Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review

Importance

The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.

Observations

Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl's high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl's unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians' understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.

Conclusions and Relevance

The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.

Benzodiazepine use in medical cannabis authorization adult patients from 2013 to 2021: Alberta, Canada

BACKGROUND

Benzodiazepines are a class of medications that are being frequently prescribed in Canada but carry significant risk of harm. There has been increasing clinical interest on the potential "sparing effects" of medical cannabis as one strategy to reduce benzodiazepine use. The objective of this study as to examine the association of medical cannabis authorization with benzodiazepine usage between 2013 and 2021 in Alberta, Canada.

METHODS

A propensity score matched cohort study with patients on regular benzodiazepine treatment authorized to use medical cannabis compared to controls who do not have authorization for medical cannabis. A total of 9690 medically authorized cannabis patients were matched to controls. To assess the effect of medical cannabis use on daily average diazepam equivalence (DDE), interrupted time series (ITS) analysis was used to assess the change in the trend of DDE in the 12 months before and 12 months after the authorization of medical cannabis.

RESULTS

Over the follow-up period after medical cannabis authorization, there was no overall change in the DDE use in authorized medical cannabis patients compared to matched controls (- 0.08 DDE, 95% CI: - 0.41 to 0.24). Likewise, the sensitivity analysis showed that, among patients consuming ≤5 mg baseline DDE, there was no change immediately after medical cannabis authorization compared to controls (level change, - 0.04 DDE, 95% CI: - 0.12 to 0.03) per patient as well as in the month-to-month trend change (0.002 DDE, 95% CI: - 0.009 to 0.12) per patient was noted.

CONCLUSIONS

This short-term study found that medical cannabis authorization had minimal effects on benzodiazepine use. Our findings may contribute ongoing evidence for clinicians regarding the potential impact of medical cannabis to reduce benzodiazepine use.

HIGHLIGHTS

• Medical cannabis authorization had little to no effect on benzodiazepine usage among patients prescribed regular benzodiazepine treatment in Alberta, Canada. • Further clinical research is needed to investigate the potential impact of medical cannabis as an alternative to benzodiazepine medication.

Assessing support for mental health policies among policy influencers and the general public in Alberta and Manitoba, Canada

BACKGROUND

There is a need to improve mental health policy in Canada to address the growing population burden of mental illness. Understanding support for policy options is critical for advocacy efforts to improve mental health policy. Our purpose was to describe support for population-level healthy public policies to improve mental health among policy influencers and the general public in Alberta and Manitoba; and, identify associations between levels of support and sociodemographic variables and relative to the Nuffield Bioethics Intervention Ladder framework.

METHODS

We used data from the 2019 Chronic Disease Prevention Survey, which recruited a representative sample of the general public in Alberta (n = 1792) and Manitoba (n = 1909) and policy influencers in each province (Alberta n = 291, Manitoba n = 129). Level of support was described for 16 policy options using a Likert-style scale for mental health policy options by province, sample type, and sociodemographic variables using ordinal regression modelling. Policy options were coded using the Nuffield Council on Bioethics Intervention Ladder to classify support for policy options by level of intrusiveness.

RESULTS

Policy options were categorized as 'Provide Information' and 'Enable Choice' according to the Nuffield Intervention Ladder. There was high support for all policy options, and few differences between samples or provinces. Strong support was more common among women and among those who were more politically left (versus center). Immigrants were more likely to strongly support most of the policies. Those who were politically right leaning (versus center) were less likely to support any of the mental health policies. Mental health status, education, and Indigenous identity were also associated with support for some policy options.

CONCLUSIONS

There is strong support for mental health policy in Western Canada. Results demonstrate a gap between support and implementation of mental health policy and provide evidence for advocates and policy makers looking to improve the policy landscape in Canada.

Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital

BACKGROUND

People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.

METHODS

We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.

RESULTS

Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.

CONCLUSIONS

Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

Medical cannabis authorization and risk of emergency department visits and hospitalization due to psychotic disorders: A propensity score-matched cohort study

Despite evidence showing that recreational cannabis use is associated with a higher risk of psychotic disorders, this risk has not been well characterized for patients using medical cannabis. Therefore, this study assessed the risk of emergency department (ED) visits and hospitalization for psychotic disorders (the study outcome) among adult patients authorized to use medical cannabis. We performed a retrospective cohort study on patients authorized to use medical cannabis in a group of Ontario cannabis clinics between 2014 and 2019. Using clinical and health administrative data, each patient was matched by propensity scores to up to 3 population-based controls. Conditional Cox proportional hazards regressions were used to assess the risk. Among 54,006 cannabis patients matched to 161,265 controls, 39 % were aged ≤50 years, and 54 % were female. Incidence rates for psychotic disorders were 3.00/1000 person-years (95%CI: 2.72-3.32) in the cannabis group and 1.88/1000 person-years (1.75-2.03) in the control group. A significant association was observed, with an adjusted hazard ratio of 1.38 (95%CI: 1.19-1.60) in the total sample and 1.63 (1.40-1.91) in patients without previous psychotic disorders. The results suggest that cannabis authorization should include a benefit-risk assessment of psychotic disorders to minimize the risk of events requiring emergency attention.

Flawed reports can harm: the case of supervised consumption services in Alberta

Supervised consumption services have been scaled up within Canada and internationally as an ethical imperative in the context of a public health emergency. A large body of peer-reviewed evidence demonstrates that these services prevent poisoning deaths, reduce infectious disease transmission risk behaviour, and facilitate clients' connections to other health and social services. In 2019, the Alberta government commissioned a review of the socioeconomic impacts of seven supervised consumption services in the province. The report is formatted to appear as an objective, scientifically credible evaluation of these services; however, it is fundamentally methodologically flawed, with a high risk of biases that critically undermine its authors' assessment of the scientific evidence. The report's findings have been used to justify decisions that jeopardize the health and well-being of people who use drugs both in Canada and internationally. Governments must ensure that future assessments of supervised consumption services and other public health measures to address drug poisoning deaths are scientifically sound and methodologically rigorous. Health policy must be based on the best available evidence, protect the right of structurally vulnerable populations to access healthcare, and not be contingent on favourable public opinion or prevailing political ideology.

