Guideline development in harm reduction: Considerations around the meaningful involvement of people who access services.

Background: Harm reduction seeks to minimizes the negative effects of drug use while respecting the rights of people with lived and living experience of substance use (PWLLE). Guideline standards ("guidelines for guidelines") provide direction on developing healthcare guidelines. To identify essential considerations for guideline development within harm reduction, we examined whether guideline standards are consistent with a harm reduction approach in their recommendations on involving people who access services. Methods: We searched the literature from 2011-2021 to identify guideline standards used in harm reduction and publications on involving PWLLE in developing harm reduction services. We used thematic analysis to compare their guidance on involving people who access services. Findings were validated with two organizations of PWLLE. Results: Six guideline standards and 18 publications met inclusion criteria. We identified three themes related to involving people who access services: Reasons for Involvement, Methods of Involvement, and Factors in Success. Subthemes varied across the literature. We identified five essential considerations for guideline development in harm reduction: establishing a shared understanding of reasons for involving PWLLE; respecting their expertise; partnering with PWLLE to ensure appropriate engagement; incorporating perspectives of populations disproportionately affected by substance use; and securing resources. Conclusion: Guideline standards and the harm reduction literature approach the involvement of people who access services from different perspectives. Thoughtful integration of the two paradigms can improve guidelines while empowering PWLLE. Our findings can support the development of high-quality guidelines that align with the fundamental principles of harm reduction in their involvement of PWLLE.

Event-level outcomes of police interactions with young people in three non-metropolitan cities across British Columbia, Canada.

This study examines encounters between youth and police to identify individual, contextual, and social factors that predict the outcome of these encounters. Young people aged 16-30 years were surveyed between May 2017 and June 2018 in three non-metropolitan cities across British Columbia, Canada. Outcomes were analysed using multinomial logistic generalized estimating equations. A total of 675 encounters were reported by 360 participants. These outcomes resulted in participants being questioned (n = 227; 33.6%); given warnings (n = 132; 19.6%); being searched (n = 104; 15.4%); being given a ticket (n = 101; 15.0%); and being handcuffed or arrested (n = 111; 16.4%). Young Indigenous people (vs. white) were significantly more likely to be handcuffed or arrested (OR=3.26; 1.43, 7.43). Statistical significance held after adjusting for history of police encounters and contextual factors. Findings suggest that police discretion, which has the potential to benefit youth, may be undermined by discriminatory applications of discretion.

"It's an emotional roller coaster But sometimes it's fucking awesome": Meaning and motivation of work for peers in overdose response environments in British Columbia.

BACKGROUND: The province of British Columbia (BC), Canada is amid dual public health emergencies in which the overdose epidemic declared in 2016 has been exacerbated by restrictions imposed by the Coronavirus Disease of 2019 (COVID-19) pandemic. Experiential workers, commonly known as 'peers' (workers with past or present drug use experience) are at the forefront of overdose response initiatives and are essential in creating safe spaces for people who use drugs (PWUD) in harm reduction. Working in overdose response environments can be stressful, with lasting emotional and mental health effects. There is limited knowledge about the personal meaning that experiential workers derive from their work, which serve as motivators for them to take on these often-stressful roles. METHODS: This project used a community-based qualitative research design. The research was based at two organizations in BC. Eight experiential worker-led focus groups were conducted (n = 31) where participants spoke about their roles, positive aspects of their jobs, challenges they face, and support needs in harm reduction work. Transcripts were coded and analyzed using interpretative description to uncover the meaning derived from experiential work. RESULTS: Three themes emerged from focus group data that describe the meanings which serve as motivators for experiential workers to continue working in overdose response environments: (1) A sense of purpose from helping others; (2) Being an inspiration for others, and; (3) A sense of belonging. CONCLUSION: Despite the frequent hardships and loss that accompany overdose response work, experiential workers identified important aspects that give their work meaning. These aspects of their work may help to protect workers from the emotional harms associated with stressful work as well as the stigma of substance use. Recognizing the importance of experiential work and its role in the lives of PWUD can help inform and strengthen organizational supports.

