Navigating the nexus between British Columbia's public consumption and decriminalization policies of illegal drugs.

In January 2023, the province of British Columbia (BC) decriminalized the possession of certain illegal drugs for personal use. The province's primary intent was to reduce the stigma associated with drug use, as well as barriers for people who use drugs (PWUD) to access treatment and supports. However, less than ten months into the decriminalization policy, due to growing concerns about public safety voiced by municipal governments and communities, the provincial government made amendments to the policy to ban the public consumption of illicit drugs in additional locations, and subsequently introduced additional legislation, Bill 34, aimed at regulating public consumption of drugs in public spaces. Some communities have also implemented local bylaws similarly regulating public drug use. Bill 34 and local bylaws may serve as tools to promote community health and safety and minimize direct and indirect harms associated with public drug use. However, such legislation may re-criminalize PWUD and reinforce negative perceptions surrounding drug use, especially if these policies are not paired with strategies to expand the availability and accessibility of critical harm reduction and housing services. Without ample access to these services, limitations on public drug use can potentially displace individuals to areas where they are more likely to use alone, further exposing them to substance use-related harms, and undermining the goals of decriminalization. The potential effects of these restrictions may also disproportionately impact marginalized populations. As of April 2024, Bill 34 remains on hold. Moving forward, it will be important to monitor this bill, as well as other public consumption bylaws and legislation, and their impact on BC's overall decriminalization initiative. Decision-makers are urged to increase engagement with PWUD and relevant stakeholders in the design and implementation of policies pertaining to public consumption to ensure that they effectively address the evolving needs and realities of PWUD, and align with decriminalization goals.

Examining inequities in access to opioid agonist treatment (OAT) take-home doses (THD): A Canadian OAT guideline synthesis and systematic review.

BACKGROUND: Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. METHODS: This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. RESULTS: A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. CONCLUSIONS: This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.

An environmental scan of residential treatment service provision in Ontario.

BACKGROUND: Ontario has one of the highest rates of substance-related harms in Canada. Residential treatment programs in the province provide a variety of in-house treatment services to support the needs of individuals with substance use disorders (SUD). However, these programs are not standardized, often varying in the type, quality, and availability of services offered, including evidence-based interventions such as Opioid Agonist Treatment (OAT). Local treatment systems are also rather fragmented and complex to navigate, creating barriers for potential services users to identify and make informed choices on available treatment options. METHODS: Between May to August 2023, we conducted an environmental scan to capture available information on all publicly-funded residential treatment programs in Ontario using the ConnexOntario service portal, a government-funded, health services information platform. Data were captured on organization name, geographical location, program description, program type (residential addictions treatment or supportive recovery programs), eligibility criteria, target population, the program's OAT policies, number of available beds, minimum and maximum length of stay, projected wait times, funding source, and associated fees for program admission. Data were extracted and organized by geographic region, and findings were presented descriptively. RESULTS: A total of 102 residential addiction treatment programs and 36 residential supportive recovery programs in Ontario were identified. The scan noted substantial regional variations in program availability and wait times, along with a lack of programs tailored to unique populations such as women, youth, and Indigenous peoples. There is also a paucity of publicly-available information on program offerings, including detailed specifics on OAT policies within residential treatment programs that are crucial to ensuring that the services being offered are safe and grounded in evidence-based practice. CONCLUSIONS: Findings from the scan highlight notable gaps in program types, offerings, and availability among residential treatment programs in the province, including a lack of standardization on OAT policies across programs. Efforts should be made to ensure access to treatment-specific program information relevant to potential service users and to enhance coordinated access to residential treatment services in the province.

Client experiences using a new supervised consumption service in Sudbury, Ontario: A qualitative study.

