Characterizing Use of Supervised Consumption Services among Street-involved Youth and Young Adults in the Context of an Overdose Crisis.

In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.

Receipt of COVID-19 emergency funds and engagement in sex work during COVID-19 among people who use drugs: evidence from Vancouver, Canada.

BACKGROUND: During the early period of the COVID-19 pandemic, public health orders disrupted income generation in numerous sectors and many governments provided emergency financial support. Access to government support and changes in engagement in sex work during the early period of the pandemic among people who use drugs (PWUD) are not well described. In the present study, we investigate the prevalence and correlates of engaging in sex work during the COVID-19 pandemic, among PWUD in Vancouver, Canada. METHODS: Data derived from three harmonized cohorts of PWUD. Using multivariable logistic regression, we characterized factors associated with engaging in sex work in the last month between July 17 and November 30, 2020. Reports of changes in frequency of engagement in sex work since the pandemic were also collected. RESULTS: Of the 864 individuals included in this analysis, 55 (6.4%) reported sex work engagement in the last month. Among these participants, 40.7% reported receiving COVID-19 income support in the past month vs. 52.7% of the rest of the sample, though receipt of income support in the past six months was similar between the two groups (72.2% vs. 75.7%, p = 0.624). In multivariable analysis, receipt of financial support in the last month was negatively associated with engagement in sex work in the last month (adjusted odds ratio [AOR] = 0.44 [95% confidence interval [CI]: 0.24-0.81]). Among 69 participants who responded to a question regarding changes in engagement in sex work, 38 (55.1%) reported a decrease, 11 (15.9%) reported an increase, 19 (27.5%) reported no change, and 1 (1.4%) reported cessation. CONCLUSIONS: Findings document that engagement in sex work appears to have declined early in the pandemic. Participants who received income support in the past month were less likely to report recent engagement in sex work. Findings suggest that recent receipt of income support may have contributed to reductions in engagement in sex work. Additional investigation is warranted.

Denial of prescription pain medication among people who use drugs in Vancouver, Canada.

BACKGROUND: People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs. METHODS: We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied. RESULTS: Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates. CONCLUSIONS: A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.

The impact of the COVID-19 pandemic on people who use drugs in three Canadian cities: a cross-sectional analysis.

BACKGROUND: The COVID-19 pandemic had a disproportionate impact on the health and wellbeing of people who use drugs (PWUD) in Canada. However less is known about jurisdictional commonalities and differences in COVID-19 exposure and impacts of pandemic-related restrictions on competing health and social risks among PWUD living in large urban centres. METHODS: Between May 2020 and March 2021, leveraging infrastructure from ongoing cohorts of PWUD, we surveyed 1,025 participants from Vancouver (n = 640), Toronto (n = 158), and Montreal (n = 227), Canada to describe the impacts of pandemic-related restrictions on basic, health, and harm reduction needs. RESULTS: Among participants, awareness of COVID-19 protective measures was high; however, between 10 and 24% of participants in each city-specific sample reported being unable to self-isolate. Overall, 3-19% of participants reported experiencing homelessness after the onset of the pandemic, while 20-41% reported that they went hungry more often than usual. Furthermore, 8-33% of participants reported experiencing an overdose during the pandemic, though most indicated no change in overdose frequency compared the pre-pandemic period. Most participants receiving opioid agonist therapy in the past six months reported treatment continuity during the pandemic (87-93%), however, 32% and 22% of participants in Toronto and Montreal reported missing doses due to service disruptions. There were some reports of difficulty accessing supervised consumption sites in all three sites, and drug checking services in Vancouver. CONCLUSION: Findings suggest PWUD in Canada experienced difficulties meeting essential needs and accessing some harm reduction services during the COVID-19 pandemic. These findings can inform preparedness planning for future public health emergencies.

Methadone Maintenance Treatment Discontinuation Among Young People who use Opioids in Vancouver, Canada.

