Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study.

BACKGROUND: In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges. METHODS: We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research. RESULTS: While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants' emphasis that knowing the composition of one's drugs is a "right to know", particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men. CONCLUSIONS: The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada.

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Responding to changes in the unregulated drug supply: the need for a dynamic approach to drug checking technologies.

Drug checking services provide individuals who use drugs with the ability to test samples of their drugs for the presence of highly potent substances. However, there has been recent concern about whether the existing repertoire of point-of-care drug checking technologies, such as immunoassay strips and Fourier-transform infrared spectroscopy (FTIR), are adequate in identifying substances in the unregulated drug supply. Carfentanil and nitazene opioids, substances that are even more potent than fentanyl in vitro, have been found in the unregulated supply in North America and pose a challenge to our existing drug checking strategy. For example, etizolam has recently permeated the unregulated drug supply in North America, and has demonstrated the ability to evade point-of-care drug checking technologies. In response to the incessantly changing nature of the unregulated supply, we argue that drug checking technologies and service delivery models must continuously adapt alongside constantly changing drug markets. We provide two examples of emerging technologies, paper spray-mass spectrometry and surface-enhanced Raman spectroscopy, which address many of the shortcomings of existing technologies. For both technologies, we discuss their feasibility, where they can be offered, their advantages, and how they address gaps in our existing technologies. We contend that these technologies, and other emerging technologies, can be integrated into a future approach to drug checking that flexibly uses different technologies and service delivery methods to adapt to changes in the drug supply.

Discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain with and without opioid use disorder in British Columbia, Canada: A retrospective cohort study.

BACKGROUND: The overdose crisis in North America has prompted system-level efforts to restrict opioid prescribing for chronic pain. However, little is known about how discontinuing or tapering prescribed opioids for chronic pain shapes overdose risk, including possible differential effects among people with and without concurrent opioid use disorder (OUD). We examined associations between discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain, stratified by diagnosed OUD and prescribed opioid agonist therapy (OAT) status. METHODS AND FINDINGS: For this retrospective cohort study, we used a 20% random sample of residents in the provincial health insurance client roster in British Columbia (BC), Canada, contained in the BC Provincial Overdose Cohort. The study sample included persons aged 14 to 74 years on long-term opioid therapy for pain (≥90 days with ≥90% of days on therapy) between October 2014 and June 2018 (n = 14,037). At baseline, 7,256 (51.7%) persons were female, the median age was 55 years (quartile 1-3: 47-63), 227 (1.6%) persons had been diagnosed with OUD (in the past 3 years) and recently (i.e., in the past 90 days) been prescribed OAT, and 483 (3.4%) had been diagnosed with OUD but not recently prescribed OAT. The median follow-up duration per person was 3.7 years (quartile 1-3: 2.6-4.0). Marginal structural Cox regression with inverse probability of treatment weighting (IPTW) was used to estimate the effect of prescribed opioid treatment for pain status (discontinuation versus tapered therapy versus continued therapy [reference]) on risk of overdose (fatal or nonfatal), stratified by the following groups: people without diagnosed OUD, people with diagnosed OUD receiving OAT, and people with diagnosed OUD not receiving OAT. In marginal structural models with IPTW adjusted for a range of demographic, prescription, comorbidity, and social-structural exposures, discontinuing opioids (i.e., ≥7-day gap[s] in therapy) was associated with increased overdose risk among people without OUD (adjusted hazard ratio [AHR] = 1.44; 95% confidence interval [CI] 1.12, 1.83; p = 0.004), people with OUD not receiving OAT (AHR = 3.18; 95% CI 1.87, 5.40; p < 0.001), and people with OUD receiving OAT (AHR = 2.52; 95% CI 1.68, 3.78; p < 0.001). Opioid tapering (i.e., ≥2 sequential decreases of ≥5% in average daily morphine milligram equivalents) was associated with decreased overdose risk among people with OUD not receiving OAT (AHR = 0.31; 95% CI 0.14, 0.67; p = 0.003). The main study limitations are that the outcome measure did not capture overdose events that did not result in a healthcare encounter or death, medication dispensation may not reflect medication adherence, residual confounding may have influenced findings, and findings may not be generalizable to persons on opioid therapy in other settings. CONCLUSIONS: Discontinuing prescribed opioids was associated with increased overdose risk, particularly among people with OUD. Prescribed opioid tapering was associated with reduced overdose risk among people with OUD not receiving OAT. These findings highlight the need to avoid abrupt discontinuation of opioids for pain. Enhanced guidance is needed to support prescribers in implementing opioid therapy tapering strategies with consideration of OUD and OAT status.

