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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada

OBJECTIVE

Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada.

STUDY DESIGN AND SETTING

Data from cohorts of people with recent (past 12 month) injection drug use, including those participating in community-based research studies or seeking drug treatment were linked to health administrative data in Ontario from 1992-2020. We assessed the validity of algorithms to identify injection drug use over varying lookback periods (i.e., all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT).

RESULTS

Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts, 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, emergency department visit or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity, 94.2% specificity) and recent IDU (using 3 years lookback: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment.

CONCLUSION

Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of injection drug use in the population in which they are applied.

Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis

BACKGROUND

Supervised consumption services (SCS) prevent overdose deaths onsite; however, less is known about their effect on population-level overdose mortality. We aimed to characterise overdose mortality in Toronto, ON, Canada, and to establish the spatial association between SCS locations and overdose mortality events.

METHODS

For this ecological study and spatial analysis, we compared crude overdose mortality rates before and after the implementation of nine SCS in Toronto in 2017. Data were obtained from the Office of the Chief Coroner of Ontario on cases of accidental death within the City of Toronto for which the cause of death involved the use of an opiate, synthetic or semi-synthetic opioid, or other psychoactive substance. We assessed overdose incident data for global spatial autocorrelation and local clustering, then used geographically weighted regression to model the association between SCS proximity and overdose mortality incidence in 2018 and 2019.

FINDINGS

We included 787 overdose mortality events in Toronto between May 1, 2017, and Dec 31, 2019. The overdose mortality rate decreased significantly in neighbourhoods that implemented SCS (8·10 deaths per 100 000 people for May 1-July 31, 2017, vs 2·70 deaths per 100 000 people for May 1-July 31, 2019; p=0·037), but not in other neighbourhoods. In a geographically weighted regression analysis that adjusted for the availability of substance-use-related services and overdose-related sociodemographic factors by neighbourhood, the strongest local regression coefficients of the association between SCS and overdose mortality location ranged from -0·60 to -0·64 per mile in 2018 and from -1·68 to -1·96 per mile in 2019, suggesting an inverse association.

INTERPRETATION

We found that the period during which SCS were implemented in Toronto was associated with a reduced overdose mortality in surrounding neighbourhoods. The magnitude of this inverse association increased from 2018 to 2019, equalling approximately two overdose fatalities per 100 000 people averted in the square mile surrounding SCS in 2019. Policy makers should consider implementing and sustaining SCS across neighbourhoods where overdose mortality is high.

FUNDING

The Canadian Institutes of Health Research.

A qualitative assessment of tablet injectable opioid agonist therapy (TiOAT) in rural and smaller urban British Columbia, Canada: Motivations and initial impacts

BACKGROUND

The evolving and unpredictable unregulated drug market has driven an unprecedented overdose crisis that requires effective intervention. Growing evidence suggests that novel opioid agonist treatments, such as tablet injectable opioid agonist therapy (TiOAT), have potential to prevent overdoses and other drug-related harms. More evidence is needed to characterize their utility in achieving these outcomes. The current article is an analysis of two TiOAT programs implemented in British Columbia, Canada, to assess impact on health and well-being, including overdose risk. Moreover, we explored participants' enrollment goals and if they were achieved.

METHODS

The study employed qualitative methods to evaluate the TiOAT program in two sites between October 2021 and April 2022. We developed a semi-structured interview tool to guide in depth interviews. All interviews (n = 32) took place on teleconference software or in person. Thematic analysis allowed for the emergence of themes associated with TiOAT participation.

RESULTS

Participants discussed various motivations for enrolling in TiOAT, which included gaining financial stability, reducing or eliminating drug use, addressing withdrawal symptoms, wanting to work, and improving social circumstances. An assessment of initial programmatic impacts revealed that many participant-identified motivators were achieved. Participants also reported fewer or no overdoses since starting TiOAT, and many reported switching from injecting to smoking drugs. Some challenges included adequate dosing as evidenced by ongoing withdrawal and pain. Some participants requested additional opioids, such as diacetylmorphine, to aid in reducing illicit drug use.

CONCLUSION

Participants described how TiOAT helped them to achieve many of their goals. Suggested programmatic improvements include enhanced patient-provider co-design with respect to dosing to address ongoing withdrawal and pain. As the unpredictability the unregulated drug market worsens, novel options, such as TiOAT, ought to be implemented broadly to reduce overdose events and improve quality of life for people who use drugs.

Financial Vulnerability and Its Association with HIV Transmission Risk Behaviors Among People Who Inject Drugs in Kyrgyzstan

The Family Resource Scale (FRS) is a three-factor financial vulnerability (FV) measure. FV may impact HIV transmission risks. Cross-sectional data from 279 people who inject drugs (PWID) in Kyrgyzstan surveyed April-October 2021 was used to validate the FRS and estimate associations between FV on past 6-month injection and sexual HIV risk outcomes. The three-factor FRS reflected housing, essential needs, and fiscal independence, and had good internal reliability and structural validity. Greater cumulative, housing, and essential needs FRS scores were associated with increased relative risk on public injection (adjusted risk ratio [aRR], 95% confidence interval [95% CI]: 1.03 [1.01, 1.04]; aRR [95% CI]: 1.06 [1.02, 1.09]; aRR [95% CI]: 1.06 [1.03, 1.08], respectively, all p < 0.001) and preparing injections with unsafe water sources (aRR [95% CI]: 1.04 [1.02, 1.07]; aRR [95% CI]: 1.09 [1.04, 1.15]; aRR [95% CI]: 1.08 [1.03, 1.14], respectively, all p < 0.001). Results suggest that PWID housing- and essential needs-related FV may exacerbate injection HIV transmission risks. Reducing PWIDs' FV may enhance the HIV response in Kyrgyzstan.

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.

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.

Young, Black/African American, and Latino communities are left behind despite legislative efforts in California to reduce HIV/STI disparities

Objectives

Sexually transmitted infections (STI) have been on the rise in the United States with racial/ethnic minority groups, gay and bisexual men, and youth experiencing the highest STI and HIV infection rates. In 2022, California became the first state in the nation to pass legislation, Senate Bill 306 (SB 306), requiring health care plans to cover the costs of home test kits for STIs, including HIV. This study examines provisions within SB 306 and its potential to reduce STI and HIV disparities among key demographic groups and geographic regions within California.

Study design

Ecological cross-sectional study involving 58 California counties.

Methods

Descriptive statistics and choropleth maps compared HIV/STI prevalence rates, uninsured rates, demographic composition, and healthcare provider coverage across California counties. Three geographically weighted Poisson regression analyses were conducted to separately examine the association between proportion of uninsured and HIV, gonorrhea, and chlamydia prevalence rates.

Results

HIV/STI rates were significantly and positively associated with the proportion of uninsured residents in Central and Southern California counties. These counties had a higher proportion of demographic groups vulnerable to HIV/STI including a large Latino, Black/African American, and younger (age 15-24) population but had a lower rate of healthcare providers with prescription authority for home testing kits, which is a requirement under SB 306.