Overdoses are increasing in the province of Ontario, Canada, where northern communities such as Sudbury have witnessed disproportionately elevated rates, with opioid-related deaths double that of the provincial average. To address this issue, governments have implemented supervised consumption services (SCS) where people who use drugs (PWUD) can use their pre-obtained substances onsite under trained supervision. In September 2022, the city of Sudbury opened its first SCS, 'The Spot', but the site's sustainability is contingent on demonstrating benefit to PWUD and the neighboring community. We undertook a qualitative study exploring experiences among clients who used the consumption service inside The Spot. In December 2022, clients of The Spot were invited to participate in a brief survey which collected socio-demographic information and substance use profiles, followed by an in-person semi-structured qualitative interview. Participant survey and interview data were combined with administrative site utilization data provided by site staff of all clients who accessed the consumption service from September 2022 to August 2023 to examine overall service utilization and uptake. Qualitative data were analyzed using iterative thematic analysis techniques, and results were informed by common responses to research questions. The responses were narratively presented. Administrative site utilization data highlighted a relatively stable increase in uptake and utilization of the site since its inception. A total of 20 clients participated in the survey and semi-structured interviews. Participants described the importance of the site in preventing and responding to overdoses, providing a safe and comfortable environment to consume their drugs, and decreasing public drug use, which they suggested may potentially reduce stigmatization in the community. However, clients also suggested challenges, including issues regarding site operational policies that hindered consumption room utilization. Service suggestions made by clients to improve site utilization include the addition of inhalation services, relocating the site to a location in downtown Sudbury where PWUD commonly congregate, and extending operational hours. Positive impacts and recommendations can be drawn on and considered by other northern or rural communities interested in implementing similar harm reduction services.

The impact of methamphetamine use on medications for opioid use disorder (MOUD) treatment retention: a scoping review.

BACKGROUND: An emerging public health threat of methamphetamine/opioid co-use is occurring in North America, including increases in overdoses related to concomitant methamphetamine/opioid use. This presents a potential risk to established treatments for opioid use disorder (i.e., medications for opioid use disorder [MOUD]). To date, few studies have examined the impact of methamphetamine use on MOUD-related outcomes, and no studies have synthesized data on MOUD retention. METHODS: A scoping review was undertaken to examine the impact of methamphetamine use on MOUD retention. All original published research articles were searched in Embase, MEDLINE, PsychINFO, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Cochrane Protocols, and Google scholar databases. Data were extracted into a standardized data extraction chart. Findings were presented narratively. RESULTS: All eight included studies demonstrated an increased likelihood of treatment discontinuation or dropout among patients enrolled in MOUD who used methamphetamine. The frequency of methamphetamine use was also associated with MOUD dropout, in that those who used methamphetamine more often were more likely to discontinue MOUD. The definitions and measurements of MOUD retention varied considerably, as did the magnitude of effect size. CONCLUSIONS: Results indicate that methamphetamine use has an undesirable impact on MOUD retention and results in an increased risk of treatment discontinuation or dropout. Strategies to identify concurrent methamphetamine use among individuals engaging in MOUD and educate them on the increased risk for dropout should be undertaken. Further research is needed to understand how MOUD retention among patients with concomitant opioid and methamphetamine use can be improved.

Identifying barriers and facilitators to COVID-19 vaccination uptake among People Who Use Drugs in Canada: a National Qualitative Study.

BACKGROUND: People Who Use Drugs (PWUD) have lower vaccination uptake than the general population, and disproportionately experience the burden of harms from vaccine-preventable diseases. We conducted a national qualitative study to: (1) identify the barriers and facilitators to receiving COVID-19 vaccinations among PWUD; and (2) identify interventions to support PWUD in their decision-making. METHODS: Between March and October 2022, semi-structured interviews with PWUD across Canada were conducted. Fully vaccinated (2 or more doses) and partially or unvaccinated (1 dose or less) participants were recruited from a convenience sample to participate in telephone interviews to discuss facilitators, barriers, and concerns about receiving COVID-19 vaccines and subsequent boosters, and ways to address concerns. A total of 78 PWUD participated in the study, with 50 participants being fully vaccinated and 28 participants partially or unvaccinated. Using thematic analysis, interviews were coded based on the capability, opportunity, and motivation-behavior (COM-B) framework. RESULTS: Many partially or unvaccinated participants reported lacking knowledge about the COVID-19 vaccine, particularly in terms of its usefulness and benefits. Some participants reported lacking knowledge around potential long-term side effects of the vaccine, and the differences of the various vaccine brands. Distrust toward government and healthcare agencies, the unprecedented rapidity of vaccine development and skepticism of vaccine effectiveness were also noted as barriers. Facilitators for vaccination included a desire to protect oneself or others and compliance with government mandates which required individuals to get vaccinated in order to access services, attend work or travel. To improve vaccination uptake, the most trusted and appropriate avenues for vaccination information sharing were identified by participants to be people with lived and living experience with drug use (PWLLE), harm reduction workers, or healthcare providers working within settings commonly visited by PWUD. CONCLUSION: PWLLE should be supported to design tailored information to reduce barriers and address mistrust. Resources addressing knowledge gaps should be disseminated in areas and through organizations where PWUD frequently access, such as harm reduction services and social media platforms.

