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BACKGROUND: The ongoing overdose crisis in Canada has prompted efforts to increase access to a "safer supply" of prescribed alternatives to the unregulated drug supply. While safer supply programs predominantly distribute hydromorphone tablets, the Safer Alternatives for Emergency Response (SAFER) program in Vancouver, Canada offers a range of prescribed alternatives, including fentanyl patches. However, little is known about the effectiveness of fentanyl patches as safer supply. Drawing on the perspectives and experiences of program participants, we sought to qualitatively evaluate the effectiveness of the SAFER fentanyl patch program in meeting its intended aims, including reducing risk of overdose by decreasing reliance on the unregulated drug supply. METHODS: As part of a larger mixed-methods evaluation of SAFER, semi-structured qualitative interviews were conducted with 17 fentanyl patch program participants between February 2022 and April 2023. Thematic analysis of interview data focused on program engagement, experiences, impacts, and challenges. RESULTS: The flexible program structure, including lack of need for daily dispensation, the extended missed dose protocol, and community pharmacy patch distribution fostered engagement and enhanced autonomy. Improved management of withdrawal symptoms and cravings due to steady transdermal dosing led to reduced unregulated drug use and overdose risk. Participants also experienced economic benefits and improvements in overall health and quality of life. However, skin irritation and patch adhesion issues were key barriers to program retention. CONCLUSION: Our findings demonstrate the value of including fentanyl patch safer supply in the substance use continuum of care and offer insights for innovations in delivery of this intervention.
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In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.
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Overdose de Drogas , Abuso de Substâncias por Via Intravenosa , Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Overdose de Drogas/epidemiologia , Adulto , Abuso de Substâncias por Via Intravenosa/epidemiologia , Estudos Prospectivos , Colúmbia Britânica/epidemiologia , Jovens em Situação de Rua/estatística & dados numéricos , Programas de Troca de Agulhas/estatística & dados numéricosRESUMO
OBJECTIVES: In 2022, the Drug User Liberation Front opened an unsanctioned compassion club in Vancouver where members could purchase illicit drugs that had been rigorously tested to ensure quality and a lack of potentially fatal contaminants. We sought to evaluate the impact of access to this novel safer supply intervention on non-fatal overdose. METHODS: Data were obtained from 47 club members via surveys completed at 3-month intervals between August 2022 and October 2023. We conducted multivariable generalized estimating equations (GEE) analyses to examine the association between club enrolment and the outcomes of: (1) any non-fatal overdose; and (2) any non-fatal overdose involving naloxone administration. RESULTS: The final sample, including 47 study participants, contributed a total of 225 observations and 44.4 person-years of follow-up during the study, and a median follow-up duration of 12.2 months (quartile 1 - 3: 10.4 - 14.7) per participant. In multivariable GEE analyses, enrolment in the compassion club was associated with reduced likelihood of non-fatal overdose (Adjusted Odds Ratio [AOR] = 0.51, 95% Confidence Interval (CI): 0.26 - 0.99) and non-fatal overdose involving naloxone administration (AOR = 0.37, 95% CI: 0.16 - 0.84) after adjusting for potential confounders. DISCUSSION: In this study, enrolment in an unsanctioned compassion club was found to be associated with reductions in any type of non-fatal overdose and non-fatal overdose involving naloxone administration. These findings highlight the need for ongoing research on safer supply interventions, as well as the potential of non-medicalized compassion clubs to complement existing safer supply programming and reduce overdose events.
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Physicians have traditionally asked about substance use within the Social History section of the consultation note. Drawing on social science theory and using the authors' own experiences as generalists and addiction scholars, we consider the possible unintended harms associated with this approach. The inclusion of the substance use history within the Social History reproduces the discourse of substance use disorders as "life-style choices" rather than medical conditions, and reinforces stigma among healthcare workers through the attribution of personal responsibility for complications associated with problematic substance use. The ongoing placement of the substance use history within the Social History may lead to a failure to diagnose and make appropriate management plans for clients with substance use disorders. These missed opportunities may include inadequate withdrawal management leading to discharge before medically advised, insufficient use of evidence-based pharmacotherapy and psychotherapy, polypharmacy, medical complications, and repeated admissions to hospital. We argue instead that the Substance Use History should be a stand-alone section within the consultation note. This new section would reduce the invisibility of substance use disorders within our medical systems and model that these chronic medical conditions are amenable to prevention, treatment and harm reduction through the application of evidence-based practices.
