Time-Series Analysis of Fentanyl Concentration in the Unregulated Opioid Drug Supply in a Canadian Setting.

North America has been contending with an unregulated street drug supply in which opioids are often adulterated with illicitly manufactured fentanyl. The unpredictability of composition may result in an increased risk of overdose due to unexpected elevated concentrations of the high-potency drug. Using data from a community-based drug-checking project, we evaluated trends in fentanyl concentration of illicit opioids in the context of an overdose epidemic. Using a quantification model for fentanyl hydrochloride, historical Fourier-transform infrared spectra from opioid drug-checking samples were analyzed to determine fentanyl concentrations. Median monthly fentanyl concentrations were plotted, and polynomial and autoregressive time-series analyses were performed to examine trends over time. A total of 3,621 fentanyl-positive samples were included in the study, spanning November 2017 to December 2019. Monthly median fentanyl concentrations ranged from 4.5% to 10.4%. Time-series analyses indicated that a third-degree polynomial model fit the data well (R2 = 0.639), suggesting a cyclical pattern in median concentration over time. Notably, absolute variance in fentanyl concentration decreased by an average 0.1% per month (P < 0.001). Future research should explore the relationship between fentanyl concentration and overdose to identify potential targeted harm-reduction interventions that can respond to changes in observed fentanyl concentration.

An exploratory study of experiences with conventional eating disorder treatment and ceremonial ayahuasca for the healing of eating disorders.

PURPOSE: Ayahuasca is a traditional Amazonian medicine that is currently being researched for its potential in treating a variety of mental disorders. This article reports on exploratory qualitative research relating to participant experiences with ceremonial ayahuasca drinking and conventional treatment for eating disorders (EDs). It also explores the potential for ayahuasca as an adjunctive ED treatment. METHODS: Thirteen individuals previously diagnosed with an ED participated in a semi-structured interview contrasting their experiences with conventional ED treatment with experiences from ceremonial ayahuasca. The interviews were analyzed using thematic analysis. RESULTS: Participant reports were organized with key themes including that ayahuasca: led to rapid reductions in ED thoughts and symptoms; allowed for the healing of the perceived root of the ED; helped to process painful feelings and memories; supported the internalization of greater self-love and self-acceptance; and catalyzed spiritual elements of healing. CONCLUSIONS: The results suggest that ayahuasca may have potential as a valuable therapeutic tool, and further research-including carefully controlled clinical trials-is warranted. LEVEL OF EVIDENCE: Level V, qualitative descriptive study.

3,4-Methylenedioxymethamphetamine (MDMA; ecstasy) use and transitions to injection drug use among street-involved youth.

Background: Despite the popularity of 3,4-methylenedioxymethamphetamine (MDMA; ecstasy) among young people across North America and Europe, MDMA is rarely explored in studies of young people at high risk of injecting drugs. We conducted a study among street-involved youth who use illicit drugs in Vancouver, Canada, to understand if use of MDMA is associated with initiation of injection drugs. Methods: We followed injection-naïve participants in the At-Risk Youth Study (ARYS), an ongoing prospective cohort of street-involved youth aged 14-26 who use illicit drugs. Bivariate and multivariate extended Cox models with time-updated variables were used to examine the association between MDMA use and initiation of injection drug use between September 2005 and May 2015. Results: Among 483 youth, 306 (63.4%) had a history of MDMA use and 218 (45.1%) had used MDMA in the previous 6 months at baseline. A total of 105 (21.7%) youth initiated injection drug use over the 10-year period, yielding an incidence density of 8.51 (95% confidence interval [CI]: 6.96-10.30) per 100 person-years. MDMA use was not significantly associated with initiating injection drugs at the bivariate (hazard ratio: 0.93, 95% CI: 0.61-1.42) or multivariate (adjusted hazard ratio: 0.88, 95% CI: 0.57-1.35) level, after adjusting for socio-demographic and substance use confounders. Conclusions: Amid ongoing frequent use of MDMA among some young people in North America, we did not observe an elevated risk of injection initiation among those who used MDMA in this cohort of street-involved youth.

