"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

Patterns of opioid toxicity deaths after the implementation of COVID-19 emergency measures in Ontario, Canada: a weekly interrupted time series

BACKGROUND

In March 2020, Ontario, Canada, implemented COVID-19 public health measures, including school and non-essential business closures, physical distancing, border restrictions, and modified health services. We examined their association with changes in opioid toxicity mortality and assessed variations across age, sex, health region, and drug type.

METHODS

We conducted an interrupted time series using opioid toxicity death records (March 2019 to February 2021) from the Office of the Chief Coroner for Ontario. Using a generalized linear model (Poisson or negative binomial), we estimated changes in weekly death counts following the first (March 17th to May 19th, 2020) and second (November 23rd, 2020, to February 14th, 2021) lockdowns, as well as the entire post-COVID-19 period, modelling interventions as level shifts in opioid toxicity deaths.

RESULTS

Of 3844 individuals who died within the study period, 74.4 % were male, and the median age was 40 (interquartile range: 31 to 51). Weekly deaths ranged from 9 to 72. Following the province-wide state of emergency and first lockdown, there was a step increase in the number of deaths, with an estimated Rate Ratio (RR) of 1.21 (95 % CI 1.02 to 1.52). Over the duration of the post-COVID-19 period, an overall sustained increase in the number of opioid toxicity deaths (RR 1.11 [95 % CI 1.02 to 1.41]) was observed across the province.

IMPLICATIONS

The period after initial COVID-19 measures was associated with increases in opioid toxicity mortality. Future responses to public health emergencies must proactively mitigate the potential unintended consequence of toxic drug-related harms among substance-using populations.

"Basically every safety protocol we have in place to protect against overdose, parents can't access": Mothers who use unregulated drugs' experiences of dual public health emergencies

BACKGROUND

A growing body of research details the impacts of COVID-19 pandemic-related public health directives and service disruptions on people who use unregulated drugs, however, there is limited research on the gendered impacts, particularly among mothers.

METHODS

To explore experiences navigating the COVID-19 pandemic during a toxic drug crisis, phone-based semi-structured interviews were conducted from May 2020-Sept. 2021 with 45 women who use unregulated drugs in British Columbia. Iterative-based thematic analysis informed by intersectional theory identified unaccounted for impacts on parents.

FINDINGS

Respondents' experiences of the COVID-19 pandemic involved contending with an increasingly toxic drug supply alongside reduced resources, including service reductions and closures and reduced access to harm reduction supplies in a context already marked by women's marginalization within treatment and policy. Mothers described pandemic-related increased custody and care barriers and burdens, resulting in inability to prioritize self-care. Decisions to prioritize associated risks of either COVID-19 or drug toxicity, given conflicting public health guidelines, were experienced as high stakes for mothers, due to their unique vulnerability to institutional scrutiny. Pandemic-informed overdose risk mitigations, such as access to legal pharmaceutical-grade alternatives to the toxic drug supply, also involved additional risks for mothers (e.g., heightened monitoring; child apprehension), thus, some respondents, responsibilized for their health and childcare, resourcefully relied upon informal, social networks to help mitigate potential harms.

CONCLUSION

While mothers and their experiences are heterogeneous, gendered distinctions impact provision and experience of health care, harm reduction and social supports. Mothers who use drugs must navigate health and care responsibilities, exacerbated by pandemic-related health barriers, while simultaneously inhabiting an unremitting state of fear of punitive measures or postapprehension despair. The continued social exclusion of mothers who use drugs, propelled by moralizing discourses framing them as deviant and consequentially undeserving, can have devastating health impacts (on individuals and communities) yet remain underaddressed.

'It just doesn't stop': Perspectives of women who use drugs on increased overdoses during the COVID-19 pandemic

INTRODUCTION

In Canada, the COVID-19 pandemic collided with an ongoing overdose crisis driven by a toxic unregulated drug supply. Public health guidance intended to limit transmission of COVID-19 (e.g., social distancing) directly contradicted guidance responding to the ongoing overdose crisis (e.g., never use drugs alone), exacerbating harms among people reliant on the toxic unregulated drug supply. While existing literature characterises many harms associated with consuming unregulated drugs during COVID-19, less is known about the specific impacts on women. We explored the perspectives of women who use unregulated drugs and experienced socio-economic marginalisation on how the COVID-19 environment shaped their overdose risk in British Columbia, Canada.