Peer engagement barriers and enablers: insights from people who use drugs in British Columbia, Canada.

OBJECTIVES: Globally, engaging people who have used drugs, or peers, in decision-making has been increasingly touted as a best practice approach to developing priorities, programs, and policies. Peer engagement ensures decisions are relevant, appropriate, and effective to the affected community. However, ensuring that inclusion is accessible and equitable for those involved remains a challenge. In this study, we examined the perspectives of people who use or have used illicit drugs (PWUD) on peer engagement in health and harm reduction settings across British Columbia (BC), Canada. METHODS: The Peer Engagement and Evaluation Project used a participatory approach to conducting 13 peer-facilitated focus groups (n = 83) across BC. Focus group data were coded and analyzed with five peer research assistants. Themes about the nature of peer engagement were generated. From this analysis, peer engagement barriers and enablers were identified. RESULTS: Barriers to peer engagement included individual, geographical, systemic, and social factors. Issues related to stigma, confidentiality, and mistrust were intensely discussed among participants. Being "outed" in one's community was a barrier to engagement, particularly in rural areas. Participants voiced that compensation, setting, and the right people help facilitate and motivate engagement. Peer networks are an essential ingredient to engagement by promoting support and advocacy. CONCLUSION: PWUD are important stakeholders in decisions that affect them. This cross-jurisdictional study investigated how PWUD have experienced engagement efforts in BC, identifying several factors that influence participation. Meaningful engagement can be facilitated by attention to communication, relationships, personal capacity, and compassion between peers and other professionals.

"It's about bloody time": Perceptions of people who use drugs regarding drug law reform.

BACKGROUND: In Australia and elsewhere, the impacts of drug prohibition have sparked a critical dialogue about the state of current drug laws. While a range of 'experts' have offered their opinion and participation in these deliberations, the voices of the affected community have largely been excluded. This study aimed to gather the opinions and preferences of people who use drugs about the current or alternative models of drug laws, in addition to how they think drug laws could be changed Author Conflict of Interest Declaration. METHODS: In March 2018, four focus groups (n = 37) were conducted with people who were in receipt of social welfare services in Sydney, Australia, where participants were encouraged to share their views about the current drug laws, drug law reform options, and important messages to politicians. Several themes were identified through a thematic analysis. RESULTS: Models of drug law reform were often understood and expressed in language and constructs different to those commonly used by researchers. Opinions were diverse and there was no consensus on a preferred model, although discussions flowed around decriminalisation, legalisation, and a medical/prescription model; the latter being the preferred approach. Participants shared pessimistic views of the drug laws ever changing, and argued that public opinion would need to adjust for reform to succeed. Furthermore, they argued that the views of the affected community are vital to any drug law reform campaign. CONCLUSIONS: Participants affinity towards a medical/prescription approach to drug regulation was an unexpected finding. This study serves as an important example of the opinions and experiential knowledge of the affected community and this knowledge could be solicited alongside other forms of 'expertise' in drug law reform campaigns.

Participant, peer and PEEP: considerations and strategies for involving people who have used illicit substances as assistants and advisors in research.

BACKGROUND: The Peer Engagement and Evaluation Project (PEEP) aimed to engage, inspire, and learn from peer leaders who represented voices of people who use or have used illicit substances, through active membership on the 'Peeps' research team. Given the lack of critical reflection in the literature about the process of engaging people who have used illicit substances in participatory and community-based research processes, we provide a detailed description of how one project, PEEP, engaged peers in a province-wide research project. METHODS: By applying the Peer Engagement Process Evaluation Framework, we critically analyze the intentions, strategies employed, and outcomes of the process utilized in the PEEP project and discuss the implications for capacity building and empowerment among the peer researchers. This process included: the formation of the PEEP team; capacity building; peer-facilitated data collection; collaborative data analysis; and, strengths-based approach to outputs. RESULTS: Several lessons were learned from applying the Peer Engagement Process Evaluation Framework to the PEEP process. These lessons fall into themes of: recruiting and hiring; fair compensation; role and project expectations; communication; connection and collaboration; mentorship; and peer-facilitated research. CONCLUSION: This project offers a unique approach to engaging people who use illicit substances and demonstrates how participation is an important endeavor that improves the relevance, capacity, and quality of research. Lessons learned in this project can be applied to future community-based research with people who use illicit substances or other marginalized groups and/or participatory settings.