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.

The prevalence and social-structural correlates of housing status among women living with HIV in Vancouver, Canada.

BACKGROUND: Women living with HIV (WLWH) experience numerous social and structural barriers to stable housing, with substantial implications for access to health care services. This study is the first to apply the Canadian Definition of Homelessness (CDOH), an inclusive national guideline, to investigate the prevalence and correlates of housing status among WLWH in Metro Vancouver, Canada. METHODS: Our study utilized data from a longitudinal open cohort of cisgender and trans WLWH aged 14 years and older, in 2010-2019. Cross-sectional descriptive statistics of the prevalence of housing status and other social and structural variables were summarized for the baseline visits. Bivariate and multivariable logistic regression analyses were conducted using generalized linear mixed models (GLMM) for repeated measures to investigate the relationship between social and structural correlates and housing status among WLWH. RESULTS: The study included 336 participants with 1930 observations over 9 years. Housing status derived from CDOH included four categories: unsheltered, unstable, supportive housing, and stable housing (reference). Evidence suggested high levels of precarious housing, with 24% of participants reporting being unsheltered, 47% reporting unstable housing, 11.9% reporting supportive housing, and 16.4% reporting stable housing in the last six months at baseline. According to the multivariable models, living in the Downtown Eastside (DTES) neighbourhood of Metro Vancouver, hospitalization, physical/sexual violence, and stimulant use were associated with being unsheltered, compared to stable housing; DTES residence, hospitalization, and physical/sexual violence were associated with unstable housing; DTES residence and stimulant use were associated with living in supportive housing. CONCLUSION: Complex social-structural inequities are associated with housing instability among WLWH. In addition to meeting basic needs for living, to facilitate access to housing among WLWH, housing options that are gender-responsive and gender-inclusive and include trauma- and violence-informed principles, low-barrier requirements, and strong connections with supportive harm reduction services are critical.

Improving opioid stewardship programs through shared decision-making.

Opioid stewardship has emerged as an innovative systems-level approach designed to reduce inappropriate opioid prescriptions and improve patient safety in acute care settings. Modeled on the successes of antimicrobial stewardship programs, key distinctions exist; in particular, the inherent subjectivity of managing acute pain is an important consideration of opioid stewardship that differentiates it with the more objective features of antibiotic selection. Shared decision-making, with pharmacists playing a central role, is regarded as an integral part of patient care and plays a vital role in managing pain. We describe important attributes of opioid stewardship and highlight the value of incorporating shared decision-making into these novel programs.

"I want to get better, but ": identifying the perceptions and experiences of people who inject drugs with respect to evolving hepatitis C virus treatments.