METHODS

We conducted semi-structured interviews remotely with 45 participants between May 2020 and September 2021, and analysed the data thematically using a social violence framework.

RESULTS

Participants identified contamination of the unregulated drug supply, particularly with benzodiazepines, as a significant driver of overdose and gendered violence among women who use drugs. 'Social distancing' guidelines (e.g., guest restrictions in supportive housing, reduced capacity in harm reduction services) compounded these risks and resulted in more women using drugs alone, reducing opportunities for timely overdose intervention. In response, participants practiced individualised acts of caregiving (e.g., establishing informal networks that regularly check on each other) to mitigate the risks of overdose and gendered violence for themselves and their community.

DISCUSSION AND CONCLUSIONS

These intersecting health crises perpetuated individualised approaches to addressing the risks of overdose and gendered violence, rather than addressing underlying social and structural drivers of these risks.

Impacts of the COVID-19 pandemic on supervised consumption service delivery in Vancouver and Surrey, Canada from the perspective of service providers

Following the onset of the COVID-19 pandemic, an ever-increasing number of people have died from the toxic drug supply in Canada. Emerging evidence suggests that reduced access to harm reduction services has been a contributing factor. However, the precise impacts of the pandemic on supervised consumption service (SCS) delivery have not been well characterized. The present study sought to explore the impacts of the pandemic on SCS delivery in Vancouver and Surrey, Canada. Between October 2021 and March 2022, in-depth, semi-structured interviews were conducted with staff from two SCS: SafePoint in Surrey (n = 12) and Insite in Vancouver (n = 9). Thematic analysis focused on key changes to SCS delivery after the emergence of the COVID-19 pandemic, with a focus on associated challenges and emergent staff responses. Participants described key challenges as: capacity restrictions hindering service access and compromising care quality; exclusion of frontline staff perspectives from evolving SCS policy and practice decision-making; intensified power dynamics between staff and service users; and modified overdose response procedures, combined with a rise in complex overdose presentations, undermining service accessibility and quality. Emergent staff responses to these challenges included: collective staff organizing for changes to policy; individual frontline staff non-compliance with emerging policies; and staff experiencing burnout in their roles. This study highlights how COVID-19-related changes to service delivery produced challenges for SCS staff and service users, while identifying strategies employed by staff to address these challenges. Additionally, the findings point to opportunities to improve care for people who use drugs during intersecting public health crises.

Navigating the COVID-19 Risk Environment, Overdose Prevention, and Self Care Practices of People Who Use Illicit Opioids in New York City

BACKGROUND

The concurrent opioid overdose crisis and COVID-19 pandemic created a perfect storm of risk for drug overdose mortality and other negative health outcomes.

METHODS

This study is based on semi-structured interviews with 29 adults in New York City who were using illicit opioids (heroin, fentanyl, and prescription opioids without prescription) between April and September 2020 to gain their perspectives on navigating COVID as the pandemic was unfolding. Interviews explored both challenges posed by the pandemic and participants' navigation of these challenges to prevent overdose, procure drugs, manage drug use, and maintain their health and safety.

RESULTS

Participants tried to adhere to best public health policies and practices and adapted as needed to protect their own and others' health. They procured larger amounts of drugs to reduce travel, arranged drop-offs, and adhered to social distancing mandates during transactions. Homeless participants formed supportive and protective "bubbles" with network members to ensure safety and maximize resources. Participants addressed service access challenges by stockpiling MOUD, injection equipment and naloxone and reported using drugs when protected by naloxone and someone to administer when possible.