"2.5 g, I could do that before noon": a qualitative study on people who use drugs' perspectives on the impacts of British Columbia's decriminalization of illegal drugs threshold limit.

BACKGROUND: In May 2022, Health Canada approved a three-year exemption from the Controlled Drugs and Substances Act decriminalizing possession of certain illegal substances for personal use among adults in the province of British Columbia. The exemption explicitly includes a cumulative threshold of 2.5 g of opioids, cocaine, methamphetamine, and MDMA. Threshold quantities are commonly included in decriminalization policies and justified within law enforcement systems to delineate personal use among people who use drugs versus drug dealers who are carrying for trafficking purposes. Understanding the impact of the 2.5g threshold can help define the extent to which people who use drugs will be decriminalized. METHODS: From June-October 2022, 45 people who use drugs from British Columbia were interviewed to gain an understanding of their perceptions on decriminalization, particularly on the proposed threshold of 2.5 g. We conduced descriptive thematic analyses to synthesize common interview responses. RESULTS: Results are displayed under two categories: 1) Implications for substance use profiles and purchasing patterns, including implications on the cumulative nature of the threshold and impacts on bulk purchasing, and 2) Implications of police enforcement, including distrust of police use of discretion, potential for net widening and jurisdictional discrepancies in enforcing the threshold. Results illustrate the need for the decriminalization policy to consider diversity in consumption patterns and frequency of use among people who use drugs, the inclination to purchase larger quantities of substances for reduced costs and to guarantee a safe and available supply, and the role police will play in delineating between possession for personal use or trafficking purposes. CONCLUSIONS: The findings underscore the importance of monitoring the impact of the threshold on people who use drugs and whether it is countering the goals of the policy. Consultations with people who use drugs can help policymakers understand the challenges they may face when trying to abide by this threshold.

Types of suicide pacts: a comparative analysis using the National Violent Death Reporting System.

Introduction: Suicide pacts are lethal acts of violence involving multiple decedents. No study has ever compared suicide pact types using a large sample, limiting our understanding of this rare but serious phenomenon. The objective of the current study was to describe suicide pacts in the United States and empirically compare suicide pacts wherein all decedents died by self-harm with those that involved assisted suicide. Methods: Using restricted access incident-level data from the National Violent Death Reporting System, we identified 277 suicide pact incidents (225 suicide pacts wherein all decedents died by self-harm and 52 suicide pacts wherein one pact member died by assisted suicide). The two suicide pact types were compared for demographics, pact characteristics, and preceding circumstances. Results: Compared with decedents of suicide pacts involving assisted suicide, decedents of suicide pacts wherein both members died by self-harm had significantly lower odds of being non-white, Hispanic or non-Hispanic (OR = 0.33, 95%CI: 0.18, 0.64), using an active method of suicide (i.e., ICD-10 codes X70-X83) (OR = 0.01, 95%CI: <0.01, 0.04), and experiencing interpersonal relationship problems (OR = 0.48, 95%CI: 0.27, 0.87) and a crisis within two weeks of their death (OR = 0.58, 95%CI: 0.36, 0.97), but greater odds of preceding physical health problems (OR = 3.25, 95%CI: 1.84, 6.04). Discussion: Overall, our findings indicate that suicide pacts wherein all decedents died by self-harm and suicide pacts that involved an assisted suicide appear to have largely distinct profiles. While further research is required, the discrete characteristics of these two types of suicide pacts have important implications for prevention.