BACKGROUND: The advent of highly tolerable and efficacious direct-acting antiviral (DAA) medications has transformed the hepatitis C virus (HCV) treatment landscape. Yet, people who inject drugs (PWID) - a population with inequitably high rates of HCV and who face significant socio-structural barriers to healthcare access - continue to have disproportionately low rates of DAA uptake. The objective of this study is to explore how PWID with lived experience of HCV perceive and experience DAA treatment, in a setting with universal coverage of these medications since 2018. METHODS: Informed by a critical interpretive framework, we thematically analyze data from in-depth, semi-structured interviews conducted between January and June 2018 in Vancouver, Canada, with a purposive sample (n = 56) of PWID at various stages (e.g., pre, peri, post) of DAA treatment. RESULTS: The analysis yielded three key themes: (i) life with HCV, (ii) experiences with and perceptions of evolving HCV treatments, and (iii) substance use and the uptake of DAA treatments. First, participants described how health and healthcare conditions, such as the deprioritizing of HCV (e.g., due to: being asymptomatic, healthcare provider inaction, gatekeeping) and catalysts to care (e.g., symptom onset, treatment for co-morbidities) shaped DAA treatment motivation and access. Second, participants described how individual and community-level accounts of evolving HCV treatments, including skepticism following negative experiences with Interferon-based treatment and uncertainty regarding treatment eligibility, negatively influenced willingness and opportunities to access DAAs. Concurrently, participants described how peer and community endorsement of DAAs was positively associated with treatment uptake. Third, participants favoured HCV care that was grounded in harm reduction, which included the integration of DAAs with other substance use-related services (e.g., opioid agonist therapy, HIV care), and which was often contrasted against abstinence-focused care wherein substance use is framed as a contraindication to HCV treatment access. CONCLUSIONS: These findings underscore several equity-oriented healthcare service delivery and clinician adaptations that are required to scale up DAAs among PWID living with HCV, including the provision of harm reduction-focused, non-stigmatizing, integrated, and peer-led care that responds to power differentials.

Artificial intelligence interventions focused on opioid use disorders: A review of the gray literature.

BACKGROUND: With the artificial intelligence (AI) paradigm shift comes momentum toward the development and scale-up of novel AI interventions to aid in opioid use disorder (OUD) care, in the identification of overdose risk, and in the reversal of overdose. OBJECTIVE: As OUD-specific AI interventions are relatively recent, dynamic, and may not yet be captured in the peer-reviewed literature, we conducted a review of the gray literature to identify literature pertaining to OUD-specific AI interventions being developed, implemented and evaluated. METHODS: Gray literature databases, customized Google searches, and targeted websites were searched from January 2013 to October 2019. Search terms include: AI, machine learning, substance use disorder (SUD), and OUD. We also requested recommendations for relevant material from experts in this area. RESULTS: This review yielded a total of 70 unique citations and 29 unique interventions, which can be sub-divided into five categories: smartphone applications (n = 12); healthcare data-related interventions (n = 7); biosensor-related interventions (n = 5); digital and virtual-related interventions (n = 2); and 'other', i.e., those that cannot be classified in these categories (n = 3). While the majority have not undergone rigorous scientific evaluation via randomized controlled trials, several AI interventions showed promise in aiding the identification of escalating opioid use patterns, informing the treatment of OUD, and detecting opioid-induced respiratory depression. CONCLUSION: This is the first gray literature synthesis to characterize the current 'landscape' of OUD-specific AI interventions. Future research should continue to assess the usability, utility, acceptability and efficacy of these interventions, in addition to the overall legal, ethical, and social implications of OUD-specific AI interventions.

Is expected substance type associated with timing of drug checking service utilization?: A cross-sectional study.

