Acceptability of a hypothetical preventative HIV vaccine among people who use drugs in Vancouver, Canada.

BACKGROUND: As research on HIV vaccines continues to advance, studies exploring the feasibility of this intervention are necessary to inform uptake and dissemination strategies with key populations, including people who use drugs (PWUD). METHODS: We conducted 25 in-depth qualitative interviews examining HIV vaccine acceptability among PWUD in Vancouver, Canada. Participants were recruited from an ongoing prospective cohort of HIV-negative PWUD. Data were coded using NVivo, and analyzed thematically. RESULTS: Acceptability was framed by practical considerations such as cost and side effects, and was influenced by broader trust of government bodies and health care professionals. While an HIV vaccine was perceived as an important prevention tool, willingness to be vaccinated was low. Results suggest that future vaccine implementation must consider how to minimize the burden an HIV vaccine may place on PWUD. Centering the role of health care providers in information dissemination and delivery may assist with uptake. CONCLUSIONS: Our findings suggest improvements in care and improved patient-provider relationships would increase the acceptability of a potential HIV vaccine among this population.

Beyond co-production: The construction of drug checking knowledge in a Canadian supervised injection facility.

Drug-checking is an ensemble of different harm reduction techniques providing people the ability to test illegally purchased drugs for strength, the presence of particular substances, and possible adulterants. Drug-checking research has primarily focused on nightlife and festival communities of people who use drugs and has overlooked how it functions as a knowledge forming process, particularly by people whose drug use is more stigmatized. The implementation of Fourier-Transform Infrared Spectroscopy (FTIR) in Vancouver, Canada's Downtown Eastside in response to the overdose crisis has made it possible for people who use drugs to receive information about the drugs that they are consuming. Using insights developed from the 'ontological turn' and approaches to co-production from public health and science and technology studies, we explore the multiple relations that come to produce and contest drug-checking knowledge in this setting. We look at how knowledge is produced by and for people who use drugs, including people who use drugs operating the FTIR. Using rapid ethnographic assessment and semi-structured interviews, participants were recruited from a low-barrier supervised injection facility to explore their experience of drug-checking. Data were coded in NVivo 12 using an initial coding scheme, as well as an iterative coding scheme as the data were explored. We find that the traditional demarcation between lay and expert, or peer and professional, which co-production idioms often rely on, creates barriers to seeing the different knowledge formations of drug-checking knowledge, and instead offer up a new idiom, trans-production, to explore how knowledge and harm reduction services are mutually enacted.

"I couldn't live with killing one of my friends or anybody": A rapid ethnographic study of drug sellers' use of drug checking.

INTRODUCTION: Drug sellers are often represented as morally bereft actors and as being, in part, responsible for North America's overdose crisis. In Canada and the United States, drug sellers selling fentanyl and fentanyl-adulterated drugs have been charged with manslaughter when their clients fatally overdose, representing a retrenchment of drug war tactics. However, targeting drug sellers for drug checking interventions may have potential for reducing fentanyl-related harms. This study explores drug sellers' negotiation of and engagement with drug checking technologies in Vancouver, Canada. METHODS: Rapid ethnographic fieldwork was conducted from November 2018 to January 2019, including 26 semi-structured interviews with people who tested their drugs at an overdose prevention site to examine perceptions of the efficacy of drug checking. As drug sellers were also using the drug checking services, we specifically examined their perceptions of drug checking and the market aspects of the overdose crisis. Data were analyzed using Nvivo 12 and interpreted drawing on the concept of structural vulnerability. FINDINGS: Drug sellers accessing drug checking services were concerned about the safety of their customers, and drug checking was one way of reducing the likelihood of harm. Drug sellers were embedded in the community, thereby, enmeshing practices of community care and ethics with the selling of drugs. When they had access to drug checking knowledge, sellers were able to modify risks related to the fentanyl market, including tailoring drugs sold to clients, returning dangerous batches and modifying fentanyl in order to make it safer to consume. CONCLUSIONS: Our findings reposition drug sellers as embedded within their communities and demonstrate their potential role in alleviating the dangers of the volatile fentanyl market. Policies that target people who sell drugs, particularly murder or manslaughter charges, are likely to make the crisis worse, and serious consideration should be put into harm reduction approaches with drug sellers.

Cannabis use is associated with reduced risk of exposure to fentanyl among people on opioid agonist therapy during a community-wide overdose crisis.

BACKGROUND: The ongoing opioid overdose crisis is driven largely by exposure to illicitly-manufactured fentanyl. Preliminary observational and experimental research suggests that cannabis could potentially play a role in reducing use of prescription opioids among individuals with chronic pain. However, there is limited data on the effects of cannabis on illicit opioid consumption, particularly fentanyl, especially among individuals on opioid agonist therapy (OAT). We sought to assess the longitudinal association between cannabis use and exposure to fentanyl among people on OAT. METHODS: Data were drawn from two community-recruited prospective cohorts of people who use drugs in Vancouver, Canada. We used generalized linear mixed-effects modeling, adjusted by relevant confounders, to investigate the relationship between cannabis use and recent fentanyl exposure (both assessed by urine drug testing) among participants on OAT between 2016 and 2018. RESULTS: Among the 819 participants on OAT who contributed 1989 observations over the study period, fentanyl exposure was common. At the baseline interview, fentanyl was detected in a majority of participants (431, 53 %), with lower prevalence among individuals with urine drug tests positive for tetrahydrocannabinol (47 vs. 56 %, p = 0.028). Over all study interviews, cannabis use was independently associated with reduced likelihood of being recently exposed to fentanyl (Adjusted Prevalence Ratio = 0.91, 95 % Confidence Interval: 0.83 - 0.99). CONCLUSIONS: Participants on OAT using cannabis had significantly lower risk of being exposed to fentanyl. Our findings reinforce the need for experimental trials to investigate the potential benefits and risks of controlled cannabinoid administration for people on OAT.

