| | - Jan Klimas
- Department of Family Practice, University of British Columbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada
| |
Collapse
|
25
|
Ferguson M, Sedgemore KO, Scow M, Choisil P, Haywood B, Xavier J, Crabtree A, Stitilis B, Liu L, Buxton JA. Preferred stimulant safer supply and associations with methamphetamine preference among people who use stimulants in British Columbia: Findings from a 2021 cross-sectional survey. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104186. [PMID: 37708585 DOI: 10.1016/j.drugpo.2023.104186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND As safer supply programs expand in Canada, stimulant safer supply is often overlooked despite the harms and criminalization faced by people who use stimulants. METHODS The 2021 Harm Reduction Client Survey was administered at 17 harm reduction sites around British Columbia, Canada. The survey included a question about what specific substance participants would want to receive as stimulant safer supply. We investigated preference of stimulant safer substance by looking at frequency of stated preference and by using multivariable logistic regression to understand factors associated with the most frequently chosen substance. RESULTS Of 330 participants who reported a stimulant safer supply preference, 58.5% (n = 193) chose crystal methamphetamine, 13% (n = 43) crack cocaine and 12.4% (n = 41) cocaine powder. The options that were available by prescription at the time of data collection were chosen by under 11% of participants (dextroamphetamine n = 21, methylphenidate n = 15). A preference for crystal methamphetamine was associated with being 29 and under compared to 50 and over (AOR: 3.96, 95% CI: 1.42-11.07, p-value: 0.01); self-identifying as a cis man versus a cis woman (AOR: 1.75, 95% CI: 1.03-2.97, p-value: 0.04); and using drugs every day (AOR: 15.43, 95% CI: 3.38-70.51, p-value: < 0.01) or a few times a week (AOR: 8.90, 95% CI: 1.78-44.44, p-value: 0.01) compared to a few times a month. CONCLUSIONS Preference of stimulant safer supply is associated with age, gender, and substance use characteristics. Safer supply programs that offer limited substances risk being poorly accessed, resulting in a continued reliance on an unregulated supply. Moreover, programs that do not offer a range of substances can contribute to health inequities.
Collapse
Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kali-Olt Sedgemore
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Marnie Scow
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Paul Choisil
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Beth Haywood
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jessica Xavier
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Alexis Crabtree
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Blake Stitilis
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Lisa Liu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
26
|
Karamouzian M, Rafat B, Kolla G, Urbanoski K, Atkinson K, Bardwell G, Bonn M, Touesnard N, Henderson N, Bowles J, Boyd J, Brunelle C, Eeuwes J, Fikowski J, Gomes T, Guta A, Hyshka E, Ivsins A, Kennedy MC, Laurence G, Martignetti L, Nafeh F, Salters K, Tu D, Strike C, Pauly B, Werb D. Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104157. [PMID: 37574645 DOI: 10.1016/j.drugpo.2023.104157] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase. METHODS We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research. RESULTS We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models). CONCLUSIONS Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.