Canadian newspaper coverage on harm reduction featuring bereaved mothers: A mixed methods analysis

A growing body of evidence suggests that news media which includes a sympathetic portrayal of a mother bereaved by substance use can increase public support for harm reduction initiatives. However, the extent to which such news media coverage occurs in Canada is unknown, and research has not documented how the news media in Canada covers such stories. We undertook a mixed-method secondary analyses of 5681 Canadian newspaper articles on harm reduction (2000-2016). Quantitative analyses described the volume and content of harm reduction reporting featuring a mother whose child's death was related to substance use while qualitative thematic analysis provided in-depth descriptions of the discourses underlying such news reporting. Newspaper articles featuring a mother whose child's death was related to substance use were rarely published (n = 63; 1.1% of total harm reduction media coverage during the study period). Deductive content analysis of these 63 texts revealed that coverage of naloxone distribution (42.9%) and supervised drug consumption services (28.6%) were prioritized over other harm reduction services. Although harm reduction (services or policies) were advocated by the mother in most (77.8%) of these 63 texts, inductive thematic analysis of a subset (n = 52) of those articles revealed that mothers' advocacy was diminished by newspaper reporting that emphasized their experiences of grief, prioritized individual biographies over structural factors contributing to substance use harms, and created rhetorical divisions between different groups of people who use drugs (PWUD). Bereaved mothers' advocacy in support of harm reduction programs and services may be minimized in the process of reporting their stories for newspaper readers. Finding ways to report bereaved mothers' stories in ways that are inclusive of all PWUD while highlighting the role of broad, structural determinants of substance use has the potential to shift public opinion and government support in favour of these life-saving services.

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.

Engaging families and parent advocates in research on substance use and drug policy reform: Guiding principles from a Canadian community-academic partnership

Canada is in the midst of a public health emergency in drug poisoning (overdose) deaths. In this context parents, and especially mothers, of those who have died from drug poisoning have mobilised to advocate for urgent responses and drug policy reforms. To document this emerging women-led advocacy, we initiated a community-academic research partnership with three parent groups representing families in Canada bereaved by drug-related deaths. In this commentary, we describe four guiding principles we developed during the course of this project, to ensure an ethical and equitable approach to conducting our research partnership. In particular, we emphasise how we navigated parents' roles as vocal advocates for addressing drug stigma and expanding harm reduction while actively working to avoid eclipsing the need to centre the perspectives of people who use drugs. Meaningful and collaborative partnerships between academics and community groups may facilitate greater understandings of how families and communities can be allied in drug policy reforms urgently needed to prevent drug poisoning deaths.

Public support for safer supply programs: analysis of a cross-sectional survey of Canadians in two provinces

OBJECTIVES

Canada's ongoing drug poisoning crisis has contributed to unprecedented rates of morbidity and mortality. Health Canada has funded safer supply pilot programs to help connect people who use drugs to pharmaceutical grade medications that reduce their reliance on a toxic drug supply. However, most provinces, including Alberta and Saskatchewan, have not endorsed these initiatives. We explored public support for safer supply programs in these two Canadian provinces and identified predictors of support for this policy option.

METHODS

Cross-sectional data were examined from an online panel survey that included measures assessing views on policy responses to substance use and addiction. A total of 1602 adults were recruited during March 2021. We used descriptive statistics to characterize support for safer supply programs in Alberta and Saskatchewan and multinominal logistic regression analysis to examine predictors of public support for safer supply.

RESULTS

The majority of respondents (AB: 63.5% and SK: 56.3%) supported safer supply programs that replace illegal street drugs with pharmaceutical alternatives for those unable to stop using. Predicted probabilities show a greater probability of support for safer supply among those with higher education and those leaning left on the political spectrum.

CONCLUSION

A majority of Canadians from Alberta and Saskatchewan supported provincial government efforts to expand safer supply, suggesting a lack of public support is not the main barrier to implementation. Efforts at mobilizing this public opinion are needed to scale up and facilitate evaluation of this drug poisoning response.

An action-oriented public health framework to reduce financial strain and promote financial wellbeing in high-income countries

BACKGROUND

Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing.

METHODS

The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires.

RESULTS

The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances.

CONCLUSIONS

The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives.

Overpoliced and Underrepresented: Perspectives on Cannabis Legalization From Members of Racialized Communities in Canada

Historically, overpolicing of some racialized and Indigenous groups in Canada has resulted in unequal application of drug laws contributing to disproportionate rates of charges and convictions in these populations. Criminal records severely and negatively impact an individual's life and can perpetuate cycles of poverty and socioeconomic disadvantage. On October 17, 2018, Canada legalized cannabis production, distribution, sale, and possession for non-medical purposes. Advocates of criminal justice reform have raised concerns that Indigenous and racialized people may not equitably benefit from legalization due to unequal police surveillance and drug enforcement. These groups are among priority populations for research on cannabis and mental health, but their views on cannabis regulation have been largely absent from research and policy-making. To address this gap, we asked self-identified members of these communities about their lived experiences and perspectives on cannabis legalization in Canada. Between September 2018 and July 2019, we conducted semistructured interviews and focus groups with 37 individuals in Québec, Ontario, Alberta and British Columbia. During this phase of early cannabis legalization, participants responded to questions about anticipated public health risks and benefits of legalization, how their jurisdiction is responding to legalization, and what community resources would be needed to address legalization impacts. We conducted a thematic analysis and identified five major themes in the data related to race and early cannabis legalization: overpolicing of racialized communities, severity of penalties in new cannabis legislation, increased police powers, and underrepresentation of racialized groups in the legal cannabis market and in cannabis research. Participants discussed opportunities to support cannabis justice, including establishing priority licenses, issuing pardons or expunging criminal records, and reinvesting cannabis revenue into impacted communities. This work begins to address the paucity of Indigenous and racialized voices in cannabis research and identifies potential solutions to injustices of cannabis prohibition.

A Policy-Ready Public Health Guidebook of Strategies and Indicators to Promote Financial Well-Being and Address Financial Strain in Response to COVID-19

INTRODUCTION

The COVID-19 pandemic has adversely affected the financial well-being of populations globally, escalating concerns about links with health care and overall well-being. Governments and organizations need to act quickly to protect population health relative to exacerbated financial strain. However, limited practice- and policy-relevant resources are available to guide action, particularly from a public health perspective, that is, targeting equity, social determinants of health, and health-in-all policies. Our study aimed to create a public health guidebook of strategies and indicators for multisectoral action on financial well-being and financial strain by decision makers in high-income contexts.

METHODS

We used a multimethod approach to create the guidebook. We conducted a targeted review of existing theoretical and conceptual work on financial well-being and strain. By using rapid review methodology informed by principles of realist review, we collected data from academic and practice-based sources evaluating financial well-being or financial strain initiatives. We performed a critical review of these sources. We engaged our research-practice team and government and nongovernment partners and participants in Canada and Australia for guidance to strengthen the tool for policy and practice.

