Characterizing opioid agonist therapy uptake and factors associated with treatment retention among people with HIV in British Columbia, Canada.

Accidental overdoses are now the leading cause of death among people with HIV (PWH) in British Columbia (BC). We examined the utilization and retention of opioid agonist therapy (OAT). Adult PWH (≥19 years) with ≥ 1 OAT dispensation in BC between 2008 and 2020 were included (n = 1,515). OAT treatment episodes were formed based on specific criteria for slow-release oral morphine (SROM), methadone, injectable OAT (iOAT), and buprenorphine/naloxone. Retention in treatment was defined as any episode lasting ≥ 12 months. Logistic regression with generalized estimating equations modeled retention-associated factors. There was a 56.6% decline in OAT retention over time. Buprenorphine treatment exhibited significantly lower odds of retention (OR: 0.58; 95% CI: 0.36-0.92) compared to methadone. Conversely, no significant change in retention odds was observed for SROM (0.72; 0.33-1.54) and iOAT (0.81; 0.31-2.12). Factors associated with increased odds of retention included a 10-year increase in age (1.69; 1.46-1.95), previous retention history (1.96; 1.40-2.73), achieving OAT therapeutic dose (8.22; 6.67-10.14), and suppressed HIV viral load (1.35; 1.10-1.67). Individuals with a lifetime HCV diagnosis receiving iOAT were more likely to retain (3.61; 1.20-10.83). Each additional year on OAT during the study period was associated with a 4% increase in the odds of retention. A significant proportion of PWH had a history of OAT prescribing but experienced low retention rates. Retention outcomes were more positive for SROM and iOAT. The association between OAT medication type and retention odds may be particularly influenced by HCV diagnosis. Optimal management of opioid use disorder among PWH, with an emphasis on attaining the therapeutic dose is crucial.

Interest in using buprenorphine-naloxone among a prospective cohort of street-involved young people in Vancouver, Canada.

INTRODUCTION: Limited research examines buprenorphine-naloxone interest among adolescents and young adults (AYA). This longitudinal study examined factors associated with initial buprenorphine-naloxone interest and the time to a positive change in buprenorphine-naloxone interest or enrollment, in addition to identifying reasons for buprenorphine-naloxone disinterest. METHODS: The study derived data from a cohort of street-involved AYA in Vancouver, Canada between December 2014 and June 2018. The analysis was restricted to AYA who reported weekly or daily illicit opioid use in the last six months but had not initiated buprenorphine-naloxone. The study examined factors associated with initial buprenorphine-naloxone interest using multivariable logistic regression, while multivariable Cox regression identified factors associated with the time to a positive change in buprenorphine-naloxone interest or actual enrollment over follow-up among AYA initially disinterested in buprenorphine-naloxone. RESULTS: Of 281 participants who reported weekly illicit opioid use but were not on buprenorphine-naloxone, 52 (18.5 %) AYA reported initial buprenorphine-naloxone interest, while 68 (24.2 %) AYA who were initially disinterested in buprenorphine-naloxone reported interest or enrollment over follow-up. In multivariable logistic regression, initial interest was positively associated with older age (Adjusted Odds Ratio [AOR] = 1.09, 95 % Confidence Interval [CI]: 1.03-1.15), but negatively associated with self-reported Indigenous identity (AOR = 0.22, 95 % CI: 0.07-0.68). In multivariable Cox regression, recent detoxification program access (Adjusted Hazard Ratio [AHR] = 0.85, 95 % CI: 0.73-0.98) was positively associated with the time to a positive change in buprenorphine-naloxone interest or enrollment. Common reasons for buprenorphine-naloxone disinterest included not wanting opioid agonist treatments (OAT) (initial n = 67, follow-up n = 105); not wanting to experience precipitated withdrawal (initial n = 42, follow-up n = 54), being satisfied with or preferring other OAT (initial n = 33, follow-up n = 52), not knowing what buprenorphine-naloxone is (initial n = 27, follow-up n = 9), previous negative treatment experiences (initial n = 19, follow-up n = 20), and wanting to continue opioid use (initial n = 13, follow-up n = 9), among others. CONCLUSIONS: We documented persistent disinterest in buprenorphine-naloxone among AYA, though participants' reasons for disinterest provide insight into the potential benefits of expanding micro-dosing induction; ensuring treatment is culturally safe; and communicating changes in buprenorphine-naloxone programming to AYA. Nevertheless, a need remains to improve the continuum of harm reduction and treatment supports for AYA.