Conclusions

Cutting-edge solutions are needed to stem the rising tide of new STI and HIV infections. While SB 306 is novel and innovative in intent, its coverage gaps will increase disparities and inequities among historically underserved populations.

Latent polydrug use patterns and the provision of injection initiation assistance among people who inject drugs in three North American settings

INTRODUCTION

We sought to identify latent profiles of polysubstance use patterns among people who inject drugs in three distinct North American settings, and then determine whether profile membership was associated with providing injection initiation assistance to injection-naïve persons.

METHODS

Cross-sectional data from three linked cohorts in Vancouver, Canada; Tijuana, Mexico; and San Diego, USA were used to conduct separate latent profile analyses based on recent (i.e., past 6 months) injection and non-injection drug use frequency. We then assessed the association between polysubstance use patterns and recent injection initiation assistance provision using logistic regression analyses.

RESULTS

A 6-class model for Vancouver participants, a 4-class model for Tijuana participants and a 4-class model for San Diego participants were selected based on statistical indices of fit and interpretability. In all settings, at least one profile included high-frequency polysubstance use of crystal methamphetamine and heroin. In Vancouver, several profiles were associated with a greater likelihood of providing recent injection initiation assistance compared to the referent profile (low-frequency use of all drugs) in unadjusted and adjusted analyses, however, the inclusion of latent profile membership in the multivariable model did not significantly improve model fit.

DISCUSSION AND CONCLUSIONS

We identified commonalities and differences in polysubstance use patterns among people who inject drugs in three settings disproportionately impacted by injection drug use. Our results also suggest that other factors may be of greater priority when tailoring interventions to reduce the incidence of injection initiation. These findings can aid in efforts to identify and support specific higher-risk subpopulations of people who inject drugs.

First-line opioid agonist treatment as prevention against assisting others in initiating injection drug use: A longitudinal cohort study of people who inject drugs in Vancouver, Canada

Background

Among people who inject drugs, frequent injecting and experiencing withdrawal are associated with facilitating others' first injections. As these factors may reflect an underlying substance use disorder, we investigated whether first-line oral opioid agonist treatment (OAT; methadone or buprenorphine/naloxone) reduces the likelihood that people who inject drugs help others initiate injecting.

Methods

We used questionnaire data from semi-annual visits between December 2014-May 2018 on 334 people who inject drugs with frequent non-medical opioid use in Vancouver, Canada. We estimated the effect of current first-line OAT on subsequent injection initiation assistance provision (i.e., helped someone initiate injecting in the following six months) using inverse-probability-weighted estimation of repeated measures marginal structural models to reduce confounding and informative censoring by time-fixed and time-varying covariates.

Results

By follow-up visit, 54-64% of participants reported current first-line OAT whereas 3.4-6.9% provided subsequent injection initiation assistance. Per the primary weighted estimate (n = 1114 person-visits), participants currently on first-line OAT (versus no OAT) were 50% less likely, on average, to subsequently help someone initiate injecting (relative risk [RR]=0.50, 95% CI=0.23-1.11). First-line OAT was associated with reduced risk of subsequent injection initiation assistance provision in participants who, at baseline, injected opioids less than daily (RR=0.15, 95% CI=0.05-0.44) but not in those who injected opioids daily (RR=0.86, 95% CI=0.35-2.11).

Conclusions

First-line OAT seemingly reduces the short-term likelihood that people who inject drugs facilitate first injections. However, the extent of this potential effect remains uncertain due to imprecise estimation and observed heterogeneity by baseline opioid injecting frequency.

Disease-related stigma among people who inject drugs in Toronto amidst the COVID-19 pandemic

Background

Stigma overwhelmingly affects people who inject drugs. The COVID-19 pandemic posed unique challenges for people who inject drugs, who are already stigmatized as being "dangerous and spreading disease." The present study explored ways in which stigma was experienced by a sample of people who inject drugs in Toronto, Canada following COVID-related public health precaution measures.

Methods

Qualitative interviews were conducted with people who inject drugs (n = 24) recruited from supervised consumption sites in Toronto, Canada. The semi-structured interview guide focused on the impact of COVID-19 on participants' health and social well-being. Interviews took place six-months after initial COVID-19 precautions (September-October 2020). We used thematic analysis to examine findings, with stigma being an emergent theme.

Results

Participants described heightened acts of stigma after COVID-19 restrictions were implemented, including feeling treated as "diseased" and the cause of COVID-19's spread. They reported being less likely to receive emergency care during events such as overdoses. Participants perceived increased disease-related stigma evident through actions of stigma, including amplified dehumanization by the public, others avoiding all contact with them, and more discrimination by police and hospital systems.

Conclusion

Participants provided specific examples of how stigmatizing behaviors harmed them after COVID-19 precautions began. It is plausible that stigma contributed to the dramatic increase in fatal overdoses, difficulty accessing housing, and further difficulty accessing needed healthcare in our setting. Integrating evidence-based harm reduction approaches in areas where stigma is evident might offset harms stemming from disease-related stigma and mitigate these harms during future public health emergencies.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Access to tablet injectable opioid agonist therapy in rural and smaller urban settings in British Columbia, Canada: a qualitative study

BACKGROUND

Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs.

METHODS

Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically.

RESULTS

TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk.

CONCLUSIONS

This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.

Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto, Canada: A cross-sectional analysis

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.

Drug checking services as a surveillance tool for clinical laboratories: Examining trends in the unregulated fentanyl supply

OBJECTIVES

Timely assessment and understanding of drug trends is essential for clinical laboratories to effectively respond to the overdose epidemic. In this proof-of-concept study, we sought to determine whether information obtained through Toronto's Drug Checking Services (DCS) and cross-provincial urine drug testing (UDT) data can be used as a surveillance tool for clinical laboratories and discuss the value of collaboration between the clinical laboratory, clinicians, and community partners to optimize patient care.

DESIGN & METHODS

Mass spectrometry-based UDT data from LifeLabs Ontario (n = 127,529) and British Columbia (n = 14,848), and drug checking data from Toronto DCS (n = 3,308 drugs or used paraphernalia) was collected between August 2020 and October 2021. Fentanyl co-positivity with toxic adulterants such as benzodiazepine-related drugs and fentanyl analogues were examined.

RESULTS

The percent co-positivity of fentanyl with etizolam, flualprazolam, flubromazolam, carfentanil, and acetylfentanyl in both Ontario UDT and DCS drugs/used paraphernalia showed similar trends. Regional differences in co-positivity with etizolam and fentanyl analogues were noted between Ontario and British Columbia UDT with patterns consistent over the entire 15-month collection period.

CONCLUSIONS

Clinical laboratories should connect with their local DCS, if available, to understand and monitor unregulated drug trends. These data can be used as an important tool to help clinical laboratories tailor their UDT menus and thereby provide a community-focused service to improve patient care.