A comparative analysis of solitary suicides, suicides following homicide, and suicide pacts using the National Violent Death Reporting System.

BACKGROUND: Incidents of suicide can be categorized into three main types: solitary suicides, suicides following homicide, and suicide pacts. Although these three suicide incidents vary by definition, no studies to-date have simultaneously examined and compared them for potential differences. The objective of the current study was to empirically and descriptively compare solitary suicides, suicides following homicide, and suicide pacts in the United States. METHODS: Restricted-access data from the National Violent Death Report System for 2003-2019 for 262,679 solitary suicides, 4,352 suicides following homicide, and 450 suicide pacts were used. Pairwise comparisons of the three suicide incident types were made for demographic factors, method of suicide, preceding circumstances, mental health status, and toxicology findings. RESULTS: Solitary suicides, suicides following homicide, and suicide pacts have distinct profiles, with statistically significant (p < 0.05) differences across all pairwise comparisons of sex, race, ethnicity, marital status, education, method of suicide, financial problems, interpersonal relationship problems, physical health problems, mental health problems, mood disorders, suicide attempt history, and opiate use at the time of death. CONCLUSION: Despite sharing a few commonalities, solitary suicides, suicides following homicide, and suicide pacts represent distinct phenomena. Each of these suicide incident types likely have their own unique prevention pathways.

What is a public health approach to substance use? A qualitative systematic review and thematic synthesis.

BACKGROUND: Psychoactive substance use and the regulations that govern it both have the potential to lead to harm. A 'public health approach' (PHA) is frequently invoked as a means of addressing these harms, but the term is used in inconsistent and contradictory ways. This study systematically reviewed the English-language academic literature to understand how a public health approach to substance use is defined and described. METHODS: This review employed thematic synthesis, a methodology designed to rigorously synthesize qualitative evidence. Eligible articles were published in peer-reviewed journals, in the English language, with full text available, and focused primarily on substance use. There were no limits on year of publication. Original research, opinion/commentary, and reviews were included. The searches were conducted in October 2021 in CINAHL, Embase, Medline, PAIS Index, PsycINFO, Scopus, Sociological Abstracts, and Web of Science. RESULTS: 272 articles from 25 countries, published between 1950 and 2021, were synthesized. Definitions of a PHA have changed over time and differ by substance. The most commonly cited characteristics of a PHA were: for alcohol, regulation, e.g. of price and availability (54% of articles); for cannabis: regulation (68%); for illicit drugs: that a PHA is distinct from a criminal justice approach (63%); for opioids: substance use disorder treatment (55%); and for tobacco: regulation (62%). CONCLUSION: There is no consensus on the definition of a public health approach to substance use, but there is substantial agreement when it comes to PHAs to specific substances. There are also similarities in how they are described for legal substances versus illicit ones. This review found areas of disagreement regarding the extent to which PHAs should focus on individual-level factors. Policymakers, academics, and others developing or implementing PHAs to substance use should be explicit about their aims and objectives - as well as the premises and assumptions underlying them.

The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions.

The overdose crisis in Canada has continuously evolved and is increasingly challenging to contain, while efforts from governments and policymakers to address it have often fallen short and resulted in unintended consequences. One of the main repercussions has been an unprecedented rise in adulterants in the illegal drug supply, including a wide array of pharmacological and psychoactive compounds and chemicals, which has resulted in a progressively toxic drug supply. Most recently, there has been a stark increase in synthetic benzodiazepine-laced opioids (i.e., 'benzodope') in some Canadian jurisdictions. This unique combination carries distinct and amplified risks for people who use drugs including fatal and non-fatal overdoses, increased dependence and withdrawal symptoms, and places them in extremely vulnerable positions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug-related morbidity and mortality in Canada, and has further complicated current public health initiatives and overdose prevention efforts. This reality underscores the need for effective and sustainable policy solutions to address the evolving overdose epidemic including increased knowledge and education on the specific harms of opioid and benzodiazepine co-use (especially in regards to the complexity of opioid/benzodiazepine overdoses), scaling-up harm reduction measures, and eliminating the toxic drug supply altogether.

