The relationship between sexual and gender stigma and suicide attempt and ideation among LGBTQI + populations in Thailand: findings from a national survey.

PURPOSE: Thailand has one of the highest suicide rates in Southeast Asia; yet, little is known about suicidality among lesbian, gay, bisexual, trans, queer, intersex, and other gender and sexually diverse (LGBTQI +) people living in the region, who may experience elevated risk for suicide. We sought to identify the prevalence of lifetime suicidal attempts and ideation among a nationally recruited sample of LGBTQI + people in Thailand. We further examined the relationship between levels of sexual/gender stigma and suicidal attempt and ideation. METHODS: Data were derived from a national online survey of Thai LGBTQI + individuals between January and March 2018. Multivariable logistic regression was used to examine the relationship between sexual/gender stigma scales, adapting a previously validated instrument, and suicide attempt and ideation. RESULTS: Among 1,290 LGBTQI + participants, the median age was 27 years. The prevalence of suicide attempt and ideation was 16.8% and 50.7%, respectively. In multivariable analyses, after adjusting for potential confounders, experiences of perceived and enacted sexual/gender stigma were independently and positively associated with suicide attempt (adjusted odds ratio [AOR] = 1.25; 95% confidence interval CI:1.10-1.41 and AOR = 1.31; 95% CI:1.11-1.55, respectively) and ideation (AOR = 1.30; 95% CI:1.17-1.43 and AOR = 1.34; 95% CI:1.14-1.58, respectively). CONCLUSION: One-sixth of the sample reported a suicide attempt, while a half reported ever contemplating suicide. Both experiences of perceived and enacted sexual/gender stigma were associated with lifetime suicide attempt and ideation. Multi-level interventions are needed to decrease stigma and in turn suicide among LGBTQ + people in Thailand, including anti-discrimination policies and support for mental health and well-being.

Prevalence and longitudinal correlates of recent exposure to fentanyl among HIV-positive people who use unregulated drugs during a community-wide overdose crisis.

The United States and Canada are experiencing an opioid overdose crisis driven largely by exposure to fentanyl (a potent synthetic opioid), with little known about fentanyl exposure among HIV-positive people who use unregulated drugs (PWUD). We sought to estimate the prevalence and correlates of fentanyl exposure among a community-recruited sample derived from a prospective cohort study of HIV-positive PWUD in Vancouver, Canada. Generalized linear mixed-effects analyses were used to identify longitudinal factors associated with a fentanyl-positive urine drug screen test. Between June 2016-November 2017, 456 participants were recruited and contributed 1007 observations. At baseline, 96% of participants were ART-exposed, 72% had an HIV viral load (VL) <50 copies/mL and 21% had a fentanyl-positive test. Longitudinally, fentanyl-positive tests were characterized by: younger participant age (Adjusted Odds Ratio [AOR] = 0.45), recent non-fatal overdose (AOR = 2.30), engagement in opioid agonist therapy (AOR = 1.91), and at least daily heroin injection (AOR = 11.27). CD4+ cell count was negatively associated with fentanyl urine positivity (AOR = 0.92) (all p < 0.05). We identified several risk factors for overdose linked to fentanyl exposure among this sample, although no link with HIV treatment engagement or detectable HIV VL. Innovative strategies are needed to reduce the harmful effects of the contaminated unregulated drug supply experienced by PWUD.

A drug-related Good Samaritan Law and calling emergency medical services for drug overdoses in a Canadian setting.