Impact of the COVID-19 pandemic on the prevalence of opioid agonist therapy discontinuation in Ontario, Canada: A population-based time series analysis

BACKGROUND

We assessed the impact of COVID-19, which includes the declaration of a state of emergency and subsequent release of pandemic-specific OAT guidance (March 17, 2020 to March 23, 2020) on the prevalence of OAT discontinuation.

METHODS

We conducted a population-based time series analysis using interventional autoregressive integrated moving average models among Ontario residents who were stable (>60 days of continuous use) and not yet stable on OAT. Specifically, we examined whether COVID-19 impacted the weekly percentage of individuals who discontinued OAT, overall and stratified by treatment type (methadone vs. buprenorphine/naloxone). Additionally, we compared demographic characteristics and patient outcomes among people stable on OAT who discontinued treatment during (March 17, 2020 to November 30, 2020) and prior (July 3, 2019 to March 16, 2020) to the pandemic.

RESULTS

The weekly prevalence of OAT discontinuation across the study period ranged between 0.6% and 1.1%, among those stable on treatment compared to 7.3% and 16.6%, among those not stable on treatment. Following COVID-19, there was no significant change in the percentage of Ontarians who discontinued OAT, regardless of whether they were stabilized on treatment. Among those stable on OAT, a similar proportion of patients restarted therapy and experienced opioid-related harm following an OAT discontinuation. However, mortality following OAT discontinuation must be noted, as approximately 1.4% and 0.8% of people who discontinued methadone and buprenorphine/naloxone respectively, died within 30 days of discontinuation.

CONCLUSIONS

Trends in the prevalence of OAT discontinuation did not significantly change during the first eight months of the COVID-19 pandemic.

Cohort profile: the Kyrgyzstan InterSectional Stigma (KISS) injection drug use cohort study

BACKGROUND

In Kyrgyzstan and other Eastern European and Central Asian countries, injection drug use and HIV-related intersectional stigma undermines HIV prevention efforts, fueling a rapidly expanding HIV epidemic. The Kyrgyzstan InterSectional Stigma (KISS) Injection Drug Use Cohort is the first study designed to assess the impact of drug use, methadone maintenance treatment (MMT) and HIV stigma experiences among people who inject drugs (PWID) on HIV prevention service utilization.

METHODS

Adult PWID were recruited from Bishkek city and the surrounding rural Chuy Oblast region in northern Kyrgyzstan via modified time location sampling and snowball sampling. All participants completed a baseline rapid HIV test and interviewer-administered survey. A subsample of participants were prospectively followed for three months and surveyed to establish retention rates for future work in the region. Internal reliability of three parallel stigma measures (drug use, MMT, HIV) was evaluated. Descriptive statistics characterize baseline experiences across these three stigma types and HIV prevention service utilization, and assess differences in these experiences by urbanicity.

RESULTS

The KISS cohort (N = 279, 50.5% Bishkek, 49.5% Chuy Oblast) was mostly male (75.3%), ethnically Russian (53.8%), median age was 40 years old (IQR 35-46). Of the 204 eligible participants, 84.9% were surveyed at month 3. At baseline, 23.6% had a seropositive rapid HIV test. HIV prevention service utilization did not differ by urbanicity. Overall, we found 65.9% ever utilized syringe service programs in the past 6 months, 8.2% were utilizing MMT, and 60.8% met HIV testing guidelines. No participants reported PrEP use, but 18.5% had heard of PrEP. On average participants reported moderate levels of drug use (mean [M] = 3.25; α = 0.80), MMT (M = 3.24; α = 0.80), and HIV stigma (M = 2.94; α = 0.80). Anticipated drug use stigma from healthcare workers and internalized drug use stigma were significantly higher among PWID from Bishkek (p < 0.05), while internalized HIV stigma among PWID living with HIV was significantly greater among PWID from Chuy Oblast (p = 0.03).

CONCLUSION

The KISS cohort documents moderate levels of HIV-related intersectional stigma and suboptimal engagement in HIV prevention services among PWID in Kyrgyzstan. Future work will aim identify priority stigma reduction intervention targets to optimize HIV prevention efforts in the region.

The influence of poly-drug use patterns on the association between opioid agonist treatment engagement and injecting initiation assistance

BACKGROUND

Evidence suggests people who inject drugs (PWID) prescribed opioid agonist treatment (OAT) are less likely to provide injection drug use (IDU) initiation assistance. We investigated the association between OAT engagement and providing IDU initiation assistance across poly-drug use practices in Vancouver, Canada.

METHODS

Preventing Injecting by Modifying Existing Responses (PRIMER) is a prospective study seeking to identify structural interventions that reduce IDU initiation. We employed data from linked cohorts of PWID in Vancouver and extended the findings of a latent profile analysis (LPA). Multivariable logistic regression models were performed separately for the six poly-drug use LPA classes. The outcome was recently assisting others in IDU initiation; the independent variable was recent OAT engagement.

RESULTS

Among participants (n = 1218), 85 (7.0%) reported recently providing injection initiation assistance. When adjusting for age and sex, OAT engagement among those who reported a combination of high-frequency heroin and methamphetamine IDU and low-to-moderate-frequency prescription opioid IDU and methamphetamine non-injection drug use (NIDU) was associated with lower odds of IDU initiation assistance provision (Adjusted Odds Ratio [AOR]: 0.18, 95% CI: 0.05-0.63, P = 0.008). Significant associations were not detected among other LPA classes.

CONCLUSIONS

Our findings extend evidence suggesting that OAT may provide a population-level protective effect on the incidence of IDU initiation and suggest that this effect may be specific among PWID who engage in high-frequency methamphetamine and opioid use. Future research should seek to longitudinally investigate potential causal pathways explaining the association between OAT and initiation assistance provision among PWID to develop tailored intervention efforts.

Requiring help injecting among people who inject drugs in Toronto, Canada: Characterising the need to address sociodemographic disparities and substance-use specific patterns

INTRODUCTION

Those requiring help injecting are at an elevated risk of injection-related injury and blood-borne infections and are thus a priority group for harm reduction programs. As supervised consumption services (SCS) are scaled-up across Canada, information on those who require help injecting is necessary to inform equitable service uptake. We characterised the sociodemographic, structural and drug use correlates of needing help injecting among a cohort of people who inject drugs in Toronto, Canada.

METHODS

A cross-sectional baseline survey was administered between November 2018 and March 2020. Unadjusted and multivariable logistic regression models examined associations with requiring help injecting in the past 6 months. A gender-stratified sub-analysis described characteristics of receiving help among those requiring it.

RESULTS

Of 701 participants (31.0% cisgender women), 294 (41.9%) needed recent help injecting. In unadjusted analyses, being a racialised, non-Indigenous person (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.13-2.86) or a cisgender woman (OR 1.72, 95% CI 1.24-2.39) were associated with needing help. In multivariable analyses, requiring assistance was associated with needing frequent help preparing drugs (adjusted OR [AOR] 9.52, 95% CI 4.78-21.28), fewer years since first injection (AOR for 1 year increase: 0.97, 95% CI 0.95-0.99) and injecting stimulants. Among those who required help, cisgender women reported needing assistance more often than cisgender men (P = 0.009).

