"If it wasn't for them, I don't think I would be here": experiences of the first year of a safer supply program during the dual public health emergencies of COVID-19 and the drug toxicity crisis.

BACKGROUND: In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model. METHODS: This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study. RESULTS: Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability. CONCLUSIONS: Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets.

Substance use care innovations during COVID-19: barriers and facilitators to the provision of safer supply at a toronto COVID-19 isolation and recovery site.

BACKGROUND: Early in the COVID-19 pandemic, there was an urgent need to establish isolation spaces for people experiencing homelessness who were exposed to or had COVID-19. In response, community agencies and the City of Toronto opened COVID-19 isolation and recovery sites (CIRS) in March 2020. We sought to examine the provision of comprehensive substance use services offered to clients on-site to facilitate isolation, particularly the uptake of safer supply prescribing (prescription of pharmaceutical opioids and/or stimulants) as part of a spectrum of comprehensive harm reduction and addiction treatment interventions. METHODS: We conducted in-depth, semi-structured interviews with 25 clients and 25 staff (including peer, harm reduction, nursing and medical team members) from the CIRS in April-July 2021. Iterative and thematic analytic methods were used to identify key themes that emerged in the interview discussions. RESULTS: At the time of implementation of the CIRS, the provision of a safer supply of opioids and stimulants was a novel and somewhat controversial practice. Prescribed safer supply was integrated to address the high risk of overdose among clients needing to isolate due to COVID-19. The impact of responding to on-site overdoses and presence of harm reduction and peer teams helped clinical staff overcome hesitation to prescribing safer supply. Site-specific clinical guidance and substance use specialist consults were crucial tools in building capacity to provide safer supply. Staff members had varied perspectives on what constitutes 'evidence-based' practice in a rapidly changing, crisis situation. CONCLUSION: The urgency involved in intervening during a crisis enabled the adoption of prescribed safer supply, meeting the needs of people who use substances and assisting them to complete isolation periods, while also expanding what constitutes acceptable goals in the care of people who use drugs to include harm reduction approaches.

Association of Illicit Fentanyl Use with Injection Risk Practices Among People who Inject Drugs.

We investigated the association between fentanyl injection frequency and sharing of injection equipment among people who inject drugs. We surveyed 249 people who inject drugs in Toronto in 2019. We estimated predicted probabilities of associations between fentanyl injection frequency and injection risk practices. In prior 6 months, 117 (47.0%) of participants injected fentanyl daily, 49 (19.7%) less than daily, and 78 (31.3%) did not inject fentanyl. Participants who injected fentanyl daily shared syringes more often than those not injecting fentanyl (25.0% vs. 4.9%; χ2 = 11.54, p = 0.0007). Participants who injected fentanyl daily (42.4% vs. 11.3%; χ2 = 18.05, p < 0.0001) and less than daily (37.2% vs. 11.3%; χ2 = 5.88 p = 0.02) shared cookers more often than those not injecting fentanyl. Participants who injected fentanyl daily (30.2% vs. 9.7%; χ2 = 9.05, p = 0.003) and less than daily (30.3% vs. 9.7%; χ2 = 4.11, p = 0.04) shared filters more often than those not injecting fentanyl. No differences in probabilities of sharing equipment were detected between participants who injected fentanyl daily and less than daily. People using fentanyl reported injection practices that increased risk for infectious disease transmission.

Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada.

OBJECTIVES: Fentanyl has contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses in Canada. It has also changed injection practices. Injection frequency has increased as a result and so has equipment sharing and health-related risks. The aim of this analysis was to explore the impact of safer supply programs on injection practices from the perspective of clients and providers in Ontario, Canada. METHODS: The data set included qualitative interviews with 52 clients and 21 providers that were conducted between February and October 2021 across four safer supply programs. Interview excerpts discussing injection practices were extracted, screened, coded and then grouped into themes. RESULTS: We identified three themes, each theme corresponding to a change in injection practices. The first change was a decrease in the amount of fentanyl used and a decrease in injection frequency. The second change involved switching to injecting hydromorphone tablets instead of fentanyl. Finally, the third change was stopping injecting altogether and taking safer supply medications orally. CONCLUSION: Safer supply programs can contribute to reducing injection-related health risks in addition to overdose risks. More specifically, they have the potential to address disease prevention and health promotion gaps that stand-alone downstream harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.

Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario.

