Self-injecting non-prescribed substances into vascular access devices: a case study of one health system's ongoing journey from clinical concern to practice and policy response.

BACKGROUND: Overdose-associated deaths and morbidity related to substance use is a global public health emergency with devastating social and economic costs. Complications of substance use are most pronounced among people who inject drugs (PWID), particularly infections, resulting in increased risk of hospitalization. PWID often require intravenous access for medical treatments such as antibiotics; however, vascular access may be limited due to the impacts of long-term self-venipuncture. While vascular access devices including peripherally inserted central catheters (PICCs) allow reliable and sustained routes of administration for indicated therapies, the use of PICCs among PWID presents unique challenges. The incidence and risks associated with self-injecting non-prescribed substances into vascular access devices (SIVAD) is one such concern for which there is limited evidence and absence of formal practice guidance. CASE PRESENTATION: We report the experience of a multidisciplinary team at a health organization in Vancouver, Canada, working to characterize the incidence, patient and healthcare provider perspectives, and overall impact of SIVAD. The case study of SIVAD begins with a patient's perspective, including patient rationale for SIVAD, understanding of risks and the varying responses given by healthcare providers following disclosure of SIVAD. Using the limited literature available on the subject, we summarize the intersection of SIVAD and substance use and outline known and anticipated health risks. The case study is further contextualized by experience from a Vancouver in-hospital Overdose Prevention Site (OPS), where 37% of all individual visits involve SIVAD. The case study concludes by describing the systematic process by which local clinical guidance for SIVAD harm reduction was developed with stakeholder engagement, medical ethics consultation, expert consensus guideline development and implementation with staff education and planned research evaluation. CONCLUSION: SIVAD is encountered with enough frequency in an urban healthcare setting in Vancouver, Canada, to warrant an organizational approach. This case study aims to enhance appreciation of SIVAD as a common and complex clinical issue with anticipated health risks. The authors conclude that using a harm reduction lens for SIVAD policy and research can provide benefit to clinicians and patients by offering a clear and a consistent healthcare response to this common issue.

Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies.

Across North America, overlapping overdose and COVID-19 emergencies have had a substantial impact on young people who use drugs (YPWUD). New risk mitigation guidance (RMG) prescribing practices were introduced in British Columbia, Canada, in 2020 to allow people to decrease risk of overdose and withdrawal and better self-isolate. We examined how the prescribing of hydromorphone tablets specifically impacted YPWUD's substance use and care trajectories. Between April 2020 and July 2021, we conducted virtual interviews with 30 YPWUD who had accessed an RMG prescription of hydromorphone in the previous six months and 10 addiction medicine physicians working in Vancouver. A thematic analysis was conducted. YPWUD participants highlighted a disjuncture between RMG prescriptions and the safe supply of unadulterated substances such as fentanyl, underscoring that having access to the latter is critical to reducing their reliance on street-based drug markets and overdose-related risks. They described re-appropriating these prescriptions to meet their needs, stockpiling hydromorphone so that it could be used as an "emergency backup" when they were unable to procure unregulated, illicit opioids. In the context of entrenched poverty, hydromorphone was also used to generate income for the purchase of drugs and various necessities. For some YPWUD, hydromorphone prescriptions could be used alongside opioid agonist therapy (OAT) to reduce withdrawal and cravings and improve adherence to OAT. However, some physicians were wary of prescribing hydromorphone due to the lack of evidence for this new approach. Our findings underscore the importance of providing YPWUD with a safe supply of the substances they are actively using alongside a continuum of substance use treatment and care, and the need for both medical and community-based safe and safer supply models.

Supporting Self-isolation for COVID-19 With "Risk Mitigation" Prescribing and Housing Supports for People Who Use Drugs: A Case Report.

BACKGROUND: Self-isolation is critical in preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. However, people who use drugs face significant barriers in adhering to the regulations. As a response, several supportive measures have been introduced in British Columbia, including temporary housing access and "risk mitigation" prescribing, in which health care providers prescribe pharmaceutical alternatives to the unregulated drug supply to prevent withdrawal and reduce overdose risk. CASE SUMMARY: We present a case of a 39-year-old male with a history of polysubstance use and frequent overdoses, who had tested positive for SARS-CoV-2 and was able to successfully self-isolate. "Risk mitigation" prescribing, supportive housing, and harm reduction services were initiated for his self-isolation and connection to community outreach teams for ongoing support. DISCUSSION: This case illustrates how "risk mitigation" prescribing supported patient's self-isolation, reduced his illicit drug use, and offered an opportunity for healthcare engagement. Access to safer alternatives to the toxic drug supply should continue beyond COVID-19 pandemic to address the persistent issues of contaminated drug supply and the overdose crisis in North America.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada.

