The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study

Barriers and facilitators to safer supply pilot program implementation in Canada: a qualitative assessment of service provider perspectives

BACKGROUND

In response to the ongoing drug toxicity crisis, driven by fentanyl and its analogues in the unregulated drug supply, Canada has funded several safer supply programs, which provide pharmaceutical-grade medications to reduce the reliance on toxic unregulated drug supply for people who use drugs. In this study, we examined barriers and facilitators that influenced the implementation of integrated safer supply pilot programs (ISSPP) across Canada.

METHODS

Between March 2022 and May 2023, we conducted a qualitative study using semi-structured interviews with key informants from ten ISSPP located in three provinces across Canada. Data analysis and interpretation of findings were guided by the Consolidated Framework for Implementation Research (CFIR). Thematic analysis was used to code transcripts and identify themes.

RESULTS

ISSPP varied greatly in the degree of ancillary and wraparound services provided. Additionally, differences existed across the ten programs in terms of eligibility criteria for enrolling clients and the availability of medication options. We found twelve constructs and three sub-constructs across four domains of CFIR that influenced the implementation of ISSPP. Implementation facilitators included low-barrier and client-centered delivery model, ongoing needs assessment through program monitoring and evaluation, integration of wraparound care, partnership with local services to coordinate client care, community buy-in, clinical protocols and standardized practices, and multidisciplinary care teams with motivated staff. Major barriers to ISSPP implementation were a volatile and toxic unregulated drug supply, complicated policy environments, unsustainable funding models, unsupportive regulatory environments, limited medication options, limited physical space, as well as staff shortage.

CONCLUSIONS

Despite several internal implementation facilitators, ISSPP faced many external and policy-level implementation barriers. Future safer supply programs should be guided by evidence-based planning and implementation, drawing from successful experiences in harm reduction implementation. Implementation facilitators, in particular, evidence-based practice guidelines along with better monitoring of client outcomes can be leveraged to enhance quality of care, address client needs and preferences, and mitigate unintended harms.

COVID-19 isolation and recovery sites evaluation: Lessons learned for systems innovation

OBJECTIVE

The City of Toronto opened COVID-19 Isolation and Recovery Sites (CIRS) in 2020 in response to the need for supported isolation spaces for people experiencing homelessness. As a team of academic researchers and community partners, we assessed how lessons from the CIRS can inform post-pandemic policies for people experiencing homelessness. We focused on identifying models and systems of care for understanding existing services and integration, identifying innovations, and imagining how care can be transformed to be more caring and just.

METHODS

We conducted 43 key informant interviews with clinicians, peer and harm reduction workers, executive leaders, operational leaders, and people who worked for funding or decision-making organizations. Data were coded and analyzed using deductive content analysis.

RESULTS

The CIRS presented a new service model that moved away from being overly medicalized towards having a community orientation, which involved greater integration of services for people experiencing homelessness, transparent decision-making, and open communication. Key to this approach were clinical case management, harm reduction services, strong support of peer workers, and adequate and consistent funding. Future models will need to address power imbalances and hierarchies through formal agreements and processes as well as establishing collaborative cultures.

CONCLUSION

The CIRS offer an important opportunity to rethink services offered within shelter settings. Such change will require a strong vision, sufficient funding, political will, and accountability among all stakeholders. The COVID-19 pandemic offers decision makers an opportunity to consider system-level transformation by looking at largely successful elements of the crisis responses.

Perceived impacts of North Americas first de-medicalized safer supply program

BACKGROUND

The Drug User Liberation Front led an evaluation of a non-medicalized model of safer supply known as a "Compassion Club." This club sourced, rigorously tested, packaged, and accurately labeled certain illicit substances and then provided them to club members at cost in order to investigate the effects and feasibility of a non-medical model of safer supply. Operating for 14 months, the club provided low-cost, quality-controlled illicit substances to individuals at risk of fatal overdose in Vancouver, Canada's Downtown Eastside neighbourhood. This study was undertaken to explore perceived impacts of the Compassion Club among its participants, as well as their perceptions regarding how the Club could be improved.

