"It's just a perfect storm": Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances.

BACKGROUND: Despite the implementation and expansion of public health and harm reduction strategies aimed at preventing and reversing overdoses, rates of overdose-related events and fatalities continue to rise in British Columbia. The COVID-19 pandemic created a second, concurrent public health emergency that further exacerbated the illicit drug toxicity crisis, reinforced existing social inequities and vulnerabilities, and highlighted the precariousness of systems in place that are meant to protect the health of communities. By exploring the perspectives of people with recent experience of illicit substance use, this study sought to characterize how the COVID-19 pandemic and associated public health measures influenced risk and protective factors related to unintentional overdose by altering the environment in which people live and use substances, influencing the ability of people who use substances to be safe and well. METHODS: One-on-one semi-structured interviews were conducted by phone or in-person with people who use illicit substances (n = 62) across the province. Thematic analysis was performed to identify factors shaping the overdose risk environment. RESULTS: Participants pointed to factors that increased risk of overdose, including: [1] physical distancing measures that created social and physical isolation and led to more substance use alone without bystanders nearby able to respond in the event of an emergency; [2] early drug price spikes and supply chain issues that created inconsistencies in drug availability; [3] increasing toxicity and impurities in unregulated substances; [4] restriction of harm reduction services and supply distribution sites; and [5] additional burden placed on peer workers on the frontlines of the illicit drug toxicity crisis. Despite these challenges, participants highlighted factors that protected against overdose and substance-related harm, including the emergence of new programs, the resiliency of communities of people who use substances who expanded their outreach efforts, the existence of established social relationships, and the ways that individuals consistently prioritized overdose response over concerns about COVID-19 transmission to care for one another. CONCLUSIONS: The findings from this study illustrate the complex contextual factors that shape overdose risk and highlight the importance of ensuring that the needs of people who use substances are addressed in future public health emergency responses.

Motivations for concurrent use of uppers and downers among people who access harm reduction services in British Columbia, Canada: findings from the 2019 Harm Reduction Client Survey.

INTRODUCTION: An increase in crystal methamphetamine (methamphetamine) use during the overdose epidemic is being observed in British Columbia (BC), Canada, and across North America. Concurrent use (ie, using uppers and downers one after the other or together) can increase the risk of fatal and non-fatal opioid overdose. OBJECTIVES: We investigated motivations for concurrent use of uppers and downers, specifically how (eg, in what order) and why people use concurrently, to identify potential interventions to prevent overdose and other harms. SETTING AND PARTICIPANTS: The 2019 Harm Reduction Client Survey was administered across 22 harm reduction supply distribution sites in BC (n=621). This thematic analysis examined 307 responses by people who affirmed concurrent use to classify order and reasons for using uppers and downers concurrently. RESULTS: Of the 307 people who responded 'yes' to concurrent use, 179 (58.3%) used downers then uppers, 76 (24.8%) used uppers then downers and 184 (59.9%) mixed uppers and downers together. Four main reasons for concurrent use emerged: self-medication, availability and preference, drug effects/properties, and financial and life situation. People who mixed drugs together predominantly wanted to achieve desired drug effects/properties, such as a specific high or balancing stimulating and sedating effects. CONCLUSIONS: The ongoing rise in overdoses in BC is multifactorial, and the recent parallel increases in methamphetamine use and concurrent use with opioids may contribute. Qualitative interviews may further elucidate reasons for concurrent use. Addressing reasons for concurrent use identified in this study through harm reduction strategies and education may affect the rates of overdose morbidity and mortality.

Identifying behaviours for survival and wellness among people who use methamphetamine with opioids in British Columbia: a qualitative study.

BACKGROUND: British Columbia (BC) has been in a state of public health emergency since 2016, due to the unprecedented numbers of fatal and non-fatal drug toxicity (i.e. overdose) events. Methamphetamine detection in illicit drug toxicity deaths increased from 14% in 2012 to 43% in 2020 suggesting a concerning trend of concurrent methamphetamine and opioid use in BC, consistent with rising patterns identified across North America. People who use methamphetamine concurrently with opioids face an elevated risk of harm. This study aimed to identify behaviours for survival and wellness practiced by people who concurrently use methamphetamine and opioids. METHODS: One-on-one semi-structured interviews were conducted by peer research assistants in person and by telephone. Thematic analysis was carried out to identify patterns in behaviours participants described as important to their safety in the context of concurrent use of methamphetamine and opioids. RESULTS: Participants (n = 22) were distributed across the province with at least four participants from each of the five geographic health regions: 64% self-identified as men, and 50% self-identified as Indigenous. Daily methamphetamine use was reported by 72.7% of participants, and 67.3% reported using alone either often or always. Participants made several considerations and adaptations in order to balance the perceived benefits and risks of their use of methamphetamine with opioids. Two overarching themes were identified to describe how participants adapted their use for survival and wellness. The first was personal safety behaviours which included self-regulation and self-care behaviours. The second was interpersonal safety behaviours which included using alongside peers, and engaging with peer-led services (e.g. community outreach organizations) and public health-led services (e.g. overdose prevention sites) to reduce the risk of harm. Participants identified many gaps in available services to meet their diverse needs. CONCLUSIONS: This manuscript identified diversity in participants' methamphetamine and opioid use (i.e. frequency, route of administration), and a range of behaviours that were performed to improve wellness and survival while using methamphetamine and opioids. Harm reduction and treatment responses must be robust and adaptable to respond to the diversity of patterns of substance use among people who use methamphetamine and opioids concurrently, so as to not perpetuate harm and leave people behind.