DISCUSSION AND CONCLUSIONS

Over two-fifths of the sample required help injecting; requiring assistance was associated with sociodemographic indicators and substance use-specific patterns. Findings highlight the need to scale-up educational resources for those who receive or provide help injecting, as well as SCS that accommodate onsite injection assistance.

Emerging synthetic cannabinoids detected by a drug checking service in Toronto, Canada

BACKGROUND

Toronto's Drug Checking Service (DCS) provides people who use drugs with information on the chemical composition of their substances and conducts real-time monitoring of the unregulated drug supply. Presented are first known data of three newly detected synthetic cannabinoids (SCs) in Toronto, Ontario.

METHODS

The present data are from samples analyzed between April and November 2020. Samples were collected at partnering harm reduction agencies in Toronto and analyzed using gas or liquid chromatography-mass spectrometry. An intake survey queried about the sample characteristics on submission, including expected drug(s).

RESULTS

Samples were analyzed between 1 April and 20 November 2020 (N = 19), which marks the period immediately following imposed COVID-19 border and movement restrictions in Canada. The newly detected, unexpected SCs were ACHMINACA (n = 15), AB-FUBINACA (n = 3), and 4-fluoro-MDMB-BUTINACA (n = 1). Fentanyl was expected in 74% (n = 14). Most SCs were detected in samples containing fentanyl or related analogues (n = 18; 95%), or benzodiazepine-related drugs (i.e., etizolam and flualprazolam) (n = 15; 79%).

CONCLUSIONS

This information can inform overdose prevention efforts and drug market monitoring of SCs in Toronto and regions served by the same drug trafficking routes. The detection of SCs during a period marked by COVID-19-related restrictions can contribute to efforts to identify global drug market trends during this time.

Health harms of non-medical prescription opioid use: A systematic review

ISSUES

Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken.

APPROACH

We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality.

KEY FINDINGS

Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%).

IMPLICATIONS

A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault.

DISCUSSION AND CONCLUSIONS

Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.

Service utilization patterns and characteristics among clients of integrated supervised consumption sites in Toronto, Canada

Introduction

Supervised consumption services (SCS), intended to reduce morbidity and mortality among people who inject drugs, have been implemented in a variety of delivery models. We describe and compare access to and uptake of co-located and external services among clients accessing harm reduction-embedded (HR-embedded) and community health center-embedded (CHC-embedded) SCS models.

Methods

Cross-sectional baseline data were collected between November 2018 and March 2020 as part of a cohort of people who inject drugs in Toronto, Canada designed to evaluate one HR-embedded and two CHC-embedded SCS. This analysis was restricted to clients who reported accessing these SCS more than once in the previous 6 months. Participants were classified as HR-embedded or CHC-embedded SCS clients based on self-reported usage patterns. Client characteristics, as well as access to onsite services and referral and uptake of external services, were compared by SCS model.

Results

Among 469 SCS clients, 305 (65.0%) primarily used HR-embedded SCS and 164 (35.0%) primarily used CHC-embedded SCS. Compared to clients accessing CHC-embedded SCS, clients accessing HR-embedded SCS were somewhat younger (37.6 vs. 41.4, p < 0.001), more likely to report fentanyl as their primary injected drug (62.6% vs. 42.7%, p < 0.001), and visited SCS more often (49.5% vs. 25.6% ≥ daily, p < 0.001). HR-embedded SCS clients were more likely to access harm reduction services onsite compared to CHC-embedded SCS clients (94.8% vs. 89.6%, p = 0.04), while CHC-embedded SCS clients were more likely to access non-harm reduction services onsite (57.3% vs. 26.6%, p < 0.001). For external services, HR-embedded SCS clients were more likely to receive a referral (p = 0.03) but less likely to report referral uptake (p = 0.009).

Conclusions

Clients accessing HR-embedded and CHC-embedded SCS were largely demographically similar but had different drug and SCS use patterns, with CHC-embedded SCS clients using the site less frequently. While clients of CHC-embedded SCS reported greater access to ancillary health services onsite, external service use remained moderate overall, underscoring the importance of co-location and support for clients with system navigation. Importantly, lack of capacity in services across the system may impact ability of staff to make referrals and/or the ability of clients to take up a referral.

Diversity among health care leaders in Canada: a cross-sectional study of perceived gender and race

BACKGROUND

Diverse health care leadership teams may improve health care experiences and outcomes for patients. We sought to explore the race and gender of hospital and health ministry executives in Canada and compare their diversity with that of the populations they serve.

METHODS

This cross-sectional study included leaders of Canada's largest hospitals and all provincial and territorial health ministries. We included individuals listed on institutional websites as part of the leadership team if a name and photo were available. Six reviewers coded and analyzed the perceived race and gender of leaders, in duplicate. We compared the proportion of racialized health care leaders with the race demographics of the general population from the 2016 Canadian Census.

RESULTS

We included 3056 leaders from 135 institutions, with reviewer concordance on gender for 3022 leaders and on race for 2946 leaders. Reviewers perceived 37 (47.4%) of 78 health ministry leaders as women, and fewer than 5 (< 7%) of 80 as racialized. In Alberta, Saskatchewan, Prince Edward Island and Nova Scotia, provinces with a centralized hospital executive team, reviewers coded 36 (50.0%) of 72 leaders as women and 5 (7.1%) of 70 as racialized. In British Columbia, New Brunswick and Newfoundland and Labrador, provinces with hospital leadership by region, reviewers perceived 120 (56.1%) of 214 leaders as women and 24 (11.5%) of 209 as racialized. In Manitoba, Ontario and Quebec, where leadership teams exist at each hospital, reviewers perceived 1326 (49.9%) of 2658 leaders as women and 243 (9.2%) of 2633 as racialized. We calculated the representation gap between racialized executives and the racialized population as 14.5% for British Columbia, 27.5% for Manitoba, 20.7% for Ontario, 12.4% for Quebec, 7.6% for New Brunswick, 7.3% for Prince Edward Island and 11.6% for Newfoundland and Labrador.

INTERPRETATION

In a study of more than 3000 health care leaders in Canada, gender parity was present, but racialized executives were substantially under-represented. This work should prompt health care institutions to increase racial diversity in leadership.

Gender and the first-time provision of injection initiation assistance among people who inject drugs across two distinct North American contexts: Tijuana, Mexico and Vancouver, Canada

INTRODUCTION

Injection drug use initiation is commonly facilitated by other people who inject drugs (PWID). We investigated how the gender of PWID influences their risk of providing initiation assistance to others across two distinct geo-cultural settings.