METHODS

At the one-year time point of club operations 43 participants from the club's membership completed an interviewer-administered survey which is utilized in this cross sectional analysis. Descriptive statistics were employed to assess the perceived influence of club membership on various factors, including drug use patterns, harm reduction practices, financial outcomes, housing stability, and overall well-being.

RESULTS

Applicable responses reported benefits from membership in the Compassion Club, including reduced drug use (64.3%), decreased reliance on illicit markets (86.7%), lowered risk of overdose (90.0%), and increased likelihood of using sterile equipment (84.6%). Mental health (74.2%), physical health (63.3%), and overall well-being (70.0%) were also noted improvements. Suggestions for club improvement included extended operating hours, broader substance selection, and improved accessibility.

CONCLUSION

The reported reductions in drug use and improved adherence to harm reduction practices described herein underscore the perceived benefits of this unique program. Compassion Clubs represent a distinct strategy to mitigate overdose risk and enhance the well-being of drug users. These insights advance ongoing dialogues on overdose prevention strategies, urging further research to refine non-medicalized approaches within the evolving landscape of interventions.

Using illicit drugs alone in Vancouver, Canada: a gender-based analysis

OBJECTIVES

Canada continues to experience an epidemic of toxic drug-related overdose deaths. Public health messaging emphasizes the dangers of using drugs alone as it restricts timely overdose response or renders it impossible, yet this practice remains prevalent among people who use drugs. While drug use practices and associated harms are known to be highly gendered, little is known about how factors shaping solitary drug use may differ across genders (including cisgender men, cisgender women, transgender women, Two-Spirit people and gender diverse people). Thus, we sought to explore solitary drug use practices according to gender in Vancouver, Canada.

METHODS

Data were collected through Vancouver Injection Drug Users Study, a prospective cohort study between June 2019 and May 2023. We used gender-stratified multivariable generalized estimating equation models to identify factors associated with using drugs alone.

RESULTS

Among the 697 participants, 297 (42.6%) reported using drugs alone in the previous 6 months at baseline. In multivariable analyses, we found that being in a relationship was negatively associated with using alone for both cisgender men and cisgender women (adjusted odds ratio [AOR] = 0.25 and 0.34, respectively), while homelessness was negatively associated for cisgender men only (AOR = 0.45). Factors positively associated for cisgender men included daily illicit stimulant use (AOR = 1.90), and binge drug use (AOR = 2.18). For cisgender women, only depression was positively associated with using drugs alone (AOR = 2.16). All p-values < 0.05. While unable to conduct a multivariable analysis on transgender, Two-Spirit and gender diverse people due to small sample sizes, bivariate analyses showed larger impact of depression on using alone for Two-Spirit (OR = 8.00) and gender diverse people (OR = 5.05) compared to others, and only gender diverse people's risk was impacted by experiences of violence (OR = 9.63). All p-values < 0.05.

CONCLUSION

The findings of this study suggest significant heterogeneity in gender-specific factors associated with using drugs alone. Factors exclusively impacting cisgender men's risk included homelessness and daily stimulant use, and depression having a significant impact on cisgender women's, but not cisgender men's, risk. Ultimately, gender-specific factors must be recognized in public health messaging, and in developing policies and harm reduction measures to address the risks associated with using alone.

Safer Opioid Supply programs: Hydromorphone prescribing in Ontario as a harm reduction intervention to combat the drug poisoning crisis

SETTING

The crisis of unregulated fentanyl-related overdose deaths presents a significant public health challenge. This article describes the implementation and evaluation of four Safer Opioid Supply programs (SSPs) in Ontario, one in London and three in Toronto.

