The changing landscape of pharmaceutical alternatives to the unregulated drug supply during COVID-19.

BACKGROUND: The dual COVID-19 and overdose emergencies amplified strain on healthcare systems tasked with responding to both. One downstream consequence of the pandemic in the USA and Canada was a surge in drug overdoses resulting from public health-restricted access to services and an increasingly toxic unregulated drug supply. This study aimed to describe changes implemented by programs prescribing pharmaceutical alternatives to the drug supply during the early stages of the COVID-19 pandemic. METHODS: An environmental scan used surveys and qualitative interviews with service providers across Canada to examine pharmaceutical alternative prescribing practices and programs before and during the pandemic. This study summarized the nature, frequency, and reasons for pandemic-driven service delivery changes using directed content analysis, counts, and thematic analysis. RESULTS: Eighty-two of the 103 participating sites reported 1193 unique changes in physical space (368), client protocols (347), program operations (342), ancillary services (127), and staffing (90). Four qualitative themes describing the reasons for these changes emerged, namely (1) decreasing risk of COVID-19 infection; (2) decreasing risk of overdose; (3) prioritizing acute care of COVID-19 patients; and (4) improving client access to treatment. CONCLUSIONS: While most changes were aimed at decreasing risk of COVID-19 infection, some were found to be at odds with the measures needed to combat the overdose crisis; others met dual objectives of decreased risk of both overdose and infection. Further research should examine which changes should be kept or reversed once COVID-19-related public health measures are lifted.

Impact of the international collaborative addiction medicine research fellowship on physicians' future engagement in addiction research.

Background: To evaluate how an international one-year intensive research training program for addiction medicine physicians contributed to subsequent research involvement and productivity. Methods: We prospectively compared addiction medicine physician fellows admitted to a one-year training program with non-admitted controls, using baseline questionnaire and peer-reviewed publication data. Participants' publication activity was assessed from fellowship application date onwards using biomedical databases (e.g., PubMed, Embase). Results: Between July 2014 and June 2020, which is six years of cohorts, 56 (39 women) physicians, both fellows (n = 25) and non-admitted applicants (n = 31), were observed and included in the study, contributing 261 person-years of observation. At baseline, in the fellows' cohort: 76% of participants (19/25) reported past research involvement, 24% (6/25) had one or more advanced graduate degrees (e.g., MPH), and the median number of peer-reviewed, first author publications was one (Interquartile Range [IQR] = 0-2). At baseline, in the controls' cohort: 84% of participants (26/31) reported past research involvement, 39% (12/31) had one or more advanced graduate degrees, and the median number of peer-reviewed, first author publications was zero. The physicians' training included internal medicine (n = 8), family medicine (n = 33), psychiatry (n = 5) and others (n = 4). At follow up, there was a significant difference between fellows (n = 25) and controls (n = 31) in total number of publications (Rate Ratio [RR] = 13.09, 95% Confidence Interval [CI], 5.01 - 34.21, p < 0.001), as well as first author publications (RR = 5.59, 95% CI, 2.23 - 14.06, p < 0.001). Conclusion: In the six-year observation period, fellows' productivity indicates undertaking this fellowship was associated with significant research outputs in comparison to controls, signaling successful training of addiction physicians to help recruit addiction medicine physicians to participate in addiction research.

In-hospital training in addiction medicine: A mixed-methods study of health care provider benefits and differences.

Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.

Integrating injectable opioid agonist treatment into a drug treatment court program: A case study.