BACKGROUND: Drug checking is a harm reduction intervention aiming to reduce substance use-related risks by improving drug user knowledge of the composition of unregulated drugs. With increasing fears of fentanyl adulteration in unregulated drugs, this study sought to examine whether the expected type of drug checked (stimulant vs. opioid) was associated with timing of drug checking service utilization (pre-consumption vs. post-consumption). METHODS: Data were derived from drug checking sites in British Columbia between October 31, 2017 and December 31, 2019. Pearson's Chi-square test was used to examine the relationship between expected sample type (stimulant vs. opioid) and timing of service utilization. Odds ratios (OR) were calculated to assess the strength of this relationship. The Mantel-Haenszel (MH) test was used to adjust for service location. RESULTS: A total of 3561 unique stimulant and opioid samples were eligible for inclusion, including 691 (19.40%) stimulant samples; and 2222 (62.40%) samples that were tested pre-consumption. Results indicated a positive association between testing stimulant samples and testing pre-consumption (OR = 1.45; 95% CI 1.21-1.73). Regions outside of the epicenter of the province's drug scene showed a stronger association with testing pre-consumption (ORMH = 2.33; 95% CI 1.51-3.56) than inside the epicenter (ORMH = 1.33; 95% CI 1.09-1.63). CONCLUSION: Stimulant samples were more likely to be checked pre-consumption as compared with opioid samples, and stimulant samples were more likely to be tested pre-consumption in regions outside the epicenter of the province's drug scene. This pattern may reflect a concern for fentanyl-adulterated stimulant drugs.

Migration Patterns from an Open Illicit Drug Scene and Emergency Department Visits among People Who Use Illicit Drugs in Vancouver, Canada.

BACKGROUND: People who use illicit drugs (PWUD) experience various adverse health outcomes leading to increased healthcare service utilization. PWUD are also a highly mobile population which poses challenges to healthcare delivery. The objective of this study was to identify migration patterns from the Downtown Eastside (DTES), an urban illicit drug scene in Vancouver and to estimate the impact of different migration patterns on two outcomes: a) emergency department (ED) visits and b) ED visits resulting in inpatient admission among PWUD. METHODS: Three prospective cohorts of PWUD in Vancouver were linked with regional ED data. We defined the optimal number of trajectory groups that best represented distinct patterns of migration from Vancouver's DTES using a latent class growth analysis. Then, generalized estimating equations were used to estimate the effect of migration patterns on the two ED outcomes. RESULTS: Four distinct migration trajectory patterns were identified among the 1210 included participants: PWUD who consistently lived in the DTES, those who migrated out of DTES early, those who migrated out of DTES late, and those who frequently revisited the DTES. Participants who frequently revisited the DTES had higher odds of an ED visit (adjusted odds ratio = 1.62; 95% confidence interval: 1.28-2.06). There was no significant association between migration patterns and inpatient admission. CONCLUSIONS: We found that PWUD who frequently revisited the DTES were more likely to have utilized the ED, suggesting that there may be a subgroup of PWUD who are at increased risk of experiencing negative health outcomes.Supplemental data for this article is available online at 10.1080/10826084.2021.1958849.

The utility of visual appearance in predicting the composition of street opioids.

Background: With the emergence of unregulated fentanyl, people who use unregulated opioids are increasingly relying on appearance in an effort to ascertain the presence of fentanyl and level of drug potency. However, the utility of visual inspection to identify drug composition in the fentanyl era has not been assessed. Methods: We assessed client expectation, appearance, and composition of street drug samples being presented for drug checking. Results of a visual screening test were compared to fentanyl immunoassay strip testing. We calculated sensitivity, specificity and likelihood ratios (LR) to assess the accuracy of the common assumption that samples with a "pebbles" appearance contain fentanyl. Results: In total, of the 2502 unregulated opioid samples tested, 1820 (73.5%) appeared as "pebbles", of which 1729 (95.0%) tested positive for fentanyl for a sensitivity of 75.9% (95% Confidence Interval [CI]: 74.2-77.6) and specificity of 59.4% (95%CI: 57.5-61.3). Although, the odds of samples containing fentanyl was 4.60 (95%CI: 3.47-6.11) times higher among pebbles samples compared to non-pebble samples, the positive LR for pebbles to contain fentanyl was only 1.87 (CI: 1.59-2.19). The negative LR was more useful at 0.41 (95% CI: 0.36-0.46). Conclusions: A positive screening test for pebbles is not strongly enough associated to be used as a proxy for detecting fentanyl. While the absence of the appearance of pebbles does somewhat reduce the likelihood of fentanyl being present in a given sample, the high prevalence of fentanyl and fentanyl analogues in the drug supply and the risks of consumption are such that public health providers should routinely advise people who use unregulated opioids against solely relying on visual characteristics of drugs as a harm reduction strategy.