INTERVENTION AND IMPLEMENTATION

SSPs aim to curtail overdose fatalities while connecting individuals using drugs to healthcare services. The programs involve a daily dispensed prescription of immediate-release hydromorphone tablets for take-home dosing alongside an observed dose of long-acting opioids like slow-release oral morphine. Implemented within a multidisciplinary primary care framework, these programs emphasize patient-centred approaches and comprehensive health and social support.

OUTCOMES

In our study conducted in 2020/2021, clients and service providers reported that receiving pharmaceutical opioids through these programs improved the clients' health and well-being. The regulated supply was reported to lead to decreases in overdose incidents, use of unregulated substances, and criminalized activities. Increased engagement with healthcare and harm reduction services and improvements in social determinants of health, such as food security, were also reported. Despite these positive outcomes, some implementation challenges, including capacity issues and provider burnout, were described by service providers.

IMPLICATIONS

Our findings suggest that the combination of safer supply, wrap-around support, and harm reduction within primary care settings can lead to increased healthcare engagement, HIV/HCV prevention, testing, and treatment uptake, reducing the burden of infectious diseases and overdose risk. SSPs have the potential to meaningfully reduce overdose rates, address the ongoing overdose crisis, and if scaled up, influence population-level outcomes.

The associations of supervised consumption services with the rates of opioid-related mortality and morbidity outcomes at the public health unit level in Ontario (Canada): A controlled interrupted time-series analysis

INTRODUCTION

This study aimed to assess the impact of the implementation of legally sanctioned supervised consumption sites (SCS) in the Canadian province of Ontario on opioid-related deaths, emergency department (ED) visits and hospitalisations at the public health unit (PHU) level.

METHODS

Monthly rates per 100,000 population of opioid-related deaths, ED visits and hospitalisations for PHUs in Ontario between December 2013 and March 2022 were collected. Aggregated and individual analyses of PHUs with one or more SCS were conducted, with PHUs that instituted an SCS being matched to control units that did not. Autoregressive integrated moving average models were used to estimate the impact of SCS implementation on opioid-related deaths, ED visits and hospitalisations.

RESULTS

Twenty-one legally sanctioned SCS were implemented across nine PHUs in Ontario during the study period. Interrupted time series analyses showed no statistically significant changes in opioid-related death rates in aggregated analyses of intervention PHUs (increase of 0.02 deaths/100,000 population/month; p = 0.27). Control PHUs saw a significant increase of 0.38 deaths/100,000 population/month; p < 0.001. No statistically significant changes were observed in the rates of opioid-related ED visits in intervention PHUs (decrease of 0.61 visits/100,000 population/month; p = 0.39) or controls (increase of 0.403 visits; p = 0.76). No statistically significant changes to the rates of opioid-related hospitalisations were observed in intervention PHUs (0 hospitalisations/100,000 population/month; p = 0.98) or controls (decrease of 0.05 hospitalisations; p = 0.95).

DISCUSSION AND CONCLUSIONS

This study did not find significant mortality or morbidity effects associated with SCS availability at the population level in Ontario. In the context of a highly toxic drug supply, additional interventions will be required to reduce opioid-related harms.

Clinicians' Perspectives and an Ethical Analysis of Safer Supply Opioid Prescribing

In British Columbia, Canada, many physicians providing care to individuals with high-risk opioid use disorder adopted safer supply (SS) opioid prescribing in the spring of 2020 with the goal of facilitating public health measures for COVID-19. This prescribing practice continued after measures were lifted. This study aimed to explore prescribers' perspectives following several years of local experience in prescribing SS opioids, primarily in the form of hydromorphone tablets, and to apply ethical concepts to explore current challenges and ongoing sources of provider distress. Addiction medicine SS prescribers participated in individual or small group semi-structured interviews. Each interview was transcribed and analysed for recurrent themes. Themes were then integrated into a narrative ethics discussion. Eleven addiction medicine physicians practicing in various settings within Vancouver participated in this study. Six themes were identified: clinical assessment, clinician distress, gaps in care, models of safer supply, research, and special populations. Ethical dilemmas in prescribing SS are identified and explored through a discussion of biomedical ethics principles and the physician role.