METHODS

Data were drawn from two prospective cohorts in Tijuana, Mexico and Vancouver, Canada which conducted semi-annual interviews within the PReventing Injecting by Modifying Existing Responses (PRIMER) study. Participants consisted of PWID who had reported never providing injection initiation assistance at baseline. We then conducted site-specific discrete-time survival analyses assessing the relationship between gender and other relevant covariates (e.g. age and past 6-month sex work) on the risk of the first reported instance of providing initiation assistance.

RESULTS

Of 1988 PWID (Tijuana: n = 596; Vancouver: n = 1392), 256 (43%) and 511 (36.7%) participants were women, and 42 (1.7%) and 78 (1.6%) reported recent injection initiation assistance across a median of three and two follow-up visits, respectively. Women had a lower risk of providing injection initiation assistance for the first time in Tijuana (adjusted hazard ratio = 0.52, 95% confidence interval 0.27-0.99), but not in Vancouver. Gendered pathways, like sex work, were associated with providing initiation assistance for the first time in Vancouver (adjusted hazard ratio = 1.97, 95% confidence interval 1.08-3.61).

DISCUSSION AND CONCLUSIONS

Women in Tijuana, but not Vancouver, were less likely to provide first-time initiation assistance among PWID. These results can inform gender- and site-specific prevention efforts aimed at reducing transitions into drug injecting across geographic contexts.

Drug checking services for people who use drugs: a systematic review

BACKGROUND AND AIMS

Drug checking services provide people who use drugs with chemical analysis results of their drug samples while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) the influence of drug checking services on the behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services.

METHODS

Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science and Dissertations and Theses Global. Eligible studies were peer-reviewed articles and conference abstracts or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools.

RESULTS

We screened 2463 titles and abstracts and 156 full texts, with 90 studies meeting inclusion criteria. Most (n = 65, 72.2%) were from Europe and used cross-sectional designs (n = 79, 87.7%). Monitoring of drug markets by drug checking services (n = 63, 70%) was the most reported domain, followed by the influence of drug checking services on behaviour (n = 31, 34.4%), including intent to use, actual use and disposal of the drug, and outcomes related to models of drug checking services (n = 17, 18.9%). The most common outcome measures were detection of unexpected substances (n = 50, 55.6%), expected substances (n = 44, 48.9%), new psychoactive substances (n = 40, 44.4%) and drugs of concern (n = 32, 36.5%) by drug checking services.

CONCLUSIONS

Drug checking services appear to influence behavioural intentions and the behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe, and increasingly in North America. Concerns about drug contents and negative health consequences facilitate the use of drug checking services; lack of concern; trust in drug sellers; lack of accessibility of drug checking services; and legal and privacy concerns are barriers to use.

Validation of Self-reported Opioid Agonist Treatment Among People Who Inject Drugs Using Prescription Dispensation Records

BACKGROUND

Studies of people who inject drugs (PWID) commonly use questionnaires to determine whether participants are currently, or have recently been, on opioid agonist treatment for opioid use disorder. However, these previously unvalidated self-reported treatment measures may be susceptible to inaccurate reporting.

METHODS

We linked baseline questionnaire data from 521 PWID in the Ontario integrated Supervised Injection Services cohort in Toronto (November 2018-March 2020) with record-level health administrative data. We assessed the validity (sensitivity, specificity, positive and negative predictive value [PPV and NPV]) of self-reported recent (in the past 6 months) and current (as of interview) opioid agonist treatment with methadone or buprenorphine-naloxone relative to prescription dispensation records from a provincial narcotics monitoring system, considered the reference standard.

RESULTS

For self-reported recent opioid agonist treatment, sensitivity was 78% (95% CI = 72, 83), specificity was 90% (95% CI = 86, 94), PPV was 90% (95% CI = 85, 93), and NPV was 79% (95% CI = 74, 84). For self-reported current opioid agonist treatment, sensitivity was 84% (95% CI = 78, 90), specificity was 87% (95% CI = 83, 91), PPV was 74% (95% CI = 67, 81), and NPV was 93% (95% CI = 89, 95).

CONCLUSIONS

Self-reported opioid agonist treatment measures were fairly accurate among PWID, with some exceptions. Inaccurate recall due to a lengthy lookback window may explain underreporting of recent treatment, whereas social desirability bias may have led to overreporting of current treatment. These validation data could be used in future studies of PWID to adjust for misclassification in similar self-reported treatment measures.

Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation

IMPORTANCE

During the COVID-19 pandemic, modified guidance for opioid agonist therapy (OAT) allowed prescribers to increase the number of take-home doses to promote treatment retention. Whether this was associated with an increased risk of overdose is unclear.

OBJECTIVE

To evaluate whether increased take-home doses of OAT early in the COVID-19 pandemic was associated with treatment retention and opioid-related harm.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective propensity-weighted cohort study of 21 297 people actively receiving OAT on March 21, 2020, in Ontario, Canada. Changes in OAT take-home dose frequency were assessed between March 22, 2020, and April 21, 2020, and individuals were observed for up to 180 days to assess outcomes (last date of follow-up, October 18, 2020).

EXPOSURES

Exposure was defined as extended take-home doses in the first month of the pandemic within each of 4 cohorts based on OAT type and baseline take-home dose frequency (daily dispensed methadone, 5-6 take-home doses of methadone, daily dispensed buprenorphine/naloxone, and 5-6 take-home doses of buprenorphine/naloxone).

MAIN OUTCOMES AND MEASURES

Primary outcomes were opioid overdose, interruption in OAT, and OAT discontinuation.

RESULTS

Among 16 862 methadone and 4435 buprenorphine/naloxone recipients, the median age ranged between 38 and 42 years, and 29.1% to 38.2% were women. Among individuals receiving daily dispensed methadone (n = 5852), initiation of take-home doses was significantly associated with lower risks of opioid overdose (6.9% vs 9.5%/person-year; weighted hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]), treatment discontinuation (51.0% vs 63.6%/person-year; weighted HR, 0.80 [95% CI, 0.72-0.90]), and treatment interruption (19.0% vs 23.9%/person-year; weighted HR, 0.80 [95% CI, 0.67-0.95]) compared with no change in take-home doses. Among individuals receiving daily dispensed buprenorphine/naloxone (n = 662), there was no significant difference in any outcomes between exposure groups. Among individuals receiving weekly dispensed OAT (n = 11 010 for methadone; n = 3773 for buprenorphine/naloxone), extended take-home methadone doses were significantly associated with lower risks of OAT discontinuation (14.1% vs 19.6%/person-year; weighted HR, 0.72 [95% CI, 0.62-0.84]) and interruption in therapy (5.1% vs 7.4%/person-year; weighted HR, 0.69 [95% CI, 0.53-0.90]), and extended take-home doses of buprenorphine/naloxone were significantly associated with lower risk of interruption in therapy (9.5% vs 12.9%/person-year; weighted HR, 0.74 [95% CI, 0.56-0.99]) compared with no change in take-home doses. Other primary outcomes were not significantly different between groups.