Opioid agonist treatment take-home doses ('carries'): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA?

Opioid agonist treatment (OAT) is the primary intervention for opioid use disorder (OUD) in Canada and the USA. Yet, a number of barriers contribute to sub-optimal treatment uptake and retention, including daily-supervised medication administration. Thus, clients are eventually granted access to take-home OAT doses (i.e., 'carries') to reduce this burden. However, this decision is based on physician discretion and whether patients can demonstrate stability in various life domains, many of which are inextricably linked to the social determinants of health (SDOH). Current Canadian and USA OAT carry guidance documents are not standardized and do not take the SDOH into consideration, resulting in the potential for inequitable access to OAT carries, which may be the case particularly among marginalized populations such as individuals with OUD who have been released from custody. This perspective article posits that current OAT guidelines contribute to inequities in access to OAT carries, and that these inequities likely result in disproportionately low coverage for OUD treatment among some high-risk groups, including individuals on release from incarceration in particular. Relevant impacts of COVID-19 and related policy changes are considered, and suggestions and recommendations to amend current OAT guidance documents are provided.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada.

INTRODUCTION: Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada. METHODS: This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants' release. Data were thematically analyzed. RESULTS: The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of 'take-home' OAT medications were common barriers. CONCLUSIONS: Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

Opioid agonist treatment (OAT) experiences and release plans among federally incarcerated individuals with opioid use disorder (OUD) in Ontario, Canada: a mixed-methods study.

BACKGROUND: Incarcerated populations experience an elevated prevalence of opioid use disorder (OUD). Federal correctional institutions in Canada have increasingly treated OUD among correctional populations via opioid agonist treatment (OAT) - an evidence based pharmacotherapy that works to reduce drug use and related health harms. However, there is limited evidence regarding incarcerated individuals' experiences with institutional-based OAT, as well potential OAT-related community release prospects. This information is important for optimal treatment retention and improved health. To address this knowledge gap, we conducted a longitudinal follow-up study examining OAT-related experiences among federally incarcerated individuals before and after community release. This article focuses on the baseline (pre-release) data. METHODS: This mixed-methods study examined OAT-related experiences and release prospects among n = 46 individuals scheduled for community release, recruited from seven federal prisons located in Ontario, Canada. Participants underwent a comprehensive interviewer-administered on-site assessment, including quantitative and qualitative items. Assessment data was furthermore linked to administrative correctional data. Data were analyzed using thematic qualitative and descriptive quantitative approaches. RESULTS: Participants had complex histories with opioid use including related negative health outcomes. Experiences with institutional OAT were divergent and provision was not standardized; those with OAT engagement pre-admission did not experience many challenges, whereas those initiating OAT during incarceration experienced barriers such as treatment waitlists and adverse process experiences. Most participants expressed a preference for buprenorphine-naloxone over methadone, but described difficulties accessing it. Participants were keen to transition into community-based treatment, yet envisaged prospective barriers and facilitators concerning successful reintegration and treatment continuity. CONCLUSIONS: Major barriers towards the current administration of OAT in federal correctional systems in Canada exist, including extensive waitlists, non-standardized practices, and challenges accessing preferred OAT formulations; this contributes to sub-optimal treatment. Eliminating waitlists, standardizing OAT provision, providing additional OAT options, and more comprehensive release planning may be essential for treatment retention and positive outcomes.

Youth substance use service provider's perspectives on use and service access in ontario: time to reframe the discourse.

