Characterizing peer roles in an overdose crisis: Preferences for peer workers in overdose response programs in emergency shelters

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

BACKGROUND

Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.

METHODS

Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.

RESULTS

Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.

CONCLUSION

Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.

The emergence of innovative cannabis distribution projects in the downtown eastside of Vancouver, Canada

The ongoing overdose crisis in the United States and Canada has highlighted the urgent need for innovative interventions to reduce drug-related harms. This, in turn, has led to increased interest in the potential of cannabis as a harm reduction strategy. While Canada has recently legalized cannabis, meaningful barriers to accessing legal cannabis remain for people who use drugs (PWUD) from marginalized communities. In the Downtown Eastside of Vancouver, Canada, innovative, grassroots cannabis distribution programs that dispense cannabis and cannabis products from unregulated sources to PWUD for free have recently emerged. In this study, we draw upon 23 in-depth qualitative interviews and ethnographic fieldwork with PWUD who access these programs. We found that these distribution programs play an important function in bridging access to cannabis for PWUD in a structurally disadvantaged neighborhood and do so by implementing few restrictions on who can access, providing a variety of cannabis products that would otherwise be inaccessible, and distributing cannabis at no cost. In addition, many people reported the program spaces provided an avenue to socialize and connect. Most of our participants reported that legal cannabis was inaccessible both through the legal medical and non-medical systems. Considering Canadian governments have made important regulatory changes in regards to cannabis, understanding emerging patterns and the structural barriers to accessing legal cannabis will be critical to maximizing the potential uses of cannabis as a harm reduction tool and ensuring equitable access to structurally disadvantaged populations. Examining the impact of cannabis use on PWUD and ensuring these groups have access to cannabis is an important component in determining whether cannabis deregulation reduces drug-related harms.

"Am I gonna get in trouble for acknowledging my will to be safe?": Identifying the experiences of young sexual minority men and substance use in the context of an opioid overdose crisis

BACKGROUND

North America and other parts of the globe are in the midst of a public health emergency related to opioid overdoses and a highly contaminated illicit drug supply. Unfortunately, there is a substantial gap in our understandings about how this crisis affects key populations not conventionally identified within overdose-related surveillance data. This gap is particularly pronounced for gay, bisexual, and other men who have sex with men (sexual minority men)-a population that experiences substance use-related inequities across adolescence and young adulthood.

METHODS

We draw on in-depth semi-structured interviews conducted in 2018 with a diverse sample (N = 50) of sexual minority men ages 15-30 who use substances and live in Vancouver, Canada, to identify how patterns and contexts of substance use are occurring in the context of the opioid overdose crisis.

RESULTS

Our analysis revealed three themes: awareness, perceptions, and experiences of risk; strategies to mitigate risk; and barriers to safer substance use. First, participants described how they are deeply impacted by the contaminated illicit drug supply, and how there is growing apprehension that fatal and non-fatal overdose risk is high and rising. Second, participants described how procuring substances from "trustworthy" drug suppliers and other harm reduction strategies (e.g., drug checking technologies, Naloxone kits, not using alone) could reduce overdose risk. Third, participants described how interpersonal, service-related, and socio-structural barriers (e.g., drug criminalization and the lack of a regulated drug supply) limit opportunities for safer substance use.

CONCLUSIONS

Equity-oriented policies and programming that can facilitate opportunities for safer substance use among young sexual minority men are critically needed, including community- and peer-led initiatives, access to low-barrier harm reduction services within commonly frequented social spaces (e.g., Pride, night clubs, bathhouses), nonjudgmental and inclusive substance use-related health services, the decriminalization of drug use, and the provision of a safe drug supply.

Police-related barriers to harm reduction linked to non-fatal overdose amongst sex workers who use drugs: Results of a community-based cohort in Metro Vancouver, Canada

BACKGROUND

High rates of overdose and overdose-related mortality in North America represent a pressing health and social concern. Women sex workers face severe health and social inequities, which have been linked to structural factors including negative police interactions; however, little is known regarding the burden of overdose or how policing impacts overdose risk amongst sex workers who use drugs. Given this, we aimed to explore the independent effects of experiencing police-related barriers to harm reduction on non-fatal overdose amongst women sex workers who use drugs in Metro Vancouver, Canada over a 7.5-year period.