OBJECTIVE: Retaining adolescents and young adults (AYA) in medications for opioid use disorder (MOUD), like methadone maintenance treatment (MMT), is critical to reducing toxic drug fatalities. This analysis sought to identify factors associated with MMT discontinuation among AYA. METHOD: Data were derived from the At-Risk Youth Study, a prospective cohort study of street-involved AYA in Vancouver, Canada, between December 2005 and June 2018. Multivariable extended Cox regression identified factors associated with time to MMT discontinuation among AYA who recently initiated MMT. In subanalysis, multivariable extended Cox regression analysis identified factors associated with time to "actionable" MMT discontinuation, which could be addressed through policy changes. RESULTS: A total of 308 participants reported recent MMT during the study period. Participants were excluded if they reported MMT in the past 6 months at baseline and were retained in MMT (n = 94, 30.5%); were missing MMT status data (n = 43, 14.0%); or completed an MMT taper (n = 11, 3.6%). Of the remaining 160 participants who initiated MMT over the study period, 102 (63.8%) discontinued MMT accounting for 119 unique discontinuation events. In multivariable extended Cox regression, MMT discontinuation was positively associated with recent weekly crystal methamphetamine use (adjusted hazard ratio [AHR] = 1.67, 95% confidence interval [CI]: 1.19 to 2.35), but negatively associated with age of first "hard" drug use (per year older) (AHR = 0.95, 95% CI: 0.90 to 1.00) and female sex (AHR = 0.66, 95% CI: 0.44 to 0.99). In subanalysis, recent weekly crystal methamphetamine use (AHR = 4.61, 95% CI: 1.78 to 11.9) and weekly heroin or fentanyl use (AHR = 3.37, 95% CI: 1.21 to 9.38) were positively associated with "actionable" MMT discontinuation, while older age (AHR = 0.87, 95% CI: 0.76 to 0.99) was negatively associated. CONCLUSIONS: Efforts to revise MMT programming; provide access to a range of MOUD, harm reduction, and treatments; and explore coprescribing stimulants to AYA with concurrent stimulant use may improve treatment retention and reduce toxic drug fatalities.

Food insecurity during the COVID-19 pandemic who use drugs in Vancouver, Canada.

OBJECTIVE: To examine prevalence and factors associated with food insecurity among people who use drugs (PWUD) during the first year of the COVID-19 pandemic and the overdose crisis. DESIGN: This cross-sectional study employs multivariable logistic regression to identify factors associated with self-reported food insecurity. PARTICIPANTS: PWUD who are part of three community-recruited cohorts. SETTING: Interviews conducted in Vancouver, Canada, via phone between July and November 2020 in adherence to COVID-19 safety procedures. RESULTS: Among 765 participants, including 433 (56·6 %) men, eligible for this study, 146 (19·1 %; 95 % CI: 16·3 %, 21·9 %) reported food insecurity in the past month. Of the participants reporting food insecurity, 114 (78·1 %) reported that their hunger levels had increased since the beginning of the pandemic. In multivariable analyses, factors independently and positively associated with food insecurity included: difficulty accessing health or social services (adjusted OR (AOR) = 2·59; 95 % CI: 1·60, 4·17); having mobility difficulties (AOR = 1·59; 95 % CI: 1·02, 2·45) and engaging in street-based income generation (e.g. panhandling and informal recycling) (AOR = 2·31; 95 % CI: 1·45, 3·65). CONCLUSION: Approximately one in five PWUD reported food insecurity during this time. PWUD with mobility issues, who experienced difficulty accessing services and/or those engaged in precarious street-based income generation were more likely to report food insecurity. Food security is paramount to the success of interventions to prevent COVID-19 and drug toxicity deaths. These findings suggest a need for a more unified state response to food insecurity that prioritises and incorporates accessibility and autonomy of the communities they serve.

Experiences of violence during the COVID-19 pandemic among people who use drugs in a Canadian setting: a gender-based cross-sectional study.

