Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study.

BACKGROUND: North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS: We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS: Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS: BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.

Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital.

BACKGROUND: People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services. METHODS: We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program. RESULTS: Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears. CONCLUSIONS: Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia.

BACKGROUND: Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers. METHODS: We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals' peers, defined as the proportion of a prescribers' professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after. RESULTS: Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers. CONCLUSIONS: The uptake of PSS in BC was highly dependent on the behavior of prescribers' peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.

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.

Everywhere and for everyone: proportionate universalism as a framework for equitable access to community drug checking.

BACKGROUND: Illicit drug overdoses have reached unprecedented levels, exacerbated by the COVID-19 pandemic. Responses are needed that address the increasingly potent and unpredictable drug supply with better reach to a wide population at risk for overdose. Drug checking is a potential response offered mainly within existing harm reduction services, but strategies are needed to increase reach and improve equitable delivery of drug checking services. METHODS: The purpose of this qualitative study was to explore how to extend the reach of drug checking services to a wide population at risk of overdose. We conducted 26 in-depth interviews with potential service users to identify barriers to service use and strategies to increase equitable delivery of drug checking services. Our analysis was informed by theoretical perspectives on equity, and themes were developed relevant to equitable delivery through attention to quality dimensions of service use: accessibility, appropriateness, effectiveness, safety, and respect. RESULTS: Barriers to equitable service delivery included criminalization and stigma, geographic and access issues, and lack of cultural appropriateness that deter service use for a broad population with diverse needs. Strategies to enhance equitable access include 1ocating services widely throughout communities, integrating drug checking within existing health care services, reframing away from risk messaging, engaging peers from a broad range of backgrounds, and using discrete methods of delivery to help create safer spaces and better reach diverse populations at risk for overdose. CONCLUSIONS: We propose proportionate universalism in drug checking as a guiding framework for the implementation of community drug checking as an equity-oriented harm reduction intervention and as a population health response. Both a universal equity-oriented approach and multiple tailored approaches are required to facilitate drug checking services that maximize reach and appropriateness to respond to diverse needs.

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment.

BACKGROUND: Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada. METHODS: We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey (N = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario. RESULTS: Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities. CONCLUSIONS: Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices.

BACKGROUND: Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians' concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms. METHODS: Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually. RESULTS: A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms. CONCLUSIONS: VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

Applicability of a national strategy for patient-oriented research to people who use(d) substances: a Canadian experience.

BACKGROUND: Europe and North America are in the grips of a devastating overdose crisis. People who use substances often feel unsafe to access healthcare due to fears of stigma, blame, judgement, poor treatment, or other repercussions. As a result, they often avoid, delay, or leave care, resulting in premature death and missed opportunities for care. Internationally, there have been concerted efforts to move towards patient-engaged research to enhance the quality of health care systems and services. In Canada, the Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) initiative promotes engagement of patients as active partners in health care research. As part of a community based patient oriented research project, we critically analyze the SPOR framework to provide insights into what constitutes safer research with people who use(d) substances. METHODS: We undertook a two-stage process that began with a review of community based research principles and the SPOR framework. At the second stage, we undertook a qualitative descriptive study employing focus groups to generate description of the adequacy and appropriateness of the SPOR framework for guiding research with people who use(d) substances on four key dimensions (patient engagement, guiding principles, core areas of engagement and benefits). The data were analyzed using qualitative content analysis to identify key issues and insights. RESULTS: While the SPOR framework includes a range of patient roles, principles and areas for engagement, there are issues and gaps related to essential elements of safe patient-oriented research for people who use substances. These include an individualized focus on patients as partners, lack of recognition of community benefits, power imbalances and distrust due to systemic stigma, engagement as one way capacity building and learning, and lack of accountability for taking action on research findings. CONCLUSIONS: Given the extent of stigma in health care and the ongoing illicit drug policy crisis, strategies for enhancing equitable Patient-Oriented Research (POR) include shifting language from patient partners to community researchers, recognizing power inequities and adding trust and equity as core POR principles including pay equity. Employing community based participatory research as a POR methodology allows the lead researchers to fully engage community throughout the research process, enhances community benefits and accountability for action.

"There are solutions and I think we're still working in the problem": The limitations of decriminalization under the good Samaritan drug overdose act and lessons from an evaluation in British Columbia, Canada.