CONCLUSIONS

Despite the many challenges posed by COVID to people who use drugs in NYC, this research documents the ways people who use drugs drew on experiences of navigating stigma, structural violence, and social exclusion on a daily basis to enhance self-care and harm reduction practices. Powerful narratives of adaptation and resilience speak to the need to include people who use drugs in future public health and disaster planning initiatives.

Impacts of the COVID-19 pandemic on the availability and retail price of unregulated drugs in Vancouver, Canada: An interrupted time-series analysis, 2018-2022

BACKGROUND

Impacts of the COVID-19 pandemic on unregulated drug markets in North America have not been well characterized. We sought to estimate potential changes in the availability and retail price of unregulated drugs in Vancouver, Canada pre- vs. post-emergence of the COVID-19 pandemic.

METHODS

We used self-report data from two prospective cohorts of people who use drugs in Vancouver. We employed interrupted time series analyses to identify changes in the monthly prevalence of immediate availability (i.e., within 10 minutes vs. any longer) and median retail price of crystal methamphetamine, powder cocaine, crack cocaine, and 'down' (the local term for unregulated opioids, e.g., heroin, fentanyl, etc), post-pandemic emergence (i.e. post-July 2020).

RESULTS

Between 2018 and 2022 among 739 participants, the monthly prevalence of immediate availability significantly decreased for all drugs immediately post- emergence of the pandemic (all p<0.05). The monthly prevalence of immediate availability of cocaine declined most (-18.1%, 95% confidence interval [CI]: -25.9, -10.4) and the immediate availability of 'down' declined least (-13.0%, 95% CI:-18.8, -7.3). In analyses of median price, the only significant change was in the price of cocaine, which increased by $3.46 per 0.5 grams (95% CI:1.0, 5.9) immediately post-emergence of the pandemic.

CONCLUSION

While more research is needed to investigate reasons for the observed trends, the stagnant price amidst decreased availability for all drugs examined in this study (save cocaine) may reflect decreased purity/increased contamination of unregulated drugs following the beginning of the pandemic in our study setting. These findings may have implications for drug policy and practice approaches, particularly in regions where synthetic psychoactive substances are increasingly dominating the unregulated drug supply.

The impact of the COVID-19 pandemic on people who use drugs in three Canadian cities: a cross-sectional analysis

BACKGROUND

The COVID-19 pandemic had a disproportionate impact on the health and wellbeing of people who use drugs (PWUD) in Canada. However less is known about jurisdictional commonalities and differences in COVID-19 exposure and impacts of pandemic-related restrictions on competing health and social risks among PWUD living in large urban centres.

METHODS

Between May 2020 and March 2021, leveraging infrastructure from ongoing cohorts of PWUD, we surveyed 1,025 participants from Vancouver (n = 640), Toronto (n = 158), and Montreal (n = 227), Canada to describe the impacts of pandemic-related restrictions on basic, health, and harm reduction needs.

RESULTS

Among participants, awareness of COVID-19 protective measures was high; however, between 10 and 24% of participants in each city-specific sample reported being unable to self-isolate. Overall, 3-19% of participants reported experiencing homelessness after the onset of the pandemic, while 20-41% reported that they went hungry more often than usual. Furthermore, 8-33% of participants reported experiencing an overdose during the pandemic, though most indicated no change in overdose frequency compared the pre-pandemic period. Most participants receiving opioid agonist therapy in the past six months reported treatment continuity during the pandemic (87-93%), however, 32% and 22% of participants in Toronto and Montreal reported missing doses due to service disruptions. There were some reports of difficulty accessing supervised consumption sites in all three sites, and drug checking services in Vancouver.

CONCLUSION

Findings suggest PWUD in Canada experienced difficulties meeting essential needs and accessing some harm reduction services during the COVID-19 pandemic. These findings can inform preparedness planning for future public health emergencies.

A qualitative study on perceptions and experiences of overdose among people who smoke drugs in Vancouver, British Columbia

BACKGROUND

Smoking unregulated drugs has increased substantially in British Columbia. Intersecting with the ongoing overdose crisis, drug smoking-related overdose fatalities have correspondingly surged. However, little is known about the experiences of overdose among people who smoke drugs accessing the toxic drug supply. This study explores perceptions and experiences of overdose among people who smoke drugs.