OBJECTIVES: People who use drugs (PWUD) experience disproportionately high rates of violent victimization. Emerging research has demonstrated that the COVID-19 pandemic has exacerbated violence against some priority populations (e.g., women), however there is limited research examining the impact of the pandemic on the experiences of violence of PWUD. METHODS: Using data collected between July and November 2020 from three prospective cohort studies of PWUD in Vancouver, Canada, we employed multivariable logistic regression stratified by gender to identify factors associated with recent experiences of violence, including the receipt of COVID-19 emergency income support. RESULTS: In total, 77 (17.3%) of 446 men, and 54 (18.8%) of 288 women experienced violence in the previous six months. Further, 33% of men and 48% of women who experienced violence reported that their experience of violence was intensified since the COVID-19 pandemic began. In the multivariable analyses, sex work (Adjusted Odds Ratio [AOR] = 2.15, 95% confidence interval [CI]: 1.06-4.35) and moderate to severe anxiety or depression (AOR = 3.00, 95% CI: 1.37-6.57) were associated with experiencing violence among women. Among men, drug dealing (AOR = 1.93, 95%CI: 1.10-3.38), street-based income sources (AOR = 1.93, 95%CI: 1.10-3.38), homelessness (AOR = 2.54, 95%CI: 1.40-4.62), and regular employment (AOR = 2.97, 95% CI: 1.75-5.04) were associated with experiencing violence. CONCLUSION: Our study results suggest economic conditions and gender were major factors associated with experiencing violence among our sample of PWUD during COVID-19. These findings highlight criminalization of drug use and widespread socioeconomic challenges as barriers to addressing violence among PWUD during periods of crisis.

Police seizure of drugs without arrest among people who use drugs in Vancouver, Canada, before provincial 'decriminalization' of simple possession: a cohort study.

BACKGROUND: Several jurisdictions in Canada have recently considered decriminalizing possession of illicit drugs for personal use (henceforth, simple possession) as part of their responses to the ongoing drug toxicity/overdose crisis. In this context, we sought to examine an early implementation case of a de facto depenalization policy of simple possession offences in Vancouver, Canada, that was enacted in 2006. Specifically, we characterized experiences of people who use drugs (PWUD) whose drugs were discretionally seized by police without arrest. METHODS: Data were derived from three prospective cohorts of community-recruited PWUD in Vancouver over 16 months in 2019-2021. We conducted multivariable generalized estimating equations analyses to determine the prevalence of and factors associated with drug seizure. Sub-analyses used data collected in 2009-2012 and examined the trends over time. RESULTS: Among 995 participants who were interviewed in 2019-2021, 63 (6.3%) had their drugs seized by police at least once in the past 6 months. In multivariable analyses, factors significantly associated with drug seizure included: homelessness (adjusted odds ratio [AOR]: 1.98; 95% confidence interval [CI] 1.09-3.61), working in the unregulated drug market (AOR: 4.93; 95% CI 2.87-8.49), and naloxone administration (AOR: 2.15; 95% CI 1.23-3.76). In 2009-2012, 67.8% reported having obtained new drugs immediately after having their drugs seized by police. Odds of drug seizure were not significantly different between the two time periods (2019-2021 vs. 2009-2012) (AOR: 0.93; 95% CI: 0.64-1.35). CONCLUSIONS: Despite the depenalization policy, the Vancouver Police Department has continued to seize illicit drugs from PWUD, even in cases where no arrest occurred. This policing practice may create health and safety risks for PWUD as it forces PWUD to increase the engagement with the unregulated illicit drug market. Our findings support calls for abolishing this often-undocumented discretionary policing practice that may exacerbate ongoing health inequities and interfere with peer-based overdose prevention efforts.

Difficulty accessing supervised consumption services during the COVID-19 pandemic among people who use drugs in Vancouver, Canada.