Pain as a risk factor for substance use: a qualitative study of people who use drugs in British Columbia, Canada.

BACKGROUND: People who use drugs have a significantly higher prevalence of chronic non-cancer pain compared to the general population, yet little is known about how various policy, economic, physical, and social environments may serve as risk or protective factors in the context of concurrent pain and substance use. Therefore, this study sought to explore perspectives, risks, and harms associated with pain among people who use drugs. METHODS: Thirteen focus group interviews were held across British Columbia, Canada, from July to September 2015. In total, 83 people who had lived experience with substance use participated in the study. Using an interpretive description approach, themes were conceptualized according to the Rhodes' Risk Environment and patient-centered care frameworks. RESULTS: Participants described how their experiences with inadequately managed pain in various policy, economic, physical, and social environments reinforced marginalization, such as restrictive policies, economic vulnerability, lack of access to socio-physical support systems, stigma from health professionals, and denial of pain medication leading to risky self-medication. Principles of patient-centered care were often not upheld, from a lack of recognition of patients as experts in understanding their unique pain needs and experiences, to an absence of shared power and decision-making, which often resulted in distrust of the patient-provider relationship. CONCLUSIONS: Various risk environments and non-patient-centered interactions may contribute to an array of health and social harms in the context of inadequately managed pain among people who use drugs.

Activism and scientific research: 20 years of community action by the Vancouver area network of drug users.

BACKGROUND: Over the past several decades, there have been numerous peer-reviewed articles written about people who use drugs (PWUDs) from the Downtown Eastside neighborhood of Vancouver, Canada. While individual researchers have engaged and acknowledged this population as participants and community partners in their work, there has been comparatively little attention given to the role of PWUDs and drug user organizations in directing, influencing, and shaping research agendas. METHODS: In this community-driven research, we examine 20 years of peer-reviewed studies, university theses, books, and reports that have been directed, influenced, and shaped by members of the activist organization the Vancouver Area Network of Drug Users (VANDU). In this paper, we have summarized VANDU's work based on different themes from each article. RESULTS: After applying the inclusion criteria to over 400 articles, 59 items containing peer-reviewed studies, books, and reports were included and three themes of topics researched or discussed were identified. Theme 1: 'health needs' of marginalized groups was found in 39% of articles, Theme 2: 'evaluation of projects' related to harm reduction in 19%, and Theme 3: 'activism' related work in 42%. Ninety-four percent of co-authors were from British Columbia and 44% of research was qualitative. Works that have been co-authored by VANDU's members or acknowledged their participations created 628 citations. Moreover, their work has been accessed more than 149,600 times. CONCLUSIONS: Peer-based, democratic harm reduction organizations are important partners in facilitating groundbreaking health and social research, and through research can advocate for the improved health and wellbeing of PWUDs and other marginalized groups in their community. This article also recommends that PWUDs should be more respectfully engaged and given appropriate credit for their contributions.

Peer engagement in harm reduction strategies and services: a critical case study and evaluation framework from British Columbia, Canada.

