A cross-sectional assessment of injection of "salts" and HIV transmission-related behaviours among a cohort of people who inject drugs in Kyrgyzstan.

INTRODUCTION: Despite the increasing availability of new psychoactive substances (hereafter referred to as "salts") in Eastern Europe and Central Asia, there is a dearth of epidemiological data on the relationship between injecting "salts" and HIV risk behaviours. This is particularly relevant in settings where injection drug use accounts for a substantial proportion of the HIV burden, such as in Kyrgyzstan, a former Soviet Republic. This study assessed whether injecting "salts" is associated with sexual and injection-related HIV risk behaviours among people who inject drugs in Kyrgyzstan. METHODS: The Kyrgyzstan InterSectional Stigma Study is a cohort of people who inject drugs in Kyrgyzstan's capital of Bishkek and the surrounding rural administrative division of Chuy Oblast. We conducted a cross-sectional analysis using survey data collected from cohort participants between July and November 2021, which included information on injection drug use (including "salts") and HIV risk behaviours. To minimize confounding by measured covariates, we used inverse-probability-weighted logistic and Poisson regression models to estimate associations between recent "salt" injection and HIV risk behaviours. RESULTS: Of 181 participants included in the analysis (80.7% men, 19.3% women), the mean age was 40.1 years (standard deviation [SD] = 8.8), and 22% (n = 39) reported that they had injected "salts" in the past 6 months. Among people who injected "salts," 72% (n = 28) were men, and most were ethnically Russian 59% (n = 23), with a mean age of 34.6 (SD = 9.6). Injecting "salts" was significantly associated with a greater number of injections per day (adjusted relative risk [aRR] = 1.59, 95% confidence interval [CI] = 1.30-1.95) but lower odds of using syringe service programmes in the past 6 months (adjusted odds ratio [aOR] = 0.20, 95% CI = 0.12-0.32). Injecting "salts" was also significantly associated with lower odds of condomless sex in the past 6 months (aOR = 0.42, 95% CI = 0.24-0.76) and greater odds of having ever heard of pre-exposure prophylaxis (aOR = 4.80, 95% CI = 2.61-8.83). CONCLUSIONS: (PWID) people who inject drugs who inject "salts" are a potentially emergent group with increased HIV acquisition risk in Kyrgyzstan. Targeted outreach bundled with comprehensive harm reduction and pre-exposure prophylaxis services are needed to prevent transmission of HIV and other blood-borne viruses.

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.

OBJECTIVES: 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 (IDU) 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 months) IDU, including those participating in community-based research studies or seeking drug treatment, were linked to health administrative data in Ontario from 1992 to 2020. We assessed the validity of algorithms to identify IDU over varying look-back periods (ie, 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 (ED) 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 and 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, ED visit, or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity and 94.2% specificity) and recent IDU (using 3-year look back: 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 their high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of IDU 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.

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.

RESUMEN: La Escala de Recursos Familiares (FRS, por sus siglas en inglés) es una medida de vulnerabilidad financiera (FV, por sus siglas en inglés) de tres factores. La FV puede afectar los riesgos de transmisión del VIH. Se utilizaron datos transversales de 279 personas que se inyectan drogas (PWID, por sus siglas en inglés) en Kirguistán encuestadas de abril a octubre de 2021 para validar la FRS y estimar las asociaciones entre la FV en la inyección y los resultados de riesgo sexual del VIH en los últimos seis meses. La FRS de tres factores reflejaba la vivienda, las necesidades esenciales y la independencia fiscal, y presentaba una buena confiabilidad interna y validez estructural. Mayores puntajes acumulativos de la FRS en vivienda y necesidades esenciales se asociaron con un mayor riesgo relativo en la inyección pública (Riesgo relativo ajustada [aRR], Intervalo de Confianza del 95% [IC95%]: 1.03 [1.01, 1.04]; aRR [IC95%]: 1.06 [1.02, 1.09]; aRR [IC95%]: 1.06 [1.03, 1.08], respectivamente, todos p < 0.001) y la preparación de inyección con fuentes de agua no seguras (aRR [IC95%]: 1.04 [1.02, 1.07]; aRR [IC95%]: 1.09 [1.04, 1.15]; aRR [IC95%]: 1.08 [1.03, 1.14], respectivamente, todos p < 0.001). Los resultados sugieren que la FV relacionada con la vivienda y las necesidades esenciales de las PWID puede exacerbar los riesgos de transmisión del VIH por la inyección. Reducir la FV de las PWID puede mejorar la respuesta al VIH en Kirguistán.