BACKGROUND: A substantial proportion of individuals involved with the North American criminal justice system are convicted for drug-related activities. Drug treatment court (DTC) programs were developed as an alternative to incarceration for drug-related offences and aim to prioritize addiction treatment and improve health and social outcomes; however, only a fraction of DTC participants have access to first-line medications for opioid use disorder (OUD). Further, despite emerging evidence for the efficacy of injectable opioid agonist therapy (OAT) in treating individuals with severe OUD where past treatment attempts with first-line therapies have been unsuccessful, this treatment has never, to our knowledge, been implemented in correctional settings. CASE: An individual in their 50s with a history of severe OUD, multiple interactions with the criminal justice system, and prior unsuccessful treatment attempts with methadone was initiated on injectable treatment with diacetylmorphine. The patient received 300 mg of diacetylmorphine witnessed 3 times daily at a supervised injection clinic. During a 1.5-year stabilization phase, the patient's illicit opioid use significantly reduced. They subsequently enrolled in a DTC program for drug-related charges preceding initiation on injectable OAT and remained on this therapy during 16 months in DTC. Following graduation from DTC, the patient continued to receive treatment and returned to gainful employment in the community, with no further charges or episodes of incarceration. DISCUSSION: This case describes the successful completion of a DTC program by an individual prescribed injectable OAT for severe OUD. The patient's treatment plan played an integral role in DTC graduation and long-term adherence, leading to improved health and social outcomes, including cessation of illicit drug use, enhanced quality of life, and improved social functioning. The case highlights the potential benefits of a stepped and integrated approach to addiction treatment in DTC programs.

Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada.

BACKGROUND: Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT. METHODS: Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes. RESULTS: Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment. CONCLUSION: This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.

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.

Supervised Tablet Injectable Opioid Agonist Therapy (TiOAT): A Strategy to Address Safer Supply for Individuals With an Opioid Use Disorder?

North America is in the midst of an overdose crisis, with up to 130 Americans dying daily from a preventable drug overdose. Opioids account for 70% of overdose deaths. Despite government efforts to improve access to opioid use disorder (OUD) treatment and the implementation of various harm reduction initiatives, overdose mortality remains unacceptably high. Although effective treatments exist for OUD (eg, opioid agonist therapies like buprenorphine/naloxone and methadone), many individuals do not achieve stabilization with these medications. Tablet injectable opioid agonist therapy (TiOAT) is an initiative being piloted in British Columbia to provide witnessed access to a safer opioid supply for individuals with treatment-refractory OUD. The program offers participants a safer opioid supply through physician-prescribed pharmaceutical-grade hydromorphone tablets. TiOAT is suitable for individuals with severe OUD who are actively injecting opioids and are refractory to conventional OUD treatment. As such, a scale-up of the TiOAT program may be a feasible alternative to address persistent opioid-related deaths in North America, while minimizing potential harms associated with unwitnessed safer supply opioid prescribing (eg, diversion and overdose). Although a comprehensive evaluation of TiOAT is of critical importance (including an assessment of the program's adverse events), completion of the evaluation should not preclude scale-up of the program in the interim as a strategy to reduce opioid-related harms.

"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.

Service delivery models for injectable opioid agonist treatment in Canada: 2 sequential environmental scans.

BACKGROUND: Injectable opioid agonist treatment (iOAT) is an emerging evidence-based option in the continuum of care for opioid use disorder in parts of Canada. Our study objective was to identify and describe iOAT programs operating during the ongoing opioid overdose crisis. METHODS: We conducted 2 sequential environmental scans. Programs were eligible to participate if they were in operation as of Sept. 1, 2018, and Mar. 1, 2019. Information was collected over 2-3 months for each scan (September-October 2018, March-May 2019). Programs that participated in the first scan and newly established programs were invited to participate in the second scan. The scans included questions about location, service delivery model, clinical and operational characteristics, numbers and demographic characteristics of clients, and program barriers and facilitators. Descriptive analysis was performed. RESULTS: We identified 14 unique programs across the 2 scans. Eleven programs located in urban centres in British Columbia and Ontario participated in the first scan. At the time of the second scan, 2 of these programs were on hold and 2 of 3 newly established programs were in Alberta. The total capacity of all participating programs was 420 clients at most. Four service delivery models were identified; iOAT was most commonly integrated within existing health and social services. All programs offered hydromorphone, and 1 program also offered diacetylmorphine. In the first scan, 73% of clients (133/183) were male; the mean age of clients was 47 years. Limited capacity, pharmacy operations and lack of diacetylmorphine access were among the most frequently reported barriers. The most commonly reported facilitators included client-centred care, client relationships and access to other health and social support. INTERPRETATION: Evidence indicates that iOAT can be successfully implemented using diverse service delivery models. Future work should facilitate scale-up of this evidence-based treatment where gaps persist in high-risk communities.