RESULTS

The guidebook presents 62 targets, 140 evidence-informed strategies, and a sample of process and outcome indicators.

CONCLUSION

The guidebook supports action on the root causes of poor financial well-being and financial strain. It addresses a gap in the academic literature around relevant public health strategies to promote financial well-being and reduce financial strain. Community organizations, nonprofit organizations, and governments in high-income countries can use the guidebook to direct initiative design, implementation, and assessment.

Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study

Background

Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay.

Methods

Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use).

Results

Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis.

Conclusions

After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00445-7.

Changes in supervised consumption site use and emergency interventions in Montréal, Canada in the first twelve months of the COVID-19 pandemic: An interrupted time series study

BACKGROUND

The COVID-19 pandemic has impacted supervised consumption site (SCS) operations in Montréal, Canada, potentially including changes in SCS visits, on-site emergency interventions, injection of specific drugs, and distribution of harm reduction materials.

METHOD

We used administrative data from all four Montréal SCS from 1 March 2018 - 28 February 2021 to conduct an interrupted time series study with 13 March 2020 as the intervention point. We employed segmented regression using generalised least squares fit by maximum likelihood. We analysed monthly SCS visits and materials distributed as counts, and emergency interventions and drugs injected as proportions of visits.

RESULTS

SCS visits (level change = -1,286; 95% CI [-1,642, -931]) and the proportion of visits requiring emergency intervention (level = -0.27% [-0.47%, -0.06%]) decreased immediately in March 2020, followed by an increasing trend in emergency interventions (slope change = 0.12% [0.10%, 0.14%]) over the ensuing 12 months. Over the same period, the proportion of injections involving opioids increased (slope = 0.05% [0.03%, 0.07%]), driven by increasing pharmaceutical opioid and novel synthetic opioid injections. Novel synthetic opioids were the drugs most often injected prior to overdose. The proportion of injections involving unregulated amphetamines increased immediately (level = 7.83% [2.93%, 12.73%]), then decreased over the next 12 months (slope = -1.86% [-2.51%, -1.21%]). There was an immediate increase in needle/syringe distribution (level = 16,552.81 [2,373, 30,732]), followed by a decreasing trend (slope = -2,398 [-4,218, -578]). There were no changes in pre-existing increasing trends in naloxone or fentanyl test strip distribution.

CONCLUSION

Reduced SCS use and increasing emergency interventions at SCS are cause for serious concern. Findings suggest increased availability of novel synthetic opioids in Montréal, heightening overdose risk.

Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting

BACKGROUND

Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada.

METHODS

Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis.

RESULTS

Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services.

CONCLUSIONS

Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.

Investigating the association between income inequality in youth and deaths of despair in Canada: a population-based cohort study from 2006 to 2019

BACKGROUND

Deaths due to suicide, drug overdose and alcohol-related liver disease, collectively known as 'deaths of despair', have been markedly increasing since the early 2000s and are especially prominent in young Canadians. Income inequality has been linked to this rise in deaths of despair; however, this association has not yet been examined in a Canadian context, nor at the individual level or in youth. The study objective was to examine the association between income inequality in youth and deaths of despair among youth over time.

METHODS

We conducted a population-based longitudinal study of Canadians aged 20 years or younger using data from the Canadian Census Health and Environment Cohorts. Baseline data from the 2006 Canadian Census were linked to the Canadian Vital Statistics Database up to 2019. We employed multilevel survival analysis models to quantify the association between income inequality in youth and time-to deaths of despair.

RESULTS

The study sample included 1.5 million Canadians, representing 7.7 million Canadians between the ages of 0 and 19 at baseline. Results from the weighted, adjusted multilevel survival models demonstrated that income inequality was associated with an increased hazard of deaths of despair (adjusted HR (AHR) 1.35; 95% CI 1.04 to 1.75), drug overdose (AHR 2.38; 95% CI 1.63 to 3.48) and all-cause deaths (AHR 1.10; 95% CI 1.04 to 1.18). Income inequality was not significantly associated with suicide deaths (AHR 1.23, 95% CI 0.93 to 1.63).

CONCLUSION

The results show that higher levels of income inequality in youth are associated with an increased hazard of all-cause death, deaths of despair and drug overdose in young Canadians. This study is the first to reveal the association between income inequality and deaths of despair in youth and does so using a population-based longitudinal cohort involving multilevel data. The results of this study can inform policies related to income inequality and deaths of despair in Canada.

Social service providers' perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study

Background

People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers’ perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care.

Methods

We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model.

Results

Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients’ ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs.

Conclusions

Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care’s ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08498-x.

Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study

BACKGROUND

Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD.

METHODS

The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings.

RESULTS

The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors.

CONCLUSIONS

Structural vulnerability is salient within Canadian policy actors' discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.

Substance Use Disorders and Psychoactive Drug Poisoning in Medically Authorized Cannabis Patients: Longitudinal Cohort Study

OBJECTIVES

Poisoning from psychoactive drugs and substance use disorders (SUD) have been reported among non-medical cannabis users. However, little is known about medical cannabis users and their risk for poisoning and/or development of SUD. This study assessed the risk of emergency department (ED) visits or hospitalization for 1) poisoning by psychoactive drugs and 2) mental/behavioural disorders due to the use of psychoactive drugs and other substances, in medically authorized cannabis patients in Ontario, Canada from 2014-2017.

METHODS

A cohort study of adult patients authorized for medical cannabis that were matched to population-based controls. ED visit/hospitalization were assessed with a main diagnostic code for: 1) poisoning by psychoactive drugs; 2) mental and behavioural disorder due to psychoactive drugs or other substance use. Conditional Cox proportional hazards regressions were conducted.

RESULTS

18,653 cannabis patients were matched to 51,243 controls. During a median follow-up of 243 days, the incidence rate for poisoning was 4.71 per 1,000 person-years (95%CI: 3.71-5.99) for cases and 1.73 per 1,000 person-years (95% CI: 1.36-2.19) for controls. The adjusted hazard ratio (aHR) was 2.45 (95%CI: 1.56-3.84). For mental/behavioural disorders, the incident rates were 8.89 (95% CI: 7.47-10.57) and 5.01 (95% CI: 4.36-5.76) in the cannabis and the controls group. The aHR was 2.27 (95%CI: 1.66-3.11). No difference was observed between males and females (P-value for interaction > 0.05).

CONCLUSIONS

Our study observed a short-term increased risk of ED visit/hospitalization for poisoning or for mental/behavioural disorders (from use of psychoactive drugs and other substances)- in medically authorized cannabis patients.