METHODS

We conducted interviews with 31 people who smoke drugs. Interviews covered a range of topics including overdose experience. Thematic analysis was used to identify themes related to participant perceptions and experiences of smoking-related overdose.

RESULTS

Some participants perceived smoking drugs to pose lower overdose risk relative to injecting drugs. Participants reported smoking-related overdose experiences, including from underestimating the potency of drugs, the cross-contamination of stimulants with opioids, and responding to smoking-related overdose events.

CONCLUSIONS

Findings highlight the impact the unpredictable, unregulated, and toxic drug supply is having on people who smoke drugs, both among people who use opioids, and among those who primarily use stimulants. Efforts to address smoking-related overdose could benefit from expanding supervised smoking sites, working with people who use drugs to disseminate accurate knowledge around smoking-related overdose risk, and offering a smokable alternative to the unpredictable drug supply.

Pivoting injury prevention efforts during a pandemic: results of an international survey

BACKGROUND

The COVID-19 a pandemic changed the world. Public health directives to socially distance with stay-at-home orders altered injury risk factor exposure, resulting injury patterns and conducting injury prevention (IP). The objective of this study was to determine the impact the COVID-19 pandemic on injury and IP at North American trauma centers (TC).

RESULTS

Sixty-two responses were received from pediatric (44%), adult (11%), and combined (31%) TC, from 22 American states, 5 Canadian provinces and Australia. The majority (91%) of programs targeted age groups from birth to 15 years old. Nearly one-third reported IP to be less of an institutional priority with funding redistributed in 15% of centers [median (IQR) - 25% (- 43, 1)], and resultant staffing changes at 38% of centers. A decrease in IP efforts was reported at 64% of TC. Overall, the majority of respondents reviewed injury data, with the top reported increased mechanisms mainly intentional: Firearm-related (75%), assaults (72%), and abuse (71%). Leading increased unintentional injuries were injuries occurring in the home such as falls (70%), followed by ATV (62%), and cycling (57%). Sites pivoted by presenting (74%) or participating (73%) in IP education virtually, social media posts (61%) and the addition of technology (29%). Top barriers were redeployment of partners (45%) and staff (31%), as well as lack of technology (40%) in the target population. Facilitators were technology at TC (74%), support of trauma program (63%), and having IP funding maintained (55%).

CONCLUSIONS

Nearly two-thirds of TC decreased IP efforts during the pandemic due to staffing and funding reductions. The leading reported increased injuries were intentional, indicating that violence prevention is needed, along with support for mental health. While TC successfully pivoted by using technology, access issues in the target population was a barrier resulting in health inequities.

Negative changes in illicit drug supply during COVID-19: Associations with use of overdose prevention and health services among women sex workers who use drugs (2020-2021)

BACKGROUND

Women sex workers are a highly criminalized population who are over-represented amongst people who use drugs (PWUD) and face gaps in overdose prevention and harm reduction services. British Columbia, Canada continues to face a pronounced drug poisoning crisis of the illicit drug supply, which has intensified during the COVID-19 pandemic. Our objective was to examine the prevalence and structural correlates of experiencing negative changes in illicit drug supply (e.g., availability, quality, cost, or access to drugs) amongst women sex workers who use drugs during the first year of the COVID-19 pandemic.

METHODS

Cross-sectional questionnaire data were drawn from a prospective, community-based cohort of women sex workers in Vancouver (AESHA) from April 2020 to 2021. Bivariate and multivariable logistic regression was used to investigate structural correlates of negative changes in drug supply during COVID-19 among sex workers who use drugs.

RESULTS

Among 179 sex workers who use drugs, 68.2% reported experiencing negative changes to drug supply during COVID-19, 54.2% recently accessed overdose prevention sites, and 44.7% reported experiencing recent healthcare barriers. In multivariable analysis adjusted for injection drug use, women who reported negative changes in illicit drug supply had higher odds of experiencing recent healthcare barriers (AOR 2.28, 95%CI 1.12-4.62); those recently accessing overdose prevention sites (AOR 1.75, 95%CI 0.86-3.54) faced marginally higher odds also.