BACKGROUND: Engaging people with drug use experience, or 'peers,' in decision-making helps to ensure harm reduction services reflect current need. There is little published on the implementation, evaluation, and effectiveness of meaningful peer engagement. This paper aims to describe and evaluate peer engagement in British Columbia from 2010-2014. METHODS: A process evaluation framework specific to peer engagement was developed and used to assess progress made, lessons learned, and future opportunities under four domains: supportive environment, equitable participation, capacity building and empowerment, and improved programming and policy. The evaluation was conducted by reviewing primary and secondary qualitative data including focus groups, formal documents, and meeting minutes. RESULTS: Peer engagement was an iterative process that increased and improved over time as a consequence of reflexive learning. Practical ways to develop trust, redress power imbalances, and improve relationships were crosscutting themes. Lack of support, coordination, and building on existing capacity were factors that could undermine peer engagement. Peers involved across the province reviewed and provided feedback on these results. CONCLUSION: Recommendations from this evaluation can be applied to other peer engagement initiatives in decision-making settings to improve relationships between peers and professionals and to ensure programs and policies are relevant and equitable.

Patient perspectives of methadone formulation change in British Columbia, Canada: outcomes of a provincial survey.

BACKGROUND: In British Columbia, Canada, methadone maintenance treatment formulation transitioned from the oral liquid compound Tang™-flavoured methadone to the ten-times more concentrated cherry-flavoured Methadose™ in February 2014. We quantitatively describe perceptions and reported consequences among a sample of patients on methadone maintenance treatment following this transition. METHODS: A province-wide survey was used. Bivariable analyses utilized independent samples t-tests, Phi associations, and Chi-square tests. Multivariable logistic regression analyses evaluated factors related to dependent variables - namely, increases in dose, pain, dope sickness, and the need to supplement with additional opioids. RESULTS: Four hundred five methadone maintenance treatment patients from fifty harm reduction sites across British Columbia reported transitioning to Methadose™ in February 2014. The majority (n = 258; 73.1 %) heard about the formulation change from their methadone provider or pharmacist. Adjusted models show worse taste was positively associated with reporting an increasing dose (OR = 2.46; CI:1.31-4.61), feeling more dope sick (OR = 3.39; CI:1.88-6.12), and worsening pain (OR = 4.65; CI:2.45-8.80). Feeling more dope sick was positively associated with dose increase (OR = 2.24; CI:1.37-3.66), and supplementing with opioids (OR = 8.81; CI:5.16-15.05). CONCLUSIONS: Methadone maintenance treatment policy changes in British Columbia affect a structurally vulnerable population who may be less able to cope with transitions and loss of autonomy. There may be a psychosocial component contributing to the perception of Methadose™ tasting worse, and increased dope sickness, pain, and dose. Our study shows the pronounced negative impacts medication changes can have on patients without informed, coordinated efforts. We stress the need to engage all stakeholders allowing for communication about the reasons, risks and consequences of medication policy changes and provision of additional psychosocial support.

Drug quality assessment practices and communication of drug alerts among people who use drugs.

BACKGROUND: Regional health bodies in British Columbia (BC) issue drug alerts to the public when health risks associated with drug quality are identified, such as increased illicit drug deaths, overdoses or other harms. There is a lack of evidence-based guidelines for producing timely, effective public health alerts to mitigate these harms. This study sought to understand (1) the practices used by people who use drugs (PWUD) to assess the quality of street drugs and reduce harms from adulterants and (2) how drug alerts could be better communicated to PWUD. METHODS: Guided by interpretive and descriptive methodology, this study consisted of brief questionnaires and in-depth focus groups with 32 PWUD. RESULTS: Findings suggest the most effective and trusted information about drug quality was primarily from: (a) trusted, reputable dealers or (b) peer-based social networks. Most PWUD thought information received through health service providers was not timely and did not discuss drug quality with them. A number of concrete guidelines were suggested by participants to improve the effectiveness of drug alert modes and methods of communication in the community, including the use of language on drug alert postings that implies harm, indicates what drug effects to look for, and suggests appropriate responses to overdose, such as the use of naloxone. Participants also emphasized the need to date posters and remove them in a timely manner so as to not desensitize the community to such alerts. CONCLUSION: Since it is difficult to control adulteration practices in an unregulated drug market, this study suggests methods of effectively producing and communicating drug alerts among PWUD to mitigate harms associated with drug use.