The role of cannabis in pain management among people living with HIV who use drugs: A qualitative study.

INTRODUCTION: People living with HIV who use drugs commonly experience chronic pain and often use illicit opioids to manage pain. Recent research suggests people living with HIV use cannabis for pain relief, including as an adjunct to opioids. This underscores the need to better understand how people living with HIV who use drugs use cannabis for pain management, particularly as cannabis markets are undergoing changes due to cannabis legalisation. METHODS: From September 2018 to April 2019, we conducted in-depth interviews with 25 people living with HIV who use drugs in Vancouver, Canada to examine experiences using cannabis to manage pain. Interviews were audio-recorded, transcribed and coded. Themes were identified using inductive and deductive approaches. RESULTS: Most participants reported that using cannabis for pain management helped improve daily functioning. Some participants turned to cannabis as a supplement or periodic alternative to prescription and illicit drugs (e.g. benzodiazepines, opioids) used to manage pain and related symptoms. Nonetheless, participants' access to legal cannabis was limited and most continued to obtain cannabis from illicit sources, which provided access to cannabis that was free or deemed to be affordable. DISCUSSION AND CONCLUSIONS: Cannabis use may lead to reduced use of prescription and illicit drugs for pain management among some people living with HIV who use drugs. Our findings add to growing calls for additional research on the role of cannabis in pain management and harm reduction, and suggest the need for concrete efforts to ensure equitable access to cannabis.

The emergence of innovative cannabis distribution projects in the downtown eastside of Vancouver, Canada.

The ongoing overdose crisis in the United States and Canada has highlighted the urgent need for innovative interventions to reduce drug-related harms. This, in turn, has led to increased interest in the potential of cannabis as a harm reduction strategy. While Canada has recently legalized cannabis, meaningful barriers to accessing legal cannabis remain for people who use drugs (PWUD) from marginalized communities. In the Downtown Eastside of Vancouver, Canada, innovative, grassroots cannabis distribution programs that dispense cannabis and cannabis products from unregulated sources to PWUD for free have recently emerged. In this study, we draw upon 23 in-depth qualitative interviews and ethnographic fieldwork with PWUD who access these programs. We found that these distribution programs play an important function in bridging access to cannabis for PWUD in a structurally disadvantaged neighborhood and do so by implementing few restrictions on who can access, providing a variety of cannabis products that would otherwise be inaccessible, and distributing cannabis at no cost. In addition, many people reported the program spaces provided an avenue to socialize and connect. Most of our participants reported that legal cannabis was inaccessible both through the legal medical and non-medical systems. Considering Canadian governments have made important regulatory changes in regards to cannabis, understanding emerging patterns and the structural barriers to accessing legal cannabis will be critical to maximizing the potential uses of cannabis as a harm reduction tool and ensuring equitable access to structurally disadvantaged populations. Examining the impact of cannabis use on PWUD and ensuring these groups have access to cannabis is an important component in determining whether cannabis deregulation reduces drug-related harms.

Cannabis legalization in the provinces and territories: missing opportunities to effectively educate youth?

Cannabis is now legal in Canada, yet important questions remain regarding how the provinces and territories are approaching cannabis education and messaging aimed at youth. Although widespread education and awareness campaigns are long considered cornerstones of substance use and related harm prevention, there is limited evidence to support the effectiveness of such campaigns. We continue to see examples of cannabis-related messaging that focus on risk and harm and often adopt a narrow view of the ways in which young people may use cannabis. This traditional risk-based messaging does not resonate with how many youth experience cannabis use. We have further observed that most provinces and territories have yet to fully reveal concrete details regarding what they are and have been planning in terms of youth engagement in the development and delivery of educational initiatives. As Canadian youth desire reliable, evidence-based educational material on cannabis, and can be credible key partners in the development of such materials, we hope that all levels of government will see the value of promoting balanced cannabis discussions and co-designing resources with youth.

A missed opportunity? Cannabis legalization and reparations in Canada.

As Canada moves towards the legalization of cannabis, the Cannabis Act itself remains void of any complementary social justice measures. Decades of criminalization for the possession, production, and sale of cannabis will remain unscathed under this ostensibly new approach, leaving intact laws that have disproportionately and prejudicially impacted Indigenous people and people of colour. This includes the overpolicing and criminalization of these communities, furthering criminal justice disparities, and the lack of meaningful initiatives to aid communities of colour and Indigenous communities in participating in the legal cannabis industry. Despite the continuing impacts, the Government of Canada has made no commitment to tandem initiatives that address the issues of reparation for those who have been most heavily targeted under cannabis prohibition. Public health implications are discussed.