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.

Navigating Opioid Agonist Therapy among Young People who use Illicit Opioids in Vancouver, Canada.

BACKGROUND: Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms. However, many young people are not accessing OAT. This study sought to explore how young people navigated OAT over time, including periods of engagement, disengagement, and avoidance. METHODS: Semi-structured, in-depth qualitative interviews were conducted between January 2018 and August 2020 with 56 young people in Vancouver, Canada who reported illicit, intensive heroin and/or fentanyl use. Following the verbatim transcription of longitudinal interviews, an iterative thematic analysis was used to extrapolate key themes. RESULTS: Young people contemplating OAT expressed fears about its addictiveness. Many experienced pressure from providers and family members to initiate buprenorphine-naloxone, despite a desire to explore other treatment options such as methadone. Once young people initiated OAT, staying on it was difficult and complicated by daily witnessed dosing requirements and strict rules around repeated missed doses, especially for those receiving methadone. Most young people envisioned tapering off OAT in the not-too-distant future. CONCLUSIONS: Findings underscore the importance of working collaboratively with young people to develop treatment plans and timelines, and suggest that OAT engagement and retention among young people could be improved by expanding access to the full range of OAT; updating clinical guidelines to improve access to safer prescription alternatives to the increasingly poisonous, unregulated drug supply; addressing treatment gaps arising from missed doses and take-home dosing; and providing a clear pathway to OAT tapering.

Initiation of opioid agonist treatment and subsequent substance use and other patterns among adolescents and young adults in Vancouver, Canada.

BACKGROUND: Opioid agonist treatments (OAT) are effective interventions for reducing illicit opioid use; however, less is known about OAT among adolescents and young adults (AYA). This study sought to examine OAT retention and discontinuation among AYA. METHODS: Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved AYA in Vancouver, Canada, between September 2005 and December 2018. Multivariable Cox regression analysis was employed to identify sociodemographic, substance use, and other factors associated with time to first OAT. Substance use, homelessness, service utilization, and criminal justice patterns among AYA who did and did not initiate OAT were examined using before and after analysis. RESULTS: Of 676 AYA who reported weekly illicit opioid use, 454 (67.2%) reported not being on OAT at some point over the study period and 217 (32.1%) initiated OAT over follow-up. In non-linear growth curve analysis, only participants retained in OAT demonstrated significant reductions in daily illicit opioid use when compared to 'no OAT' controls (p < 0.05). Nevertheless, reductions in homelessness (p = 0.070) and increases in difficulty accessing services (p = 0.078) were observed between participants retained in OAT vs. 'no OAT' controls, while reductions in homelessness (p = 0.085) and weekly non-medical prescription opioid use (NMPOU) (p = 0.061) were observed between 'OAT discontinuers' vs. 'no OAT' controls. CONCLUSIONS: Despite finding that OAT retention was associated with significant reductions in daily illicit opioid use, no significant improvements in other key indicators were observed. This underscores the importance of providing supports alongside OAT to improve treatment outcomes among AYA.

The Vancouver Community Analytics Tool (VCAT): Software Enabling Operationalization of the Building Blocks of High-Performing Primary Care at Community Health Centers in British Columbia, Canada.

BACKGROUND: Community health centers (CHCs) in British Columbia, Canada, are using a data-driven approach to enable functions related to the design, organization, management, delivery, and evaluation of primary health care services for complex populations. METHODS: Descriptive study leveraging case studies from 4 CHCs in Vancouver, Canada, to provide an overview and examples of the functions and outputs of the Vancouver Community Analytics Tool (VCAT). Quantitative data were derived from electronic medical record data and regional emergency department data. Data were analyzed and reported by the VCAT software. RESULTS: VCAT is a health system modeling, analytics, and reporting application suite that enables operationalization of the Ten Building Blocks of High-Performing Primary Care framework via 1) creation of a virtual patient record, 2) modeling and measurement of epidemiological profiles, 3) population management and quality improvement, 4) measurement and assessment of biopsychosocial complexity, 5) empanelment, and 6) design and optimization of team-based care. The software captures data on patient pathways and service operations for over 300 service sites, including community health centers, detox centers, and emergency departments. The software integrates data on service utilization and myriad other variables for over 750,000 individuals. DISCUSSION: Using case studies, the article describes how the software helps solve practical clinical, organizational, and performance issues facing CHCs. CONCLUSIONS: VCAT models, analyzes, and visualizes the complexity profiles and service utilization patterns of complex populations, thereby enabling system administrators and clinicians to improve system performance and quality of care. The software represents a significant advance for health services research and is transforming the organization, delivery, and evaluation of primary health care services.

