A qualitative study on perceptions and experiences of overdose among people who smoke drugs in Vancouver, British Columbia.

BACKGROUND: Smoking unregulated drugs has increased substantially in British Columbia. Intersecting with the ongoing overdose crisis, drug smoking-related overdose fatalities have correspondingly surged. However, little is known about the experiences of overdose among people who smoke drugs accessing the toxic drug supply. This study explores perceptions and experiences of overdose among people who smoke drugs. METHODS: We conducted interviews with 31 people who smoke drugs. Interviews covered a range of topics including overdose experience. Thematic analysis was used to identify themes related to participant perceptions and experiences of smoking-related overdose. RESULTS: Some participants perceived smoking drugs to pose lower overdose risk relative to injecting drugs. Participants reported smoking-related overdose experiences, including from underestimating the potency of drugs, the cross-contamination of stimulants with opioids, and responding to smoking-related overdose events. CONCLUSIONS: Findings highlight the impact the unpredictable, unregulated, and toxic drug supply is having on people who smoke drugs, both among people who use opioids, and among those who primarily use stimulants. Efforts to address smoking-related overdose could benefit from expanding supervised smoking sites, working with people who use drugs to disseminate accurate knowledge around smoking-related overdose risk, and offering a smokable alternative to the unpredictable drug supply.

The single-cell transcriptome program of nodule development cellular lineages in Medicago truncatula.

Legumes establish a symbiotic relationship with nitrogen-fixing rhizobia by developing nodules. Nodules are modified lateral roots that undergo changes in their cellular development in response to bacteria, but the transcriptional reprogramming that occurs in these root cells remains largely uncharacterized. Here, we describe the cell-type-specific transcriptome response of Medicago truncatula roots to rhizobia during early nodule development in the wild-type genotype Jemalong A17, complemented with a hypernodulating mutant (sunn-4) to expand the cell population responding to infection and subsequent biological inferences. The analysis identifies epidermal root hair and stele sub-cell types associated with a symbiotic response to infection and regulation of nodule proliferation. Trajectory inference shows cortex-derived cell lineages differentiating to form the nodule primordia and, posteriorly, its meristem, while modulating the regulation of phytohormone-related genes. Gene regulatory analysis of the cell transcriptomes identifies new regulators of nodulation, including STYLISH 4, for which the function is validated.

Using alone at home: What's missing in housing-based responses to the overdose crisis?

BACKGROUND: Against the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis. HARM REDUCTION AND OVERDOSE PREVENTION IN HOUSING: In response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts. CONCLUSION: Emerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings.

Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis.

BACKGROUND: Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase. METHODS: We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research. RESULTS: We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models). CONCLUSIONS: Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.

"We just don't have the space for it": Geographies of survival and spatial triage in overdose prevention sites.

This study explores the role of Overdose Prevention Sites (OPS) within the geographies of survival of vulnerably housed people who use drugs (PWUD) in Vancouver, British Columbia (BC), Canada. In BC, OPS are low-barrier spaces where people may use drugs under monitoring of trained staff. OPS have been established by people who use drugs, activists, and allied organizations as an emergency measure to prevent overdose deaths. However, OPS have other important uses for PWUD who are vulnerably housed and rely on public spaces for survival. Drawing on two years (2018-2020) of ethnographic fieldwork and interviews with fifty-five people who work at and/or use OPS, we explore how OPS operators negotiated multiple and at times competing uses of service space for everyday survival. Data analysis was guided by critical urban theory to explore the place of OPS within PWUD's geographies of survival, with attention to how different uses of space were negotiated within the context of an illicit drug poisoning crisis and urban control practices that displace and exclude unhoused and vulnerably housed PWUD from the city. We find that OPS accommodated other important potential uses of space for unhoused and vulnerably housed PWUD who relied on public space for survival and were routinely displaced by revanchist urban control strategies. Low-barrier approaches and facility enhancements to OPS improved program accessibility and enabled PWUD to use the sites more broadly to meet survival needs including for mutual-aid, sheltering, and income-generation. However, these secondary uses of OPS presented multiple operational challenges as service volumes increased. We observed processes of 'spatial triage' emerge within sites to manage these challenges, which we characterise as a pragmatic set of rules, procedures, and spatial practices that constrained broader uses of OPS within PWUD's geographies of survival. While spatial triage offered a pragmatic way of prioritizing service delivery to address the most acute survival threats of overdose fatality, these practices had unintended and inequitable impacts on service access. Our findings indicate the need for complementary structural changes as part of overdose responses to reduce the need for spatial triage (i.e., safe, affordable housing and drug decriminalisation) and service innovations to mitigate potential harms (e.g., Expanded drop-in and chill spaces, temporary storage spaces for service user).

Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada.

BACKGROUND: Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT. METHODS: Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes. RESULTS: Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment. CONCLUSION: This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.

Women who use drugs: engagement in practices of harm reduction care.

BACKGROUND: Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada. METHODS: Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction. FINDINGS: Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection. CONCLUSION: The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

"It's no foundation, there's no stabilization, you're just scattered": A qualitative study of the institutional circuit of recently-evicted people who use drugs.

People who use drugs (PWUD) commonly experience housing instability due to intersecting structural vulnerabilities (e.g., drug prohibition, discriminatory housing policies), and prejudicial or illegal evictions are common. In Vancouver, Canada, evictions have proliferated in the Downtown Eastside, a historically low-income neighbourhood with high rates of drug use and housing instability, resulting in many PWUD being evicted into homelessness. This study characterizes housing trajectories of recently-evicted PWUD through the lens of the institutional circuit of homelessness, and explores how wider contexts of structural vulnerability shape experiences within this. Qualitative interviews were conducted with PWUD recently evicted in the Downtown Eastside (<60 days). Peer research assistants recruited 58 PWUD through outreach activities. All PWUD participated in baseline interviews on the causes and contexts of evictions. Follow-up interviews were completed with 41 participants 3-6 months later, focusing on longer-term impacts of eviction, including housing trajectories. Most participants were evicted into homelessness, remaining so at follow-up. Participants described patterns of residential instability consisting of frequent cycling between shelters, streets, and kin-based networks. While participants normalized this cycling as characteristic of their marginalized social positions, narratives revealed how the demands of the institutional circuit deepened vulnerabilities and prolonged experiences of homelessness. Experiences were framed by participants' (in)ability to navigate survival needs (e.g., shelter, drug use), with tensions and trade-offs between needs increasing participants' and their peers' risks of harms. Constructions of agency further shaped experiences; accounts highlighted tensions between the control inherent to indoor spaces and participants' need for autonomy. Findings demonstrate how the demands of the institutional circuit foregrounded structural vulnerabilities to perpetuate cycles of instability. Interventions that address survival needs and preserve agency will be necessary to mitigate risks within the institutional circuit, in tandem with upstream interventions that target housing vulnerability and broader social-structural conditions (e.g., poverty, affordability) that entrap recently-evicted PWUD in the institutional circuit.

Emergency department experiences of people who use drugs who left or were discharged from hospital against medical advice.

BACKGROUND: People who use drugs (PWUD) frequent emergency departments at a higher rate than the general population, and experience a greater frequency of soft tissue infections, pneumonia, and chronic conditions such as, HIV/AIDs and hepatitis C. This population has distinct health care considerations (e.g. withdrawal management) and are also more likely to leave or be discharged from hospital against medical advice. METHODS: This study examines the experiences of PWUD who have left or been discharged from hospital against medical advice to understand the structural vulnerabilities that shape experiences with emergency departments. Semi-structured qualitative interviews were conducted with 30 PWUD who have left or been discharged from hospital against medical advice within the past two years as part of a larger study on hospital care and drug use in Vancouver, Canada. RESULTS: Findings characterize the experiences and perceptions of PWUD in emergency department settings, and include: (1) stigmatization of PWUD and compounding experiences of discrimination; (2) perceptions of overall neglect; (3) inadequate pain and withdrawal management; and (4) leaving ED against medical advice and a lack of willingness to engage in future care. CONCLUSIONS: Structural vulnerabilities in ED can negatively impact the care received among PWUD. Findings demonstrate the need to consider how structural factors impact care for PWUD and to leverage existing infrastructure to incorporate harm reduction and a structural competency focused care. Findings also point to the need to consider how withdrawal and pain are managed in emergency department settings.

(Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada.

Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of supportive environments and team-based approaches for overdose response; and the benefits of community-driven training that extends beyond technical skills of overdose identification and naloxone administration.

The perspectives of street-involved youth who use drugs regarding the acceptability and feasibility of HIV pre-exposure prophylaxis: a qualitative study.

Street-involved youth who use drugs (YWUD) face an elevated risk of HIV acquisition and represent a key population for HIV prevention initiatives, including pre-exposure prophylaxis (PrEP). However, little is known regarding the acceptability and feasibility of PrEP uptake and adherence among this multiply-marginalized population. Semi-structured qualitative interviews were conducted with 24 street-involved YWUD (ages 17-24) to examine their perspectives toward PrEP; youth were recruited through a longitudinal prospective cohort study in Vancouver, Canada. Youth reported high levels of ambivalence toward PrEP despite engagement in HIV-related risk behaviors. This ambivalence was driven by misperceptions regarding HIV transmission, including stigmatizing associations between HIV transmission and personal hygiene. Such misperceptions led participants to enact strategies that were ineffective in preventing HIV transmission. Participants contested their inclusion as a "key population" for PrEP, which limited their enthusiasm for PrEP uptake and adherence. Participants also highlighted that wider social-structural inequities (e.g., housing vulnerability, poverty) that produced HIV-related risks were likely to undermine sustained PrEP use. Findings demonstrate the need for tailored implementation strategies to increase PrEP acceptability, including targeted education and anti-stigma interventions to increase awareness about HIV transmission. Interventions should also target structural inequities in order to fully address HIV risk and PrEP ambivalence.

Beyond co-production: The construction of drug checking knowledge in a Canadian supervised injection facility.

Drug-checking is an ensemble of different harm reduction techniques providing people the ability to test illegally purchased drugs for strength, the presence of particular substances, and possible adulterants. Drug-checking research has primarily focused on nightlife and festival communities of people who use drugs and has overlooked how it functions as a knowledge forming process, particularly by people whose drug use is more stigmatized. The implementation of Fourier-Transform Infrared Spectroscopy (FTIR) in Vancouver, Canada's Downtown Eastside in response to the overdose crisis has made it possible for people who use drugs to receive information about the drugs that they are consuming. Using insights developed from the 'ontological turn' and approaches to co-production from public health and science and technology studies, we explore the multiple relations that come to produce and contest drug-checking knowledge in this setting. We look at how knowledge is produced by and for people who use drugs, including people who use drugs operating the FTIR. Using rapid ethnographic assessment and semi-structured interviews, participants were recruited from a low-barrier supervised injection facility to explore their experience of drug-checking. Data were coded in NVivo 12 using an initial coding scheme, as well as an iterative coding scheme as the data were explored. We find that the traditional demarcation between lay and expert, or peer and professional, which co-production idioms often rely on, creates barriers to seeing the different knowledge formations of drug-checking knowledge, and instead offer up a new idiom, trans-production, to explore how knowledge and harm reduction services are mutually enacted.

Advancing virtual primary care for people with opioid use disorder (VPC OUD): a mixed-methods study protocol.

INTRODUCTION: The emergence of COVID-19 introduced a dual public health emergency in British Columbia, which was already in the fourth year of its opioid-related overdose crisis. The public health response to COVID-19 must explicitly consider the unique needs of, and impacts on, communities experiencing marginalisation including people with opioid use disorder (PWOUD). The broad move to virtual forms of primary care, for example, may result in changes to healthcare access, delivery of opioid agonist therapies or fluctuations in co-occurring health problems that are prevalent in this population. The goal of this mixed-methods study is to characterise changes to primary care access and patient outcomes following the rapid introduction of virtual care for PWOUD. METHODS AND ANALYSIS: We will use a fully integrated mixed-methods design comprised of three components: (a) qualitative interviews with family physicians and PWOUD to document experiences with delivering and accessing virtual visits, respectively; (b) quantitative analysis of linked, population-based administrative data to describe the uptake of virtual care, its impact on access to services and downstream outcomes for PWOUD; and (c) facilitated deliberative dialogues to co-create educational resources for family physicians, PWOUD and policymakers that promote equitable access to high-quality virtual primary care for this population. ETHICS AND DISSEMINATION: Approval for this study has been granted by Research Ethics British Columbia. We will convene PWOUD and family physicians for deliberative dialogues to co-create educational materials and policy recommendations based on our findings. We will also disseminate findings via traditional academic outputs such as conferences and peer-reviewed publications.