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services. Thirty participants were recruited via posters placed throughout the building and semi-structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma-free care. Close proximity and convenience of drop-in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre-existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low-barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.

"COVID just kind of opened a can of whoop-ass": The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada.

OBJECTIVES: In the context of the ongoing overdose crisis, a stark increase in toxic drug deaths from the unregulated street supply accompanied the onset of the COVID-19 pandemic. Injectable opioid agonist treatment (iOAT - hydromorphone or medical-grade heroin), tablet-based iOAT (TiOAT), and safer supply prescribing are emerging interventions used to address this crisis in Canada. Given rapid clinical guidance and policy change to enable their local adoption, our objectives were to describe the state of these interventions before the pandemic, and to document and explain changes in implementation during the early pandemic response (March-May 2020). METHODS: Surveys and interviews with healthcare providers comprised this mixed methods national environmental scan of iOAT, TiOAT, and safer supply across Canada at two time points. Quantitative data were summarized using descriptive statistics; interview data were coded and analyzed thematically. RESULTS: 103 sites in 6 Canadian provinces included 19 iOAT, 3 TiOAT and 21 safer supply sites on March 1, 2020; 60 new safer supply sites by May 1 represented a 285% increase. Most common substances were opioids, available at all sites; most common settings were addiction treatment programs and primary care clinics, and onsite pharmacies models. 79% of safer supply services were unfunded. Diversity in service delivery models demonstrated broad adaptability. Qualitative data reinforced the COVID-19 pandemic as the driving force behind scale-up. DISCUSSION: Data confirmed the capacity for rapid scale-up of flexible, community-based safer supply prescribing during dual public health emergencies. Geographical, client demographic, and funding gaps highlight the need to target barriers to implementation, service delivery and sustainability.

Initiation of injectable opioid agonist treatment in hospital: A case report.

Uncontrolled opioid withdrawal and pain often drive inpatients with opioid use disorder to leave hospital against medical advice, resulting in suboptimal medical and addiction treatment. When oral opioid agonist treatments such as methadone and buprenorphine/naloxone fail for management of craving and withdrawal, injectable opioid agonist treatment may serve to retain patients in care and link them to addiction services. We describe the case of a 47-year-old man with a severe, active opioid use disorder and daily use of illicitly manufactured fentanyl, who was re-admitted to hospital for post-operative management after leaving against medical advice due to uncontrolled opioid withdrawal. Intravenous hydromorphone was used to retain him in care, allowing for completion of his antibiotics and enrolment in ongoing community injectable opioid agonist treatment.

Trajectories of retention in opioid agonist therapy in a Canadian setting.

BACKGROUND: Long-term engagement in opioid agonist therapy (OAT) has been consistently associated with reduced risk for morbidity and mortality in people with opioid use disorder (OUD). However, the dynamic nature of engagement/disengagement in OUD care for over time is poorly captured by traditional metrics. We characterized long-term longitudinal trajectories of engagement in OAT in Vancouver, Canada, between 2005 and 2018. METHODS: Data were derived from two community-recruited prospective cohorts of people who use drugs. Retention in OAT was defined as self-reported enrolment in OAT for two consecutive follow-up periods (an approximately six-month retention interval). We used latent class growth analysis to identify OAT engagement trajectories during the first five years after OAT initiation and multivariable logistic regression to evaluate predictors of trajectory group membership. RESULTS: We identified four OAT retention trajectories among 438 OAT initiators: "consistently high" (36%), "consistently low" (23%), "increasing" (23%), and "decreasing" (15%). Employment was a significant cross-cutting predictor of membership of all sub-optimal OAT engagement patterns compared to consistently high trajectories. We also found that initiating OAT after 2014 (when regulatory changes to the provincial OAT program were introduced) was associated with the "consistently low" engagement group relative to others. CONCLUSIONS: We identified four distinct OAT engagement trajectories in Vancouver, Canada, with employment being a common predictor of sub-optimal care trajectories, suggesting the need to explore alternative OAT models to address employment-related barriers. Care trajectory analysis could help inform tailored interventions to specific populations of people with OUD at specific time points to improve engagement in OAT, and decrease opioid-related morbidity and mortality.

Supervised injectable opioid agonist therapy in a supported housing setting for the treatment of severe opioid use disorder.

Currently, North America is facing a national opioid overdose crisis. Opioid use disorder (OUD) is a chronic, relapsing condition requiring varying intensities of treatment. Injectable opioid agonist therapy (iOAT) is an effective, high-intensity treatment option for people who are unsuccessful on conventional oral opioid agonist treatments (eg, methadone, buprenorphine). This case highlights the effectiveness of the provision of iOAT in a low-barrier setting. More specifically, we discuss a patient with severe OUD and untreated HIV infection, who was disengaged from medical care and, consequently, was prescribed iOAT in a supportive housing setting.