BACKGROUND: People who use drugs (PWUD) are known to fear calling emergency medical services (EMS) for drug overdoses. In response, drug-related Good Samaritan Laws (GSLs) have been widely adopted in the USA and Canada to encourage bystanders to call emergency medical services (EMS) in the event of a drug overdose. However, the effect of GSLs on EMS-calling behaviours has been understudied. We sought to identify factors associated with EMS-calling, including the enactment of the Canadian GSL in May 2017, among PWUD in Vancouver, Canada, a setting with an ongoing overdose crisis. METHODS: Data were derived from three prospective cohort studies of PWUD in Vancouver in 2014-2018. Multivariable logistic regression was used to determine factors associated with EMS-calling among PWUD who witnessed an overdose event. An interrupted time series (ITS) analysis was employed to assess the impact of GSL on monthly prevalence of EMS-calling. RESULTS: Among 540 eligible participants, 321 (59%) were males and 284 (53%) reported calling EMS. In multivariable analysis, ever having administered naloxone three or more times (adjusted odds ratio [AOR] 2.00; 95% confidence interval [CI] 1.08-3.74) and residence in the Downtown Eastside (DTES) neighbourhood of Vancouver (AOR 1.96; 95% CI 1.23-3.13) were positively associated with EMS-calling, while living in a single occupancy hotel (SRO) was negatively associated with EMS-calling (AOR 0.51; 95% CI 0.30-0.86). The post-GSL enactment period was not associated with EMS-calling (AOR 0.81; 95% CI 0.52-1.25). The ITS found no significant difference in the monthly prevalence of EMS-calling between pre- and post-GSL enactment periods. CONCLUSION: We observed EMS being called about half the time and the GSL did not appear to encourage EMS-calling. We also found that individuals living in SROs were less likely to call EMS, which raises concern given that fatal overdose cases are concentrated in SROs in our setting. The link between many naloxone administrations and EMS-calling could indicate that those with prior experience in responding to overdose events were more willing to call EMS. Increased efforts are warranted to ensure effective emergency responses for drug overdoses among PWUD.

High prevalence of unmet healthcare need among people who use illicit drugs in a Canadian setting with publicly-funded interdisciplinary primary care clinics.

Background: People who use illicit drugs (PWUD) experience significant barriers to healthcare. However, little is known about levels of attachment to primary care (defined as having a regular family doctor or clinic they feel comfortable with) and its association with unmet healthcare needs in this population. In a Canadian setting that features novel publicly-funded interdisciplinary primary care clinics, we sought to examine the prevalence and correlates (including attachment to primary care) of unmet healthcare needs among PWUD. Methods: Data were derived from two prospective cohort studies of PWUD in Vancouver, Canada between December 2017 and November 2018. Multivariable logistic regression was used to identify factors associated with self-reported unmet healthcare needs among participants reporting any health issues. Results: In total, 743 (83.6%) of 889 eligible participants reported attachment to primary care and 220 (24.7%) reported an unmet healthcare need. In multivariable analyses, attachment to primary care at an integrated care clinic (adjusted odds ratio [AOR] = 0.14; 95% Confidence Interval [CI]: 0.06-0.34) was negatively associated with an unmet healthcare need, while being treated poorly at a healthcare facility (AOR = 5.50; 95% CI: 3.59-8.60) and self-reported chronic pain (AOR = 2.00, 95% CI: 1.30-3.01) were positively associated with an unmet healthcare need. Conclusion: Despite the high level of attachment to primary care, a quarter of our sample reported an unmet healthcare need. Our findings suggest that multi-level interventions are required to address the unmet need, including pain management and integrated care, to support PWUD with complex health needs.

Suboptimal nonmedical qualities of primary care linked with care avoidance among people who use drugs in a Canadian setting amid an integrated health care reform.

BACKGROUND: People who use unregulated drugs (PWUD) often face significant barriers to-and thereby avoid seeking-health care. In Vancouver, Canada, a neighborhood-wide health care system reform began in 2016 to improve health care delivery and quality. In the wake of this reform, we sought to determine the prevalence of health care avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported nonmedical qualities of health care ("responsiveness"). METHODS: The study derived data from two prospective cohort studies of community-recruited PWUD in Vancouver in 2017-18. Responsiveness was ascertained by the World Health Organizations' standardized measurements and we evaluated seven domains of responsiveness (dignity, autonomy, communication, confidentiality, prompt attention, choice of provider, and quality of basic amenities). The study used Pearson chi-squared test to examine differences in responsiveness between those who did and did not avoid care. The study team used multivariable logistic regression to determine the relationship between care avoidance due to past mistreatment and emergency department use, adjusting for potential confounders. RESULTS: Among 889 participants, 520 (58.5%) were male, 204 (22.9%) reported avoiding health care, most commonly for chronic pain (47.4%). Overall, 6.6% to 36.2% reported suboptimal levels (i.e., not always meeting the expected quality) across all seven measured domain of responsiveness. Proportions reporting suboptimal qualities were significantly higher among those who avoided care than those who did not across all domains, including care as soon as wanted (51.0% vs. 31.8%), listened to carefully (44.1% vs. 20.4%), and involved in health care decision-making (27.9% vs. 12.7%) (all p < 0.05). In multivariable analyses, avoidance of health care was independently associated with self-reported emergency department use (adjusted odds ratio = 1.49; 95% confidence interval:1.01-2.19). CONCLUSION: We found that almost a quarter of our sample of PWUD avoided seeking health care due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of health care were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of health care and thereby reduce care avoidance.