CONCLUSIONS

Over two-thirds of participants experienced negative changes to illicit drug supply during the first year of the COVID-19 pandemic. The association between experiencing negative changes in the illicit drug supply and accessing overdose prevention services highlights the agency of women in taking measures to address overdose-related risks. Highly criminalized women who experience structural barriers to direct services are also vulnerable to fluctuations in the illicit drug supply. Attenuating health consequences requires interventions tailored to sex workers' needs.

Recent and lifetime maternal substance use: Rurality and economic distress

Research on opioid use disorder (OUD) in pregnancy has mainly considered women in urban areas receiving treatment, with less known about women in rural areas. We sought to describe demographics and substance use characteristics of pregnant women with OUD and to compare the women based on urbanicity, in a state (Kentucky) with unfavorable economic conditions in many rural counties; we hypothesized that pregnant women in rural areas would have greater adversity, broadly defined, related to substance use. Using data collected from a larger project between 2017 and 2020, we analyzed characteristics of 93 pregnant women (59 rural and 34 urban) with OUD; we examined data in medical, employment, substance use, legal, family history, relationship, and psychiatric health domains, both overall and within rural (population <50,000) and urban (population ≥50,000) strata. Pregnant women with OUD from rural and urban areas were similar on almost all attributes. Among the few significant differences, 30% from urban areas perceived inadequate prenatal care versus 11% from rural areas (p = 0.024); 21% of urban women used amphetamines/methamphetamines in the month before delivery versus 0% of rural women (p < 0.001); and rural women had longer most recent abstinence from substance use than their urban counterparts (medians 7.0 and 2.8 months, p = 0.049). The few significant differences that were discovered favored rural women. These findings, contrary to our hypothesis, suggest that tailoring interventions may require more than focusing on geography. The participants in this study were pregnant women being treated for OUD, and as such there is patient contribution of data.

Association of drug overdoses and user characteristics of Canada's national mobile/virtual overdose response hotline: the National Overdose Response Service (NORS)

BACKGROUND

Several novel overdose response technology interventions, also known as mobile overdose response services (MORS), have emerged as adjunct measures to reduce the harms associated with the drug poisoning epidemic. This retrospective observational study aims to identify the characteristics and outcomes of individuals utilizing one such service, the National Overdose Response Service (NORS).

METHODS

A retrospective analysis was conducted using NORS call logs from December 2020 to April 2023 imputed by operators. A variety of variables were examined including demographics, substance use and route, location, and call outcomes. Odds ratios and 95% confidence intervals were calculated around variables of interest to test the association between key indicators and drug poisonings.

RESULTS

Of the 6528 completed calls on the line, 3994 (61.2%) were for supervised drug consumption, 1703 (26.1%) were for mental health support, 354 (5.42%) were for harm reduction education or resources, and 477 (7.31%) were for other purposes. Overall, there were 77 (1.18%) overdose events requiring a physical/ in-person intervention. Of the total calls, 3235 (49.5%) were from women, and 1070 (16.3%) were from people who identified as gender diverse. Calls mostly originated from urban locations (n = 5796, 88.7%) and the province of Ontario (n = 4137, 63.3%). Odds ratios indicate that using opioids (OR 6.72, CI 95% 3.69-13.52), opioids in combination with methamphetamine (OR 9.70, CI 95% 3.24-23.06), multiple consumption routes (OR 6.54, CI 95% 2.46-14.37), and calls occurring in British Columbia (B.C) (OR 3.55, CI 95% 1.46-7.33) had a significantly higher likelihood of a drug poisoning. No deaths were recorded and only 3 false callouts had occurred. The overall drug poisoning event incidence to phone calls was 1.2%.

CONCLUSION

NORS presents a complimentary opportunity to access harm reduction services for individuals that prefer to use alone or face barriers to accessing in-person supervised consumption services especially gender minorities with high-risk use patterns.