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Anamnese , Transtornos Relacionados ao Uso de Substâncias , Humanos , Transtornos Relacionados ao Uso de Substâncias/terapia , Transtornos Relacionados ao Uso de Substâncias/psicologiaRESUMO
INTRODUCTION: The proliferation of fentanyl and its analogs in illegal, unregulated drug markets remains a major driver of the overdose crisis in North America. Drug checking services have been implemented as a harm reduction strategy to address the crisis. However, little is known about their potential utility as a mechanism for monitoring population-level risk of overdose stemming from changing fentanyl concentration in unregulated drugs over time. Therefore, this study assessed the relationship between median fentanyl concentration in expected opioid drug checking samples and the death rate due to illicit drug toxicity over time in Vancouver, Canada. METHODS: Monthly population-based rates of death due to illicit drug toxicity were drawn from provincial coroner records. Monthly median percent fentanyl concentration was calculated using a validated quantification model from point-of-care Fourier-transform infrared spectra among expected opioid samples that tested positive for fentanyl at community drug checking services. A time-series analysis using generalized additive modeling was conducted to examine the association between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, controlling for calendar month. Analyses were conducted in 2021-2022. RESULTS: Between January 2019 and October 2020, 577 deaths due to illicit drug toxicity occurred in Vancouver, and the observed monthly rate ranged from 1.75 to 7.65 deaths per 100,000 population. A significant, positive association was observed between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, adjusting for calendar month (chi-square=52.21, p<0.001). CONCLUSIONS: Findings suggest a role for point-of-care drug checking as a tool for monitoring evolving overdose risk at the population level.
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Overdose de Drogas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Drogas Ilícitas , Humanos , Fentanila , Analgésicos Opioides/efeitos adversos , Heroína , Overdose de Drogas/epidemiologia , Canadá/epidemiologiaRESUMO
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.
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Redução do Dano , Serviço Social , Humanos , Alberta/epidemiologiaRESUMO
OBJECTIVE: The aim of this study was to explore client experiences in a community-based injectable opioid agonist therapy (iOAT) program. STUDY SETTING: The study occurred across two cities in Alberta, Canada. STUDY DESIGN: The research team conducted secondary interpretive description analysis on qualitative interview transcripts. DATA COLLECTION: Twenty-three iOAT clients were interviewed as part of a prior quality improvement initiative. Using secondary analysis of the transcripts, interviews were analyzed for themes, to create an understanding of clients' experiences. PRINCIPAL FINDINGS: Participants accessed iOAT through other health services, for treatment of opioid use disorder. Participants reported that building trusting and supportive relationships with nurses was crucial to their success in the program. Through these relationships, participants experienced stopping and starting. They stopped behaviors such as illicit drug use, having withdrawal symptoms and anxiety, and prohibited income generation activities. They started taking care of themselves, accessing housing, increasing financial stability, receiving primary care, and connecting with friends and family. The global experience of iOAT was one of positive change for participants. CONCLUSIONS: The findings of this study are largely consistent with other published examples-iOAT programs create benefits for both clients and their communities. Although clients may join the program to access the hydromorphone, the relationships between staff and clients are the key driver of success.
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Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Canadá , Pesquisa QualitativaRESUMO
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.
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BACKGROUND: Supervised consumption sites (SCS) and overdose prevention sites (OPS) have been increasingly implemented in response to the ongoing overdose epidemic in Canada. Although there has been a dramatic increase in overdose deaths since the start of the SARS-CoV 2 (COVID-19) pandemic, little is known about how SCS access may have been affected by this pandemic. Therefore, we sought to characterize potential changes in access to SCS during the COVID-19 pandemic among people who use drugs (PWUD) in Vancouver, Canada. METHODS: Between June and December 2020, data were collected through the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), two cohort studies involving people who use drugs. Multivariable logistic regression was used to examine individual, social and structural factors associated with self-reported reduced frequency of SCS/OPS use since COVID-19. RESULTS: Among 428 participants, 223 (54.7%) self-identified as male. Among all individuals surveyed, 63 (14.8%) reported a decreased frequency of use of SCS/OPS since COVID-19. However, 281 (66%) reported that they "did not want to" access SCS in the last 6 months. In multivariable analyses, younger age, self-reported fentanyl contamination of drugs used and reduced ease of access to SCS/OPS since COVID-19 were positively associated with a decreased frequency of use of SCS/OPS since COVID-19 (all p < 0.05). CONCLUSIONS: Approximately 15% of PWUD who accessed SCS/OPS reported reduced use of these programs during the COVID-19 pandemic, including those at heightened risk of overdose due to fentanyl exposure. Given the ongoing overdose epidemic, efforts must be made to remove barriers to SCS access throughout public health crises.