A comparison of the COVID-19 response for urban underserved patients experiencing healthcare transitions in three Canadian cities

OBJECTIVES

The COVID-19 pandemic and response has highlighted existing strengths within the system of care for urban underserved populations, but also many fault lines, in particular during care transitions. The objectives of this study were to describe COVID-19 response policies for urban underserved populations in three Canadian cities; examine how these policies impact continuity of care for urban underserved populations; determine whether and how urban underserved community members were engaged in policy processes; and develop policy and operational recommendations for optimizing continuity of care for urban underserved populations during public health crises.

METHODS

Using Walt & Gilson's Policy Triangle framework as a conceptual guide, 237 policy and media documents were retrieved. Five complementary virtual group interview sessions were held with 22 front-line and lived-experience key informants to capture less well-documented policy responses and experiences. Documents and interview transcripts were analyzed inductively for policy content, context, actors, and processes involved in the pandemic response.

RESULTS

Available documents suggest little focus on care continuity for urban underserved populations during the pandemic, despite public health measures having disproportionately negative impacts on their care. Policy responses were largely reactive and temporary, and community members were rarely involved. However, a number of community-based initiatives were developed in response to policy gaps. Promising practices emerged, including examples of new multi-level and multi-sector collaboration.

CONCLUSION

The pandemic response has exposed inequities for urban underserved populations experiencing care transitions; however, it has also exposed system strengths and opportunities for improvement to inform future policy direction.

Generalized Anxiety Disorder 7-Item (GAD-7) Scores in Medically Authorized Cannabis Patients-Ontario and Alberta, Canada

OBJECTIVES

Despite increasing rates of legalization of medical cannabis worldwide, the current evidence available on its effect on mental health outcomes including anxiety is of mixed results. This study assesses the effect of medical cannabis on generalized anxiety disorder 7-item (GAD-7) scores in adult patients between 2014 and 2019 in Ontario and Alberta, Canada.

METHODS

An observational cohort study of adults authorized to use medical cannabis. The GAD-7 was administered at the time of the first visit to the clinic and subsequently over the follow-up time period of up to 3.2 years. Overall changes in GAD-7 scores were computed (mean change) and categorized as: no change (<1 point); improvement; or worsening-over time.

RESULTS

A total of 37,303 patients had initial GAD-7 scores recorded and 5,075 (13.6%) patients had subsequent GAD-7 follow-up scores. The average age was 54.2 years (SD 15.7 years), 46.0% were male, and 45.6% noted anxiety symptoms at the baseline. Average GAD-7 scores were 9.11 (SD 6.6) at the baseline and after an average of 282 days of follow-up (SD 264) the average final GAD-7 score recorded was 9.04 (SD 6.6): mean change -0.23 (95% CI, -0.28 to -0.17, t[5,074]: -8.19, p-value <0.001). A total of 4,607 patients (90.8%) had no change in GAD-7 score from their initial to final follow-up, 188 (3.7%) had a clinically significant decrease, and 64 (1.3%) noted a clinically significant increase in their GAD-7 scores.

CONCLUSIONS

Overall, there was a statistically significant decrease in GAD-7 scores over time (in particular, in the 6-12-month period). However, this change did not meet the threshold to be considered clinically significant. Thus, we did not detect clinical improvements or detriment in GAD-7 scores in medically authorized cannabis patients. However, future well-controlled clinical trials are needed to fully examine risks or benefits associated with using medical cannabis to treat anxiety conditions.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices

Background

Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians’ concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms.

Methods

Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually.

Results

A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms.

Conclusions

VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

Impact of health system engagement on the health and well-being of people who use drugs: a realist review protocol

BACKGROUND

Although community-level benefits of health system engagement (i.e., health service planning, delivery, and quality improvement, engaged research and evaluation, and collaborative advocacy) are well established, individual-level impacts on the health and well-being of community members are less explored, in particular for people who use or have used illegal drugs (PWUD). Capacity building, personal growth, reduced/safer drug use, and other positive outcomes may or may not be experienced by PWUD involved in engagement activities. Indeed, PWUD may also encounter stigma and harm when interacting with healthcare and academic structures. Our objective is to uncover why, how, and under what circumstances positive and negative health outcomes occur during health system engagement by PWUD.

METHODS

We propose a realist review approach due to its explanatory lens. Through preliminary exploration of literature, lived experience input, and consideration of formal theories, an explanatory model was drafted. The model describes contexts, mechanisms, and health outcomes (e.g., mental health, stable/safer drug use) involved in health system engagement. The explanatory model will be tested against the literature and iteratively refined against formal theories. A participatory lens will also be used, wherein PWUD with lived experience of health system engagement will contribute throughout all stages of the review.

DISCUSSION

We believe this is the first realist review to explore the contextual factors and underlying mechanisms of health outcomes for PWUD who participate in health system engagement. A thorough understanding of the relevant literature and theoretical underpinnings of this process will offer insights and recommendations to improve the engagement processes of PWUD.

Incidence and Predictors of Cannabis-Related Poisoning and Mental and Behavioral Disorders among Patients with Medical Cannabis Authorization: A Cohort Study

OBJECTIVE

As medical cannabis use increases in North America, establishing its safety profile is a priority. The objective of this study was to assess rates of emergency department (ED) visits and hospitalizations due to poisoning by cannabis, and cannabis-related mental health disorders among medically authorized cannabis patients in Ontario, Canada, between 2014 and 2017.

METHODS

This is a retrospective cohort study of patients who received medical cannabis authorization in Ontario, Canada, using data collected in participating cannabis clinics. Outcomes included ED visit/hospitalization with a main diagnosis code for: cannabis/cannabinoid poisoning; and mental/behavioral disorders due to cannabis use. Cox proportional hazard regressions were utilized to analyze the data.

RESULTS

From 29,153 patients who received medical authorization, 23,091 satisfied the inclusion criteria. During a median follow-up of 240 days, 14 patients visited the ED or were hospitalized for cannabis poisoning-with an incidence rate of 8.06 per 10,000 person-years (95% CI: 4.8-13.6). A total of 26 patients visited the ED or were hospitalized for mental and behavioral disorders due to cannabis use-with an incidence rate of 15.0 per 10,000 person-years (95% CI: 10.2-22.0). Predictors of cannabis-related mental and behavioral disorders include prior substance use disorders, other mental disorders, age, diabetes, and chronic obstructive pulmonary disease.