BACKGROUND: Drug prohibition has been associated with increased risk of overdose. However, drug prohibition remains the dominant drug policy, including in Canada with the Controlled Drugs and Substances Act. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted, to encourage people to contact emergency medical services by providing bystanders at the scene of an overdose with legal protection for simple possession and conditions related to simple possession. METHODS: We conducted an evaluation of the GSDOA in British Columbia, Canada that included one-on-one interviews with people who use illicit drugs (PWUD), to determine peoples' experiences and perceptions surrounding this form of decriminalization. We present findings from a thematic analysis of 37 interviews. RESULTS: We identified limitations of the GSDOA at overdose events; key themes and concerns causing PWUD to hesitate to or avoid contacting emergency medical services included drug confiscation, the thin line between simple possession and drug trafficking, and enforcement of other charges and court ordered conditions that are not legally protected by the GSDOA. Moreover, participants discussed the GSDOA as inequitable; benefiting some while excluding PWUD with intersecting marginalized identities. CONCLUSION: Our findings are pertinent in light of many jurisdictions across the world considering dejure decriminalization, including BC and Vancouver. The GSDOA and associated limitations that emerged in our evaluation can serve to guide jurisdictions implementing or amending dejure decriminalization policies.

Homeless encampments: connecting public health and human rights.

The COVID-19 pandemic is exacerbating longstanding issues related to homelessness, including lack of affordable housing, unemployment, poverty, wealth inequality, and ongoing impacts of colonization. Homelessness is often accompanied by narratives rooted in individual blame, criminalization, and reinforcement of substance use and mental health-related stigma. Visible homelessness, in the form of encampments, is a manifestation of government policy failures that neglect to uphold the human right to housing, and demonstrate eroding investments in affordable housing, income and systemic supports. Encampments make visible that some in our community lack basic determinants of health such as food, water, sanitation, safety, and the right to self-determination. In order for public health to effectively and equitably promote health and enact commitments to social justice, we argue that public health must adopt a human rights approach to housing and to homeless encampments. Embracing a human rights perspective means public health would advocate first and foremost for adequate housing and other resources rooted in self-determination of encampment residents. In the absence of housing, public health would uphold human rights through the provision of public health resources and prohibition on evictions of encampments until adequate housing is available.

RéSUMé: La pandémie de COVID-19 exacerbe des problèmes de longue date liés au sans-abrisme, dont le manque de logements abordables, le chômage, la pauvreté, l'inégalité de richesse et les impacts continus de la colonisation. Le sans-abrisme s'accompagne souvent de discours narratifs ancrés dans le blâme personnel, la criminalisation et le renforcement de la stigmatisation de l'usage de substances et des troubles de santé mentale. Le sans-abrisme visible, qui prend la forme des campements, est un constat d'échec des politiques gouvernementales qui négligent de faire respecter le droit fondamental au logement, et il démontre l'érosion des investissements dans les logements abordables, le soutien du revenu et le soutien systémique. Les campements rendent visible le fait qu'il manque à certains membres de la collectivité les déterminants de base de la santé, comme la nourriture, l'eau, les installations sanitaires, la sécurité et le droit à l'autodétermination. Pour que la santé publique fasse efficacement et équitablement la promotion de la santé et pour qu'elle donne suite à ses engagements envers la justice sociale, nous faisons valoir qu'elle doit aborder le logement et les campements de sans-abri selon une approche fondée sur les droits humains. L'adoption d'une perspective axée sur les droits humains signifie que la santé publique doit d'abord et avant tout plaider en faveur de ressources, dont des logements adéquats, ancrées dans l'autodétermination des résidents des campements. En l'absence de logements, la santé publique devrait faire respecter les droits humains par la mise à disposition de ses ressources et par l'interdiction des expulsions des campements jusqu'à ce que des logements adéquats deviennent disponibles.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review.

OBJECTIVE: The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids. INCLUSION CRITERIA: To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts. METHODS: An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives. RESULTS: A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed. CONCLUSIONS: We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

The potential impacts of community drug checking within the overdose crisis: qualitative study exploring the perspective of prospective service users.