Collapse
Affiliation(s)
- Mohammad Karamouzian
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Bijan Rafat
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Kate Atkinson
- Parkdale Queen West Community Health Centre, Toronto, ON, Canada
| | - Geoff Bardwell
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada; British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Matthew Bonn
- Canadian Association of People Who Use Drugs, Dartmouth, NS, Canada
| | | | - Nancy Henderson
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada; Peterborough 360 Degree Nurse Practitioner-Led Clinic, Peterborough, ON, Canada
| | - Jeanette Bowles
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Caroline Brunelle
- Department of Psychology, University of New Brunswick-Saint John campus, Saint John, NB, Canada
| | - Jolene Eeuwes
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Jill Fikowski
- Changemark Research + Evaluation, Vancouver, BC, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, ON, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Alberta, AB, Canada
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Mary Clare Kennedy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; School of Social Work, University of British Columbia (Okanagan Campus), BC, Canada
| | - Gab Laurence
- Parkdale Queen West Community Health Centre, Toronto, ON, Canada
| | - Lucas Martignetti
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Frishta Nafeh
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Kate Salters
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - David Tu
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada; Kilala Lelum, Urban Indigenous Health and Healing Co-operative, Vancouver, BC, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Bernadette Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
27
|
Small W, O'Callaghan S. Commentary on Brothers et al.: The role of safer environment interventions in addressing injecting-related bacterial and fungal infections. Addiction 2023; 118:1878-1880. [PMID: 37544882 DOI: 10.1111/add.16313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Will Small
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Sean O'Callaghan
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| |
Collapse
|
28
|
Olding M, Boyd J, Kerr T, McNeil R. "We just don't have the space for it": Geographies of survival and spatial triage in overdose prevention sites. Health Place 2023; 83:103067. [PMID: 37352615 PMCID: PMC10589902 DOI: 10.1016/j.healthplace.2023.103067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/22/2023] [Accepted: 06/10/2023] [Indexed: 06/25/2023]
Abstract
This study explores the role of Overdose Prevention Sites (OPS) within the geographies of survival of vulnerably housed people who use drugs (PWUD) in Vancouver, British Columbia (BC), Canada. In BC, OPS are low-barrier spaces where people may use drugs under monitoring of trained staff. OPS have been established by people who use drugs, activists, and allied organizations as an emergency measure to prevent overdose deaths. However, OPS have other important uses for PWUD who are vulnerably housed and rely on public spaces for survival. Drawing on two years (2018-2020) of ethnographic fieldwork and interviews with fifty-five people who work at and/or use OPS, we explore how OPS operators negotiated multiple and at times competing uses of service space for everyday survival. Data analysis was guided by critical urban theory to explore the place of OPS within PWUD's geographies of survival, with attention to how different uses of space were negotiated within the context of an illicit drug poisoning crisis and urban control practices that displace and exclude unhoused and vulnerably housed PWUD from the city. We find that OPS accommodated other important potential uses of space for unhoused and vulnerably housed PWUD who relied on public space for survival and were routinely displaced by revanchist urban control strategies. Low-barrier approaches and facility enhancements to OPS improved program accessibility and enabled PWUD to use the sites more broadly to meet survival needs including for mutual-aid, sheltering, and income-generation. However, these secondary uses of OPS presented multiple operational challenges as service volumes increased. We observed processes of 'spatial triage' emerge within sites to manage these challenges, which we characterise as a pragmatic set of rules, procedures, and spatial practices that constrained broader uses of OPS within PWUD's geographies of survival. While spatial triage offered a pragmatic way of prioritizing service delivery to address the most acute survival threats of overdose fatality, these practices had unintended and inequitable impacts on service access. Our findings indicate the need for complementary structural changes as part of overdose responses to reduce the need for spatial triage (i.e., safe, affordable housing and drug decriminalisation) and service innovations to mitigate potential harms (e.g., Expanded drop-in and chill spaces, temporary storage spaces for service user).
Collapse
Affiliation(s)
- Michelle Olding
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Dalla Lana School of Public Health, 155 College Street, Toronto, ON, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
29
|
Stahler GJ, Mennis J, Belenko S. At the Crossroads in the Opioid Overdose Epidemic: Will Evidence-Based "Radical" but Rational Drug Policy Strategies Prevail? Am J Public Health 2023; 113:747-749. [PMID: 37285573 PMCID: PMC10262258 DOI: 10.2105/ajph.2023.307320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Gerald J Stahler
- Gerald J. Stahler and Jeremy Mennis are with the Department of Geography and Urban Studies, Temple University, Philadelphia, PA. Steven Belenko is with the Department of Criminal Justice, Temple University
| | - Jeremy Mennis
- Gerald J. Stahler and Jeremy Mennis are with the Department of Geography and Urban Studies, Temple University, Philadelphia, PA. Steven Belenko is with the Department of Criminal Justice, Temple University
| | - Steven Belenko
- Gerald J. Stahler and Jeremy Mennis are with the Department of Geography and Urban Studies, Temple University, Philadelphia, PA. Steven Belenko is with the Department of Criminal Justice, Temple University
| |
Collapse
|
30
|
Mayer S, Boyd J, Fairbairn N, Chapman J, Brohman I, Jenkins E, McNeil R. Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 117:104054. [PMID: 37192557 PMCID: PMC10330495 DOI: 10.1016/j.drugpo.2023.104054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/18/2023] [Accepted: 04/30/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT. METHODS Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes. RESULTS Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment. CONCLUSION This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.