BACKGROUND: London InterCommunity Health Centre (LIHC) launched a safer opioid supply (SOS) program in 2016, where clients are prescribed pharmaceutical opioids and provided with comprehensive health and social supports. We sought to evaluate the impact of this program on health services utilization and health care costs. METHODS: We conducted an interrupted time series analysis of London, Ontario, residents who received a diagnosis of opioid use disorder (OUD) and who entered the SOS program between January 2016 and March 2019, and a comparison group of individuals matched on demographic and clinical characteristics who were not exposed to the program. Primary outcomes were emergency department (ED) visits, hospital admissions, admissions for infections and health care costs. We used autoregressive integrated moving average (ARIMA) models to evaluate the impact of SOS initiation and compared outcome rates in the year before and after cohort entry. RESULTS: In the time series analysis, rates of ED visits (-14 visits/100, 95% confidence interval [CI] -26 to -2; p = 0.02), hospital admissions (-5 admissions/100, 95% CI -9 to -2; p = 0.005) and health care costs not related to primary care or outpatient medications (-$922/person, 95% CI -$1577 to -$268; p = 0.008) declined significantly after entry into the SOS program (n = 82), with no significant change in rates of infections (-1.6 infections/100, 95% CI -4.0 to 0.8; p = 0.2). In the year after cohort entry, the rate of ED visits (rate ratio [RR] 0.69, 95% CI 0.53 to 0.90), hospital admissions (RR 0.46, 95% CI 0.29 to 0.74), admissions for incident infections (RR 0.51, 95% CI 0.27 to 0.96) and total health care costs not related to primary care or outpatient medications ($15 635 v. $7310/person-year; p = 0.002) declined significantly among SOS clients compared with the year before. We observed no significant change in any of the primary outcomes among unexposed individuals (n = 303). INTERPRETATION: Although additional research is needed, this preliminary evidence indicates that SOS programs can play an important role in the expansion of treatment and harm-reduction options available to assist people who use drugs and who are at high risk of drug poisoning.

Service utilization patterns and characteristics among clients of integrated supervised consumption sites in Toronto, Canada.

INTRODUCTION: Supervised consumption services (SCS), intended to reduce morbidity and mortality among people who inject drugs, have been implemented in a variety of delivery models. We describe and compare access to and uptake of co-located and external services among clients accessing harm reduction-embedded (HR-embedded) and community health center-embedded (CHC-embedded) SCS models. METHODS: Cross-sectional baseline data were collected between November 2018 and March 2020 as part of a cohort of people who inject drugs in Toronto, Canada designed to evaluate one HR-embedded and two CHC-embedded SCS. This analysis was restricted to clients who reported accessing these SCS more than once in the previous 6 months. Participants were classified as HR-embedded or CHC-embedded SCS clients based on self-reported usage patterns. Client characteristics, as well as access to onsite services and referral and uptake of external services, were compared by SCS model. RESULTS: Among 469 SCS clients, 305 (65.0%) primarily used HR-embedded SCS and 164 (35.0%) primarily used CHC-embedded SCS. Compared to clients accessing CHC-embedded SCS, clients accessing HR-embedded SCS were somewhat younger (37.6 vs. 41.4, p < 0.001), more likely to report fentanyl as their primary injected drug (62.6% vs. 42.7%, p < 0.001), and visited SCS more often (49.5% vs. 25.6% ≥ daily, p < 0.001). HR-embedded SCS clients were more likely to access harm reduction services onsite compared to CHC-embedded SCS clients (94.8% vs. 89.6%, p = 0.04), while CHC-embedded SCS clients were more likely to access non-harm reduction services onsite (57.3% vs. 26.6%, p < 0.001). For external services, HR-embedded SCS clients were more likely to receive a referral (p = 0.03) but less likely to report referral uptake (p = 0.009). CONCLUSIONS: Clients accessing HR-embedded and CHC-embedded SCS were largely demographically similar but had different drug and SCS use patterns, with CHC-embedded SCS clients using the site less frequently. While clients of CHC-embedded SCS reported greater access to ancillary health services onsite, external service use remained moderate overall, underscoring the importance of co-location and support for clients with system navigation. Importantly, lack of capacity in services across the system may impact ability of staff to make referrals and/or the ability of clients to take up a referral.

Responding to Ontario's Overdose Crisis in the Context of the COVID-19 Pandemic.