CONCLUSIONS

The results suggest that the incidence of cannabis poisoning or cannabis-related mental and behavioral disorders was low among patients who were authorized to use cannabis for medical care. Identified predictors can help to target patients with potential risk of the studied outcomes.

Perceived unmet substance use and mental health care needs of acute care patients who use drugs: A cross-sectional analysis using the Behavioral Model for Vulnerable Populations

INTRODUCTION

The perceived unmet service needs of acute care-seeking people who use illegal drugs (PWUD) have been poorly documented, despite evidence of frequent hospital utilisation. This study applies the Behavioral Model for Vulnerable Populations to investigate correlates of unmet service needs in this subpopulation.

METHODS

Survey data from 285 PWUD at three urban Canadian acute care centres were examined. The survey included the Perceived Need for Care Questionnaire, which measured service seeking and care satisfaction for mental health and substance use concerns across seven types of services, as well as barriers to having care needs met. The Behavioral Model for Vulnerable Populations was applied in hierarchical setwise logistic regression to examine associations between high unmet service need and socio-structural predictors (i.e. predisposing, enabling and need factors).

RESULTS

Almost half (46%) of participants reported a high level of unmet service need, despite seeking services during the past year. Participants reporting recent criminal activity, adverse childhood experiences, transitory sleeping, having no community support worker, and meeting screening criteria for depression were more likely to report a high level of unmet service needs. Structural barriers to care (57%) were more commonly reported than motivational barriers (43%).

DISCUSSION AND CONCLUSIONS

Acute care-seeking PWUD experience high rates of unmet service needs for their mental health and substance use problems. Strategies that can help overcome structural barriers to care are necessary to help address the service needs of this population.

Towards cross-Canada monitoring of the unregulated street drug supply

Background

The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions.

Methods

The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018–March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use.

Results

The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal.

Conclusions

This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.

Medical cannabis authorization and the risk of cardiovascular events: a longitudinal cohort study

Background

Cannabis is increasingly used for therapeutic purpose. However, its safety profile is not well known. This study assessed the risk of cardiovascular-related emergency department (ED) visit and hospitalization in adult patients authorized to use medical cannabis in Ontario, Canada from 2014 to 2017.

Methods

This is a longitudinal cohort study of patients who received medical cannabis authorization and followed-up in cannabis clinics, matched to population-based controls. The primary outcome was an ED visit or hospitalization for acute coronary syndrome (ACS) or stroke; and secondary outcome was for any cardiovascular event. Conditional Cox proportional hazards regression was used to assess the association between cannabis authorization and risk.

Results

18,653 cannabis patients were matched to 51,243 controls. During a median follow-up of 242 days, the incidence rates for ACS or stroke were 7.19/1000 person-years and 5.67/1000 person-years in the cannabis and controls group, respectively- adjusted hazard ratio (aHR) of 1.44 (95% CI 1.08–1.93). When stratified by sex, the association was only statistically significant among males: aHR 1.77 (1.23–2.56). For the secondary outcome (any CV events), the aHR was 1.47 (1.26–1.72). The aHR among males and females were 1.52 (1.24–1.86) and 1.41 (1.11–1.79), respectively. Tested interaction between cannabis authorization and sex was not significant (p > 0.05).

Conclusions

Medical cannabis authorization was associated with an increased risk of ED visits or hospitalization for CV events including stroke and ACS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02229-6.

"It's a Bit of a Double-Edged Sword": Motivation and Personal Impact of Bereaved Mothers' Advocacy for Drug Policy Reform

North America's overdose crisis is an urgent public health issue that has resulted in thousands of deaths. As the crisis began to take hold across Canada in 2016, bereaved parents, mainly mothers, emerged as vocal advocates for drug policy reform and harm reduction, using their stories to challenge the stigma of drug-related death. In 2017, we launched a qualitative research partnership with leading family organizations in Canada, conducting interviews with 43 mothers whose children had died from substance use, to understand their experiences of drug policy advocacy. Our findings showed that participants' motivations for engaging in advocacy were rooted in their experiences of grief, and that advocacy led to feelings of empowerment and connection to others. Our research suggests that advocacy can be cathartic and associated with healing from grief, but that "going public" in sharing a family story of substance use death can also have a considerable personal cost.

Gaps in evidence for the use of medically authorized cannabis: Ontario and Alberta, Canada

BACKGROUND

With legal access to medical cannabis in Canada since 2001, there is a need to fully characterize its use at both the individual and population levels. We draw on data from Canada's largest cohort study of medical cannabis to identify the primary reasons for medical cannabis authorization in Canada from 2014 to 2019 in two major provinces: Alberta (AB) and Ontario (ON), and review the extent that evidence supports each indication.

METHODS

Self-reported baseline assessments were collected from adult patients in ON (n = 61,835) and AB (n = 3410) who were authorized medical cannabis. At baseline, sociodemographic, primary medical information, and validated clinical questionnaires were completed by patients as part of an individual assessment. Patients' reasons for seeking medical cannabis were compared to published reviews and guidelines to assess the level of evidence supporting medical cannabis use for each condition.

RESULTS

Medical cannabis use in both AB and ON was similar in both demographic and reason for authorization. The most common reasons for medical cannabis authorization were: (1) pain (AB = 77%, ON = 76%) primarily due to chronic musculoskeletal, arthritic, and neuropathic pain, (2) mental health concerns (AB = 32.9%, ON = 38.7%) due to anxiety and depression, and (3) sleep problems (AB = 28%, ON = 25%). More than 50 other conditions were identified as reasons for obtaining authorization.

CONCLUSION

In both AB and ON, the majority of reasons for medical cannabis authorization are not substantiated by clinical evidence to fully support its efficacy for long-term use. Ongoing epidemiological studies on medical cannabis on these treatments are warranted to fully outline its treatment benefits or risks.

Public support for harm reduction: A population survey of Canadian adults

We described public views toward harm reduction among Canadian adults and tested a social exposure model predicting support for these contentious services, drawing on theories in the morality policy, intergroup relations, addiction, and media communication literatures. A quota sample of 4645 adults (18+ years), randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across Canadian provinces, was recruited in June 2018. Participants completed survey items assessing support for harm reduction for people who use drugs (PWUD) and for seven harm reduction interventions. Additional items assessed exposure to media coverage on harm reduction, and scales assessing stigma toward PWUD (α = .72), personal familiarity with PWUD (α = .84), and disease model beliefs about addiction (α = .79). Most (64%) Canadians supported harm reduction (provincial estimates = 60% - 73%). Five of seven interventions received majority support, including: outreach (79%), naloxone (72%), drug checking (70%), needle distribution (60%) and supervised drug consumption (55%). Low-threshold opioid agonist treatment and safe inhalation interventions received less support (49% and 44%). Our social exposure model, adjusted for respondent sex, household income, political views, and education, exhibited good fit and accounted for 17% of variance in public support for harm reduction. Personal familiarity with PWUD and disease model beliefs about addiction were directly associated with support (βs = .07 and -0.10, respectively), and indirectly influenced public support via stigmatized attitudes toward PWUD (βs = 0.01 and -0.01, respectively). Strategies to increase support for harm reduction could problematize certain disease model beliefs (e.g., "There are only two possibilities for an alcoholic or drug addict-permanent abstinence or death") and creating opportunities to reduce social distance between PWUD, the public, and policy makers.