METHODS

Data were drawn from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women sex workers in Metro Vancouver, from 2010 to 2017. Using multivariate logistic regression with generalized estimating equations (GEE), we used a confounder modeling approach to identify the independent effect of experiencing police-related barriers to harm reduction strategies on non-fatal overdose amongst sex workers using drugs within the last six months at each study visit.

RESULTS

Amongst 624 participants, 7.7% overdosed within the last six months at baseline and 27.6% overdosed during the study period, contributing 287 non-fatal overdose events over the 7.5-year period. 68.6% reported police-related barriers to harm reduction strategies during the study. In a multivariate confounder model, exposure to police-related barriers to harm reduction strategies [AOR: 2.15, CI: 1.60-2.90] was independently associated with higher odds of non-fatal overdose after adjustment for key confounders.

CONCLUSIONS

Our findings suggest that in the context of the current overdose crisis, adversarial policing practices may undermine access to lifesaving overdose prevention services and exacerbate overdose risks for marginalized women. Findings underscore the urgent need to scale-up access and remove barriers to progressive harm reduction strategies for women sex workers.

Reducing harm and promoting recovery through community-based mutual aid: Characterizing those who engage in a hybrid peer recovery community organization

BACKGROUND

Peer-based support services are often used within harm reduction organizations, and more recently within recovery community organizations (RCO). Identifying the characteristics of individuals who engage with these novel RCOs is needed. Additionally, conducting collaborative research with communities of people who use drugs (PWUD) or are in recovery is an effective and rewarding approach that allows individuals to take ownership and play a critical role in the study.

METHODS

This exploratory study employs a community-based participatory research (CBPR) framework in partnership with a peer-led hybrid recovery community organization, Rebel Recovery, in Florida. Peer staff participated in all phases of the study, helping to inform the study protocol, data collection, analysis, interpretation, and results write-up. A cross-sectional survey instrument was used to collect consumer intake data. Pearson Chi-square tests and multivariate binomial logistic regressions were used to examine relationships between consumer characteristics and service utilization.

RESULTS

Consumers (n = 396) of Rebel Recovery peer support services had a mean age of 35.60 years (SD = 9.74). Many were experiencing homelessness (35.4%), unemployed (69.7%), high school graduates or GED holders (68.2%) and had a last year income of less than $10,000 (58.3%). The majority were users of heroin primarily (70.7%), with intravenous use being the preferred route of administration (63.9%). Exploratory analysis found that gender, marital status, and involvement in the child welfare system were significantly related to primary substance of use. Past 30-day engagement in recovery meetings had several statistically significant predictors including primary substance of use, age, housing status, annual income level, past-30-day arrests, tobacco use, and alcohol harm perception. Process findings from the CBPR methods used reconfirm the value of including peers in research involving PWUD and individuals in recovery.

CONCLUSIONS

Results suggest that peer-based support services at a hybrid recovery community organization can successfully engage populations that are often underserved (i.e., experiencing homelessness, involved in drug court, intravenous users, etc.). Significant relationships identified in the exploratory analysis suggest that additional education concerning overdose and the potential benefits of recovery meetings may be useful for specific consumers. Additionally, several recommendations and benefits of engaging in community-based participatory research with peer-led organizations are made for future research.

A scoping review of post opioid-overdose interventions

INTRODUCTION

Nonfatal opioid overdose is a significant risk factor for subsequent fatal overdose. The time after a nonfatal overdose may provide a critical engagement opportunity to both reduce subsequent overdose risk and link individuals to treatment. Post-overdose interventions have emerged in affected communities throughout the United States (US). The objective of this scoping review is to identify US-based post-overdose intervention models (1) described in peer-reviewed literature and (2) implemented in public health and community settings.

METHODS

Using the adapted PRISMA Checklist for Scoping Reviews, we searched PubMed, PsychInfo, Academic OneFile, and federal and state databases for peer-reviewed and gray literature descriptions of post-overdose programs. We developed search strings with a reference librarian. We included studies or programs with at least the following information available: name of program, description of key components, intervention team, and intervention timing.