Collapse
Affiliation(s)
- Samara Mayer
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street. Vancouver, BC V6Z 1Y6, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street. Vancouver, BC V6Z 1Y6, Canada
| | - Jules Chapman
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada
| | - Isabella Brohman
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada
| | - Emily Jenkins
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall. Vancouver, BC V6T 2B5, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street. Vancouver, BC V6Z 1Y6, Canada; Internal Medicine, Yale School of Medicine, New Haven, 06510, United States; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, 06510, United States; Department of Anthropology, Yale University, New Haven, 06510, United States.
| |
Collapse
|
31
|
Gagnon M, Rudzinski K, Guta A, Schmidt RA, Kryszajtys DT, Kolla G, Strike C. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J 2023; 20:81. [PMID: 37380995 DOI: 10.1186/s12954-023-00817-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVES Fentanyl has contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses in Canada. It has also changed injection practices. Injection frequency has increased as a result and so has equipment sharing and health-related risks. The aim of this analysis was to explore the impact of safer supply programs on injection practices from the perspective of clients and providers in Ontario, Canada. METHODS The data set included qualitative interviews with 52 clients and 21 providers that were conducted between February and October 2021 across four safer supply programs. Interview excerpts discussing injection practices were extracted, screened, coded and then grouped into themes. RESULTS We identified three themes, each theme corresponding to a change in injection practices. The first change was a decrease in the amount of fentanyl used and a decrease in injection frequency. The second change involved switching to injecting hydromorphone tablets instead of fentanyl. Finally, the third change was stopping injecting altogether and taking safer supply medications orally. CONCLUSION Safer supply programs can contribute to reducing injection-related health risks in addition to overdose risks. More specifically, they have the potential to address disease prevention and health promotion gaps that stand-alone downstream harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.
Collapse
Affiliation(s)
- Marilou Gagnon
- School of Nursing, University of Victoria, Victoria, BC, Canada.
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Avenue, Victoria, BC, V8N 5M8, Canada.
| | | | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, ON, Canada
| | - Rose A Schmidt
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - David T Kryszajtys
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Avenue, Victoria, BC, V8N 5M8, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
32
|
Valasek C, Streuli SA, Pines HA, Strathdee SA, Borquez A, Bourgois P, Stamos-Buesig T, Vera CF, Harvey-Vera A, Bazzi AR. " A lotta people switched playing hard ball to playing Russian roulette": Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100154. [PMID: 37089868 PMCID: PMC10113744 DOI: 10.1016/j.dadr.2023.100154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/13/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023]
Abstract
Background People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic. Methods From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access. Results Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone. Conclusion Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.
Collapse
Affiliation(s)
- C.J. Valasek
- Associate Professor, Herbert Wertheim School of Public Health, University of California San Diego, 9500 Gilman Drive, MTF 265E (Mail Code 0725), La Jolla, San Diego, CA 92161, USA
| | - Samantha A. Streuli
- Associate Professor, Herbert Wertheim School of Public Health, University of California San Diego, 9500 Gilman Drive, MTF 265E (Mail Code 0725), La Jolla, San Diego, CA 92161, USA
| | - Heather A. Pines
- Associate Professor, Herbert Wertheim School of Public Health, University of California San Diego, 9500 Gilman Drive, MTF 265E (Mail Code 0725), La Jolla, San Diego, CA 92161, USA
- School of Public Health, San Diego State University, San Diego, CA, USA
| | | | - Annick Borquez
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Philippe Bourgois
- UCLA Semel Institute, University of California Los Angeles Center for Social Medicine, B7–435, Los Angeles, CA, USA
| | | | - Carlos F. Vera
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Alicia Harvey-Vera
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Angela R. Bazzi
- Associate Professor, Herbert Wertheim School of Public Health, University of California San Diego, 9500 Gilman Drive, MTF 265E (Mail Code 0725), La Jolla, San Diego, CA 92161, USA
- Boston University School of Public Health, Boston, MA, USA
| |
Collapse
|
33
|