Knowledge of a Drug-Related Good Samaritan Law Among People Who Use Drugs, Vancouver, Canada.

BACKGROUND: Across the United States and Canada drug-related Good Samaritan laws (GSLs) have been enacted to encourage observers of acute drug overdose events to contact emergency medical services (EMS) without fear of legal repercussions. However, little is known about the working knowledge of GSLs among people who use illicit drugs (PWUD). We sought to evaluate the prevalence and factors associated with accurate knowledge of a GSL among PWUD in Vancouver, Canada, 1 year after the GSL was enacted. METHOD: We used data from participants in three community-recruited prospective cohort studies of PWUD interviewed between June and November 2018. Multivariable logistic regression was used to identify factors associated with accurate knowledge of the GSL. RESULTS: Among 1,258 participants, including 760 males (60%), 358 (28%) had accurate knowledge of the GSL. In multivariable analyses, participants who reported ever having a negative police encounter (defined as being stopped, searched, or detained by the police) were less likely to have accurate knowledge of the GSL (adjusted odds ratio [AOR] = 0.70; 95% CI [0.54, 0.90]), while those involved in drug dealing were more likely to have accurate knowledge of the GSL (AOR = 1.50; 95% CI [1.06, 2.06]). DISCUSSION: Despite having been enacted for a full year, approximately three quarters of participants did not have accurate GSL knowledge, warranting urgent educational efforts among PWUD. Additional research is needed to understand whether GSLs can mitigate the fears of legal repercussions among those engaged in drug dealing and with past negative experiences with the police.

Intention to seek emergency medical services during community overdose events in British Columbia, Canada: a cross-sectional survey.

INTRODUCTION: Canada and the United States continue to experience increasing overdose deaths attributed to highly toxic illicit substances, driven by fentanyl and its analogues. Many bystanders report being hesitant to call 9-1-1 at an overdose due to fears around police presence and arrests. In Canada, a federal law was enacted in 2017, the Good Samaritan Drug Overdose Act (GSDOA), to provide protection from simple drug possession and related charges when 9-1-1 is called to an overdose. There is limited evidence, however, that the GSDOA has improved rates of intention to call 9-1-1 at overdose events. We therefore sought to examine intent to call 9-1-1 among persons who received GSDOA education and were at risk of witnessing an overdose. METHODS: A cross-sectional survey was conducted with people at risk of witnessing an overdose recruited at 19 Take Home Naloxone (THN) program sites across British Columbia as well as online through Foundry from October 2020 to April 2021. Descriptive statistics were used to examine intention to call 9-1-1 at future overdoses. Multivariable logistic regression models were built in hierarchical fashion to examine factors associated with intention to call 9-1-1. RESULTS: Overall, 89.6% (n = 404) of the eligible sample reported intention to call 9-1-1. In the multivariable model, factors positively associated with intention to call 9-1-1 included identifying as a cisgender woman (adjusted odds ratio [AOR]: 3.37; 95% CI: 1.19-9.50) and having previous GSDOA awareness ([AOR]: 4.16; 95% CI: 1.62-10.70). Having experienced a stimulant overdose in the past 6 months was negatively associated with intention to call 9-1-1 ([AOR]: 0.24; 95% CI: 0.09-0.65). CONCLUSION: A small proportion of the respondents reported that, despite the enactment of GSDOA, they did not intend to call 9-1-1 and those who were aware of the act were more likely to report an intention to call at future overdose events. Increasing GSDOA awareness and/or additional interventions to support the aims of the GSDOA could address ongoing reluctance to seek emergency medical care by people who use drugs.

Inability to contact opioid agonist therapy prescribers during the COVID-19 pandemic in a Canadian setting: a cross-sectional analysis among people on opioid agonist therapy.