An Acute Care Contingency Management Program for the Treatment of Stimulant Use Disorder: A Case Report.

BACKGROUND: Illicit stimulants such as crystal methamphetamine and cocaine are a rising cause of morbidity and mortality in North America. Unfortunately, there are few evidence-based approaches for the management of stimulant use disorder. Contingency management programs are currently the best evidenced treatment strategy, designed to reward behavior change and offer competing reinforcers toward the goal of reducing substance use, but these programs are often difficult to access. Given that it is well understood that hospitalization presents a valuable opportunity for the initiation of treatment for a variety of substance use disorders, the adaptation of contingency management programs to an acute medicine inpatient setting is a potentially viable option to improve care, and to increase access to effective treatment for stimulant use disorders. CASE SUMMARY: We present a case outlining the clinical care of a complex medical patient admitted with osteomyelitis, whose course in hospital changed significantly upon enrollment in a pilot contingency management program in an urban hospital in Canada. DISCUSSION: This case illustrates how effective treatment programs can be adapted as needed for use in novel settings, especially where current options are inaccessible, inadequate, or ineffective.

Comparing Canadian and United States opioid agonist therapy policies.

Canada and the United States (U.S.) face an opioid use disorder (OUD) and opioid overdose epidemic. The most effective OUD treatment is opioid agonist therapy (OAT)-buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited OAT access. Through a non-systematic literature scan and a review of publicly available policy documents, we examined and compared OAT policies and practice at the federal (Canada vs. U.S.) and local levels (British Columbia [B.C.] vs. Oregon). Differences and similarities were noted between federal and local OAT policies, and subsequently OAT access. In Canada, OAT policy control has shifted from federal to provincial authorities. Conversely, in the U.S., federal authorities maintain primary control of OAT regulations. Local OAT health insurance coverage policies were substantively different between B.C. and Oregon. In B.C., five OAT options were available, while in Oregon, only two OAT options were available with administrative limitations. The differences in local OAT access and coverage policies between B.C. and Oregon, may be explained, in part, to the differences in Canadian and U.S. federal OAT policies, specifically, the relaxation of special federal OAT regulatory controls in Canada. The analysis also highlights the complicating contributions, and likely policy solutions, that exist within other drug policy sub-domains (e.g., the prescription regime, and drug control regime) and broader policy domains (e.g., constitutional rights). U.S. policymakers and health officials could consider adopting Canada's regulatory policy approach to expand OAT access to mitigate the harms of the ongoing opioid overdose epidemic.

Development and Evaluation of the Online Addiction Medicine Certificate: Free Novel Program in a Canadian Setting.