Access and barriers to safer supply prescribing during a toxic drug emergency: a mixed methods study of implementation in British Columbia, Canada

BACKGROUND

In March 2020, British Columbia, Canada, introduced prescribed safer supply involving the distribution of pharmaceutical grade alternatives to the unregulated toxic drug supply. Prior research has demonstrated positive impacts on overdose mortality, but with limited reach to people who use substances. Objectives of this study were to (1) identify barriers to accessing safer supply prescribing among people who use substances; and (2) determine whether and how barriers differed between people with and without prescriptions, and between urban and rural settings.

METHODS

We conducted a participatory mixed-methods study guided by the Consolidated Framework for Implementation Research. Participants (≥ 19 years old) had received a safer supply prescription or were seeking one (survey n = 353; interviews n = 54).

RESULTS

Participants who had a prescription were more likely to be living in a large urban centre, compared to medium/smaller centres and rural areas (78.5% vs. 65.8%, standardized mean difference = 0.286). Participants who did not have a prescription were more likely to report an array of structural, interpersonal, and health-related barriers (compared to those who had a prescription). In interviews, participants linked experiences of barriers to stigma and criminalization, low availability of services, lack of information and prescribers, not being able to get what they need, and anxieties, worries and doubts stemming from personal circumstances. There were no notable differences between large urban centres and medium/smaller centres and rural areas in the presence of specific types of barriers.

CONCLUSIONS

Findings demonstrate restricted access to safer supply prescribing outside of large urban centres and provide future targets for enhancing implementation. Attention is needed to promote equity and counter systemic barriers in the implementation of responses to the ongoing toxic drug emergency.

Increasing linkage to hepatitis C care following trauma-informed rehabilitation: An education and quality improvement project among women

INTRODUCTION

The on-going substance use crisis has led to unprecedented rates of hepatitis C virus (HCV) in Canada, with increasing positivity among women who use drugs (WWUD). Despite efforts to reduce barriers to HCV testing and treatment, follow-up remains a major issue.

METHODS

In this quality improvement project (QIP), we partnered with a short-stay trauma-informed residential drug treatment facility specifically for WWUD, to provide an engaging peer-led HCV education session, followed by low-barrier nurse and peer-led testing and treatment. We sought to evaluate these interventions, as well as determine what factors could improve engagement after women leave.

RESULTS

The session was attended by 217 participants, 130 completed the survey and 153 opted into testing. Survey results indicated that participants were highly motivated to access general care as well as HCV testing and treatment. The most frequently reported barriers to testing and treatment were a previous negative test and being asymptomatic, respectively. Follow-up facilitators included a non-judgmental provider (88%), monetary incentives (67%), follow-up phone calls (77%), e-mails (66%) and text messages (58%). Of those who were RNA positive, 5 of 13 initiated treatment on-site. By using the results of the QIP in real-time, 6 of 13 were started after leaving the centre (one pending and one lost to follow-up).

DISCUSSION AND CONCLUSIONS

The implementation of co-localised peer-led testing and treatment for HCV, along with persistent follow-up efforts, led to increases in linkage to care and treatment. Co-localisation of testing and care with substance-use services, especially if residential, is a viable, low-barrier strategy for increasing linkage to care among WWUD.

"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

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.

Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study

BACKGROUND

North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC.

METHODS

We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation.

RESULTS

Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure.

CONCLUSIONS

BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prescribed safer opioid supply: A scoping review of the evidence

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.

British Columbia's Safer Opioid Supply Policy and Opioid Outcomes

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.