BACKGROUND: As drug checking becomes more integrated within public health responses to the overdose crisis, and potentially more institutionalized, there is value in critically questioning the impacts of drug checking as a harm reduction response. METHODS: As part of a pilot project to implement community drug checking in Victoria, BC, Canada, in-depth interviews (N = 27) were held with people who use or have used substances, family or friends of people who use substances, and/or people who make or distribute substances. Critical harm reduction and social justice perspectives and a socioecological model guided our analysis to understand the potential role of drug checking within the overdose crisis, from the perspective of prospective service users. RESULTS: Participants provided insight into who might benefit from community drug checking and potential benefits. They indicated drug checking addresses a "shared need" that could benefit people who use substances, people who care for people who use substances, and people who sell substances. Using a socioecological model, we identified four overarching themes corresponding to benefits at each level: "drug checking to improve health and wellbeing of people who use substances", "drug checking to increase quality control in an unregulated market", "drug checking to create healthier environments", and "drug checking to mediate policies around substance use". CONCLUSIONS: Drug checking requires a universal approach to meet the needs of diverse populations who use substances, and must not be focused on abstinence based outcomes. As a harm reduction response, community drug checking has potential impacts beyond the individual level. These include increasing power and accountability within the illicit drug market, improving the health of communities, supporting safer supply initiatives and regulation of substances, and mitigating harms of criminalization. Evaluation of drug checking should consider potential impacts that extend beyond individual behaviour change and recognize lived realities and structural conditions.

COVID-19 Social Restrictions: An Opportunity to Re-visit the Concept of Harm Reduction in the Treatment of Alcohol Dependence. A Position Paper.

The COVID-19 pandemic is presenting significant challenges for health and social care systems globally. The implementation of unprecedented public health measures, alongside the augmentation of the treatment capacity for those severely affected by COVID-19, are compromising and limiting the delivery of essential care to people with severe substance use problems and, in some cases, widening extreme social inequities such as poverty and homelessness. This global pandemic is severely challenging current working practices. However, these challenges can provide a unique opportunity for a flexible and innovative learning approach, bringing certain interventions into the spotlight. Harm reduction responses are well-established evidenced approaches in the management of opioid dependence but not so well-known or implemented in relation to alcohol use disorders. In this position paper, we explore the potential for expanding harm reduction approaches during the COVID-19 crisis and beyond as part of substance use treatment services. We will examine alcohol use and related vulnerabilities during COVID-19, the impact of COVID-19 on substance use services, and the potential philosophical shift in orientation to harm reduction and outline a range of alcohol harm reduction approaches. We discuss relevant aspects of the Structured Preparation for Alcohol Detoxification (SPADe) treatment model, and Managed Alcohol Programs (MAPs), as part of a continuum of harm reduction and abstinence orientated treatment for alcohol use disorders. In conclusion, while COVID-19 has dramatically reduced and limited services, the pandemic has propelled the importance of alcohol harm reduction and created new opportunities for implementation of harm reduction philosophy and approaches, including programs that incorporate the provision of alcohol as medicine as part of the substance use treatment continuum.

"Running myself ragged": stressors faced by peer workers in overdose response settings.

BACKGROUND: Peer workers or "peers" (workers with past or present drug use experience) are at the forefront of overdose response initiatives, and their role is essential in creating safe spaces for people who use drugs (PWUD). Working in overdose response settings has benefits for peer workers but is also stressful, with lasting emotional and mental health effects. Yet, little is known about the stressors peer workers face and what interventions can be implemented to support them in their roles. METHODS: This project used a community-based sequential mixed-methods research design. Eight peer researcher-led focus groups (n = 31) were conducted between November 2018 and March 2019 to assess needs of peer workers. The transcripts were thematically coded and analysed using interpretative description. These results informed a survey, which was conducted (n = 50) in September 2019 to acquire quantitative data on peer workers' perception of health, quality of life, working conditions and stressors. Frequency distributions were used to describe characteristics of participants. X2 distribution values with Yates correction were conducted to check for association between variables. RESULTS: Five themes emerged from the focus groups that point to stressors felt by peer workers: (1) financial insecurity; (2) lack of respect and recognition at work; (3) housing challenges; (4) inability to access and/or refer individuals to resources; and (5) constant exposure to death and trauma. Consistent with this, the factors that survey participants picked as one of their "top three stressors" included financial situation, work situation, and housing challenges. CONCLUSION: Peer workers are faced with a diversity of stressors in their lives which often reflect societal stigmatization of drug use. Recognition of these systemic stressors is critical in designing interventions to ease the emotional, physical and financial burden faced by peer workers.