BACKGROUND: Age is a critical factor in substance use and related outcomes, with adolescence being a particularly sensitive period. Early initiation of substance use has been linked with higher risk for developing substance use disorders. In Ontario, Canada, substance use is common among youth, yet treatment is underutilized, suggesting the potential for an unmet need in terms of substance use care. Despite these challenges, there is limited research examining factors that contribute to youth substance use and youth-specific barriers to substance use care. To fill this knowledge gap, this study sought to include the unique perspectives of service providers who work directly with youth to examine these issues. METHODS: We used a cross-sectional mixed-methods design to examine factors that contribute to substance use among youth and identify youth-specific barriers to substance use among a sample of 54 Ontario-based youth service providers. Data collection included an online survey completed by all study participants followed by qualitative interviews of a subsample of 16 participants. Data analysis included basic frequency tabulations for survey results and thematic qualitative analyses to identify common themes. RESULTS: Licit substances were identified as the most commonly used among youth, where 94% of respondents identified cannabis use and 81% identified alcohol use. Thematic analyses identified the role of dominant substance use discourses in normalizing certain substances (i.e., cannabis and alcohol) while also endorsing stigmatizing beliefs and sentiments. According to youth service providers, the intersection of these two discourses simultaneously lead to an increase in substance use while deterring youth from seeking substance use care. CONCLUSIONS: Normalization and stigmatization are two dominant discourses around youth substance use, with important implications for public health interventions. Key public health strategies, as identified by participants, to reduce the overall negative effect of these factors include the need to reframe substance use discourse, from a moral failing to a public health issue and to educate youth about the impacts of use. To accomplish this goal educational campaigns to raise awareness around the health effects of use and address stigmatization are needed. Educational reforms are also needed to ensure that these programs are integrated into the school system.

Comparing characteristics and outcomes of different opioid agonist treatment modalities among opioid-dependent federal men correctional populations in Canada.

BACKGROUND: Limited evidence exists in Canada on outcomes related to Opioid Agonist Treatment (OAT) and/or differences between OAT modalities among persons in correctional institutions. This study addresses this knowledge gap by examining key characteristics and outcomes of men in Canadian federal correctional institutions across treatment modalities. METHODS: A retrospective cohort of men incarcerated in federal correctional institutions (N = 2833) were classified into four groups - three OAT participant groups: prescribed methadone (M-OAT), prescribed buprenorphine/naloxone (Suboxone®; S-OAT) and those who switched between the two OAT modalities at least once (X-OAT). The fourth group was a non-treatment comparison group (Non-OAT). Two-thirds of study participants were released and examined for post-release outcomes. Descriptive statistics and multi-variate Cox proportional hazards regression were used. RESULTS: The X-OAT group was more likely than the other study groups to have positive urinalysis tests, disciplinary charges, or institutional security or behavioral incidents. Survival analysis indicated that the X-OAT had an adjusted hazard of a return to custody that was 57% greater than the other groups. CONCLUSIONS: This study indicates that individuals switching OAT modalities are a more complex group needing additional supports, especially for community reintegration. Although few of the returns to custody were due to new offences, a third of participants in the OAT groups had their release revoked, indicating a high need population mostly due to their substance use.

A qualitative examination of substance use service needs among people who use drugs (PWUD) with treatment and service experience in Ontario, Canada.

BACKGROUND: People who use drugs (PWUD) often have complex health and social support needs related to substance use, yet face numerous barriers to service access, resulting in unmet treatment needs and a corresponding gap in treatment. While initiatives to scale up substance use services for PWUD in Canada - and Ontario - have been undertaken, these have excluded PWUD' perspectives, and their needs have largely been defined by other actors. As end-users of services, PWUD' perspectives are vital to understanding what services are required, and whether existent services are adequate, appropriate and effective. Thus, the present study aimed to elicit in-depth knowledge from PWUD with lived experience of accessing services to better understand their unmet treatment and service needs, towards closing the service and treatment gap in Ontario. METHODS: This qualitative study included one-on-one interviews conducted with a cohort of n = 45 adult PWUD with substance use and treatment experience in Ontario, Canada. Participants were recruited from substance use services based on ConnexOntario's directory of all provincial addiction services, as well as by word-of-mouth. Questions focused on participants' experiences and perspectives on substance use services towards understanding their service needs. Data underwent an inductive thematic analysis based on key themes that emerged. RESULTS: Participants commonly engaged in polysubstance use, and identified a number of unmet substance use service needs including complex factors within the current service system that influenced access to available programs. Specifically, participants suggested the need to address stigmatization and system fragmentation, increase service provision and capacity, and scale up specific services and related supports such as harm reduction, counseling, treatment, and housing. CONCLUSIONS: This study identified PWUD' needs in relation to substance use service provision in Ontario, Canada, and highlighted important areas for policy change and program planning and implementation. Concrete recommendations include the development of a government-funded, low-barrier, comprehensive and integrated service delivery and referral models that include PWUD as collaborators and program facilitators to ensure that services are as accessible, effective, and cohesive as possible. Results from this study can be used to enhance provincial substance use treatment and service provision.