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COVID-19 , Overdose de Drogas , Usuários de Drogas , Humanos , Masculino , Pandemias , COVID-19/epidemiologia , Overdose de Drogas/epidemiologia , Canadá/epidemiologia , FentanilaRESUMO
BACKGROUND: The overdose crisis in North America has prompted system-level efforts to restrict opioid prescribing for chronic pain. However, little is known about how discontinuing or tapering prescribed opioids for chronic pain shapes overdose risk, including possible differential effects among people with and without concurrent opioid use disorder (OUD). We examined associations between discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain, stratified by diagnosed OUD and prescribed opioid agonist therapy (OAT) status. METHODS AND FINDINGS: For this retrospective cohort study, we used a 20% random sample of residents in the provincial health insurance client roster in British Columbia (BC), Canada, contained in the BC Provincial Overdose Cohort. The study sample included persons aged 14 to 74 years on long-term opioid therapy for pain (≥90 days with ≥90% of days on therapy) between October 2014 and June 2018 (n = 14,037). At baseline, 7,256 (51.7%) persons were female, the median age was 55 years (quartile 1-3: 47-63), 227 (1.6%) persons had been diagnosed with OUD (in the past 3 years) and recently (i.e., in the past 90 days) been prescribed OAT, and 483 (3.4%) had been diagnosed with OUD but not recently prescribed OAT. The median follow-up duration per person was 3.7 years (quartile 1-3: 2.6-4.0). Marginal structural Cox regression with inverse probability of treatment weighting (IPTW) was used to estimate the effect of prescribed opioid treatment for pain status (discontinuation versus tapered therapy versus continued therapy [reference]) on risk of overdose (fatal or nonfatal), stratified by the following groups: people without diagnosed OUD, people with diagnosed OUD receiving OAT, and people with diagnosed OUD not receiving OAT. In marginal structural models with IPTW adjusted for a range of demographic, prescription, comorbidity, and social-structural exposures, discontinuing opioids (i.e., ≥7-day gap[s] in therapy) was associated with increased overdose risk among people without OUD (adjusted hazard ratio [AHR] = 1.44; 95% confidence interval [CI] 1.12, 1.83; p = 0.004), people with OUD not receiving OAT (AHR = 3.18; 95% CI 1.87, 5.40; p < 0.001), and people with OUD receiving OAT (AHR = 2.52; 95% CI 1.68, 3.78; p < 0.001). Opioid tapering (i.e., ≥2 sequential decreases of ≥5% in average daily morphine milligram equivalents) was associated with decreased overdose risk among people with OUD not receiving OAT (AHR = 0.31; 95% CI 0.14, 0.67; p = 0.003). The main study limitations are that the outcome measure did not capture overdose events that did not result in a healthcare encounter or death, medication dispensation may not reflect medication adherence, residual confounding may have influenced findings, and findings may not be generalizable to persons on opioid therapy in other settings. CONCLUSIONS: Discontinuing prescribed opioids was associated with increased overdose risk, particularly among people with OUD. Prescribed opioid tapering was associated with reduced overdose risk among people with OUD not receiving OAT. These findings highlight the need to avoid abrupt discontinuation of opioids for pain. Enhanced guidance is needed to support prescribers in implementing opioid therapy tapering strategies with consideration of OUD and OAT status.
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Dor Crônica , Overdose de Drogas , Transtornos Relacionados ao Uso de Opioides , Feminino , Humanos , Pessoa de Meia-Idade , Masculino , Analgésicos Opioides/efeitos adversos , Colúmbia Britânica/epidemiologia , Dor Crônica/tratamento farmacológico , Dor Crônica/epidemiologia , Estudos Retrospectivos , Padrões de Prática Médica , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/epidemiologia , Overdose de Drogas/etiologiaRESUMO
BACKGROUND: The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada. METHODS: Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS. RESULTS: Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42-58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28-5.30), active injection drug use (AOR = 4.06; 95% CI 1.38-11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24-4.85), and unstable housing (AOR = 2.14; 95% CI 1.08-4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93-0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%). CONCLUSIONS: We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.