"You don't have to squirrel away in a staircase": Patient motivations for attending a novel supervised drug consumption service in acute care

BACKGROUND

Acute care hospitals have been described as a high risk environment for people who use drugs (PWUD). Formal and informal bans on drug use can lead patients to conceal their use and consume under unsafe circumstances. Provision of hospital-based supervised consumption services (SCS) could help reduce drug-related harms and improve patient care. However, no peer-reviewed research documents patient experiences with attending SCS in this setting. To address this gap, the present study examines key factors that shape patients' decisions to attend or not attend a novel SCS embedded within a large, urban acute care hospital in Western Canada.

METHODS

We adopted a focused ethnographic design and conducted 28 semi-structured interviews with SCS-eligible patients. We examined participant accounts thematically, and Rhodes' "Risk Environment" framework helped guide our analysis.

RESULTS

Most participants perceived the SCS as a safer environment that made it possible to reduce drug-related risks and avoid using in unsafe areas of the hospital where they could be caught by staff, security, or police. However, some participants did not trust that the SCS would provide adequate protection from criminalization, which motivated them to avoid the site. Several participants also worried about the potential for unwanted changes to their patient care following SCS use. Physical site and policy limitations, such as eligibility requirements and a lack of infrastructure to support supervised inhalation, were additional reasons for not attending the SCS.

CONCLUSION

PWUD in this study attended the hospital-based SCS in an attempt to reduce risks associated with their hospital stay. However, we note a number of access barriers that should be addressed to ensure optimal uptake. Wider provision of SCS in acute care requires both changes to the hospital environment and broader drug policy reform.

Opioid use in medical cannabis authorization adult patients from 2013 to 2018: Alberta, Canada

BACKGROUND

The opioid overdose epidemic in Canada and the United States has become a public health crisis - with exponential increases in opioid-related morbidity and mortality. Recently, there has been an increasing body of evidence focusing on the opioid-sparing effects of medical cannabis use (reduction of opioid use and reliance), and medical cannabis as a potential alternative treatment for chronic pain. The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013 and 2018 in Alberta, Canada.

METHODS

All adult patients defined as chronic opioid users who were authorized medical cannabis by their health care provider in Alberta, Canada from 2013 to 2018 were propensity score matched to non-authorized chronic opioid using controls. A total of 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured. Interrupted time series (ITS) analyses was used to assess the trend change in OME during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis among adult chronic opioid users.

RESULTS

Average age was 52 years and 54% were female. Patients on low dose opioids (< 50 OME) had an increase in their weekly OME per week (absolute increase of 112.1 OME, 95% CI: 104.1 to 120.3); whereas higher dose users (OME > 100), showed a significant decrease over 6 months (- 435.5, 95% CI: - 596.8 to - 274.2) compared to controls.

CONCLUSIONS

This short-term study found that medical cannabis authorization showed intermediate effects on opioid use, which was dependent on initial opioid use. Greater observations of changes in OME appear to be in those patients who were on a high dosage of opioids (OME > 100); however, continued surveillance of patients utilizing both opioids and medical cannabis is warranted by clinicians to understand the long-term potential benefits and any harms of ongoing use.

Cohort study of medical cannabis authorization and motor vehicle crash-related healthcare visits in 2014-2017 in Ontario, Canada

Background

With increasing numbers of countries/jurisdictions legalizing cannabis, cannabis impaired driving has become a serious public health concern. Despite substantive research linking cannabis use with higher rates of motor vehicle crashes (MVC), there is an absence of conclusive evidence linking MVC risk with medical cannabis use. In fact, there is no clear understanding of the impact of medical cannabis use on short- and long-term motor vehicle-related healthcare visits. This study assesses the impact of medical cannabis authorization on motor vehicle-related health utilization visits (hospitalizations, ambulatory care, emergency department visits, etc) between 2014 and 2017 in Ontario, Canada.

Methods

A matched cohort study was conducted on patients authorized to use medical cannabis and controls who did not receive authorization for medical cannabis – in Ontario, Canada. Overall, 29,153 adult patients were identified and subsequently linked to the administrative databases of the Ontario Ministry of Health, providing up to at least 6 months of longitudinal follow-up data following the initial medical cannabis consultation. Interrupted time series analyses was conducted to evaluate the change in rates of healthcare utilization as a result of MVC 6 months before and 6 months after medical cannabis authorization.

Results

Over the 6-month follow-up period, MVC-related visits in medical cannabis patients were 0.50 visits/10000 patients (p = 0.61) and − 0.31 visits/10000 patients (p = 0.64) for MVC-related visits in controls. Overall, authorization for medical cannabis was associated with an immediate decrease in MVC-related visits of − 2.42 visits/10000 patients (p = 0.014) followed by a statistically significant increased rate of MVC-related visits (+ 0.89 events/10,000 in those authorized medical cannabis) relative to controls in the period following their authorization(p = 0.0019). Overall, after accounting for both the immediate and trend effects, authorization for medical cannabis was associated with an increase of 2.92 events/10,000 (95%CI 0.64 to 5.19) over the entire follow-up period. This effect was largely driven by MVC-related emergency department visits (+ 0.80 events/10,000, p < 0.001).

Conclusions

Overall, there was an association between medical cannabis authorization and healthcare utilization, at the population level, in Ontario, Canada. These findings have public health importance and patients and clinicians should be fully educated on the potential risks. Continued follow-up of medically authorized cannabis patients is warranted to fully comprehend long-term impact on motor vehicle crash risk.

Emergency physician perspectives on initiating buprenorphine/naloxone in the emergency department: A qualitative study

OBJECTIVES

The objective of this study was to examine the perspectives of Canadian emergency physicians on the care of patients with opioid use disorders in the emergency department (ED), in particular the real-world facilitators to prescribing buprenorphine/naloxone (BUP) in the ED.