Morris H, Bwala H, Wesley J, Hyshka E. Public support for safer supply programs: analysis of a cross-sectional survey of Canadians in two provinces. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2023; 114:484-492. [PMID: 36689127 PMCID: PMC9869824 DOI: 10.17269/s41997-022-00736-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/19/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Canada's ongoing drug poisoning crisis has contributed to unprecedented rates of morbidity and mortality. Health Canada has funded safer supply pilot programs to help connect people who use drugs to pharmaceutical grade medications that reduce their reliance on a toxic drug supply. However, most provinces, including Alberta and Saskatchewan, have not endorsed these initiatives. We explored public support for safer supply programs in these two Canadian provinces and identified predictors of support for this policy option. METHODS Cross-sectional data were examined from an online panel survey that included measures assessing views on policy responses to substance use and addiction. A total of 1602 adults were recruited during March 2021. We used descriptive statistics to characterize support for safer supply programs in Alberta and Saskatchewan and multinominal logistic regression analysis to examine predictors of public support for safer supply. RESULTS The majority of respondents (AB: 63.5% and SK: 56.3%) supported safer supply programs that replace illegal street drugs with pharmaceutical alternatives for those unable to stop using. Predicted probabilities show a greater probability of support for safer supply among those with higher education and those leaning left on the political spectrum. CONCLUSION A majority of Canadians from Alberta and Saskatchewan supported provincial government efforts to expand safer supply, suggesting a lack of public support is not the main barrier to implementation. Efforts at mobilizing this public opinion are needed to scale up and facilitate evaluation of this drug poisoning response.
Collapse
Affiliation(s)
- Heather Morris
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Hauwa Bwala
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Jared Wesley
- Faculty of Arts-Political Science Department, University of Alberta, Edmonton, AB, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
34
|
Foreman-Mackey A, Xavier J, Corser J, Fleury M, Lock K, Mehta A, Lamb J, McDougall J, Newman C, Buxton JA. "It's just a perfect storm": Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances. BMC Public Health 2023; 23:640. [PMID: 37013524 PMCID: PMC10069735 DOI: 10.1186/s12889-023-15474-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Despite the implementation and expansion of public health and harm reduction strategies aimed at preventing and reversing overdoses, rates of overdose-related events and fatalities continue to rise in British Columbia. The COVID-19 pandemic created a second, concurrent public health emergency that further exacerbated the illicit drug toxicity crisis, reinforced existing social inequities and vulnerabilities, and highlighted the precariousness of systems in place that are meant to protect the health of communities. By exploring the perspectives of people with recent experience of illicit substance use, this study sought to characterize how the COVID-19 pandemic and associated public health measures influenced risk and protective factors related to unintentional overdose by altering the environment in which people live and use substances, influencing the ability of people who use substances to be safe and well. METHODS One-on-one semi-structured interviews were conducted by phone or in-person with people who use illicit substances (n = 62) across the province. Thematic analysis was performed to identify factors shaping the overdose risk environment. RESULTS Participants pointed to factors that increased risk of overdose, including: [1] physical distancing measures that created social and physical isolation and led to more substance use alone without bystanders nearby able to respond in the event of an emergency; [2] early drug price spikes and supply chain issues that created inconsistencies in drug availability; [3] increasing toxicity and impurities in unregulated substances; [4] restriction of harm reduction services and supply distribution sites; and [5] additional burden placed on peer workers on the frontlines of the illicit drug toxicity crisis. Despite these challenges, participants highlighted factors that protected against overdose and substance-related harm, including the emergence of new programs, the resiliency of communities of people who use substances who expanded their outreach efforts, the existence of established social relationships, and the ways that individuals consistently prioritized overdose response over concerns about COVID-19 transmission to care for one another. CONCLUSIONS The findings from this study illustrate the complex contextual factors that shape overdose risk and highlight the importance of ensuring that the needs of people who use substances are addressed in future public health emergency responses.