BACKGROUND: The COVID-19 pandemic and consequent public health response may have undermined key responses to the protracted drug poisoning crisis, including reduced access to opioid agonist therapy (OAT) among people with opioid use disorder. Our study objectives were to estimate the prevalence of and identify factors associated with inability to contact OAT prescribers when in need among people on OAT in a Canadian setting during the dual public health crises. METHODS: Survey data were collected from three prospective cohort studies of community-recruited people who use drugs between July and November 2020, in Vancouver, Canada. A multivariable logistic regression analysis was used to identify potential factors associated with inability to contact OAT prescribers among patients who accessed OAT in the past 6 months. RESULTS: Among 448 respondents who reported accessing OAT in the past 6 months, including 231 (54.9%) men, 85 (19.0%) reported having been unable to contact OAT prescribers when needed, whereas 268 (59.8%) reported being able to talk to their prescriber when needed, and 95 (21.2%) reported that they did not want to talk to their medication prescriber in the previous 6 months. Among those who reported inability to contact prescribers, 45 (53.6%) reported that their overall ability to contact prescribers decreased since the start of the pandemic. In multivariable analyses, factors independently associated with inability to talk to OAT prescribers included: chronic pain (Adjusted Odds Ratio [AOR] = 1.82; 95% Confidence Interval [CI] 1.02, 3.27), moderate to severe symptoms of depression or anxiety (AOR = 4.74; 95% CI 2.30, 9.76), inability to access health/social services (AOR = 2.66; 95% CI 1.41, 5.02), and inability to self-isolate or socially distance most or all of the time (AOR = 2.13; 95% CI 1.10, 4.14). CONCLUSIONS: Overall, approximately one fifth of the sample reported inability to contact their OAT prescribers when needed, and those people were more likely to have co-occurring vulnerabilities (i.e., co-morbidities, inability to access health/social services) and higher vulnerability to COVID-19. Interventions are needed to ensure optimal access to OAT and mitigate the deepening health inequities resulting from the COVID-19 pandemic and the escalating drug poisoning crisis.

Day-to-day impact of COVID-19 and other factors associated with risk of nonfatal overdose among people who use unregulated drugs in five cities in the United States and Canada.

BACKGROUND: The COVID-19 pandemic has compounded the longstanding drug poisoning crisis in Canada and the United States (US). Research is needed to understand the contributions of COVID-19 and subsequent infection control measures. We sought to estimate the prevalence of and factors associated with nonfatal overdose among participants in nine prospective cohorts of people who use unregulated drugs (PWUD) in Canada and the US. METHODS: Data were derived from nine cohorts of PWUD in urban centres in Canada (Vancouver, BC) and the US (Baltimore, MD; Miami, FL; Chicago, IL; Los Angeles, CA) between May, 2020 and April, 2021. Multivariable logistic regression was used to identify factors associated with nonfatal overdose among participants who used unregulated drugs in the past month. RESULTS: Among 885 participants (including 253 females), 41 (4.6 %) experienced a non-fatal overdose in the past month, and 453 (51.2 %) reported being highly impacted day-to-day by the pandemic. In multivariable analyses, people who experienced a non-fatal overdose were more likely to be female (Adjusted Odds Ratio [AOR]=2.18;95 % Confidence Interval [CI]=1.10-4.30); unstably housed/homeless (AOR=2.16;95 % CI=1.11-4.26); engaged in medications for opioid use disorder (AOR=2.45;95 % CI=1.19-4.97); and highly impacted day-to-day (AOR=2.42;95 % CI=1.22-5.10). CONCLUSION: Our findings may reflect characteristics of participants who experienced a compounding of vulnerabilities during the pandemic and thus are vulnerable to overdose, including women, those unstably housed/homeless, and those who perceived their daily lives were highly impacted by the pandemic. Multi-level interventions are needed to remediate the vulnerabilities and address the main driver of poisoning crisis.

The effectiveness of drug-related Good Samaritan laws: A review of the literature.