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COVID-19 , Overdose de Drogas , Masculino , Humanos , Pessoa de Meia-Idade , Pandemias , Estudos Prospectivos , Estudos Transversais , Canadá/epidemiologia , Overdose de Drogas/epidemiologiaAssuntos
Overdose de Drogas , Transtornos Relacionados ao Uso de Opioides , Humanos , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Tratamento de Substituição de Opiáceos , América do Norte/epidemiologia , Analgésicos Opioides/efeitos adversos , Overdose de Drogas/epidemiologia , Overdose de Drogas/prevenção & controleRESUMO
BACKGROUND: Although factors associated with completion of medical detoxification treatment for substance use disorders (SUD) are well described, there is limited information on barriers and facilitators to subsequent linkage to SUD treatment in the community. This study aimed to evaluate correlates of successful linkage to community SUD treatment on discharge. METHODS: Data were drawn from 2 prospective cohorts of people who use unregulated drugs in Vancouver, Canada between December 2012 and May 2018. Multivariable generalized estimating equations were used to investigate factors associated with linkage to community SUD treatment in the 6-month period after attending detoxification treatment. RESULTS: Of the 264 detoxification treatment encounters contributed by 178 people who use unregulated drugs, these were most often (n = 104, 39%) related to polysubstance use, and the majority (n = 174, 66%) resulted in subsequent linkage to community treatment. In the multivariable analysis, compared to attending detoxification treatment for opioid use, attending detoxification treatment for stimulants (adjusted odds ratio [AOR] = 0.23, 95% confidence interval [CI] : 0.10-0.51) and alcohol (AOR = 0.17, 95% CI: 0.06-0.54) were associated with lower odds of subsequent linkage to community treatment. Conversely, later calendar year of detoxification treatment remained associated with higher odds (AOR = 1.23, 95% CI: 1.06-1.42). CONCLUSIONS: Only two-thirds of detoxification treatment encounters in Vancouver were subsequently linked to community SUD treatment, with those related to nonopioid substances being less likely. Findings suggest the need for tailored interventions for specific substances to improve linkage to SUD treatment in the community on discharge.
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Transtornos Relacionados ao Uso de Opioides , Transtornos Relacionados ao Uso de Substâncias , Humanos , Estudos Prospectivos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Alta do Paciente , CanadáRESUMO
BACKGROUND AND AIMS: In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed 'overdose prevention sites' (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID). DESIGN: Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends. SETTING: Vancouver, Canada. PARTICIPANTS: Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline. MEASUREMENTS: Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment. FINDINGS: Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation. CONCLUSIONS: Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.
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Overdose de Drogas , Abuso de Substâncias por Via Intravenosa , Canadá/epidemiologia , Overdose de Drogas/epidemiologia , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Pessoa de Meia-Idade , Uso Comum de Agulhas e Seringas , Estudos Prospectivos , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/epidemiologiaRESUMO
BACKGROUND: Although non-medical use of pharmaceutical opioids (POs) is associated with a number of risks, in the context of the opioid-overdose crisis, it may have the secondary benefit of decreasing the risk of exposure to more potent opioids from unregulated sources. The aim of this study was to assess the effects of using diverted POs on fentanyl exposure. METHODS: Using data from two prospective community-recruited cohorts of people who use drugs (PWUD) in Vancouver, Canada, we estimated the independent relationship between using diverted POs and fentanyl exposure (assessed through urine drug test [UDT]) between 2016 and 2018. We also explored if participant characteristics modified this relationship. RESULTS: Over the study period, among 1150 participants, 241 (21.0%) reported using diverted POs in 292 (12.8%) occasions. In adjusted analyses, PWUD using diverted POs had decreased odds of fentanyl exposure (Adjusted odds ratio [AOR] = 0.70, 95% CI: 0.52-0.94). The reduced odds of fentanyl exposure persisted among participants with morphine positive UDT (AOR = 0.57, 95% CI: 0.40-0.82), but not among those with negative morphine UDT (AOR = 0.91, 95% CI: 0.54-1.55). CONCLUSION: PWUD using diverted POs in our sample were 30% less likely to be exposed to fentanyl. This reduced likelihood was primarily observed among PWUD with morphine positive UDT, which could partially be explained by longer duration of action and lower street cost of slow-release oral morphine relative to other POs and fentanyl. Findings suggest that access to a regulated supply of pharmaceutical-grade opioids may serve to reduce fentanyl-related harms.
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Overdose de Drogas , Preparações Farmacêuticas , Analgésicos Opioides/efeitos adversos , Canadá , Overdose de Drogas/tratamento farmacológico , Fentanila/efeitos adversos , Humanos , Estudos ProspectivosRESUMO
BACKGROUND: People who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada. METHODS: Data were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS. RESULTS: Between June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 - 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 - 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 - 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 - 3.47) were associated with increased odds of receiving injection assistance at SIS. CONCLUSION: Although uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.
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BACKGROUND: Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting. METHODS: Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively. RESULTS: Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46-0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57-1.66). CONCLUSION: In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.