Correlates of concurrent use of stimulants and opioids among people who access harm reduction services in British Columbia, Canada: Findings from the 2019 Harm Reduction Client Survey.

BACKGROUND: During a public health overdose emergency driven by fentanyl in British Columbia (BC), Canada, a parallel increase in concurrent use of methamphetamines may be contributing to the risk of overdose. Concurrent use refers to the use of stimulants and opioids one after the other, or together. Describing substance use practices and elucidating correlates of concurrent use can inform harm reduction service provision and prevent overdose events. METHODS: This cross-sectional study analyzed the 2019 Harm Reduction Client Survey administered at 22 harm reduction sites across BC and sampled individuals aged 19 and older. Bivariable and multivariable logistic regression models identified correlates of concurrent use of stimulants and opioids in the last three days. RESULTS: The study sample was composed of 574 individuals who used stimulants and/or opioids, among whom 307 (53.5%) reported concurrent use. Compared with individuals who used stimulants and/or opioids separately, the odds of concurrent use were significantly increased (OR=2.74, 95%CI 1.71-4.51) while the adjusted odds were increased (aOR=1.79, 95%CI 0.98-3.34) among individuals who experienced an opioid overdose. Further, the adjusted odds of concurrent use decreased with every one-year increase in age (aOR=0.97, 95%CI 0.95-0.99), among individuals with paid work (aOR=0.58, 95%CI 0.33-0.99), and stable housing (aOR=0.61, 95%CI 0.37-1.02). The adjusted odds of concurrent use increased among individuals who used drugs daily (aOR=3.78, 95%CI 2.28-6.40), used tobacco (aOR=2.03, 95%CI 1.09-3.87), used benzodiazepines (aOR=3.72, 95%CI 1.76-8.41), owned a naloxone kit (aOR=1.94, 95%CI 1.15-3.31), used observed consumption sites (aOR=2.51, 95%CI 1.57-4.07), and were prescribed opioid agonist therapy (aOR=2.92, 95%CI 1.81-4.77). CONCLUSIONS: Individuals who used stimulants and opioids concurrently tend to be younger, without paid work or housing. They were engaged in harm reduction and treatment services, yet used illicit drugs with unknown concentration daily. Improving access to age-appropriate services and expanding the availability of both legal and regulated stimulants and opioids may further reduce harms of concurrent use.

Characterizing Traumatic Brain Injury and Its Association with Losing Stable Housing in a Community-based Sample.

OBJECTIVE: Traumatic brain injury (TBI) is increasingly recognized as a common and impactful health determinant in homeless and precariously housed populations. We sought to describe the history of TBI in a precariously housed sample and evaluate how TBI was associated with the initial loss and lifetime duration of homelessness and precarious housing. METHOD: We characterized the prevalence, mechanisms, and sex difference of lifetime TBI in a precariously housed sample. We also examined the impact of TBI severity and timing on becoming and staying homeless or precariously housed; 285 precariously housed participants completed the Brain Injury Screening Questionnaire in addition to other health assessments. RESULTS: A history of TBI was reported in 82.1% of the sample, with 64.6% reporting > 1 TBI, and 21.4% reporting a moderate or severe TBI. Assault was the most common mechanism of injury overall, and females reported significantly more traumatic brain injuries due to physical abuse than males (adjusted OR = 1.26, 95% CI = 1.14 to 1.39, P < 0.0001). The first moderate or severe TBI was significantly closer to the first experience of homelessness (b = 2.79, P = 0.003) and precarious housing (b = 2.69, P < 0.0001) than was the first mild TBI. In participants who received their first TBI prior to becoming homeless or precariously housed, traumatic brain injuries more proximal to the initial loss of stable housing were associated with a longer lifetime duration of homelessness (RR = 1.04, 95% CI = 1.02 to 1.06, P < 0.0001) and precarious housing (RR = 1.03, 95% CI = 1.01 to 1.04, P < 0.0001). CONCLUSIONS: These findings demonstrate the high prevalence of TBI in this vulnerable population, and that aspects of TBI severity and timing are associated with the loss and lifetime duration of stable housing.