METHODS

We conducted semistructured qualitative interviews using a multi-site-focused ethnographic design. Purposive sampling via an existing national research network was used to recruit ED physicians. Interviews were conducted by phone using an interview guide and continued until theoretical data saturation was reached. Interviews were transcribed and analyzed using latent content analysis. Interviews took place between June 21, 2019, and February 11, 2020.

RESULTS

A total of 32 physicians were included in the analysis. Participants had a median of 10 years of experience, and most (29/32) worked in urban settings. Clinical care of patients with opioid use disorder was found to be variable and physician dependent. Although some physicians reported routinely prescribing BUP, others felt that this was outside the clinical scope of emergency medicine. Access to clinical pathways, incentivized training, dedicated human resources, and follow-up care were identified as critical facilitators for supporting BUP prescribing. Participants also identified a shared responsibility between patients and the ED, including the importance of a patient-centered approach that enhanced patient autonomy. ED BUP prescribing became self-reinforcing over time.

CONCLUSIONS

Although there remains practice variability among Canadian emergency physicians, successful implementation of ED BUP prescribing has occurred in some locations. Jurisdictions wanting to facilitate BUP uptake should consider providing incentivized training, treatment protocols, dedicated human resources, and streamlined access to follow-up care.

Bereaved mothers' engagement in drug policy reform: A multisite qualitative analysis

BACKGROUND

Globally, a tainted drug supply is claiming the lives of tens of thousands of people who use drugs and current measures are not quelling this crisis. Within this context, mothers who have lost a child to substance use have emerged as vocal advocates for drug policy changes. This paper explores mothers' experiences in drug policy advocacy to uncover how they are using their stories to drive policy change.

METHODS

Critical qualitative and narrative methods informed individual interviews with 43 mothers who had lost a child to substance use from across three regions in Canada: British Columbia, Prairie Provinces, and Eastern Provinces. Multisite qualitative analysis (MSQA) provided a rigorous analytical method to identify how social context informed participants' advocacy efforts within and across geographies, together with a theoretical lens from Haraway to understand mothers' activism as situated knowledge.

RESULTS

Mothers' drug policy advocacy was shaped by social context and norms, which influenced the types of advocacy targets pursued, within the constraints of the social and political ethos of each geographic region. Yet across regions, narratives of shared aims and experiences also emerged. Specifically, the notion that people of all backgrounds are dying and that losing a child to substance use can "happen to anyone" - though people who experience structural vulnerabilities are disproportionately impacted. Additionally, mothers' stories were identified as a particularly powerful tool for conveying emotional knowledge and prompting action that complements other forms of knowledge or evidence.

CONCLUSION

To date, efforts to address the drug poisoning epidemic have done little to curb casualties. Mothers whose child's death is related to substance use are one group who are bringing their experiences to advocacy efforts aimed at generating new solutions, including calls for decriminalization and legal regulation of drugs. This and other lived experience perspectives represent a critical voice in decision-making and hold the potential to inform more responsive and impactful drug policy.

To what extent do supervised drug consumption services incorporate non-injection routes of administration? A systematic scoping review documenting existing facilities

BACKGROUND

Most of the existing research on supervised consumption services (SCS) is focused on injection drug use. Less is known about the applicability of SCS for people who consume drugs orally, intranasally, or through inhalation. This is problematic because people who use drugs through modes other than injection are also at risk of overdose death and other harm, and experience barriers accessing health and social services. We aimed to describe existing SCS models that accommodate these alternate routes of drug consumption, and synthesize available information on characteristics of program participants.

METHODS

We conducted a systematic scoping review of 9 peer-reviewed and 13 grey literature databases on SCS that incorporate non-injection routes of consumption. We screened 22,882 titles, and excluded 22,843 (99.8%) articles. We ultimately included 39 (0.2%) full-text articles; 28 (72%) of these articles explicitly identified SCS that permit alternate routes of consumption and 21 (54%) discussed characteristics of participants who consume drugs through non-injection routes. Data on study characteristics, terms and definitions, and site and program participant characteristics were extracted and double-coded. Extracted data were analyzed using descriptive statistics and narrative synthesis.

RESULTS

Included articles describe 48 SCS that permit non-injection routes of consumption, most of which were located in Germany. The majority of these SCS were legally sanctioned and had models of care that were largely comparable to supervised injection services. Notable differences included physical infrastructure such as ventilated rooms or outdoor areas to accommodate inhalation, and shorter time limits on non-injection drug consumption episodes. Program participants engaging in non-injection forms of consumption were typically men over the age of 30 and structurally vulnerable (e.g., experiencing homelessness or unstable housing).

CONCLUSIONS

Extant academic and grey literature indicates that site characteristics and demographics of program participants of SCS that permit non-injection routes of consumption largely reflect those of supervised injection services. Further research on the range of existing SCS that incorporate non-injection routes of consumption is needed to ensure high quality service provision, and improved health outcomes for people who consume drugs via oral, intranasal, and inhalation routes.

Supporting the full participation of people who use drugs in policy fora: Provision of a temporary, conference-based overdose prevention site

The overdose epidemic in North America remains acute and interventions are needed to mitigate harm and prevent death. People who use/d drugs (PWUD) hold essential knowledge to guide the development of these interventions and conferences are vital fora for hearing their perspectives and building support for new policies and programs. However, little guidance exists on how to best ensure the safety of PWUD during conferences. In October 2018, a low-threshold overdose prevention site (OPS) was implemented at a national drug policy and harm reduction conference in Edmonton, Canada. The OPS provided delegates with a monitored space to consume drugs and access drug consumption supplies. This commentary describes the implementation of the OPS with the aim of providing practical guidance for organizers of future substance use-related conferences, meetings, and other events.

Changes in patient health questionnaire (PHQ-9) scores in adults with medical authorization for cannabis

Background

Legal access to medical cannabis is increasing world-wide. Despite this, there is a lack of evidence surrounding its efficacy on mental health outcomes, particularly, on depression. This study assesses the effect of medical cannabis on Patient Health Questionnaire (PHQ-9) scores in adult patients between 2014 and 2019 in Ontario and Alberta, Canada.

Methods

An observational cohort study of medically authorized cannabis patients in Ontario and Alberta. Overall change in PHQ-9 scores from baseline to follow-up were evaluated (mean change) over a time period of up to 3.2 years.