The COVID-19 pandemic has exacerbated the overdose crisis in Canada. Using data from ICES and the Office of the Chief Coroner of Ontario, the authors characterized changing patterns of medication use and health services utilization during the pandemic. This analysis suggests that responses to the overdose crisis must confront the rapidly changing unregulated drug supply with a tailored response that addresses varied population needs, expands accessible treatment and harm reduction services and responds to the missed opportunities for engagement and support within various healthcare settings.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone.

BACKGROUND: Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees. METHODS: Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used. RESULTS: We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings. CONCLUSION: Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

Practices of care among people who buy, use, and sell drugs in community settings.

BACKGROUND: Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community. METHODS: Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors. RESULTS: Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong. CONCLUSION: Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.

Ambivalence about supervised injection facilities among community stakeholders.

BACKGROUND: Community stakeholders express a range of opinions about supervised injection facilities (SIFs). We sought to identify reasons for ambivalence about SIFs amongst community stakeholders in two Canadian cities. FINDINGS: We used purposive sampling methods to recruit various stakeholder representatives (n = 141) for key informant interviews or focus group discussions. Data were analyzed using a thematic process. We identified seven reasons for ambivalence about SIFs: lack of personal knowledge of evidence about SIFs; concern that SIF goals are too narrow and the need for a comprehensive response to drug use; uncertainty that the community drug problem is large enough to warrant a SIF(s); the need to know more about the "right" places to locate a SIF(s) to avoid damaging communities or businesses; worry that a SIF(s) will renew problems that existed prior to gentrification; concern that resources for drug use prevention and treatment efforts will be diverted to pay for a SIF(s); and concern that SIF implementation must include evaluation, community consultation, and an explicit commitment to discontinue a SIF(s) in the event of adverse outcomes. CONCLUSIONS: Stakeholders desire evidence about potential SIF impacts relevant to local contexts and that addresses perceived potential harms. Stakeholders would also like to see SIFs situated within a comprehensive response to drug use. Future research should determine the relative importance of these concerns and optimal approaches to address them to help guide decision-making about SIFs.

Initiation Stories: An Examination of the Narratives of People Who Assist With a First Injection.

BACKGROUND: Research in the area of initiation to injection drug use that focuses on the perspective of initiators, or those who help with a first injection, is rare. OBJECTIVE: To explore the process of initiation to injection drug use from the point of view of initiators. METHODS: Semi-structured, in-depth qualitative interviews were conducted at a harm reduction program in Toronto, Canada. Twenty participants who had injected drugs in the last 30 days and who reported ever having initiated another person to injection drug use were recruited. A narrative analytic approach was used to explore the spectrum of narratives surrounding their experiences initiating others to injection drug use. RESULTS: Initiation events arise in a complex interplay of individual circumstances and social contexts. People who inject may assist with a first injection for a variety of reasons, from conceding to social pressure, to wanting to help reduce a perceived risk of harm, to assisting because it provides a sense of pride at possessing a skill or of having helped someone achieve a desired state, to assisting to obtain drugs or to cope with withdrawal, or a mix of several of these reasons at once. CONCLUSIONS/IMPORTANCE: Narratives reveal that preventing all instances of initiation is unrealistic. Combining elements from existing interventions that focus on enhancing reluctance to assist with initiation with safer injection training has the potential to reduce initiations and perhaps reduce injection related harm for novices if initiation occurs.

Transition to injection drug use: the role of initiators.

Data are limited about the role of initiators in the transition to injection drug use. We examined the prevalence and predictors of giving someone their first injection using baseline data from a study involving 98 injection drug users (IDUs) in Toronto, Canada. Participants were recruited in 2011 using respondent-driven sampling. Findings revealed that 27.4 % (95 % CI 14.7-42.2) of IDUs had ever given anyone their first injection. In the logistic regression analysis, being unemployed and having ever spoken positively about injecting to a non-injector were associated with giving someone their first injection. Furthermore, the odds of initiating non-IDUs increased with the number of years that IDUs had been injecting. Our results provide support for interventions that aim to reduce the initiation of non-IDUs; however, further research is needed to shed light on the link between unemployment and initiation of non-injectors.

Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada.