RESULTS

We identified a total of 27 programs, 3 from the peer-reviewed literature and 24 from the gray literature. 9 programs operated out of the ED, while 18 programs provided post-overdose support in other ways: through home or overdose location visits, mobile means, or as law enforcement diversion. Commonly, they include partnerships among public safety and community service providers.

CONCLUSIONS

Programs are emerging throughout the US to care for individuals after a nonfatal opioid overdose. There is variability in the timing, components, and follow-up in these programs and little is known about their effectiveness. Future work should focus on evaluation and testing of post-overdose programs so that best practices for care can be implemented.

The intersectional risk environment of people who use drugs

Current conceptual models for examining the production of risk and harm (e.g. syndemics, 'risk environment') in substance use research have been fundamental in emphasizing broader environmental factors that shape health outcomes for people who use drugs (PWUD). However, the application of these frameworks in ways that highlight nuance and complexity has remained challenging, with much of this research focusing on select social positions (e.g. race, gender) and social-structural factors (e.g. poverty, drug policies). It is crucial that we move to better accounting for these relations in the context of substance use research to enhance equity in research and ensure understanding of diverse and complex needs. Building on the risk environment framework and complementary approaches, this article introduces the 'intersectional risk environment' as an approach to understanding the interconnected ways that social locations converge within the risk environment to produce or mitigate drug-related outcomes. This framework integrates a relational intersectional lens to examine how differential outcomes across populations of PWUD are produced in relation to social location and processes operating across social-structural dimensions. In doing so, the intersectional risk environment highlights how outcomes are products of processes and relations that are embodied, reflected, and challenged while situated within social, historical, and geographic contexts. Incorporating this framework into future research may improve understandings of health outcomes for PWUD and better orient structural interventions and public health approaches to address differential risks and experiences of PWUD.

Fentanyl and Drug Overdose: Perceptions of Fentanyl Risk, Overdose Risk Behaviors, and Opportunities for Intervention among People who use Opioids in Baltimore, USA

BACKGROUND

Fentanyl-related mortality has skyrocketed among people who use opioids (PWUO) in North America. The current study of PWUO aims to examine the perceived fentanyl risk and training needs; fatal overdose prevention behaviors; and, feasibility of a peer education approach to reducing fentanyl-related fatal overdoses in Baltimore, Maryland, USA.

METHODS

316 street-recruited PWUO were interviewed about fentanyl in Baltimore, MD.

RESULTS

Most participants (56%) reported that "all" or "almost all" heroin in Baltimore was adulterated with fentanyl and were worried (75%) about their drug buddies overdosing on fentanyl. Half (54%) the participants felt that they needed more training to respond to an overdose. Many participants (66%) reported receiving naloxone or a prescription for it, yet only 17% carried naloxone with them "often" or "always." Among people who inject drugs (PWID) only 13% had naloxone available "often" or "always" when they injected with others, and 51% "often" or "always" injected alone. Almost half of participants (47%) were "very willing" to talk with people in their neighborhood about fentanyl.

CONCLUSIONS

The majority of PWUO perceived that most heroin in Baltimore was adulterated with fentanyl, yet most did not carry naloxone and PWID often did so alone. Given the high perceived risk of fentanyl and relatively low uptake of fatal overdose prevention behaviors, there is an urgency for safe injection facilities, access to medically assisted treatment, and programs that work with the drug-using community to deliver overdose prevention training as well as promote behaviors to carry naloxone and not use drugs alone.

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

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

Negotiating space & drug use in emergency shelters with peer witness injection programs within the context of an overdose crisis: A qualitative study

Vancouver, Canada is experiencing an overdose crisis due to the proliferation of fentanyl and related analogues and novel overdose response interventions are being implemented across multiple high overdose risk environments, including emergency shelters. We draw on ethnographic fieldwork and qualitative interviews to examine how social, structural, and physical contexts at two emergency shelters implementing a peer-based supervised injection intervention influenced injection drug use and overdose risks. Findings reveal that the implementation of this intervention reduced stigma and shame through the normalization of drug use in shelter spaces, and yet underlying social norms and material constraints led people to inject alone in non-designated injecting spaces. Whereas these spatial dynamics of injection drug use potentially increased overdose vulnerability, an emerging sense of collective responsibility in relation to the overdose crisis led to the routinization of peer witnessing practices across the shelter environment to extend the impact of the intervention.