CONCLUSIONS AND RELEVANCE

In Ontario, Canada, during the COVID-19 pandemic, dispensing of increased take-home doses of opioid agonist therapy was significantly associated with lower rates of treatment interruption and discontinuation among some subsets of patients receiving opioid agonist therapy, and there were no statistically significant increases in opioid-related overdoses over 6 months of follow-up. These findings may be susceptible to residual confounding and should be interpreted cautiously.

Impact of the COVID-19 pandemic on the provision of take-home doses of opioid agonist therapy in Ontario, Canada: a population-based time-series analysis

Background

In March 2020, the Ontario government declared a state of emergency due to the growing risk of COVID-19. In response, new guidance for the management of opioid agonist therapy (OAT) was released, which included the expansion of eligibility for take-home doses. We investigated the impact of these changes on trends in the distribution of take-home doses of OAT.

Methods

We conducted a population-based time series analysis among residents of Ontario, Canada who were dispensed OAT between June 25, 2019 and November 30, 2020. For each week of the study period, we calculated the percentage of people dispensed (a) methadone and (b) buprenorphine/naloxone by the number of take-home doses received. We used interventional autoregressive integrated moving average models to estimate changes in the percentage of people dispensed each category of take-home doses in the weeks following the declaration of the state of emergency and release of the OAT dispensing guidance.

Results

Following the state of emergency and release of the OAT dispensing guidance, there was a significant increase in the percentage of Ontarians dispensed 7 to 13 (3.6% increase; p = 0.033) and 14 or more (0.8% increase; p<0.001) take-home doses of methadone, and in the percentage of people dispensed 7 to 13 (4.3% increase; p = 0.001), 14 to 27 (2.8% increase; p<0.001), and 28 or more (0.3% increase; p = 0.008) take-home doses of buprenorphine/naloxone. There were significant decreases in the percentage of Ontarians receiving daily dispensed buprenorphine/naloxone (-3.1%; p = 0.001), as well as the percentage dispensed 1 to 6 take-home doses of methadone (-4.5%; p = 0.001) and buprenorphine/naloxone (-4.9%; p = 0.001).

Conclusion

The new guidance for dispensing OAT in Ontario resulted in increases in the duration of take-home doses of methadone and buprenorphine/naloxone supplied. However, given that changes were small, strategies to improve retention in OAT and ensure equitable access to take-home dosing should continue.

Articulating the Trauma-Informed Theory of Individual Health Behavior

Exposure to trauma increases the risk of engaging in detrimental health behaviours such as tobacco and substance use. In response, the United States Substance Abuse and Mental Health Services Administration developed Trauma-Informed Care (TIC), an organisational framework for improving the provision of behavioural health care to account for the role exposure to trauma plays in patients' lives. We adapt TIC to introduce a novel theory of behaviour change, the Trauma-Informed Theory of Individual Health Behavior (TTB). TTB posits that individual capacity to undertake intentional health-promoting behaviour change is dependent on three factors: (1) the forms and severity of trauma they have been and are exposed to, (2) how this trauma physiologically manifests (i.e., the trauma response) and (3) resilience to undertake behaviour change despite this trauma response. We define each of these factors and their relationships to one another. We anticipate that the introduction of TTB will provide a foundation for developing theory-driven research, interventions, and policies that improve behavioural health outcomes in trauma-affected populations.

Diverse psychotropic substances detected in drug and drug administration equipment samples submitted to drug checking services in Toronto, Ontario, Canada, October 2019-April 2020

BACKGROUND

The overdose crisis has generated innovative harm reduction and drug market monitoring strategies. In Toronto, Ontario, Canada, a multi-site drug checking service (DCS) pilot project was launched in October 2019. The project provides people who use drugs with information on the chemical composition of their substances, thereby increasing their capacity to make more informed decisions about their drug use and avoid overdose. DCS also provides real-time market monitoring to identify trends in the unregulated drug supply.

METHODS

Sample data were obtained through analyses of drug and used drug administration equipment samples submitted anonymously and free of charge to DCS in downtown Toronto from October 10, 2019, to April 9, 2020, representing the first six months of DCS implementation. Analyses were conducted in clinical laboratories using liquid chromatography- and/or gas chromatography-mass spectrometry (LC-MS, GC-MS) techniques.

RESULTS

Overall, 555 samples were submitted, with 49% (271) of samples that were found to contain high-potency opioids, of which 87% (235) also contained stimulants. Benzodiazepine-type drugs were found in 21% (116) of all samples, and synthetic cannabinoids in 1% (7) of all samples. Negative effects (including overdose, adverse health events, and extreme sedation) were reported for 11% (59) of samples submitted for analysis.

CONCLUSIONS

Toronto's DCS identified a range of high-potency opioids with stimulants, benzodiazepine-type drugs, and a synthetic cannabinoid, AMB-FUBINACA. This information can inform a range of evidence-informed overdose prevention efforts.

Xylazine detected in unregulated opioids and drug administration equipment in Toronto, Canada: clinical and social implications

BACKGROUND

The North American opioid overdose crisis is driven in large part by the presence of unknown psychoactive adulterants in the dynamic, unregulated drug supply. We herein report the first detection of the psychoactive veterinary compound xylazine in Toronto, the largest urban center in Canada, by the city's drug checking service.

METHODS

Toronto's Drug Checking Service launched in October 2019. Between then and February 2021, 2263 samples were submitted for analysis. The service is offered voluntarily at harm reduction agencies that include supervised consumption services. Samples were analyzed using gas chromatography-mass spectrometry or liquid chromatography-high resolution mass spectrometry. Targeted and/or untargeted screens for psychoactive substances were undertaken.

RESULTS

In September 2020, xylazine was first detected by Toronto's Drug Checking Service. Among samples analyzed from September 2020 to February 2021 expected to contain fentanyl in isolation (610) or in combination with methamphetamine (16), xylazine was detected in 46 samples (7.2% and 12.5% of samples, respectively). Samples were predominantly drawn from used drug equipment. Three of the samples containing xylazine (6.5%) were associated with an overdose.

CONCLUSION

We present the first detection of xylazine in Toronto, North America's fourth-largest metropolitan area. The increased risk of overdose associated with use of xylazine and its detection within our setting highlights the importance of drug checking services in supporting rapid responses to the emergence of potentially harmful adulterants. These data also highlight the clinical challenges presented by the dynamic nature of unregulated drug markets and the concomitant need to establish regulatory structures to reduce their contribution to overdose morbidity and mortality.

Involvement of people who inject drugs in injection initiation events: a cross-sectional analysis identifying similarities and differences across three North American settings

OBJECTIVES

People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk.

DESIGN

We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis.

SETTING

Tijuana, Mexico; San Diego, USA; Vancouver, Canada.

PARTICIPANTS

A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825).

MEASUREMENTS

The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models.

RESULTS

Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I²: 52%), recent housing insecurity (I²: 39%) and recent non-injection heroin use (I²: 78%).

CONCLUSION

We identified common and site-specific factors related to PWID's risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.