Fentanyl Concentration in Drug Checking Samples and Risk of Overdose Death in Vancouver, Canada.

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.

"We don't got that kind of time, man. We're trying to get high!": Exploring potential use of drug checking technologies among structurally vulnerable people who use drugs.

BACKGROUND: Novel public health interventions are being considered to address the opioid overdose epidemic, including drug checking technologies. We examined the willingness to use various drug checking technologies among structurally-vulnerable people who use drugs (PWUD). METHODS: We conducted one-to-one qualitative semi-structured interviews with 20 PWUD in Vancouver, Canada's Downtown Eastside. Participants were purposively recruited from ongoing cohort studies of PWUD. RESULTS: Overall willingness to use drug checking technologies was low among participants. A range of factors undermined potential use of various drug checking technologies including: having to give up a drug sample; time dedication; discrepancies regarding measurements and accuracy; recourse following positive fentanyl results; ambivalence to overdose risk; and availability and accessibility of drug checking technologies. CONCLUSIONS: Participants discussed numerous factors that undermined potential willingness to use drug checking technologies. These factors underscore the structural vulnerabilities experienced by PWUD and how they may constrain uptake of drug checking technologies. Future drug checking programming should consider these influencing factors prior to the implementation of drug checking technologies to ensure that drug checking interventions are appropriate and meeting the needs of target populations.

The tripping point: The potential role of psychedelic-assisted therapy in the response to the opioid crisis.

The increasing contamination of the drug supply with illicitly manufactured fentanyl and related analogs in North America has resulted in the most severe drug-overdose crisis in history. Available pharmacotherapy options for the treatment of opioid use disorder have had limited success in curbing the current crisis, and a growing body of evidence highlights the need for innovative interventions that target underlying social-structural drivers of opioid use disorder. Re-emerging clinical research suggests that psychedelic-assisted therapy has potential as an alternative treatment for refractory substance use disorders and related comorbidities. Based on the available evidence, our viewpoint supports advancing research on the potential role of psychedelic-assisted therapy within a multifaceted response to the opioid crisis.

Exploring ayahuasca-assisted therapy for addiction: A qualitative analysis of preliminary findings among an Indigenous community in Canada.

INTRODUCTION AND AIMS: A previous observational study of ayahuasca-assisted therapy demonstrated statistically significant reductions in self-reported problematic cocaine use among members of an Indigenous community in Canada. This paper aims to qualitatively explore the impact of ayahuasca-assisted therapy on addiction and other substance use-related outcomes and elucidate the lived experiences of participants. DESIGN AND METHODS: Qualitative interviews were conducted with 11 adult Indigenous participants of the ayahuasca-assisted 'Working with Addiction and Stress' ceremonial retreats (June-September 2011). Semi-structured interviews assessed experiences of participants following the retreats at 6-month follow up. Thematic analysis of interview transcripts was conducted. RESULTS: Narratives revealed that the retreats helped participants identify negative thought patterns and barriers related to their addiction in ways that differed from conventional therapies. All participants reported reductions in substance use and cravings; eight participants reported complete cessation of at least one substance at follow up. Increased connectedness with self, others and nature/spirit was described as a key element associated with reduced substance use and cravings. DISCUSSION AND CONCLUSIONS: This analysis expands upon prior quantitative results highlighting the therapeutic potential of ayahuasca-assisted therapy and provides important contextual insights into why ayahuasca-assisted therapy may have been beneficial for members of an Indigenous community seeking to address their problematic use of substances. Given limited efficacy of conventional treatments for resolving addiction issues, further research should investigate the role of ayahuasca and other psychedelic-assisted therapies in enhancing connectedness and other key factors that may improve well-being and reduce harmful substance use.

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

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

Initial results of a drug checking pilot program to detect fentanyl adulteration in a Canadian setting.