BACKGROUND: The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada. METHODS: Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS. RESULTS: Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42-58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28-5.30), active injection drug use (AOR = 4.06; 95% CI 1.38-11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24-4.85), and unstable housing (AOR = 2.14; 95% CI 1.08-4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93-0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%). CONCLUSIONS: We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

Low awareness of risk mitigation prescribing in response to dual crises of COVID-19 and overdose deaths among people who use unregulated drugs in Vancouver, Canada.

BACKGROUND: When the novel coronavirus pandemic emerged in March 2020, many settings across Canada and the USA were already contending with an existing crisis of drug overdoses due to the toxic unregulated drug supply. In response, the Canadian province of British Columbia (BC) released innovative risk mitigation prescribing (RMP) guidelines for medical professionals to prescribe pharmaceutical alternatives to unregulated drugs in an effort to support the self-isolation of people who use unregulated drugs (PWUD) in preventing both SARS-CoV-2 virus infection and overdoses. We sought to assess the level of awareness of RMP and identify factors associated with this awareness among PWUD in Vancouver, BC. METHODS: Cross-sectional data were derived from participants enrolled in three community-recruited prospective cohort studies of PWUD in Vancouver, interviewed between July and November 2020. Multivariable logistic regression analysis was used to identify factors associated with awareness of RMP. RESULTS: Among 633 participants, 302 (47.7%) had heard of RMP. Of those 302 participants, 199 (65.9%) had never tried to access RMP services, ten (3.3%) made an unsuccessful attempt to access RMP, and 93 (30.8%) received RMP. In the multivariable analysis, participants who had awareness of RMP guidelines were more likely to self-identify as white (adjusted odds ratio [AOR] = 1.47; 95% confidence interval [CI]: 1.01, 2.13), to have completed secondary school education or higher (AOR = 1.67; 95% CI: 1.16, 2.39), to have used drugs at a supervised consumption or overdose prevention site in the past six months (AOR = 1.66; 95% CI: 1.10, 2.52), and to have received opioid agonist therapy as treatment for opioid use disorder in the past six months (AOR = 1.51; 95% CI: 1.02, 2.24). CONCLUSION: At least four months after the release of the guidelines, RMP was known to less than half of our study participants, warranting urgent educational efforts for PWUD, particularly among racialized groups and those who were not accessing other harm reduction services. Furthermore, the majority of participants who were aware of RMP guidelines had never tried to access the service, suggesting the need to improve perceived accessibility and knowledge of eligibility criteria.

Social-Structural Predictors of Fentanyl Exposure among Street Involved Youth.

ObjectiveThe emergence of synthetic fentanyl has been a main contributor to North America's rising overdose death rates. While increasing attention has been given to drug-related harm among youth, little is known about how social-structural conditions influence their risk of fentanyl exposure. Therefore, we evaluated potential relationships between social-structural conditions and fentanyl exposure among youth who use illicit drugs in Vancouver, BC. Methods: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort study. The ARYS cohort involves street-involved youth, who use illicit substances in Vancouver, Canada. A multivariable logic regression analysis model was used to identify social factors associated with recent fentanyl exposure as determined through urine drug screening. Results: Overall, 423 participants were included in this analysis, with 380 (38.23%) testing positive for recent fentanyl exposure. In a multivariable relative risk analysis, living in Vancouver's Downtown Eastside in the last six months (RR = 1.16, 95% CI: 1.03-1.32) and daily heroin injection drug use (RR = 1.31, 95% CI: 1.15 - 1.50) were positively associated with fentanyl exposure. As a secondary measure, we found that within the encounters who denied using fentanyl (92.25% of total encounters), 321 (35.05%) still tested positive. Conclusions: We found that youth residing in Vancouver's Downtown Eastside was positively associated with being exposed to fentanyl. Our findings highlight the need to support youth in finding secure housing outside of Vancouver's drug use epicenter to reduce fentanyl exposure.

Prevalence and correlates of intentional substance use to reduce illicit opioid use in a Canadian setting.