Collapse
Affiliation(s)
- Annie Foreman-Mackey
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
- Faculty of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Jessica Xavier
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jenny Corser
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Mathew Fleury
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Faculty of Health Sciences, SFU, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
- First Nations Health Authority, 540-757 West Hastings St, Vancouver, BC, V6C 1A1, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Amiti Mehta
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- First Nations Health Authority, 540-757 West Hastings St, Vancouver, BC, V6C 1A1, Canada
| | - Jessica Lamb
- Professionals for Ethical Engagement of Peers, Peer Engagement and Evaluation Project, British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jenny McDougall
- Professionals for Ethical Engagement of Peers, Peer Engagement and Evaluation Project, British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Cheri Newman
- Professionals for Ethical Engagement of Peers, Peer Engagement and Evaluation Project, British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| |
Collapse
|
35
|
Cloud DH, Garcia-Grossman IR, Armstrong A, Williams B. Public Health and Prisons: Priorities in the Age of Mass Incarceration. Annu Rev Public Health 2023; 44:407-428. [PMID: 36542770 PMCID: PMC10128126 DOI: 10.1146/annurev-publhealth-071521-034016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mass incarceration is a sociostructural driver of profound health inequalities in the United States. The political and economic forces underpinning mass incarceration are deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people and is inextricably connected to labor exploitation, racial discrimination, the criminalization of immigration, and behavioral health problems such as mental illness and substance use disorders. This article focuses on major public health crises and advances in state and federal prisons and discusses a range of practical strategies for health scholars, practitioners, and activists to promote the health and dignity of incarcerated people. It begins by summarizing the historical and sociostructural factors that have led to mass incarceration in the United States. It then describes the ways in which prison conditions create or worsen chronic, communicable, and behavioral health conditions, while highlighting priority areas for public health research and intervention to improve the health of incarcerated people, including decarceral solutions that can profoundly minimize-and perhaps one day help abolish-the use of prisons.
Collapse
Affiliation(s)
- David H Cloud
- Center for Vulnerable Populations, San Francisco School of Medicine, University of California, San Francisco, California, USA;
- Rollins School of Public Health, Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - Ilana R Garcia-Grossman
- Center for Vulnerable Populations, San Francisco School of Medicine, University of California, San Francisco, California, USA;
| | - Andrea Armstrong
- College of Law, Loyola University New Orleans, New Orleans, Louisiana, USA
| | - Brie Williams
- Center for Vulnerable Populations, San Francisco School of Medicine, University of California, San Francisco, California, USA;
| |
Collapse
|
36
|
Giang K, Charlesworth R, Thulien M, Mulholland A, Barker B, Brar R, Pauly B, Fast D. Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 115:104023. [PMID: 37059025 PMCID: PMC10067449 DOI: 10.1016/j.drugpo.2023.104023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- Karen Giang
- Department of Family Practice, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Reith Charlesworth
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Madison Thulien
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Alanna Mulholland
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Vancouver Coastal Health Authority, 520 West 6(th) Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Brittany Barker
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Canadian Institute of Substance Use Research, 2300 McKenzie Avenue, Victoria, BC V8N 5M8, Canada
| | - Rupinder Brar
- Department of Family Practice, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Vancouver Coastal Health Authority, 520 West 6(th) Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Bernie Pauly
- Canadian Institute of Substance Use Research, 2300 McKenzie Avenue, Victoria, BC V8N 5M8, Canada; School of Nursing, University of Victoria, PO Box 1700 STN CSC, Victoria BC V8W 2Y2, Canada
| | - Danya Fast
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine (Division of Social Medicine), 317-2914 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada.
| |
Collapse
|
37
|
Dunn KE. Iteration is not solving the opioid crisis, it's time for transformation. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:151-158. [PMID: 36920881 DOI: 10.1080/00952990.2023.2170807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Opioid use disorder (OUD) produces exceedingly high rates of morbidity and mortality in the United States and throughout the world. Almost 90% of persons qualifying for treatment do not enter treatment and 72% of those who initiate treatment leave within 60 days. This Perspective posits that over the past decade our OUD treatment system has produced only small iterative gains in treatment access because, in part, it is founded in a series of top-down regulatory policies dating back more than 100 years. These policies prioritized restricting persons with OUD from having access to opioid agonists over empirical discovery of treatment best practice. It further suggests that for persons who are not already responding positively to our existing treatments, we may need to fundamentally transform care to enact true, meaningful change. Four potential considerations are outlined: expanding beyond long-acting opioids for treatment, embracing safe use as a viable therapeutic target, ending closed medication distribution systems, and partnering with our patients. The overarching aim of this discussion is to motivate broader thinking about new solutions for the patients for whom the existing strategies are not working and who may benefit from more transformative approaches. Though efforts to-date to expand existing treatment systems and find new ways to promote existing MOUDs have been important, these efforts have represented iterative changes. For us to meet our goal of substantially reducing opioid-related harms, it may be time to consider strategies that represent true transformation.
