The perspectives of people who use drugs regarding short term involuntary substance use care for severe substance use disorders

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study

BACKGROUND

Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community.

METHODS

Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes.

RESULTS

Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release.

CONCLUSIONS

OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.

"They are always focusing on the person who is doing the worst": Exploring how crisis shapes young people's pathways in and out of supportive housing in Vancouver, Canada

Housing instability, homelessness, and mental health among young people who use drugs in Vancouver, Canada, and elsewhere have increasingly been framed through a language of crisis. The declaration of overlapping housing, mental health, and addictions crises in our own setting has prompted a wide range of interventions, including the rapid expansion of supportive housing programs that include integrated housing-based substance use and mental health care. There is growing evidence demonstrating that these models are effective at stabilizing people who are experiencing protracted housing instability, mental health, and substance use related health concerns. We recount stories of three young people who have lived in supportive housing to argue that achieving the relative stability afforded by these interventions is partially contingent on maintaining a delicate balance between being in a state of "too much" or "too little" in crisis. These stories demonstrate two key findings. First, being in crisis has made these young people visible to housing, substance use, and mental health programs that may not otherwise be available to them. Secondly, entering periods of protracted or intense mental health crisis may reopen pathways into unstable housing and homelessness by activating undesirable institutional responses that conflict with young people's desire for self-determination in relation to their care. This study underscores that supportive housing should be part of a broader youth focused system of housing and care that seeks to address the needs of young people before they enter states of crisis.

"Grasping at straws," experiences of Canadian parents using involuntary stabilization for a youth's substance use

BACKGROUND

In Canada, involuntary stabilization programs are used to apprehend and confine youth who use drugs for the purpose of stabilization, assessment, and discharge planning. In the Canadian province of Alberta, the Protection of Children Using Drugs (PChAD) act allows parents to apply for involuntary stabilization of their children for up to 15 days. Given that research on involuntary stabilization programs is scarce, this qualitative study was designed to explore parents' experiences with PChAD and their perceptions of the program's benefits and drawbacks.

METHODS

We conducted semi-structured interviews with 18 parents who had used PChAD for their children between 2007-2018. Interviews were conducted between 2019-2020 and were analyzed inductively using Interpretive Phenomenological Analysis.

RESULTS

Most parents sought involuntary stabilization because they were desperate to protect their child's health and safety, or to motivate them to reduce their substance use. Many also felt lost and overwhelmed because their child was unwilling to attend voluntary treatment, and they lacked professional guidance as to how to care for their child. Consequently, many parents used involuntary stabilization because they did not know what else to do. While some parents were grateful to have their child temporarily safe, many were disappointed because involuntary stabilization had little impact on their child's substance use. Parents also felt they did not receive sufficient support in coordinating their child's care following involuntary stabilization. Parents identified several risks of involuntary stabilization, such as angering the youth and undermining trust, and exposing them to negative peer influences.

IMPLICATIONS

It is important for policymakers and clinicians to carefully consider whether the immediate benefits of keeping youth safe are worth the potential risks. Efforts are needed to provide families with greater guidance and support, and to ensure coordinated access to a continuum of voluntary services, including treatment and harm reduction.

Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018

INTRODUCTION

Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018.

METHOD

We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender.

RESULTS

Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15-24 (162%) and men ages 15-34 (81%) and 85 and older (106%).

CONCLUSION

Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications.

A pilot study of a mixed-method approach to design an ED-based peer mHealth referral tool for HIV/HCV and opioid overdose prevention services

BACKGROUND

The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings.

METHODS

A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated 'patient to peer social network referral program' for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19).

RESULTS

Overall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives.

CONCLUSION

ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

The association between involuntary alcohol treatment and subsequent emergency department visits and hospitalizations: a Bayesian analysis of treated patients and matched controls

BACKGROUND AND AIMS

Many nations have provisions for involuntary treatment of alcohol dependence where the person is at serious risk of harm to themselves. To date, there has been little thorough evaluation of its effectiveness. This study aimed to determine if there were differences between involuntary and voluntary treatment for alcohol dependence on subsequent emergency and hospital care.

DESIGN

A retrospective cohort design using linked routinely collected administrative data on health-care utilization.

SETTING

Hospital and community-based alcohol treatment, New South Wales, Australia.

PARTICIPANTS

A total of 231 patients who were involuntarily treated for alcohol dependence and 231 matched controls who received treatment as usual within the period May 2012 to April 2018.

INTERVENTION AND COMPARATOR

Involuntary treatment comprised a 28-day mandated hospital admission which included supervised withdrawal, comprehensive assessment, rehabilitation and support followed by voluntary aftercare support for up to 6 months. Treatment as usual comprised three not mutually exclusive forms of intensive voluntary alcohol treatment: withdrawal management, rehabilitation and pharmacotherapies for alcohol dependence.

MEASUREMENTS

Outcome measures: changes in the number of emergency department (ED) visits and number of unplanned hospital admissions 12 months before and 12 months after completion of index treatment.

FINDINGS

Both groups showed a reduction in ED visits (incidence rate ratio (IRR) = 0.56, 95% credible intervals (CrI) = 0.39-0.78) and unplanned hospital admissions (IRR = 0.49, 95% CrI = 0.37-0.65). There was no statistically significant difference between the two groups (IRR = 0.77, 95% CrI = 0.58-1.03 for ED visits and IRR = 0.79, 95% CrI = 0.62-1.01 for hospital admissions). The Bayes factors were 0.925 and 0.936 for ED visits and unplanned hospital admissions, respectively, interpreted as weak evidence in support of the null hypothesis of no difference between the interventions.

CONCLUSIONS

Involuntary treatment of alcohol dependence was associated with reduced health service utilization in the year following treatment, and the outcomes did not differ from those of a matched control group.