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal.

STUDY OBJECTIVE: Alcohol withdrawal is a common emergency department (ED) presentation. Although benzodiazepines reduce symptoms of withdrawal, there is little ED-based evidence to assist clinicians in selecting appropriate pharmacotherapy. We compare lorazepam with diazepam for the management of alcohol withdrawal to assess 1-week ED and hospital-related outcomes. METHODS: From January 1, 2015, to December 31, 2018, at 3 urban EDs in Vancouver, Canada, we studied patients with a discharge diagnosis of alcohol withdrawal. We excluded individuals presenting with a seizure or an acute concurrent illness. We performed a structured chart review to ascertain demographics, ED treatments, and outcomes. Patients were stratified according to initial management with lorazepam versus diazepam. The primary outcome was hospital admission, and secondary outcomes included in-ED seizures and 1-week return visits for discharged patients. RESULTS: Of 1,055 patients who presented with acute alcohol withdrawal, 898 were treated with benzodiazepines. Median age was 47 years (interquartile range 37 to 56 years) and 73% were men. Baseline characteristics were similar in the 2 groups. Overall, 69 of 394 patients (17.5%) receiving lorazepam were admitted to the hospital compared with 94 of 504 patients receiving diazepam (18.7%), a difference of 1.2% (95% confidence interval -4.2% to 6.3%). Seven patients (0.7%; 95% confidence interval 0.3% to 1.4%) had an in-ED seizure, but all seizures occurred before receipt of benzodiazepines. Among patients discharged home, 1-week return visits occurred for 78 of 325 (24.0%) who received lorazepam and 94 of 410 (23.2%) who received diazepam, a difference of 0.8% (95% confidence interval -5.3% to 7.1%). CONCLUSION: In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam. The few in-ED seizures occurred before medication administration. For discharged patients, the 1-week ED return visit rate of nearly 25% could warrant enhanced follow-up and community support.

Effect of witnessing an overdose on the use of drug checking services among people who use illicit drugs in Vancouver, Canada.

BACKGROUND: Since 2013, fentanyl-contaminated drugs have been driving North America's opioid-overdose epidemic. Drug checking, which enables people who use illicit drugs (PWUD) to test and receive feedback regarding the contents of their drugs, is being considered as a potential tool to address the toxic drug supply. While some PWUD witness overdoses, little is known about the impact of these experiences on subsequent risk reduction practices. OBJECTIVE: The purpose of this study was to examine the effect of witnessing an overdose on drug checking service use. METHODS: Data were derived from prospective cohorts of PWUD in Vancouver, Canada, a setting with a community-wide fentanyl overdose crisis, between June 1, 2018 and December 1, 2018. Multivariable logistic regression was used to estimate the effect of witnessing an overdose on drug checking service use. RESULTS: 1,426 participants were eligible for the study, including 530 females; 767 (53.8%) participants reported witnessing an overdose and 196 (13.7%) reported using drug checking services in the last 6 months. In multivariable analyses, after adjusting for a range of confounders including the use of fentanyl, witnessing an overdose was positively associated with drug checking service use (adjusted odds ratio = 2.32; 95% confidence interval: 1.57-3.49). CONCLUSION: Our findings suggest that witnessing an overdose may motivate PWUD to use drug checking services. Given that only a small proportion of PWUD in the study reported using drug checking services, our findings highlight the need to continue to scale-up a range of overdose prevention interventions.

Factors associated with drug checking service utilization among people who use drugs in a Canadian setting.