The Ontario Integrated Supervised Injection Services Cohort Study of People Who Inject Drugs in Toronto, Canada (OiSIS-Toronto): Cohort Profile

The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases (90.2% consented; of whom 82.4% were successfully linked) and SCS client databases. At baseline, 86.5% of participants (64.0% cisgender men, median ([IQR] age= 39 [33-49]) had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of "safer opioid supply" programs and impacts of COVID-19.

Trends and outcomes of serious complications associated with non-fatal opioid overdoses in Ontario, Canada

BACKGROUND

Non-fatal opioid overdoses can lead to serious complications and consequently, long-term health effects. We sought to characterize trends of hospitalizations for serious complications associated with opioid overdoses in Ontario, Canada and report health services utilization and mortality in the year following hospital discharge.

METHODS

We conducted a cross-sectional study in Ontario among individuals who experienced a hospitalization for a serious complication (required intubation, rhabdomyolysis, or a brain injury) associated with an opioid overdose between 2010 and 2019. We examined inpatient characteristics at the time of hospital admission, and health services utilization and mortality rates in the year following hospital discharge.

RESULTS

The rate of hospitalizations for serious complications associated with opioid overdoses increased by 66.7 % from 1.8 per 100,000 population in 2010 to 3.0 per 100,000 population in 2019 in Ontario. Individuals that were discharged alive from hospital experienced high health services utilization in the following year; 71.2 % (N = 953 of 1,338) visited the emergency department (ED), 34.2 % (N = 458) were admitted to hospital, and 16.4 % (N = 219) were treated in hospital for an opioid overdose. However only a quarter of individuals (N = 332; 24.8 %) initiated on opioid agonist therapy within 90 days. Additionally, 8.0 % (N = 127) of hospitalizations resulted in death within 1 year.

CONCLUSIONS

This study highlights increasing rates of serious complications associated with opioid overdoses, with a high demand of health services and a high mortality rate in the following year. These findings highlight an ongoing need for support and harm reduction services to allow for early intervention and follow-up care.

The impact of recent homelessness on the provision of injection drug use initiation assistance among persons who inject drugs in Tijuana, Mexico and Vancouver, Canada

OBJECTIVE

To assess the relationship between experiencing homelessness and assisting injection drug use (IDU) initiation among people who inject drugs (PWID) in Tijuana, Mexico and Vancouver, Canada.

METHODS

We used self-reported questionnaire data collected semi-annually on PWID from Tijuana (n = 703) and Vancouver (n = 1551) between 2014 and 2017. Within each setting, the effect of recent (i.e., past six months) homelessness on recent provision of injection initiation assistance (i.e., helping anybody inject for the first time in the past six months) was estimated using inverse-probability-of-treatment (IPT)-weighted estimation of a marginal structural model.

RESULTS

Across follow-up, the prevalence of recent homelessness at a given visit ranged from 11.6%-16.5% among Tijuana-based participants and 9.4%-18.9% among Vancouver-based participants; the prevalence of recent provision of injection initiation at a given follow-up visit was lower, ranging from 3.3%-5.4% in Tijuana and 2.5%-4.1% in Vancouver. Based on the IPT-weighted estimates, recent homelessness was associated with 66% greater odds among Tijuana-based PWID (Adjusted Odds Ratio [AOR] = 1.66; 95% CI: 1.01-2.73) and 47% greater odds among Vancouver-based PWID (AOR = 1.47, 95% CI: 1.02-2.13) of providing injection initiation assistance over the same six-month period.

CONCLUSION

We found that recently experiencing homelessness was associated with an increased likelihood of PWID reporting IDU initiation assistance over time in both Tijuana and Vancouver. Addressing homelessness may decrease the initiation of IDU via multiple pathways.

The intersection of gender and drug use-related stigma: A mixed methods systematic review and synthesis of the literature

BACKGROUND

Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma?

METHODS

Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma.

RESULTS

Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma.

CONCLUSION

The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.

Reprint of: The regulation project: Tools for engaging the public in the legal regulation of drugs

Lack of legal regulation and oversight of scheduled drugs in Canada has led to an unsafe drug supply responsible for the deaths of tens of thousands. In addition to contributing to the worst unregulated drug poisoning crisis in Canada's history, the policy framework prohibiting non-medical access to certain drugs has exacerbated numerous public health and safety concerns. An alternative approach to prohibition is for government to retake control of the currently illegal drug market through legal regulatory mechanisms. This paper presents the work of an ongoing international collaboration of organizations advocating legal regulation and some of the knowledge translation tools used to educate and engage the public on legal regulation within Canada. In order to encourage thinking and decision-making among stakeholders in a productive way, models of legal regulation for various substances were created as discussion tools to emerge values and considerations supporting different approaches. The models focus on five questions: 1) who has access to drugs; 2) how access is obtained; 3) where drugs can be accessed; 4) how much people can obtain; and 5) where drugs can be consumed. The models were presented to stakeholders in the context of an international meeting on legal regulation, and then adapted to a more "user-friendly" form: a collaborative negotiation-based Regulation Game, which was presented at a workshop in Montréal, Canada. Engaging different stakeholder groups on policy choices of legal regulation revealed initial barriers that we feel more confident can be overcome through creative and innovative tools such as the Regulation Game. Use of the game as a foundation for more traditional focus groups could be effective in reducing barriers to fulsome policy discussions on legal regulation.

Supervised consumption service use and recent non-fatal overdose among people who inject drugs in Toronto, Canada

BACKGROUND

Aiming to reducing overdose mortality, over 40 supervised drug consumption services (SCS) presently operate in Canada. Arguments against SCS include the potential for increased non-fatal overdoses mediated by risk compensation. This study estimates associations between SCS use and recent non-fatal overdose among people who inject drugs (PWID).

METHODS

We analyzed cross-sectional baseline data collected between November 2018 and March 2020 from a cohort of adult PWID in Toronto, Canada. Recent non-fatal overdose was self-reported over the previous six months. The primary exposure was frequency of SCS use, self-reported as the proportion of injections performed at an SCS (all or most [75-100%], some [26-74%], few [≤25%], or none) in the previous six months. The prevalence of recent overdose was compared between all unique pairs of groups based on their frequency of SCS use and expressed as covariate-adjusted prevalence ratios (PR) estimated using modified Poisson regression.

RESULTS

Among 701 PWID (median [IQR] age, 40 [33 to 49]; 64.3% cisgender men; 56.8% injecting daily), most reported SCS use (all/most, 26.2%; some, 30.9%; few, 29.4%) versus no use (13.5%), with 38.6% reporting a recent overdose. From adjusted regression analyses, more frequent SCS use was not statistically significantly associated with overdose when compared to either no SCS use or less frequent use. Associations between SCS use frequency and overdose were notably smaller among SCS clients compared to associations between SCS clients and non-users (e.g., all/most versus none: PR, 1.43 [95% CI, 0.93 to 2.21]; all/most versus some: PR, 0.94 [95% CI, 0.75 to 1.17]; all/most versus few: PR, 1.15 [95% CI, 0.89 to 1.48]).