Results

37,338 patients from the cohort had an initial PHQ-9 score recorded with 5103 (13.7%) patients having follow-up PHQ-9 scores. The average age was 54 yrs. (SD 15.7), 46% male, 50% noted depression at baseline. The average PHQ-9 score at baseline was 10.5 (SD 6.9), following a median follow-up time of 196 days (IQR: 77–451) the average final PHQ-9 score was 10.3 (SD 6.8) with a mean change of − 0.20 (95% CI: − 0.26, − 0.14, p-value < 0.0001). Overall, 4855 (95.1%) had no clinically significant change in their PHQ-9 score following medical cannabis use while 172 (3.4%) reported improvement and 76 (1.5%) reported worsening of their depression symptoms.

Conclusions

Although the majority showed no clinically important changes in PHQ-9 scores, a number of patients showed improvement or deteriorations in PHQ-9 scores. Future studies should focus on the parallel use of screening questionnaires to control for PHQ-9 sensitivity and to explore potential factors that may have attributed to the improvement in scores pre- and post- 3-6 month time period.

Empowering Students and Influencing Policy Change Through Experiential Public Health Advocacy Education

BACKGROUND

Public health advocacy is central to the work of many health professionals, including nurses. Although deemed to be a core competency for public health practitioners, courses described in the literature often lack a focus on experiential learning, which is an essential component to acquiring public health advocacy skills.

METHOD

This article describes an innovative, 12-week graduate course that provides students with a combination of theory and experiential learning through an opportunity to engage in political advocacy, community mobilization, and media engagement on a current public health issue.

RESULTS

An advocacy campaign undertaken by students to increase community access to the overdose reversal medication naloxone is described in light of the current North American overdose epidemic. Key considerations for teaching public health advocacy to facilitate development of nursing courses elsewhere are highlighted.

CONCLUSION

Public health advocacy education is important and needs to be expanded both within the nursing profession and across all disciplines. [J Nurs Educ. 2019;58(12):698-703.].

Recognizing and responding to women experiencing homelessness with gendered and trauma-informed care

Background

The purpose of this study is to highlight the experiences of women who are often hidden in what we know and understand about homelessness, and to make policy and practice recommendations for women-centred services including adaptations to current housing interventions.

Methods

Three hundred survey interviews were conducted with people experiencing homelessness in Calgary, Alberta, Canada. The survey instrument measured socio-demographics, adverse childhood experiences, mental and physical health, and perceived accessibility to resources. Eighty-one women participants were identified as a subsample to be examined in greater depth. Descriptive statistics and logistic regressions were calculated to provide insight into women respondents’ characteristics and experiences of homelessness and how they differed from men’s experiences.

Results

Women’s experiences of homelessness are different from their male counterparts. Women have greater mental health concerns, higher rates of diagnosed mental health issues, suicidal thoughts and attempts, and adverse childhood trauma. The results should not be considered in isolation, as the literature suggests, because they are highly interconnected.

Conclusion

In order to ensure that women who are less visible in their experiences of homelessness are able to access appropriate services, it is important that service provision is both gender specific and trauma-informed. Current Housing First interventions should be adapted to ensure women’s safety is protected and their unique needs are addressed.

Social values for health technology assessment in Canada: a scoping review of hepatitis C screening, diagnosis and treatment

Background

Health care system decision makers face challenges in allocating resources for screening, diagnosis and treatment of hepatitis C. Approximately 240,000 individuals are infected with the hepatitis C virus (HCV) in Canada. Populations most affected by HCV include Indigenous people, people who inject drugs, immigrants and homeless or incarcerated populations as well as those born between 1946 and 1965. Curative but expensive drug regimens of novel direct acting antivirals (DAAs) are available. We aim to identify social values from academic literature for inclusion in health technology assessments.

Methods

We conducted a scoping review of academic literature to identify and analyze the social values and evidence-based recommendations for screening, diagnosis and treatment of HCV in Canada. After applying inclusion/exclusion criteria, we abstracted: type of intervention(s), population(s) affected, study location, screening methods, diagnostics and treatments. We then abstracted and applied qualitative codes for social values. We extracted social value statements and clustered them into one of 4 categories: (1) equity and justice, (2) duty to provide care, (3) maximization of population benefit, and (4) individual versus community interests.

Results

One hundred and eighteen articles met our inclusion criteria on screening, diagnosis and treatment of HCV in Canada. Of these, 54 (45.8%) discussed screening, 4 (3.4%) discussed diagnosis and 60 (50.8%) discussed treatment options. Most articles discussed the general population and other non-vulnerable populations. Articles that discussed vulnerable populations focused on people who inject drugs. We coded 1243 statements, most of which fell into the social value categories of equity and justice, duty to provide care and maximization of population benefit.

Conclusion

The academic literature identified an expanded set of social values to be taken into account by resource allocation decision makers in financially constrained environments. In the context of hepatitis C, authors called for greater consideration of equity and justice and the duty to provide care in making evidence-based recommendations for screening, diagnosis and treatment for different populations and in different settings that also account for individual and community interests.

Cohort study of medical cannabis authorisation and healthcare utilisation in 2014-2017 in Ontario, Canada

BACKGROUND

The impact of medical cannabis on healthcare utilisation between 2014 and 2017 in Ontario, Canada. With cannabis legalisation in Canada and some states in the USA, high-quality longitudinal cohort research studies are of urgent need to assess the impact of cannabis use on healthcare utilisation.

METHODS

A matched cohort study of 9925 medical cannabis authorised adult patients (inhaled (smoked or vaporised) or orally consumed (oils)) at specialised cannabis clinics, and inclusion of 17 732 controls (not authorised) between 24 April 2014 and 31 March 2017 from Ontario, Canada. Interrupted time series and multivariate Poisson regression analyses were conducted. Medical cannabis impact on healthcare utilisation was measured over 6 months: all-cause physician visits, all-cause hospitalisation, ambulatory care sensitive conditions (ACSC)-related hospitalisations, all-cause emergency department (ED) visits and ACSC-related ED visits.

RESULTS

For medical cannabis patients compared with controls, there was an initial (within the first month) increase in physician visits (additional 4330 visits per 10 000 patients). However, a numerical reduction was noted over the 6-month follow-up, and no statistical difference was observed (p=0.126). Likewise, in hospitalisations and ACSC ED visits, there was an initial increase (44 per 10 000 people, p<0.05) but no statistical difference after follow-up (p=0.34). Conversely, no initial increase in all-cause ED visits was observed with a slight decrease (19 visits per 10 000 patients, p=0.014) in follow-up.

CONCLUSIONS

An initial increase (within first month) in healthcare utilisation may be expected among medical cannabis users that appears to wane over time. Proactive follow-up of patients using medical cannabis is warranted to minimise initial risks to patients and actively assess potential benefits/harms of ongoing use.