Background: While preliminary evidence has begun to document intentional use of one substance to reduce the use of another, the phenomenon of drug substitution among people who use illicit opioids remains understudied. Therefore, we sought to estimate the prevalence and correlates of intentional substance use to reduce illicit opioid use among persons who use drugs (PWUD). Methods: We analysed data from three prospective cohorts of PWUD in Vancouver, Canada, using multivariable generalized estimating equations (GEE). Results: Between June 2012 and June 2016, 1527 participants were recruited and contributed 4991 interviews. Of those, 336 (22%) illicit opioid-using participants self-reported substitution to reduce illicit opioid use at least once during study period contributing 467 (9.4%) interviews. Among those interviews, substances substituted for opioids were alcohol (15 participants, 3.2%), stimulants (235, 50.3%), cannabis (129, 27.6%), benzodiazepines (21, 4.5%), and others (20, 4.3%). In multivariable GEE model adjusted for socio-demographic factors, reporting substitution to reduce illicit opioid use was positively associated with greater likelihood of daily cannabis use (Adjusted Odds Ratio = 1.56, 95% Confidence Interval: 1.24-1.96]. Conclusions: While daily cannabis use was associated with reporting opioid substitution attempts, additional study is needed to examine potential of cannabis/cannabinoids to reduce illicit opioid use.

Use of Cannabis for Harm Reduction Among People at High Risk for Overdose in Vancouver, Canada (2016-2018).

Objectives. To characterize the prevalence and reasons for the use of cannabis as a strategy to reduce the harms arising from other substances.Methods. We drew data about recent cannabis use and intentions from 3 prospective cohort studies of marginalized people who use drugs based in Vancouver, Canada, from June 2016 to May 2018. The primary outcome was "use of cannabis for harm reduction," defined as using cannabis for substitution for licit or illicit substances such as heroin or other opioids, cocaine, methamphetamine, or alcohol; treating withdrawal; or coming down off other drugs.Results. Approximately 1 in 4 participants reported using cannabis for harm reduction at least once during the study period. The most frequent reasons included substituting for stimulants (50%) and substituting for illicit opioids (31%).Conclusions. The use of cannabis for harm reduction is a common strategy among people who use drugs in our setting. Further research into the factors associated with this strategy is needed. Better characterization of the risks and benefits of substitution strategies, including for opioids and stimulants, may prompt new treatment options for PWUD.

High-intensity cannabis use and hospitalization: a prospective cohort study of street-involved youth in Vancouver, Canada.

BACKGROUND: There is concern that cannabis use negatively affects vulnerable groups such as youth; however, the relationship between cannabis use and health care utilization has not been well characterized in this population. We longitudinally evaluated the association between daily cannabis use and hospitalization among a prospective cohort of street-involved youth. METHODS: Data were collected from the At-Risk Youth Study (ARYS) in Vancouver, Canada, from September 2005 to May 2015. Participants were interviewed semi-annually and multivariable generalized estimating equation (GEE) logistic regression was used to examine the relationship between daily cannabis use and hospitalization. RESULTS: A total of 1216 participants (31.2% female) were included in this analysis, and 373 (30.7%) individuals reported hospitalization at some point during the study period. In a multivariable GEE analysis, daily cannabis use was not significantly associated with hospitalization (Adjusted Odds Ratio [AOR] = 1.17, 95% Confidence interval [CI] = 0.84, 1.65). We did observe a significant interaction between daily cannabis use and sex (AOR = 0.51, 95% CI = 0.34, 0.77), whereby cannabis use was associated with a decreased odds of hospitalization among males (AOR = 0.60, 95% CI = 0.47, 0.78), yet was not significantly associated with hospitalization among females (AOR = 1.19, 95% CI = 0.84, 1.67). CONCLUSIONS: The finding that daily cannabis use was not associated with hospitalization among street-involved youth is encouraging given the high rates of cannabis use in this population and the expansion of cannabis legalization and regulation. Future studies, however, are warranted to monitor possible changes in the consequences of cannabis use as cannabis legalization and regulation increase internationally.