BACKGROUND: The United States (US) and Canada are in the midst of an opioid overdose epidemic. Many people who use illicit drugs (PWUD) do not call an emergency number 911 at the scene of an overdose due to fear of arrest. In the US and Canada, when an individual calls 911, both emergency medical services (EMS) and police are notified to attend the overdose event. In response, many settings in North America have introduced drug-related 'Good Samaritan' laws (GSLs) that aim to encourage PWUD to call 911 by providing legal immunity (mainly protections from drugs possessed for personal use) to those at the scene of the overdose. However, little is known about the effectiveness of these laws in increasing calls to 911. METHODS: We conducted a literature review of the published literature between 2005 and 2019 to examine the effectiveness of GSLs. Searches were referenced using keywords that included: "good samaritan", "overdose", "emergency services", and "drug use". RESULTS: Among 68 articles identified, after eligibility screening, 12 publications were deemed to meet the inclusion criteria. These publications were largely quantitative observational studies (9/12), with a minority (3/12) being qualitative in design. Two major themes emerged: "knowledge of GSLs and calling EMS" and "overdose-related hospital admissions and mortality assessment". CONCLUSION: At this time, the current body of evidence regarding the effectiveness of GSLs in increasing calls to EMS and reducing drug-related harms is limited and mixed. Studies show that PWUD have low levels of knowledge regarding GSLs while some evidence suggests their effectiveness in increasing calls to EMS at the scene of an overdose. Given the current overdose crisis, further investigation is warranted to establish the effectiveness of these laws in reducing drug-related harms.

Non-disclosure of drug use in outpatient health care settings: Findings from a prospective cohort study in Vancouver, Canada.

BACKGROUND: Illicit drug use is associated with severe health-related harms, yet people who use drugs (PWUD) face substantial barriers to healthcare. We sought to identify factors associated with disclosure of drug use to a healthcare provider and describe differences in self-reported quality of care received based on disclosure status. METHODS: A client-reported experience questionnaire on healthcare access and quality, adapted from the World Health Organization Survey on Health and Health System Responsiveness, was administered within two ongoing prospective cohort studies of PWUD in Vancouver, Canada. Respondents not currently receiving addiction treatment were asked about experience of care and drug use disclosure to their most commonly accessed outpatient healthcare provider in the past 6 months. We used an adjusted logistic regression model to identify client characteristics associated with disclosure. RESULTS: From a total of 261 respondents (34.1% female), less than half (n = 125, 47.8%) reported disclosing drug use to their healthcare provider. Indigenous participants were less likely to disclose compared to non-Indigenous participants (adjusted OR: 0.55, 95% confidence interval: 0.30, 0.97). Disclosure was associated with lower self-reported quality of care (overall rating: disclosed 8.2 vs. did not disclose 8.8, p = 0.04). CONCLUSIONS: In a sample of PWUD accessing outpatient healthcare services, we observed low rates of drug use disclosure, particularly for Indigenous respondents, and reduced quality of care for those who disclosed. These findings highlight the need for culturally safe and non-stigmatizing care to address pervasive stereotyping in the healthcare system and improved screening for substance use disorder in outpatient healthcare services.

Knowledge of Fentanyl and Perceived Risk of Overdose Among Persons Who Use Drugs in Vancouver, Canada.

OBJECTIVES: In North America, the illicit drug supply is increasingly contaminated by illicitly manufactured fentanyl. We sought to assess the level and source of fentanyl risk knowledge, defined as knowledge of the overdose risks associated with fentanyl, and characterize the prevalence and correlates of perceived risk of personally having a fentanyl overdose among persons who use illicit drugs (PWUD) in Vancouver, British Columbia. METHODS: We derived data from 3 prospective cohorts of PWUD in Vancouver from December 2016 through May 2017. We used multivariable ordinal regression analysis to identify factors associated with a lower perceived risk of having a fentanyl overdose. RESULTS: Of 1166 participants, 1095 (93.9%) had fentanyl risk knowledge. Of 1137 participants who answered questions about their perceived risk of having a fentanyl overdose, 398 (35.0%) perceived having no risk, 426 (37.5%) perceived having low risk, and 313 (27.5%) perceived having moderate or high risk. Never or rarely using opioids (n = 541, 65.7%) was the most common reason for reporting no or low perceived risk (n = 824), whereas 137 (16.6%) participants reported daily heroin use. In multivariable analysis, compared with participants who perceived a moderate or high risk, participants who perceived a lower risk were less likely to report a recent nonfatal overdose (adjusted odds ratio [aOR] = 0.28; P < .001), recent injection drug use (aOR = 0.34; P < .001), and awareness of recent exposure to fentanyl (aOR = 0.34; P < .001). CONCLUSION: Despite a high level of fentanyl risk knowledge, most study participants did not translate this knowledge into a risk of having an overdose. Although participants who perceived a lower risk were less likely to have had an overdose, a considerable proportion was engaged in daily opioid use, suggesting the need to improve overdose prevention efforts.