The ongoing overdose and drug toxicity crisis in North America has contributed momentum to the emergence of safer supply prescribing and programs in Canada as a means of providing an alternative to the highly volatile unregulated drug supply. The implementation and scale-up of safer supply have been met with a vocal reaction on the part of news media commentators, conservative politicians, recovery industry representatives, and some prominent addiction medicine physicians. This reaction has largely converged around several narratives, based on unsubstantiated claims and anecdotal evidence, alleging that safer supply programs are generating a "new opioid epidemic", reflecting an emerging alignment among key institutional and political actors. Employing situational analysis method, and drawing on the policy studies and social science scholarship on moral panics, this essay examines news media coverage from January to July 2023, bringing this into dialogue with other existing empirical sources on safer supply (e.g. Coroner's reports, program evaluations, debates among experts in medical journals). We employ eight previously established criteria delineating moral panics to critically appraise public dialogue regarding safer supply, diverted medication, and claims of increased youth initiation to drug use and youth overdose. In detailing the emergence of a moral panic regarding safer supply, we trace historic continuities with earlier drug scares in Canadian history mobilized as tools of racialized poverty governance, as well as previous backlashes towards healthcare interventions for people who use drugs (PWUD). The essay assesses the claims of moral entrepreneurs against the current landscape of opioid use, diversion, and overdose among youth, notes the key role played by medical expertise in this and previous moral panics, and identifies what the convergence of these narratives materialize for PWUD and healthcare access, as well as the broader policy responses such narratives activate.

Prescribed safer opioid supply: A scoping review of the evidence.

BACKGROUND: Safer opioid supply programs provide prescription pharmaceutical opioids, often with supportive services, to people at high risk of experiencing harms related to substance use. However, questions regarding the effectiveness and safety of this practice remain. We conducted a scoping review of literature describing client outcomes from formal opioid supply programs providing prescriptions for pharmaceutical opioids, and the perceptions of involved clients/providers. METHODS: We performed a scoping review of peer-reviewed studies and grey literature published between January 1, 2012, to September 12, 2023. We included articles reporting either safer opioid supply client outcomes or clients/providers perspectives. Extracted data included study objectives, substance use patterns, client outcomes, client/provider perspectives, and estimates of effectiveness and/or harm. RESULTS: Our search yielded 1,597 articles. Following removal of duplicates and application of exclusion criteria, 24 publications comprising 17 peer-reviewed and seven grey literature publications were included in our study. We generated eight themes summarizing topics in the available literature: opioid-related toxicities, infectious complications, other clinical outcomes, client-reported outcomes, program access barriers, diversion, program retention, and costs to the healthcare system. Specific findings included low rates of opioid toxicities, improved physical and mental health, and improved quality of life among clients. A lack of access to adequate opioid doses and the limited range of opioid options offered within safer opioid supply programs was described by clients and providers as a potential reason for diversion and a barrier to program access. CONCLUSIONS: Generally, evidence suggests that safer opioid supply programs are beneficial to clients through measurable outcomes. However, the available literature has important limitations, including limited inferences about the effectiveness, safety, and potential for diversion within safer opioid supply programs. Further research is needed to support the ongoing evaluation of safer opioid supply programs as one component of a multifactorial response to escalating rates of substance-related harms.

Characteristics, treatment patterns and retention with extended-release subcutaneous buprenorphine for opioid use disorder: A population-based cohort study in Ontario, Canada.

BACKGROUND: Uptake and retention for opioid agonist treatment (OAT) remains low. Novel extended-release formulations may improve OAT accessibility by reducing the frequency of healthcare visits. Our aim was to examine uptake, characteristics, treatment patterns and retention of individuals initiating extended-release subcutaneous buprenorphine (BUP-ER), a monthly injectable OAT. METHODS: We conducted a population-based cohort study among adults aged 18+ initiated on BUP-ER between February 3, 2020 and March 31, 2022 in Ontario, Canada. Using administrative health data, we defined continuous BUP-ER use based on repeat injections within a 56-day period and used Kaplan-Meier curves to estimate time on treatment. Among new BUP-ER recipients, we described individual and prescriber characteristics, healthcare utilization and treatment patterns. RESULTS: 2366 individuals initiated BUP-ER. The median time to BUP-ER discontinuation was 183 days (interquartile range: 66-428 days) and 52.0% of individuals were co-prescribed buprenorphine/naloxone at least once throughout the period of BUP-ER receipt. Among individuals who initiated on a dose of 300mg BUP-ER and had three or more injections, 18.8% continued to receive only 300mg doses (N=276 of 1470). Furthermore, 28.6% of those whose dose was reduced to 100mg (N=341 of 1194) had a subsequent dose increase to 300mg. CONCLUSIONS: On average, people initiating BUP-ER discontinue within the first 6 months of treatment. While BUP-ER is likely providing an important OAT option, the high occurrence of discontinuation, supplementation with buprenorphine/naloxone, and frequent dose increases suggest inadequacy of current dosing recommendations among a proportion of individuals.