Substance use care innovations during COVID-19: barriers and facilitators to the provision of safer supply at a toronto COVID-19 isolation and recovery site

BACKGROUND

Early in the COVID-19 pandemic, there was an urgent need to establish isolation spaces for people experiencing homelessness who were exposed to or had COVID-19. In response, community agencies and the City of Toronto opened COVID-19 isolation and recovery sites (CIRS) in March 2020. We sought to examine the provision of comprehensive substance use services offered to clients on-site to facilitate isolation, particularly the uptake of safer supply prescribing (prescription of pharmaceutical opioids and/or stimulants) as part of a spectrum of comprehensive harm reduction and addiction treatment interventions.

METHODS

We conducted in-depth, semi-structured interviews with 25 clients and 25 staff (including peer, harm reduction, nursing and medical team members) from the CIRS in April-July 2021. Iterative and thematic analytic methods were used to identify key themes that emerged in the interview discussions.

RESULTS

At the time of implementation of the CIRS, the provision of a safer supply of opioids and stimulants was a novel and somewhat controversial practice. Prescribed safer supply was integrated to address the high risk of overdose among clients needing to isolate due to COVID-19. The impact of responding to on-site overdoses and presence of harm reduction and peer teams helped clinical staff overcome hesitation to prescribing safer supply. Site-specific clinical guidance and substance use specialist consults were crucial tools in building capacity to provide safer supply. Staff members had varied perspectives on what constitutes 'evidence-based' practice in a rapidly changing, crisis situation.

CONCLUSION

The urgency involved in intervening during a crisis enabled the adoption of prescribed safer supply, meeting the needs of people who use substances and assisting them to complete isolation periods, while also expanding what constitutes acceptable goals in the care of people who use drugs to include harm reduction approaches.

Prescription opioid use among people with opioid dependence and concurrent benzodiazepine and gabapentinoid exposure: An analysis of overdose and all-cause mortality

BACKGROUND

Studies investigating mortality risk associated with use of opioid analgesics, benzodiazepines, gabapentinoids, and opioid agonist treatment (OAT) among people with opioid dependence (PWOD) are lacking. This study addresses this gap using a cohort of 37,994 PWOD initiating opioid analgesics between July 2003 and July 2018 in New South Wales, Australia.

METHODS

Linked administrative records provided data on dispensings, sociodemographics, clinical characteristics, OAT, and mortality. Cox proportional hazards models assessed associations between time-varying measures of individual and concurrent medicine use and OAT with all-cause mortality, accidental opioid overdose, non-drug induced accidents, and non-drug-induced suicide. Opioid analgesic dose effects, expressed as oral morphine equivalents (OMEs) per day, were also examined.

OUTCOMES

During the study period, 3167 individuals died. Compared with no use, all medicines of interest were associated with increased accidental opioid overdose risk; hazard ratios (HR) ranged from 1.33 (95 % CI: 1.05-1.68) for opioid analgesic use to 6.10 (95 % CI: 4.11-9.06) for opioid analgesic, benzodiazepine and gabapentinoid use. Benzodiazepine use was associated with increased non-drug-induced accidents and non-drug-induced suicides. For all-cause mortality, all combinations of benzodiazepines and gabapentinoids with opioid analgesics were associated with increased risk (aHRs ranged from 1.35 to 2.73). For most medicines/medicine combinations, all-cause mortality risk was reduced when in OAT compared to out of OAT. Higher opioid analgesic doses were associated with increased all-cause mortality (e.g., 90-199 mg vs 1-49 mg OME per day: HR 1.90 [95 % CI: 1.52-2.40]).

INTERPRETATION

The increased mortality risk associated with benzodiazepines and gabapentinoids among PWOD appear to be reduced when engaged in OAT. A greater focus on encouraging OAT engagement, providing overdose prevention education, and access and coverage of overdose antidotes is necessary to minimise the unintended consequences of medicines use in this population.

Opioid Overdose Hospitalizations During COVID-19: The Experience of Pennsylvania

Objective

The COVID-19 pandemic placed extreme burden on hospitals, while opioid overdose is another challenging public health issue. This study aimed to examine the trends and outcomes of opioid overdose hospitalizations in Pennsylvania during 2018 to 2021.