The impact of the novel coronavirus disease (COVID-19) pandemic on drug overdose-related deaths in the United States and Canada: a systematic review of observational studies and analysis of public health surveillance data.

BACKGROUND: There are preliminary indications that the trajectory of drug overdose-related deaths in North America has been exacerbated due to the novel coronavirus disease pandemic (COVID-19). As such, the impact of COVID-19 on drug overdose-related deaths was examined through a systematic review of the literature and percentage change analyses of surveillance data. METHODS: Systematic searches in electronic databases were conducted, a topical issue brief and bibliography were reviewed, reference lists of included studies were searched and expert consultations were held to identify studies (Registration # CRD42021230223). Observational studies from the United States and Canada were eligible for inclusion if drug overdose-related deaths were assessed in quantitative or qualitative analyses onwards from at least March 2020. In addition, percentage changes comparing drug overdose-related deaths in the second annual quarter (Q2 2020 [April to June]) with the first annual quarter (Q1 2020 [January to March]) were generated using national and subnational data from public health surveillance systems and reports from jurisdictions in the United States and Canada. RESULTS: Nine studies were included in the systematic review, eight from the United States and one from Canada. The maximum outcome assessment period in the included studies extended until September 2020. Drug overdose-related deaths after the onset of COVID-19 were higher compared with the months leading up to the pandemic in 2020 and the comparative months in 2019. In additional percentage change analyses, drug overdose-related deaths increased by 2 to 60% in jurisdictions in the United States and by 58% in Canada when comparing Q2 2020 with Q1 2020. CONCLUSIONS: Drug overdose-related deaths increased after the onset of COVID-19. The current situation necessitates a multi-pronged approach, encompassing expanded access to substance use disorder treatment, undisrupted access to harm reduction services, emphasis on risk reduction strategies, provision of a safe drug supply and decriminalization of drug use.

Identifying the impacts of the COVID-19 pandemic on service access for people who use drugs (PWUD): A national qualitative study.

INTRODUCTION: Closures and reductions in capacity of select health and social services in response to the COVID-19 pandemic may have placed people who use drugs (PWUD) at a disproportionately increased risk for experiencing harms, and resulted in critical treatment disruptions. We conducted the current national study among a cohort of PWUD to understand how COVID-19 has affected service access, including any significant impacts PWUD may have experienced. Results will contribute to the evidence base for informing future pandemic and public health policy planning for vulnerable populations. METHODS: The project involved qualitative telephone-based interviews with 196 adult (aged 18+) PWUD from across Canada. Eligibility criteria included daily or weekly use of psychoactive substance(s), and/or current enrollment in opioid agonist treatment (OAT). Data collection took place between May and July 2020. Data underwent thematic analyses, and common themes informed the results. RESULTS: Most participants experienced detrimental service access issues and treatment disruptions during COVID-19, including reduced access to harm reduction services, OAT, withdrawal management and treatment services, medical professionals (e.g., addictions and mental health counseling), shelters/housing, and food banks. Positive impacts included greater access to OAT take-home 'carries' and prescription deliveries. Decreases in service capacity resulted in increased health issues and risky substance use behaviors among PWUD, such as unaccompanied substance use, sharing/re-use of supplies, and overdose events. CONCLUSIONS: Reductions in the accessibility of critical services PWUD rely on during COVID-19 has increased existent substance use and health issues among PWUD, while decreasing their ability to mitigate risks related to substance use. Thus, the expansion of the depth and breadth of support options is crucial. Services must remain open and flexible to the unique needs of PWUD during COVID-19, while novel and effective adaptations and interventions should remain available and accessible post-COVID-19.