"Everybody is impacted. Everybody's hurting": Grief, loss and the emotional impacts of overdose on harm reduction workers.

BACKGROUND: The emotional impacts of witnessing and responding to overdose and overdose-related deaths have been largely overlooked during the drug toxicity overdose crisis in North America. Scarce research has analyzed these impacts on the health and well-being of harm reduction workers, and the broader determinants of harm reduction work. Our study investigates the experiences and impacts of witnessing and responding to frequent and escalating rates of overdose on harm reduction workers in Toronto, Canada. METHODS: Using semi-structured interviews, 11 harm reduction workers recruited from harm reduction programs with supervised consumption services in Toronto, Canada, explored experiences with and reactions to overdose in both their professional and personal lives. They also provided insights on supports necessary to help people cope with overdose-related loss. We used thematic analysis to develop an initial coding framework, subsequent iterations of codes and emergent themes. RESULTS: Results revealed that harm reductions workers experienced physical, emotional, and social effects from overdose-related loss and grief. While some effects were due to the toll of overdose response and grief from overdose-related losses, they were exacerbated by the lack of political response to the scale of the drug toxicity overdose crisis and the broader socio-economic-political environment of chronic underfunding for harm reduction services. Harm reduction workers described the lack of appropriate workplace supports for trauma from repeated overdose response and overdose-related loss, alongside non-standard work arrangements that resulted in a lack of adequate compensation or access to benefits. CONCLUSIONS: Our study highlights opportunities for organizational practices that better support harm reduction workers, including formal emotional supports and community-based supportive care services. Improvement to the socio-economic-political determinants of work such as adequate compensation and access to full benefit packages are also needed in the harm reduction sector for all workers.

Characteristics of Opioid Toxicity Deaths Among Adolescents and Young Adults in Ontario Prior To and During the COVID-19 Pandemic.

PURPOSE: To characterize opioid toxicity deaths among adolescents and young adults in Ontario, Canada, prior to and during the first year of the COVID-19 pandemic. METHODS: We conducted a descriptive, cross-sectional study of opioid toxicity deaths among individuals aged 15-24 in Ontario in the year prior to (March 17, 2019, to March 16, 2020) and the first year of the pandemic (March 17, 2020, to March 16, 2021) using administrative health databases. We analyzed circumstances surrounding death, substances contributing to death, and health-care encounters prior to death. RESULTS: We identified 284 deaths among Ontarians aged 15-24, including 115 in the year preceding and 169 in the first year of the pandemic. Fentanyl contributed to 84.3% of deaths in the prepandemic year, rising to 93.5% (p = .012) the following year. Stimulants contributed to approximately half of deaths in both periods (41.7% prepandemic and 49.1% during pandemic). In both periods, roughly one in 4 decedents had a health-care encounter in the week prior to death and less than 20% of those with an opioid use disorder received opioid agonist treatment in the 30 days prior to death. DISCUSSION: Among young Ontarians, the number of opioid-related deaths increased by 47% in the first year of the COVID-19 pandemic. Fentanyl contributed to the vast majority of deaths, with non-opioid substances (primarily stimulants) also contributing to approximately half of deaths. Patterns of health-care utilization prior to death suggest opportunities to better connect this population to services that address opioid use disorder needs and promote harm reduction.

Trends in Rates of Opioid Agonist Treatment and Opioid-Related Deaths for Youths in Ontario, Canada, 2013-2021.