BACKGROUND: The United States and Canada are amidst an opioid overdose crisis, with the Canadian province of British Columbia (BC) among the hardest hit. In response, drug checking services (DCS) have been introduced in this setting as a novel pilot harm reduction intervention though little is known about usage rates. Therefore, we sought to identify factors associated with drug checking uptake among people who use drugs (PWUD) in Vancouver, BC. METHODS: Data were derived from three ongoing prospective cohort studies of PWUD in Vancouver between June and November 2018. Multivariable logistic regression was used to determine factors associated with self-reported DCS utilization in the past 6 months among participants at high risk of fentanyl exposure (i.e., those self-reporting illicit opioid use or testing positive for fentanyl via urine drug screen). RESULTS: Among 828 eligible participants, including 451 (55%) males, 176 (21%) reported recent use of DCS. In multivariable analyses, factors significantly associated with DCS utilization included: homelessness (Adjusted Odds Ratio [AOR] 1.47; 95% Confidence Interval [CI] 1.01-2.13) and involvement in drug dealing (AOR 1.59; 95% CI 1.05-2.39). CONCLUSIONS: In our sample of PWUD, uptake of DCS was low, although those who were homeless, a sub-population known to be at a heightened risk of overdose, were more likely to use the services. Those involved in drug dealing were also more likely to use the services, which may imply potential for improving drug market safety. Further evaluation of drug checking is warranted.

Disparities in uptake of direct-acting antiviral therapy for hepatitis C among people who inject drugs in a Canadian setting.

BACKGROUND & AIMS: Despite the high burden of hepatitis C virus (HCV) infection among people who inject drugs (PWID), uptake of interferon-based therapies has been extremely low. Increasing availability of direct-acting antiviral (DAA)-based therapies offers the possibility of rapid treatment expansion with the goal of controlling the HCV epidemic. We evaluated DAA-based treatment uptake among HCV-positive PWID in Vancouver after introduction of DAAs in the government drug formulary. METHODS: Using data from three cohorts of PWID in Vancouver, Canada, we investigated factors associated with DAA-therapies uptake among participants with HCV between April 2015 and November 2017. RESULTS: Of the 915 HCV-positive PWID, 611 (66.8%) were recent PWID and 369 (40.3%) had HIV coinfection. During the study period, 146 (16.0%) initiated DAA-therapies, a rate of 6.0 per 100 person-year, with higher initiation rates among non-recent PWID and an increasing trend over time. In multivariable analysis, HIV coinfection (Adjusted Odds Ratio [AOR] = 2.29, 95% Confidence Interval [CI]: 1.55-3.40), white race (AOR = 1.56, 95% CI: 1.05-2.35), and engagement in HCV care (AOR = 1.94, 95% CI: 1.31-2.90) were positively associated with DAA-therapies uptake, while high-risk drinking (AOR = 0.47, 95% CI: 0.23-0.88) and daily crack use were negatively associated (AOR = 0.41, 95% CI: 0.17-0.85). Among recent PWID, engagement in opioid agonist therapy emerged as an independent correlate of DAA uptake. CONCLUSIONS: Despite increases in HCV treatment uptake among PWID after the introduction of DAAs in our setting, disparities in access remain. Social-structural and behavioural barriers to HCV care should be addressed for the success of any HCV elimination strategy.

Prescription of High-Dose Opioids Among People Living with HIV in British Columbia, Canada.

People living with HIV (PLHIV) often experience pain for which opioid medications may be prescribed. Thus, these individuals are particularly vulnerable to opioid-related harms, including overdose, misuse, and addiction, particularly when prescribed at high doses. We used a comprehensive linked population-level database of PLHIV in British Columbia (BC) to identify demographic and clinical characteristics associated with being prescribed any high-dose opioid analgesic, defined as > 90 daily morphine milligram equivalents (MME/day). Among PLHIV who were prescribed opioids between 1996 and 2015 (n = 10,780), 28.2% received prescriptions of > 90 MME/day at least once during the study period. Factors positively associated with being prescribed high-dose opioid analgesics included: co-prescription of benzodiazepines (adjusted odds ratio [AOR] = 1.14; 95% confidence interval 1.11-1.17); presence of an AIDS-defining illness (ADI; AOR = 1.78; 95% CI 1.57-2.02); seen by an HIV specialist (AOR = 1.24; 95% CI 1.20-1.29); substance use disorder (AOR = 1.46; 95% CI 1.25-1.71); and more recent calendar year (AOR = 1.05; 95% CI 1.04-1.06). Given the known risks associated with high-dose opioid prescribing, future research efforts should focus on the clinical indication and outcomes associated with these prescribing practices.