"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.

Defining culturally safe primary care for people who use substances: a participatory concept mapping study.

BACKGROUND: People who use substances experience high levels of substance-related stigma, both within and outside of health care settings, which can prevent people from help-seeking and contribute further to health inequities. Recognizing and respecting how political, social, economic, and historical conditions influence health and health care, cultural safety, with origins in addressing Indigenous racism, is a potential strategy for mitigating stigma and marginalization in health care. Using a participatory research approach, we applied the concept of cultural safety to develop a model of safe primary care from the perspective of people who use substances. METHODS: People who use or used substances were involved in all phases of the research and led data collection. Study participants (n = 75) were 42.5 years old on average; half identified as female and one quarter as Indigenous. All were currently using or had previous experience with substances (alcohol and/or other drugs) and were recruited through two local peer-run support agencies. Concept mapping with hierarchical cluster analysis was used to develop the model of safe primary care, with data collected over three rounds of focus groups. RESULTS: Participants identified 73 unique statements to complete the focus prompt: "I would feel safe going to the doctor if …" The final model consisted of 8 clusters that cover a wide range of topics, from being treated with respect and not being red-flagged for substance use, to preserving confidentiality, advocacy for good care and systems change, and appropriate accommodations for anxiety and the effects of poverty and criminalization. CONCLUSIONS: Developing a definition of safe care (from the patient perspective) is the necessary first step in creating space for positive interactions and, in turn, improve care processes. This model provides numerous concrete suggestions for providers, as well as serving as starting point for the development of interventions designed to foster system change.

Values are not enough: qualitative study identifying critical elements for prioritization of health equity in health systems.

BACKGROUND: Health system policies and programs that reduce health inequities and improve health outcomes are essential to address unjust social gradients in health. Prioritization of health equity is fundamental to addressing health inequities but challenging to enact in health systems. Strategies are needed to support effective prioritization of health equity. METHODS: Following provincial policy recommendations to apply a health equity lens in all public health programs, we examined health equity prioritization within British Columbia health authorities during early implementation. We conducted semi-structured qualitative interviews and focus groups with 55 senior executives, public health directors, regional directors, and medical health officers from six health authorities and the Ministry of Health. We used an inductive constant comparative approach to analysis guided by complexity theory to determine critical elements for prioritization. RESULTS: We identified seven critical elements necessary for two fundamental shifts within health systems. 1) Prioritization through informal organization includes creating a systems value for health equity and engaging health equity champions. 2) Prioritization through formal organization requires explicit naming of health equity as a priority, designating resources for health equity, requiring health equity in decision making, building capacity and competency, and coordinating a comprehensive approach across levels of the health system and government. CONCLUSIONS: Although creating a shared value for health equity is essential, health equity - underpinned by social justice - needs to be embedded at the structural level to support effective prioritization. Prioritization within government and ministries is necessary to facilitate prioritization at other levels. All levels within health systems should be accountable for explicitly including health equity in strategic plans and goals. Dedicated resources are needed for health equity initiatives including adequate resourcing of public health infrastructure, training, and hiring of staff with equity expertise to develop competencies and system capacity.

'Most at risk' for COVID19? The imperative to expand the definition from biological to social factors for equity.

First recognized in December 2019, the Coronavirus Disease 2019 (COVID19) was declared a global pandemic by the World Health Organization on March 11, 2020. To date, the most utilized definition of 'most at risk' for COVID19 morbidity and mortality has focused on biological susceptibility to the virus. This paper argues that this dominant biomedical definition has neglected the 'fundamental social causes' of disease, constraining the effectiveness of prevention and mitigation measures; and exacerbating COVID19 morbidity and mortality for population groups living in marginalizing circumstances. It is clear - even at this early stage of the pandemic - that inequitable social conditions lead to both more infections and worse outcomes. Expanding the definition of 'most at risk' to include social factors is critical to implementing equitable interventions and saving lives. Prioritizing populations with social conditions is necessary for more effective control of the epidemic in its next phase; and should become standard in the planning for, and prevention and mitigation of all health conditions. Reversing disparities and health inequities is only possible through an expansion of our 'most-at-risk' definition to also include social factors.