Moving into an urban drug scene among people who use drugs in Vancouver, Canada: Latent class growth analysis.

BACKGROUND: Urban drug scenes are characterized by high prevalence of illicit drug dealing and use, violence and poverty, much of which is driven by the criminalization of people who use illicit drugs (PWUD) and the associated stigma. Despite significant public health needs, little is understood about patterns of moving into urban drug scenes among PWUD. Therefore, we sought to identify trajectories of residential mobility (hereafter 'mobility') among PWUD into the Downtown Eastside (DTES), an urban neighbourhood with an open drug scene in Vancouver, Canada, as well as characterize distinct trajectory groups among PWUD. METHODS: Data were derived from three prospective cohort studies of community-recruited PWUD in Vancouver between 2005 and 2016. We used latent class growth analysis (LCGA) to identify distinct patterns of moving into the DTES among participants residing outside of DTES at baseline. Multivariable multinomial logistic regression was used to determine baseline factors associated with each trajectory group. RESULTS: In total, 906 eligible participants (30.9% females) provided 9,317 observations. The LCGA assigned four trajectories: consistently living outside of DTES (52.8%); early move into DTES (11.9%); gradual move into DTES (19.5%); and move in then out (15.8%). Younger PWUD, those of Indigenous ancestry, those who were homeless or living in a single-room occupancy hotel (SRO), and those injecting drugs daily were more likely to move in then out of DTES (all p<0.05). Living in an SRO, daily injection drug use, and recent incarceration were also positively associated with early mobility (all p<0.05). CONCLUSIONS: Nearly half of the participants moved into the DTES. Younger PWUD and Indigenous peoples appeared to have particularly high mobility, as did those with markers of social-structural vulnerability and high intensity drug use. These findings indicate a need to tailor existing social and health services within the DTES and expand affordable housing options outside the DTES.

A Multi-sourced Data Analytics Approach to Measuring and Assessing Biopsychosocial Complexity: The Vancouver Community Analytics Tool Complexity Module (VCAT-CM).

Operationalization of the fundamental building blocks of primary care (i.e. empanelment, team-based care and population management) within the context of Community Health Centers requires accurate and real-time measures of biopsychosocial complexity, at both client and population-levels. This article describes the conceptualization, design and development of a novel software tool (the VCAT-Complexity Module) that can calculate and report real-time person-oriented biopsychosocial complexity profiles, using multiple data sources. The tool aligns with a profile approach to conceptualizing health outcomes, and represents a potentially significant advance over disease-oriented complexity assessment tools. The results and face validity of the software's complexity score outputs are discussed, along with their practical implications on functions related to the development of primary care within Vancouver Coastal Health, a Canadian Regional Health Authority.

Changing risk and presentation of overdose associated with consumption of street drugs at a supervised injection site in Vancouver, Canada.

BACKGROUND: British Columbia is experiencing a public health emergency due to overdoses resulting from consumption of street drugs contaminated with fentanyl. While the risk of overdoses appears to be increasing, the overdose rate and severity of overdose presentations have yet to be quantified. METHODS: Insite is a supervised injection site in Vancouver. Data from Insite's client database from January 2010 to June 2017 were used to calculate overdose rates as well as the proportion of overdoses involving rigidity and naloxone administration over time in order to estimate changes in the risk and severity of overdose resulting from changes in the local drug supply. RESULTS: The overdose rate increased significantly for all drug categories. Heroin used alone or with other drugs continues to be associated with the highest overdose rate. The overdose rate associated with heroin increased from 2.7/1000 visits to 13/1000 visits over the study period, meaning that clients were 4.8 times more likely to overdose in the most recent period as in the baseline period. The proportion of overdose events involving rigidity, a known complication of intravenous fentanyl use, increased significantly from 10.4% to 18.9%. The proportion of overdoses requiring naloxone administration increased significantly from 48.4% to 57.1% and is now similar across all drug categories. CONCLUSIONS: The risk and severity of overdoses at Insite have increased since the emergence of illicit fentanyl. This information derived from supervised injection site data can be used to inform local harm reduction efforts and the response to the overdose emergency.

A community-based innovative model of care for the management of severe bacterial infections in persons who use injection drugs.