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.

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.

Trust in research physicians as a key dimension of randomized controlled trial participation in clinical addictions research.

Background: In the development of pharmacotherapies for substance use disorders, willingness to participate in randomized controlled trials (RCTs) among people who use drugs (PWUD) is influenced by numerous social and structural factors. Considering the criminalization and stigma experienced by PWUD and range of experiences in healthcare and research, PWUD may vary in their trust of health providers, health research physicians, or medical research processes. We therefore examine associations between trust in these three domains and willingness to participate in a hypothetical RCT for a novel pharmacotherapy for stimulant use among PWUD. Methods: Data were derived from a cross-sectional questionnaire administered to participants using crack and/or cocaine from three cohort studies of PWUD in Vancouver (N = 229). Results: A majority of participants were "definitely" or "probably" willing to participate in an RCT. In multivariable ordinal regression, trust in research physicians was positively associated with willingness to participate, while trust in primary care providers or medical research processes were not significantly associated. Conclusions: This data suggests trust in research physicians plays a role in RCT decision-making among PWUD, while trust in healthcare providers and research processes appears less relevant. These findings highlight opportunities for supporting RCT recruitment by building trust in research physicians.

Inability to access primary care clinics among people who inject drugs in a Canadian health care setting.

OBJECTIVE: To examine the prevalence and correlation of self-reported inability to access community primary care clinics among people who inject drugs (PWID). DESIGN: Self-report questionnaire data. SETTING: Vancouver, BC. PARTICIPANTS: Data were derived from 3 prospective cohort studies of PWID between 2013 and 2016. MAIN OUTCOME MEASURES: Multivariable generalized estimating equations were used to determine prevalence of and reasons for self-reported inability to access primary care, as well as factors associated with inability to access care. RESULTS: Of 1396 eligible participants, including 525 (37.6%) women, 209 (15.0%) persons were unable to access a primary care clinic at some point during the study period. In the multivariable analysis, factors independently associated with inability to access clinics included ever being diagnosed with a mental health disorder (adjusted odds ratio [AOR] = 1.63, 95% CI 1.14 to 2.35), dealing drugs (AOR = 1.60, 95% CI 1.15 to 2.22), using emergency services (AOR = 1.51, 95% CI 1.13 to 2.02), being female (AOR = 1.49, 95% CI 1.08 to 2.08), and testing positive for HIV (AOR = 0.47, 95% CI 0.30 to 0.72) (for all factors, P < .05). CONCLUSION: Specific exposures were linked to challenges in accessing primary care among the sample of PWID, even in a publicly funded health care setting. Notably, models designed for care of people with HIV appear to increase access to primary care among PWID. Further research is needed to determine how to effectively treat accompanying mental illness, how to provide women-centred services, and how to connect people with primary care who would likely otherwise go to the emergency department.

Frequent Cannabis Use and Cessation of Injection of Opioids, Vancouver, Canada, 2005-2018.

Objectives. To evaluate the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID).Methods. Three prospective cohorts of PWID from Vancouver, Canada, provided the data for these analyses. We used extended Cox regression analysis with time-updated covariates to analyze the association between cannabis use and injection cessation and injection relapse.Results. Between 2005 and 2018, at-least-daily cannabis use was associated with swifter rates of injection cessation (adjusted hazard ratio [AHR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). A subanalysis revealed that this association was only significant for opioid injection cessation (AHR = 1.26; 95% CI = 1.12, 1.41). At-least-daily cannabis use was not significantly associated with injection relapse (AHR = 1.08; 95% CI = 0.95, 1.23).Conclusions. We observed that at-least-daily cannabis use was associated with a 16% increase in the hazard rate of injection cessation, and this effect was restricted to the cessation of injection opioids. This finding is encouraging given the uncertainty surrounding the impact of cannabis policies on PWID during the ongoing opioid overdose crisis in many settings in the United States and Canada.

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.