Design

We identified opioid overdose hospitalizations in the state of Pennsylvania using the state-wide hospital discharge database (PHC4) 2018 to 2021. We examined the number of opioid overdose hospitalizations, the corresponding mortality and discharges against medical advice comparing the pre-COVID period (2018-2019) and the COVID period (2020-2021). We also assessed what patient and hospital characteristics were associated with in-hospital death or leaving against medical advice.

Results

A total of 13 446 opioid-related hospitalizations were identified in 2018 to 2021. Compared to pre-pandemic, a higher percentage of cases involving synthetics (17.0%vs 10.3%, P < .0001) were observed during COVID. After controlling for covariates, there was no significant difference in opioid overdose in-hospital deaths in the years 2020 to 2021 compared to 2018 to 2019 (OR = 0.846, 95% CI: 0.71-1.01, P = .065). The COVID period was significantly associated with more leaving against medical advice compared to years 2018 to 2019 (OR = 1.265, 95% CI: 1.11-1.44, P = .0003). Compared to commercial insurance, Medicaid insurance was associated with higher odds of both in-hospital death (OR = 1.383, 95% CI: 1.06-1.81, P = .0176) and leaving against medical advice (OR = 1.903, 95% CI: 1.56-2.33, P < .0001).

Conclusion

There were no substantial changes in the number of overall opioid overdose cases and deaths at hospitals following the outbreak of COVID-19 in Pennsylvania. This observation suggests that an increased number of patients may have succumbed to overdoses outside of hospital settings, possibly due to a higher severity of overdoses. Further, we found that patients were more likely to leave against medical advice during the COVID-19 pandemic.

"Safer Drug Supply" Measures in Canada to Reduce the Drug Overdose Fatality Toll: Clarifying Concepts, Practices and Evidence Within a Public Health Intervention Framework

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.

'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

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.

Operating an overdose prevention site within a temporary emergency shelter during the COVID-19 pandemic

SETTING

A temporary emergency shelter was established inside the Commonwealth Stadium in Edmonton, Alberta, to reduce COVID-19 transmission and mitigate health risks among people experiencing homelessness.

INTERVENTION

A non-profit organization, Boyle Street Community Services, opened an overdose prevention site (OPS) between February and March 2022 inside the temporary emergency shelter. People accessed the shelter-based OPS to consume unregulated drugs (via injection, intranasally, or orally), receive medical aid, access sterile drug use equipment, and be connected to additional health and social supports, without leaving the shelter. We conducted short interviewer-administered surveys with OPS participants to examine participant views and identify suggested improvements.

OUTCOMES

The shelter-based OPS was accessed a total of 1346 times by 174 unique people. Fentanyl was the most common self-reported drug consumed (59%) and most consumption (99% of episodes) was by injection. OPS staff responded to 66 overdoses and reported no deaths. Survey respondents reported that the shelter-based OPS was convenient, with no need to forfeit their shelter spot or find transportation to another OPS. Respondents indicated that the OPS felt safe and accessible and reported that it reduced drug use in other shelter areas. Participants identified the OPS' exclusion of inhalation as a limitation.

IMPLICATIONS

People who use unregulated drugs and are experiencing homelessness are at a higher risk of negative health outcomes, which COVID-19 exacerbated. Integrating temporary shelter/housing and harm reduction services may be an innovative way to lower barriers, increase accessibility, and improve well-being for this structurally vulnerable population. Future operators should consider incorporating inhalation services to further reduce service gaps.

Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis

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.

Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis

The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters. Service users' perceptions of shelter dangerousness were shaped by the service model and environment, interpersonal relationships and interactions in shelter, availability of drugs, and previous living arrangements. 2SLGBTQ+ individuals were identified as being at heightened risk of victimization in shelters. No studies examined rates of shelter-based victimization or tested interventions to improve safety, with the exception of overdose risk. These knowledge gaps hinder the establishment of evidence-based practices for promoting safety and preventing violence in shelter settings.