The opioid crisis and complications related to injection drug use are a public health emergency. The combination of addiction and injection drug use is a devastating double-edged sword: it predisposes patients to severe life-threatening infections like endocarditis, and epidural abscess, as well as to disorganized behaviour and impaired decision-making that interferes with the completion of prolonged courses of required antibiotic therapy. Poverty and stigma add further fuel to the fire. The Community Transitional Care Team (CTCT) is a revolutionary community-based short-term residence where people who inject drugs can stay to complete their course of antibiotics. We present the case of a young woman struggling with addiction, tremendous social barriers to health, and life threating Staphylococcus aureus infection that highlights the benefits of strong, community-based, and individualized models of patient care.

La crise des opioïdes et les complications liées à la consommation de drogues injectables représentent une urgence de santé publique. L'association de la dépendance et de la consommation de drogues injectables est une épée à double tranchant dévastatrice. En effet, elle prédispose les patients à de graves infections au potentiel mortel comme l'endocardite et l'abcès épidural, de même qu'à une désorganisation du comportement et à une altération des décisions qui compromettent les antibiothérapies prolongées. La pauvreté et l'opprobre jettent de l'huile sur le feu. L'équipe communautaire de soins transitoires est une résidence communautaire de courte durée révolutionnaire où les personnes qui s'injectent des drogues peuvent habiter pour terminer leur antibiothérapie. Les auteurs présentent le cas d'une jeune femme aux prises avec la dépendance, d'énormes obstacles sociaux en matière de santé et une infection à Staphylococcus aureus au potentiel mortel qui fait ressortir les avantages de modèles communautaires et personnalisés robustes pour les soins aux patients.

Treatment of opioid use disorder in an innovative community-based setting after multiple treatment attempts in a woman with untreated HIV.

Opioid use disorder is associated with significant health and social harms. Various evidence-based interventions have proven successful in mitigating these harms, including harm reduction strategies and pharmacological treatment such as methadone. We present a case of a 35-year-old HIV-positive woman who was off antiretroviral therapy due to untreated opioid use disorder, and had a history of frequently self-discharging from hospital against medical advice. During the most recent hospital admission, the patient was transferred to an innovative community-based clinical support residence that supported harm reduction. Initially, she received methadone to only manage the withdrawal symptoms rather than for long-term maintenance therapy. However, with gradual dose increases to treat cravings and withdrawal, she ultimately discontinued all drug use and reinitiated antiretroviral therapy. This case highlights that patients whose goal is not abstinence can be successfully treated for acute medical illnesses and comorbid substance use disorders using harm reduction approaches, including appropriate dosing of pharmacotherapy.

A Community Care Model of Intravenous Antibiotic Therapy for Injection Drug Users with Deep Tissue Infection for "Reduce Leaving Against Medical Advice"

Deep tissue infection is a serious sequela that often demands intravenous (IV) antibiotic treatment. With respect to IV drug users (IDU's), research and lived experience demonstrates a trend of failed treatment outcomes, most notably associated with leaving hospital against medical advice (LAMA) prior to treatment completion, increased adverse outcomes and patient hardship. This paper examines an alternative model for delivering and completing IV antibiotic treatment to IDU's in a community care setting. A retrospective study was designed to review client characteristics. A total of 33 in-depth interviews were conducted with clients, clinicians and with staff. The impact of treatment adherence and completion, as well as client satisfaction of care was explored. A total of 165 patients were admitted during the study period. Osteomyelitis was the primary cause for IV antibiotics. Risk of leaving AMA was significantly lower for community model (p value <0.0000). Qualitative narrative analysis is also described with respect to satisfaction, stigma and the need for better models of care. With lower rates of LAMA a community model ought to be considered on a wider scale for provision of comprehensive support for populations with complex underlying health needs.

Bringing electronic patient records into health professional education: software architecture and implementation.

This paper describes the implementation of an Electronic Medical Record (EMR) which has been redesigned specifically for the purposes of teaching medical and other health professional students. Currently available EMR software is designed specifically for use in actual practice settings and not for the needs of students and educators. The authors identified many unique requirements of an EMR in order to satisfy the educational goals unique to the electronic medium. This paper describes the specific architecture and many of the unique features of the EMR implemented for the University of British Columbia (UBC) Medical School program for teaching medical students. This implementation describes 200 participating students participating in a hands-on use of an EMR with a single standardized patient case. The participating students were distributed across three physical sites in the Province of British Columbia UBC curricula in December, 2007.