CONCLUSION

Findings did not indicate statistically significant associations between SCS use frequency and recent non-fatal overdose, particularly among SCS clients who may be more comparable. Nevertheless, overdose was common, underscoring the need to prevent non-fatal overdose and associated morbidity.

The role of drug treatment and recovery services: an opportunity to address injection initiation assistance in Tijuana, Mexico

BACKGROUND

In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use.

METHODS

PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision.

RESULTS

At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment.

CONCLUSION

Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.

The regulation project: Tools for engaging the public in the legal regulation of drugs

Lack of legal regulation and oversight of scheduled drugs in Canada has led to an unsafe drug supply responsible for the deaths of tens of thousands. In addition to contributing to the worst unregulated drug poisoning crisis in Canada's history, the policy framework prohibiting non-medical access to certain drugs has exacerbated numerous public health and safety concerns. An alternative approach to prohibition is for government to retake control of the currently illegal drug market through legal regulatory mechanisms. This paper presents the work of an ongoing international collaboration of organizations advocating legal regulation and some of the knowledge translation tools used to educate and engage the public on legal regulation within Canada. In order to encourage thinking and decision-making among stakeholders in a productive way, models of legal regulation for various substances were created as discussion tools to emerge values and considerations supporting different approaches. The models focus on five questions: 1) who has access to drugs; 2) how access is obtained; 3) where drugs can be accessed; 4) how much people can obtain; and 5) where drugs can be consumed. The models were presented to stakeholders in the context of an international meeting on legal regulation, and then adapted to a more "user-friendly" form: a collaborative negotiation-based Regulation Game, which was presented at a workshop in Montréal, Canada. Engaging different stakeholder groups on policy choices of legal regulation revealed initial barriers that we feel more confident can be overcome through creative and innovative tools such as the Regulation Game. Use of the game as a foundation for more traditional focus groups could be effective in reducing barriers to fulsome policy discussions on legal regulation.

Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use

Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.

Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review

OBJECTIVES

To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.

DESIGN

Systematic review with narrative synthesis.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.

INCLUSION CRITERIA

Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.

RESULTS

We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.

CONCLUSIONS

Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

The role of gender and power dynamics in injection initiation events within intimate partnerships in the US-Mexico border region

Women's initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation; sub-themes were identified drawing on three concepts within the theory of gender and power. With reference to sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. With regard to structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in understanding the intersection of risk, gender and harm reduction within injection initiation events across socio-cultural contexts.

Self-perception of assisting with future injection drug initiation: The influence of relationships in the process of drug injecting initiation

INTRODUCTION AND AIMS

People who inject drugs (PWID) play critical roles in assisting others into injection drug use (IDU) initiation. Understanding perceptions of PWID's risk of initiating others is needed to inform interventions for prevention. The objective was to examine factors associated with self-perception of assisting with future IDU initiation events. The primary variables of interest are the relationships of PWID with the person(s) they assisted and their reasons for previously providing initiation assistance.

DESIGN AND METHODS

Data from Preventing Injecting by Modifying Existing Responses, a multi-site prospective community-recruited cohort study, were analysed. Analyses were restricted to PWID who reported ever providing IDU initiation assistance. Site-specific (Vancouver, Canada [n = 746]; San Diego, USA [n = 95] and Tijuana, Mexico [n = 92]) multivariable logistic regression analyses were performed to determine factors associated with self-perception of assisting with future IDU initiation.

RESULTS

Having provided IDU initiation assistance to a family member or intimate partner decreased the odds of self-perception of assisting with future IDU initiation in Vancouver (AOR = 0.4; 95% CI 0.2-0.8); however, previous IDU initiation assistance to an 'other' increased the odds of self-perception of assisting with future IDU in Tijuana (AOR = 12.0; 95% CI 2.1-70.3). Daily IDU (Vancouver: AOR = 3.7; 95% CI 2.1-6.4) and less than daily IDU (San Diego: AOR = 5.9; 95% CI 1.3-27.1) (Vancouver: AOR = 2.6; 95% CI 1.4-2.9) were associated with increased self-perception of assisting with future IDU compared to current non-injectors.

DISCUSSION AND CONCLUSIONS

Relationship to past initiates and IDU frequency might increase PWID's self-perception of assisting with future IDU. Interventions focused on social support and reducing IDU frequency may decrease occurrences of IDU initiation assistance.

Preventing transitions into injection drug use: A call for gender-responsive upstream prevention

In 2017, there were large increases (260-500%) in overdose deaths among women in the United States across age groups (30-64 years and 55-64 years). In addition, U.S. women who inject drugs (WWID) are at increased risk for substance use-related disease transmission, bacterial infections, as well as sexual and physical violence compared to men who inject drugs. Relatedly, women face unique access barriers to substance use-related services, such as stigma and low coverage of gender-specific drug use-related services. Despite these heightened risks experienced by WWID, interventions specifically tailored to preventing women from transitioning into injection drug use have not been developed to date. As such, we advocate for the development of gender-responsive programs to prevent injection drug use initiation. This is critical to ensuring a comprehensive approach to preventing injection drug use initiation among those populations at highest risk of injection-related morbidity and mortality.

Recent incarceration and risk of first-time injection initiation assistance: A prospective cohort study of persons who inject drugs

BACKGROUND

Given the prevalence and harms of incarceration among persons who inject drugs (PWID) and their role in injection drug use initiation, we aimed to investigate whether recent incarceration influences the likelihood PWID assist others in their first-ever injection.

METHODS

Prospective cohort study of PWID in Vancouver, Canada who had their PReventing Injecting by Modifying Existing Responses (PRIMER) baseline visit between December 2014 and May 2017, reported never providing injection initiation assistance previously, and had ≥1 follow-up visit. The primary outcome, provision of injection initiation assistance, was defined via self-report as helping anybody inject for the first time in the past six months. The primary exposure was recent incarceration, i.e., self-report of being jailed, imprisoned or detained in the past six months. Participants were assessed biannually until November 2017, drop-out, or their first report of the primary outcome.

RESULTS

1,199 PWID (62.1% male; mean (SD) age, 44.4 (12.3) years) were included in our study. Across 4,171 follow-up visits, 67 participants (5.6%) reported providing injection initiation assistance. The proportion of participants reporting recent incarceration varied between 2.4% to 5.1% per follow-up visit. Based on a multivariable discrete-time proportional hazards regression analysis, recent incarceration was associated with an increased risk of providing injection initiation assistance during the same six-month period (adjusted hazard ratio, 2.64; 95% CI, 1.19 to 5.86).

CONCLUSIONS

The observed association between recent incarceration and risk of providing injection initiation assistance suggests that incarceration could be contributing to the expansion of injection drug use practices within vulnerable populations over time.

Expanding access to diacetylmorphine and hydromorphone for people who use opioids in Canada

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.