Collapse
Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
38
|
Rich KM, Solomon DA. Medical Complications of Injection Drug Use - Part II. NEJM EVIDENCE 2023; 2:EVIDra2300019. [PMID: 38320028 DOI: 10.1056/evidra2300019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Medical Complications of Injection Drug Use - Part IIDuring the past 2 decades, the risk of death, as well as the prevalence of hospitalizations in the United States, has increased substantially among people who inject drugs, mainly because of the opioid epidemic. In Part Two of this two-part review, the authors review complications observed in people who inject drugs and strategies to reduce harm.
Collapse
Affiliation(s)
| | - Daniel A Solomon
- Harvard Medical School, Boston
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston
| |
Collapse
|
39
|
Fischer B. The continuous opioid death crisis in Canada: changing characteristics and implications for path options forward. LANCET REGIONAL HEALTH. AMERICAS 2023; 19:100437. [PMID: 36950034 PMCID: PMC10025405 DOI: 10.1016/j.lana.2023.100437] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Benedikt Fischer
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- University of the Fraser Valley, Abbotsford, British Columbia, Canada
- School of Population Health, University of Auckland, Auckland, New Zealand
- Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
- Centre for Research in Mental Health and Addiction, Simon Fraser University Faculty of Health Sciences, Suite 2400, 515 West Hastings Street, Vancouver, British Columbia, V6B 5K3, Canada.
| |
Collapse
|
40
|
Abadie R. "The Drug Sellers Were Better Organized than the Government": A Qualitative Study of Participants' Views of Drug Markets during COVID-19 and Other Big Events. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1295. [PMID: 36674050 PMCID: PMC9859057 DOI: 10.3390/ijerph20021295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 06/17/2023]
Abstract
"Big events", such as wars, economic crises, pandemics, or natural disasters, affect the risk environment in which people use drugs. While the impact of big events on injection risk behaviors and access to drug-treatment services is well documented, less is known about the effects of big events on drug markets. Based on self-reporting data on drug availability among people who use drugs (PWUD) in the aftermath of Hurricane Maria in Puerto Rico and during the COVID-19 lockdown in a Midwestern US state, this study aims to document the effects of big events on drug markets. Qualitative data on the effects of Hurricane Maria on drug markets are based on participants' self-reporting (N = 31). Data collection started after the hurricane and ended in 2020. Data on changes to the drug supply during the COVID-19 lockdown were collected based on semi-structured interviews with PWUD (N = 40) in a Midwestern US state. Findings show that while the drug markets might have initially been affected by big events, most effects were temporary. Drug availability, pricing, and quality might have suffered some initial fluctuations but stabilized as the drug markets absorbed the initial shocks caused by the hurricane and the lockdown measures. In preparation for increasingly more frequent and virulent pandemics and natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also drug-related harms.
Collapse
Affiliation(s)
- Roberto Abadie
- School of Global Integrative Studies, University of Nebraska-Lincoln, Lincoln, NE 68588-0368, USA
| |
Collapse
|
41
|
Buchman DZ, Lo S, Ding P, Dosani N, Fazelzad R, Furlan AD, Isenberg SR, Spithoff S, Tedesco A, Zimmermann C, Lau J. Palliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelines. Palliat Med 2022; 37:426-443. [PMID: 36522840 PMCID: PMC9760505 DOI: 10.1177/02692163221143153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities. AIM To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs. DESIGN Scoping review. DATA SOURCES We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics. RESULTS Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma. CONCLUSIONS Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.