Perspectives and recommendations of opioid overdose survivors experiencing unsheltered homelessness on housing, overdose, and substance use treatment in Boston, MA

INTRODUCTION

Opioid overdose causes one in four deaths among people experiencing homelessness in Boston, MA. To reduce overdose risks, the experience and perspectives of people experiencing homelessness should be incorporated into housing, overdose prevention, and substance use treatment efforts.

METHODS

In 2021, we conducted qualitative interviews with 59 opioid overdose survivors to inform equitable access to treatment services. In response to policy debate surrounding a public drug scene near a key recruitment site, we conducted a targeted thematic analysis of transcribed interview data from a subset of participants experiencing unsheltered homelessness (n=29) to explore their perspectives and recommendations on housing, overdose prevention, and substance use treatment.

RESULTS

Among 29 participants who identified as non-Hispanic Black (n=10), Hispanic/Latinx (n=10), or as non-Hispanic White (n=9), the median number of self-reported opioid overdoses in the past three months was 2.0 (SD 3.7). Three themes emerged from this targeted analysis: (1) Participants described inadequate housing resources and unwelcoming shelter environments. (2) Participants near a large public drug scene explained how unsheltered homelessness was chaotic, dangerous, and disruptive to recovery goals. (3) Participants provided recommendations for improving housing and addiction treatment systems and including their perspectives in the development of solutions to the intersecting housing and opioid overdose crises.

CONCLUSIONS

The overdose prevention, housing and substance use treatment systems must address the needs of opioid overdose survivors experiencing unsheltered homelessness. Overdose survivors experiencing unsheltered homelessness described a chaotic public drug scene but resorted to residing in nearby encampments because the existing shelter, housing, and addiction treatment systems were unwelcoming, difficult to navigate, or unaffordable. Despite efforts to provide low-threshold housing in Boston, additional low-barrier housing services (i.e., including harm reduction resources and without "sobriety" requirements) could promote the health and safety of people who use drugs and are experiencing homelessness.

Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada

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.

Self-reported impacts of the COVID-19 pandemic among people who use drugs: a rapid assessment study in Montreal, Canada

BACKGROUND

People who use drugs (PWUD) are at high risk of experiencing indirect harms of measures implemented to curb the spread of COVID-19, given high reliance on services and social networks. This study aimed to document short-term changes in behaviours and health-related indicators among PWUD in Montreal, Canada following declaration of a provincial health emergency in Quebec.

METHODS

We administered a structured rapid assessment questionnaire to members of an existing cohort of PWUD and individuals reporting past-year illicit drug use recruited via community services. Telephone and in-person interviews were conducted in May-June and September-December 2020. Participants were asked to report on events and changes since the start of the health emergency (March 13, 2020). Descriptive analyses were performed.

RESULTS

A total of 227 participants were included (77% male, median age = 46, 81% Caucasian). 83% and 41% reported past six-month illicit drug use and injection drug use, respectively. 70% of unstably housed participants reported increased difficulty finding shelter since the start of the health emergency. 48% of opioid agonist treatment recipients had discussed strategies to avoid treatment disruptions with providers; 22% had missed at least one dose. Many participants perceived increased difficulty accessing non-addiction health care services. Adverse changes were also noted in indicators pertaining to income, drug markets, drug use frequency, and exposure to violence; however, many participants reported no changes in these areas. Among persons reporting past six-month injection drug use, 79% tried to access needle-syringe programmes during the health emergency; 93% of those obtained services. 45% tried to access supervised injection sites, of whom 71% gained entry.

CONCLUSIONS

This snapshot suggests mixed impacts of the COVID-19 pandemic on PWUD in Montreal in the months following declaration of a provincial health emergency. There were signals of increased exposure to high-risk environments as well as deteriorations in access to health services. Pandemic-related measures may have lasting impacts among vulnerable subgroups; continued monitoring is warranted.