BACKGROUND: Opioid overdose deaths in North America have been rising largely as a result of fentanyl adulteration in the illegal drug supply. Drug checking is an established harm reduction intervention in some European settings but has not been broadly implemented or evaluated in North America. We are evaluating a pilot program offering drug checking for people who use street drugs in Vancouver, British Columbia. METHODS: Drug checking services were implemented at two locations in Vancouver between November 2017 and April 2018 using a Fourier transform infrared (FTIR) spectrometer and fentanyl immunoassay strips. We report on the findings generated by this technological combination during the study period. RESULTS: During the study period, a total of 1714 samples were tested. Of 907 samples expected to be heroin, only 160 (17.6%) contained the expected substance, and 822 (90.6%) tested positive for fentanyl. Of 256 samples expected to be speed or crystal meth, 225 (87.9%) contained amphetamine or methamphetamine, and 15 (5.9%) tested positive for fentanyl. The FTIR also found unexpected and potentially dangerous substances and adulterants other than fentanyl. CONCLUSIONS: This pilot program has demonstrated the feasibility of drug checking for identifying individual drug samples containing unexpected or hazardous substances, including fentanyl. By identifying the range of adulterants and diluents and giving an estimate of their prevalence in different drug types, it has also provided information about the composition of the illicit drug supply in an urban North American setting.

Drug checking at an electronic dance music festival during the public health overdose emergency in British Columbia.

SETTING: Shambhala is a 5-day electronic dance music (EDM) festival held in rural British Columbia that annually hosts between 15,000 and 18,000 people on a 500-acre ranch. The AIDS Network Outreach & Support Society (ANKORS) has provided harm reduction services throughout the duration of the festival since 2003, including point-of-care drug checking, which allows real-time testing of illicit substances to assess their composition. Drug checking results are provided directly to clients and displayed in aggregate on a screen for all attendees to see. INTERVENTION: In 2017, ANKORS added fentanyl checking to their repertoire of drug checking technologies for festivalgoers. Volunteers used a brief survey to collect information on what clients expected the samples to contain. Volunteers carried out drug checks and subsequently logged test results. ANKORS provided an amnesty bin at the tent for clients who chose to discard their substances. OUTCOMES: Of the 2683 surveys, 2387 included data on both the client's belief and the actual test result. Clients were more likely to discard when the test result differed from their belief (5.16%) than when their belief was confirmed (0.69%). Discarding increased to 15.54% when the test could not clearly identify a substance and to 30.77% if the client did not have a prior belief of the substance. Of 1971 samples tested for fentanyl, 31 tested positive and 16.13% of clients discarded compared to 2.63% in the negative group. IMPLICATIONS: Drug checking services appeal to festivalgoers who, when faced with uncertainty, may discard their substances. This innovative harm reduction service allows for a personalized risk discussion, potentially reaching others via word-of-mouth and early warning systems.

Nourishing the Spirit: Exploratory Research on Ayahuasca Experiences along the Continuum of Recovery from Eating Disorders.

Eating disorders (EDs) are serious health conditions that are among the most difficult to treat. Innovative treatments are needed and modalities from across cultures must be considered. Ayahuasca is a psychoactive plant-based tea originally used by Amazonian indigenous groups. A growing body of research points to its promise in the healing of various mental health issues. This study explored the potential therapeutic value of ayahuasca in the context of EDs, including the perceived impact of the preparatory diet and the ayahuasca purge. Sixteen individuals previously diagnosed with an ED participated in a semi-structured interview relating to their experiences with ceremonial ayahuasca drinking. Interviews were analyzed using thematic analysis. Themes presented relate to the reduction or cessation of ED and mental health symptoms, shifts in body perception, and the importance of a ceremonial setting and after-care. For some, the preparatory diet resulted in familiar patterns of concern; however, none felt triggered by the purge in ayahuasca. Ceremonial ayahuasca drinking shows promise in the healing of EDs and warrants further research.

A Public-Health-Based Vision for the Management and Regulation of Psychedelics.