Collapse
Affiliation(s)
- Daniel Z Buchman
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada
| | - Samantha Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Philip Ding
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Naheed Dosani
- Department of Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Palliative Education And Care for the Homeless (PEACH), Inner City Health Associates, Toronto, ON, Canada.,Division of Palliative Care, McMaster University, Hamilton, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Rouhi Fazelzad
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Andrea D Furlan
- Toronto Rehab, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Work & Health, Toronto, ON, Canada
| | - Sarina R Isenberg
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Alissa Tedesco
- Palliative Education And Care for the Homeless (PEACH), Inner City Health Associates, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, ON, Canada.,Division of Palliative Care, University Health Network, Toronto, ON, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Division of Palliative Care, University Health Network, Toronto, ON, Canada
| |
Collapse
|
42
|
Korona-Bailey J, Mukhopadhyay S. Characteristics of fatal drug overdoses among college age decedents in Tennessee, 2019-2020. DIALOGUES IN HEALTH 2022; 1:100050. [PMID: 38515907 PMCID: PMC10953990 DOI: 10.1016/j.dialog.2022.100050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/02/2022] [Accepted: 09/25/2022] [Indexed: 03/23/2024]
Abstract
Purpose College age persons experienced unique disruptions to their regular lives during the COVID-19 pandemic, sometimes resulting in negative coping mechanisms. We examined changes in the number of and characteristics of college age fatal drug overdoses before and during the early COVID-19 pandemic. Methods We conducted a statewide cross-sectional study to determine the changes in the number and characteristics of college age fatal drug overdose decedents before and during the COVID-19 pandemic using 2019-2020 data from the Tennessee State Unintentional Drug Overdose Reporting System. We defined college age as 18-24 years. Frequencies and rates were generated to compare demographics, circumstances, and toxicology between 2019 and 2020. Results From 2019 to 2020, 336 college age persons experienced an unintentional or undetermined fatal drug overdose in Tennessee. Characteristics of college age decedents: mean age 21.7 years, 68.5% males, and 71.4% White. Rates of fatal overdoses among college age persons increased 50.0% overall, 150.1% for female decedents, and 141.7% for Black decedents. Fewer people were treated for substance use disorder or mental health conditions (p = 0.0243) in 2020. Conclusion This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts to curtail the overdose epidemic among college age persons in Tennessee.
Collapse
Affiliation(s)
- Jessica Korona-Bailey
- Tennessee Department of Health, Office of Informatics and Analytics, Andrew Johnson Tower 7 Floor, 710 James Robertson Parkway, Nashville, TN 37243, United States
| | - Sutapa Mukhopadhyay
- Tennessee Department of Health, Office of Informatics and Analytics, Andrew Johnson Tower 7 Floor, 710 James Robertson Parkway, Nashville, TN 37243, United States
| |
Collapse
|
43
|
A concept mapping study of service user design of safer supply as an alternative to the illicit drug market. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 110:103849. [PMID: 36215793 DOI: 10.1016/j.drugpo.2022.103849] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Within North America and worldwide, drug-related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply of illicit substances to reduce overdoses with hopes of replacing substances obtained from the illicit drug market. Drug users1 should be at the centre of program and policy decisions related to the development and implementation of safer supply. Yet, there is little empirical research that conceptualizes effective safer supply from their perspectives. METHOD Within a community based participatory approach to research, we conducted a concept mapping study to foreground the perspectives of drug users and develop a conceptual model of effective safer supply. Our team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The focused prompt developed by the team was: "Safe supply would work well if…" Sixty-three drug users participated in three rounds of focus groups as part of the concept mapping process, involving brainstorming, sorting, rating and naming of themes. RESULTS The concept mapping process resulted in six clusters of statements: 1) Right dose and right drugs for me; 2) Safe, positive and welcoming spaces; 3) Safer supply and other services are accessible to me; 4) I am treated with respect; 5) I can easily get my safer supply; and 6) Helps me function and improves my quality of life (as defined by me). The statements within each cluster describe key components central to an effective model of safer supply as defined by drug users. CONCLUSION The results of this study provide insights into key components of effective safer supply to inform planning and evaluation of future safer supply programs informed by drug user perspectives.