Impact of personality disorders on leaving hospital against medical advice among people living with HIV in British Columbia, Canada.

PURPOSE: Leaving hospital against medical advice (AMA) is a significant source of morbidity, mortality, and a major burden to the healthcare system. Studies have indicated that marginalized populations, including people living with HIV (PLHIV) and those living with a personality disorder (PD), experience high hospitalization rates. We sought to identify whether being diagnosed with a PD was associated with leaving hospital AMA among PLHIV in British Columbia (BC), Canada. METHODS: Data were derived from the STOP HIV/AIDS in BC cohort, a provincial-level linkage of a series of surveillance, laboratory, and health administrative databases of all identified PLHIV in BC. Using multivariable generalized estimating equations (GEE), we examined the relationship between diagnoses of PD and premature hospital discharge among PLHIV. RESULTS: Among 8763 PLHIV included in the study sample, 1321 (15%) were diagnosed with a PD. The prevalence of leaving hospital AMA at least once during the study period was 9%. In multivariable GEE analyses, after adjusting for a range of demographic and clinical confounders, there remained a positive association between being diagnosed with a PD and leaving hospital prematurely. Results showed a significant and independent association between a PD diagnosis and leaving AMA among PLHIV. CONCLUSIONS: These findings underscore the importance of identifying and addressing specific PD-related behaviour which negatively impact inpatient treatment completion among this subpopulation of PLHIV. Furthermore, these findings suggest a need to develop novel health system interventions to minimize AMA discharge among this population.

The impact of HCV co-infection status on healthcare-related utilization among people living with HIV in British Columbia, Canada: a retrospective cohort study.

BACKGROUND: The burden of HCV among those living with HIV remains a major public health challenge. We aimed to characterize trends in healthcare-related visits (HRV) of people living with HIV (PLW-HIV) and those living with HIV and HCV (PLW-HIV/HCV), in British Columbia (BC), and to identify risk factors associated with the highest HRV rates over time. METHODS: Eligible individuals, recruited from the BC Seek and Treat for Optimal Prevention of HIV/AIDS population-based retrospective cohort (N = 3955), were ≥ 18 years old, first started combination antiretroviral therapy (ART) between 01/01/2000-31/12/2013, and were followed for ≥6 months until 31/12/2014. The main outcome was HRV rate. The main exposure was HIV/HCV co-infection status. We built a confounder non-linear mixed effects model, adjusting for several demographic and time-dependent factors. RESULTS: HRV rates have decreased since 2000 in both groups. The overall age-sex standardized HRV rate (per person-year) among PLW-HIV and PLW-HIV/HCV was 21.11 (95% CI 20.96-21.25) and 41.69 (95% CI 41.51-41.88), respectively. The excess in HRV in the co-infected group was associated with late presentation for ART, history of injection drug use, sub-optimal ART adherence and a higher number of comorbidities. The adjusted HRV rate ratio for PLW-HIV/HCV in comparison to PLW-HIV was 1.18 (95% CI 1.13-1.24). CONCLUSIONS: Although HRV rates have decreased over time in both groups, PLW-HIV/HCV had 18% higher HRV than those only living with HIV. Our results highlight several modifiable risk factors that could be targeted as potential means to minimize the disease burden of this population and of the healthcare system.