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.

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.

RéSUMé: Les services de consommation supervisée ont été établis au Canada et à l'étranger en tant qu'impératif éthique dans le contexte d'une urgence de santé publique. Un grand nombre d'études rigoureuses démontrent que ces services préviennent les décès par empoisonnement, réduisent les comportements à risque de transmission de maladies infectieuses, et facilitent les liens avec d'autres services sociaux et de santé. En 2019, le gouvernement de l'Alberta a commandé un examen des impacts socioéconomiques de sept services de consommation supervisée dans la province. La présentation du rapport donne l'impression que l'évaluation de ces services est objective et scientifiquement crédible; cependant, il présente des faiblesses importantes au plan méthodologique, notamment en raison de la présence de biais qui compromet l'évaluation des preuves scientifiques. Ses conclusions ont été utilisées pour justifier des décisions qui mettent en péril la santé et le bien-être des personnes qui consomment des drogues, tant au Canada qu'à l'étranger. Les gouvernements doivent s'assurer que les futures évaluations des services de consommation supervisée et d'autres mesures de santé publique pour lutter contre les décès par empoisonnement dû aux drogues sont scientifiquement fondées. Les politiques en matière de santé doivent être basées sur les meilleures données disponibles, protéger les droits des populations structurellement vulnérables à accéder aux soins de santé, et ne pas dépendre de l'opinion publique ou d'une idéologie politique dominante.

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.

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.

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.

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.

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.

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.

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.

Drug checking use and interest among people who inject drugs in Toronto, Canada.

BACKGROUND: Drug checking services (DCS) provide information on drug composition to inform consumption practices and monitor unregulated drug markets. We sought to identify correlates of recent informal DCS use (e.g., fentanyl test strips) and willingness to use a formal DCS (co-located within a supervised consumption site and employing laboratory-based analyses) in Toronto, Canada prior to its implementation. METHODS: We calculated outcome prevalence based on baseline questionnaire data from a cohort of people who inject drugs in downtown Toronto between November 2018-October 2019 and conducted multivariable Poisson regression analyses. Outcomes included recent (i.e., past six-month) informal DCS use and willingness to use a formal DCS, if implemented. We also conducted a sub-analysis assessing willingness to use a formal DCS following an unexpected drug reaction. RESULTS: Among 604 participants, 12% (n=74) reported recent informal DCS use, 73% (n=442) reported willingness to use a formal DCS, and 88% (n=530) reported willingness to use a formal DCS in response to an unexpected drug reaction. Based on 567 participants with complete data, we found that recent injection at a supervised consumption site or overdose prevention site were both associated with recent informal DCS use (respectively, adjusted prevalence ratio [aPR]=2.44, 95% confidence interval [CI]: 1.11-5.35; aPR=1.78, 95% CI: 1.00-3.15). Recent informal DCS use and recent overdose were both associated with willingness to use a formal DCS (respectively, aPR=1.15, 95% CI: 1.02-1.30; aPR=1.10, 95% CI: 1.00-1.22). CONCLUSION: Although recent informal DCS use was infrequently reported in our study, willingness to use a formal DCS was high. Our findings indicate a potential role for laboratory-based DCS in mitigating overdose risk among individuals accessing the unregulated drug supply. However, barriers that impede service access or reduce interest should be addressed to ensure equitable use among those at heightened risk of overdose.

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.