The Health Officers Council of British Columbia has proposed post-prohibition regulatory models for currently illegal drugs based on public health principles, and this article continues this work by proposing a model for the regulation and management of psychedelics. This article outlines recent research on psychedelic substances and the key determinants of benefit and harm from their use. It then describes a public-health-based model for the regulation of psychedelics, which includes governance, supervision, set and setting controls, youth access, supply control, demand limitation, and evaluation.

Ayahuasca, psychedelic studies and health sciences: the politics of knowledge and inquiry into an Amazonian plant brew.

This article offers critical sociological and philosophical reflections on ayahuasca and other psychedelics as objects of research in medicine, health and human sciences. It situates 21st century scientific inquiry on ayahuasca in the broader context of how early modern European social trends and intellectual pursuits translated into new forms of empiricism and experimental philosophy, but later evolved into a form of dogmatism that convenienced the political suppression of academic inquiry into psychedelics. Applying ideas from the field of science and technology studies, we consider how ayahuasca's myriad ontological representations in the 21st century--for example, plant teacher, traditional medicine, religious sacrament, material commodity, cognitive tool, illicit drug--influence our understanding of it as an object of inquiry. We then explore epistemological issues related to ayahuasca studies, including how the indigenous and mestizo concept of "plant teacher" or the more instrumental notion of psychedelics as "cognitive tools" may impact understanding of knowledge. This leads to questions about whether scientists engaged in ayahuasca research should be expected to have personal experiences with the brew, and how these may be perceived to help or hinder the objectivity of their pursuits. We conclude with some brief reflections on the politics of psychedelic research and impediments to academic knowledge production in the field of psychedelic studies.

Ayahuasca-assisted therapy for addiction: results from a preliminary observational study in Canada.

INTRODUCTION: This paper reports results from a preliminary observational study of ayahuasca-assisted treatment for problematic substance use and stress delivered in a rural First Nations community in British Columbia, Canada. METHODS: The "Working with Addiction and Stress" retreats combined four days of group counselling with two expert-led ayahuasca ceremonies. This study collected pre-treatment and six months follow-up data from 12 participants on several psychological and behavioral factors related to problematic substance use, and qualitative data assessing the personal experiences of the participants six months after the retreat. FINDINGS: Statistically significant (p < 0.05) improvements were demonstrated for scales assessing hopefulness, empowerment, mindfulness, and quality of life meaning and outlook subscales. Self-reported alcohol, tobacco and cocaine use declined, although cannabis and opiate use did not; reported reductions in problematic cocaine use were statistically significant. All study participants reported positive and lasting changes from participating in the retreats. CONCLUSIONS: This form of ayahuasca-assisted therapy appears to be associated with statistically significant improvements in several factors related to problematic substance use among a rural aboriginal population. These findings suggest participants may have experienced positive psychological and behavioral changes in response to this therapeutic approach, and that more rigorous research of ayahuasca-assisted therapy for problematic substance use is warranted.

The globalization of ayahuasca: harm reduction or benefit maximization?

Ayahuasca is a tea made from two plants native to the Amazon, Banisteriopsis caapi and Psychotria viridis, which, respectively, contain the psychoactive chemicals harmala alkaloids and dimethyltryptamine. The tea has been used by indigenous peoples in countries such as Brazil, Ecuador and Peru for medicinal, spiritual and cultural purposes since pre-Columbian times. In the 20th century, ayahuasca spread beyond its native habitat and has been incorporated into syncretistic practices that are being adopted by non-indigenous peoples in modern Western contexts. Ayahuasca's globalization in the past few decades has led to a number of legal cases which pit religious freedom against national drug control laws. This paper explores some of the philosophical and policy implications of contemporary ayahuasca use. It addresses the issue of the social construction of ayahuasca as a medicine, a sacrament and a "plant teacher." Issues of harm reduction with respect to ayahuasca use are explored, but so too is the corollary notion of "benefit maximization."