Importance: Data suggest that the opioid crisis in North America has recently been reflected in opioid-related mortality among youths. Despite recommendation for its use, youths encounter barriers to accessing OAT, including stigma, burden of witnessed dosing, and lack of availability of youth-oriented services and prescribers comfortable treating this population. Objective: To compare rates of opioid agonist treatment (OAT) and opioid-related mortality between youths aged 15 to 24 years and adults aged 25 to 44 years in Ontario, Canada, over time. Design, Setting, and Participants: This cross-sectional analysis of rates of OAT and opioid-related deaths between 2013 and 2021 used data obtained from the Ontario Drug Policy Research Network, Public Health Ontario, and Statistics Canada. Individuals included in the analysis were aged 15 to 44 years and residing in Ontario, the most populous province in Canada. Exposures: Youths aged 15 to 24 years compared with adults aged 25 to 44 years. Main Outcomes and Measures: OAT (methadone, buprenorphine, and slow-release oral morphine) per 1000 population and opioid-related deaths per 100 000 population. Results: Between 2013 and 2021, 1021 youths aged 15 to 24 years died from opioid toxicity; 710 were male (69.5%). In the final year of the study period, 225 youths (146 male [64.9%]) died from opioid toxicity, and 2717 (1494 male [55.0%]) were dispensed OAT. Over the study period, the rate of opioid-related deaths among youths in Ontario increased 369.2% from 2.6 to 12.2 per 100 000 population (48 to 225 total deaths) and the rate of OAT use decreased 55.9% from 3.4 to 1.5 per 1000 (6236 to 2717 individuals). For adults aged 25 to 44 years, the rate of opioid-related deaths increased 371.8% from 7.8 to 36.8 per 100 000 (283 to 1502 deaths), and the rate of OAT increased 27.8% from 7.9 to 10.1 per 1000 population (28 667 to 41 200 individuals). Trends for youths and adults persisted across both sexes. Conclusions and Relevance: The findings of this study suggest that opioid-related deaths are increasing among youths while OAT use is paradoxically declining. The reasons for these observed trends require further investigation, including a consideration of changing trends in opioid use and opioid use disorder among youths, barriers to OAT, and opportunities to optimize care and reduce harms for youths who use substances.

Trends in varying modes of drug use in opioid toxicity deaths in Ontario from 2017 to 2021.

BACKGROUND: Preliminary data indicate a shift toward inhalation instead of injection in opioid toxicity deaths. Understanding changing modes of drug use is essential to addressing the North American drug toxicity crisis driven primarily by unregulated fentanyl. This study aims to comprehensively characterize this shift across Ontario, Canada. METHODS: We conducted a population-based repeated cross-sectional study of accidental opioid toxicity deaths in Ontario from July 1, 2017 to June 30, 2021. For each quarter of the study period, the number and percent of deaths by mode of drug use (inhalation only, injection only, both or other) were reported. Descriptive characteristics were reported in the last two years of the study. RESULTS: There were 6687 accidental opioid toxicity deaths in Ontario over the study period, with a 62.1 % increase in the quarterly number of deaths observed. The prevalence of deaths where inhalation was the only mode of drug use almost doubled, rising from 22.0 % to 43.5 %. There was a corresponding 64.4 % decrease in opioid toxicity deaths with indication of injection alone (29.0 % to 10.3 %). CONCLUSIONS: This study reveals a shift in mode of drug use toward inhalation that is increasingly contributing to opioid toxicity deaths in Ontario. Understanding the shifts in patterns of opioid use serves to provide essential insights into more effective harm reduction and treatment approaches to address the drug toxicity crisis.

Disease-related stigma among people who inject drugs in Toronto amidst the COVID-19 pandemic.

Background: Stigma overwhelmingly affects people who inject drugs. The COVID-19 pandemic posed unique challenges for people who inject drugs, who are already stigmatized as being "dangerous and spreading disease." The present study explored ways in which stigma was experienced by a sample of people who inject drugs in Toronto, Canada following COVID-related public health precaution measures. Methods: Qualitative interviews were conducted with people who inject drugs (n = 24) recruited from supervised consumption sites in Toronto, Canada. The semi-structured interview guide focused on the impact of COVID-19 on participants' health and social well-being. Interviews took place six-months after initial COVID-19 precautions (September-October 2020). We used thematic analysis to examine findings, with stigma being an emergent theme. Results: Participants described heightened acts of stigma after COVID-19 restrictions were implemented, including feeling treated as "diseased" and the cause of COVID-19's spread. They reported being less likely to receive emergency care during events such as overdoses. Participants perceived increased disease-related stigma evident through actions of stigma, including amplified dehumanization by the public, others avoiding all contact with them, and more discrimination by police and hospital systems. Conclusion: Participants provided specific examples of how stigmatizing behaviors harmed them after COVID-19 precautions began. It is plausible that stigma contributed to the dramatic increase in fatal overdoses, difficulty accessing housing, and further difficulty accessing needed healthcare in our setting. Integrating evidence-based harm reduction approaches in areas where stigma is evident might offset harms stemming from disease-related stigma and mitigate these harms during future public health emergencies.