Collapse
|
44
|
Foreman-Mackey A, Pauly B, Ivsins A, Urbanoski K, Mansoor M, Bardwell G. Moving towards a continuum of safer supply options for people who use drugs: A qualitative study exploring national perspectives on safer supply among professional stakeholders in Canada. Subst Abuse Treat Prev Policy 2022; 17:66. [PMID: 36209227 PMCID: PMC9547673 DOI: 10.1186/s13011-022-00494-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/30/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Novel public health interventions are needed to address the toxic drug supply and meet the needs of people who use drugs amidst the overdose crisis. Safer supply - low-barrier distribution of pharmaceutical grade substances - has been implemented in some jurisdictions to provide safer alternatives to the unregulated drug supply, yet no studies to date have explored professional stakeholder perspectives on this approach. METHODS We used purposive sampling to recruit professional stakeholders (n = 17) from four locations in British Columbia, Ontario, and Nova Scotia, including program managers, executive directors, political and health authority representatives, and healthcare providers involved in the design, implementation, and/or operation of safer supply programs in their communities. Semi-structured, one-to-one interviews were conducted, and interview data were coded and analyzed using thematic analyses. RESULTS Participants defined safer supply as low-barrier access to substances of known quality and quantity, offered on a continuum from prescribed to a legal, regulated supply, and focused on upholding autonomy and liberation of people who use drugs. Stakeholders expressed support for safer supply but explained that current iterations do not meet the needs of all people who use drugs and that implementation is limited by a lack of willing prescribers, stigma towards people who use drugs, and precarity of harm reduction programs to political ideology. Stakeholders expressed strong support for wider-reaching approaches such as decriminalization, legalization, and regulation of substances as a way to fully realize a continuum of safer supply, directly address the overdose crisis and toxic drug supply, and ensure equity of access nationally. CONCLUSION The results of this study highlight the need for innovative strategies to address the overdose crisis and that safer supply has the potential to benefit certain people who use drugs. A one-size-fits-all approach is not sufficient and the perspectives of professional stakeholders should be considered alongside those of people who use drugs when designing and implementing future safer supply.
Collapse
Affiliation(s)
- Annie Foreman-Mackey
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081, V6Z 1Y6 Burrard Street, Vancouver, BC Canada
| | - Bernie Pauly
- grid.143640.40000 0004 1936 9465Canadian Institute on Substance Use Research, University of Victoria, 2300 McKenzie Avenue, V8P 5C2 Victoria, BC Canada ,grid.143640.40000 0004 1936 9465School of Nursing, University of Victoria, Box 1700 STN CSC, V8W 2Y2 Victoria, BC Canada
| | - Andrew Ivsins
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081, V6Z 1Y6 Burrard Street, Vancouver, BC Canada
| | - Karen Urbanoski
- grid.143640.40000 0004 1936 9465Canadian Institute on Substance Use Research, University of Victoria, 2300 McKenzie Avenue, V8P 5C2 Victoria, BC Canada ,grid.143640.40000 0004 1936 9465School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Road, V8P 5C2 Victoria, BC Canada
| | - Manal Mansoor
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada
| | - Geoff Bardwell
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 2A9 Vancouver, BC Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081, V6Z 1Y6 Burrard Street, Vancouver, BC Canada ,grid.46078.3d0000 0000 8644 1405School of Public Health Sciences, University of Waterloo, 200 University Ave. West, N2L 3G1 Waterloo, ON Canada ,grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, V6Z 1Y6 Vancouver, BC Canada
| |
Collapse
|
45
|
Guta A, Buchman DZ, Schmidt RA, Perri M, Strike C. Trauma-Informed Approaches in Healthcare Ethics Consultation: A Missing Element in Healthcare for People Who Use Drugs during the Overdose Crisis? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:68-70. [PMID: 35475957 DOI: 10.1080/15265161.2022.2055208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Adrian Guta
- School of Social Work, University of Windsor
| | - Daniel Z Buchman
- Centre for Addiction and Mental Health
- Dalla Lana School of Public Health, University of Toronto
- Joint Centre for Bioethics, University of Toronto
| | - Rose A Schmidt
- Centre for Addiction and Mental Health
- Dalla Lana School of Public Health, University of Toronto
| | - Melissa Perri
- Dalla Lana School of Public Health, University of Toronto
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto
| |
Collapse
|