BACKGROUND: Despite the enormous bur-den of disease attributable to drug and alcohol addiction, there remain major challenges in implementing evi-dence-based addiction care and treatment modalities. This is partly because of a persistent lack of accessible, specialized training in addiction medicine. In response, a new online certificate in addiction medicine has been established in Vancouver, Canada, free of charge to participants globally. OBJECTIVE: The objective of this study was to evaluate and examine changes in knowledge acquisition among health care professionals before and after the completion of an online certificate in addiction medicine. METHODS: Learners enrolled in a 17-module certificate program and completed pre- and postknowledge tests using online multiple-choice questionnaires. Knowledge acquisition was then evaluated using a repeated measures t test of mean test scores before and after the online course. Following the certificate completion, a subset of learners completed the online course evaluation form. RESULTS: Of the total 6985 participants who registered for the online course between May 15, 2017 and February 22, 2018, 3466 (49.62%) completed the online pretest questionnaire. A total of 1010 participants completed the full course, achieving the required 70% scores. TThe participants self-reported working in a broad range of health-related fields, including nursing (n=371), medicine (n=92), counseling or social work (n=69), community health (n=44), and pharmacy (n=34). The median graduation year was 2010 (n=363, interquartile range 2002-2015). Knowledge of the addiction medicine increased significantly postcertificate (mean difference 28.21; 95% CI 27.32 to 29.10; P<.001). Physicians scored significantly higher on the pretest than any other health discipline, whereas the greatest improvement in scores was seen in the counseling professions and community outreach. CONCLUSIONS: This free, online, open-access certificate in addiction medicine appeared to improve knowledge of learners from a variety of disciplines and backgrounds. Scaling up low threshold learning opportunities may further advance addiction medicine training, thereby helping to narrow the evidence-to-practice gap.

Expanding supervised injection facilities across Canada: lessons from the Vancouver experience.

The opioid crisis has led to an unprecedented rise in the number of overdose deaths across Canada. In response, there has been an expansion of supervised injection facilities (SIFs), with several new SIFs approved or under review across the country. Much of the evidence for the benefits of SIFs in reducing overdose mortality, infectious-related complications, and public disorder comes from Insite in Vancouver, North America's first SIF. While implementing SIFs in other Canadian cities is a major step forward in combating the opioid epidemic, the diversity within our country's socio-demographic and political landscape leaves the application of SIFs in these new settings a matter of uncertainty. This commentary highlights key lessons learned from Vancouver and the potential modifications required to enhance implementation in other cities to ensure the success of new SIFs across Canada.

Patients With Substance Use Disorders Leaving Against Medical Advice: Strategies for Improvement.

: In this issue of the Journal of Addiction Medicine, 2 studies fill an important gap in knowledge by examining predictors of leaving against medical advice from inpatient withdrawal management settings. The studies identify important risk factors for leaving against medical advice and highlight important areas for inpatient withdrawal management. These include the use of substance specific standardized protocols and initiation of opioid agonist treatment instead of opioid detoxification given harms associated with opioid withdrawal. Further need for increased training in addiction medicine for primary care physicians, and use of inpatient addiction medicine consult services as part of early intervention for substance withdrawal are also discussed.

Drug checking as a potential strategic overdose response in the fentanyl era.

Adulteration of illicit drug supplies with synthetic opioids such as fentanyl has contributed to a dramatic rise in overdose morbidity and mortality in North America. One promising response to this crisis is the implementation of "drug checking" services. Drug checking encompasses a range of interventions used to assess the constituents of illicit drug samples, such as colour-spot testing, gas or liquid chromatography, and various methods of spectroscopy. Testing may be performed on-site at events or harm reduction service locales, performed independently by consumers, or sent to a centralized lab for analysis. This information may then serve to inform individual decision-making, enhance harm reduction efforts and strengthen public health surveillance and response strategies to prevent harms associated with illicit drug use. Historical examples of drug checking services that emerged with the 1990s synthetic "party drug" movement in Europe provide a theoretical and practical basis for the adaptation of these services for use in context of the current opioid overdose crisis. Potential harm reduction benefits of drug checking for synthetic opioid adulterants include individuals being more likely to use drugs more safely or to dispose of drugs found to contain harmful adulterants. Public health benefits of drug checking may also include negative feedback on the illicit drug supply with decreased availability or consumption of drugs from sources adulterated with synthetic opioids following public health warning campaigns. As part of the response to the current synthetic opioid epidemic in BC, pilot efforts are being undertaken in Vancouver to determine the feasibility and effectiveness of drug checking as an overdose response strategy. Models of drug checking service delivery and comparison of differing technologies, including unique challenges and potential solutions related to access to these services, legal obstacles, and sensitivity and specificity of testing technologies, are explored, alongside suggestions for future research and directions.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic.

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.