"That's what I'm supposed to do at work": Gendered labor, self-care, and overdose risk among women who use drugs in Vancouver, Canada.

Through rapid ethnography undertaken in Vancouver, Canada's Downtown Eastside - one of Canada's overdose epicenters - this article examines how gendered expectations of labor shape overdose risk for structurally vulnerable women and gender diverse people who use drugs. Drawing on two participant narratives, we explore how structural, symbolic, and everyday violence frame the lives of women and gender diverse people who use drugs in ways that drive their overdose risk as they balance self-care with caretaking, paid work, and basic survival. This article underscores the need for structural reform of peer overdose response work and funding for gender-attentive harm reduction and ancillary supports to better mitigate overdose risk for these populations.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting.

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021.

Objectives. To explore the implementation and effectiveness of the British Columbia, Canada, risk mitigation guidelines among people who use drugs, focusing on how experiences with the illicit drug supply shaped motivations to seek prescription alternatives and the subsequent impacts on overdose vulnerability. Methods. From February to July 2021, we conducted qualitative interviews with 40 people who use drugs in British Columbia, Canada, and who accessed prescription opioids or stimulants under the risk mitigation guidelines. Results. COVID-19 disrupted British Columbia's illicit drug market. Concerns about overdose because of drug supply changes, and deepening socioeconomic marginalization, motivated participants to access no-cost prescription alternatives. Reliable access to prescription alternatives addressed overdose vulnerability by reducing engagement with the illicit drug market while allowing greater agency over drug use. Because prescriptions were primarily intended to manage withdrawal, participants supplemented with illicit drugs to experience enjoyment and manage pain. Conclusions. Providing prescription alternatives to illicit drugs is a critical harm reduction approach that reduces exposure to an increasingly toxic drug supply, yet further optimizations are needed. (Am J Public Health. 2022;112(S2):S151-S158. https://doi.org/10.2105/AJPH.2021.306692).

"They went down that road, and they get it": A qualitative study of peer support worker roles within perinatal substance use programs.

BACKGROUND: Perinatal substance use programs employ multidisciplinary teams to support women who use drugs through pregnancies and parenting, with some programs expanding to include peer support workers with lived experience of parenting and substance use. Research has shown peer support to enhance care in substance use treatment; however, little research exists that examines this model of support within perinatal substance use programs. We explore the current and potential role of peer support workers within perinatal substance use programs, from the perspectives of mothers accessing these programs. METHODS: We conducted focus groups with 20 mothers enrolled in three perinatal substance use programs serving the greater Vancouver area, including two community-based programs that employed peer workers and an acute care maternity ward that did not. We recorded focus groups, had them professionally transcribed, and analyzed them thematically. RESULTS: Participants characterized peer support workers as extending and complementing informal care practices already occurring within programs, including mother-to-mother support with breastfeeding, childcare, and system navigation. Integrating peer workers shifted care relations and practices in ways that participants found beneficial. Participants emphasized how support workers with similar social locations and life experiences-beyond just their substance use-helped to foster trust and safety for mothers in the program. Indigenous mothers discussed the importance of having Indigenous support workers whose practice is grounded in their cultures and experiences under colonization. Participants ascribed an aspirational status to peer support workers, conveying that it was motivational to see other mothers working in the program, and described the role as a means of maintaining connection and community. However, some expressed concerns about managing professional-personal boundaries and being emotionally "triggered" by the work. CONCLUSION: This study evidences benefits of employing peer support workers within perinatal substance use programs, while also indicating the need for organizational processes to ensure that peer staff are integrated equitably and supported adequately.

Navigating post-eviction drug use amidst a changing drug supply: A spatially-oriented qualitative study of overlapping housing and overdose crises in Vancouver, Canada.

BACKGROUND: North American cities are experiencing intersecting housing and overdose crises as illicit drug markets become marked by the proliferation of fentanyl and methamphetamine. Despite recent research documenting associations between evictions and drug-related risks and harms, including overdose, the mechanisms through which these occur remain poorly understood. This study to examines how evictions shape the drug use practices of people who use drugs in Vancouver's Downtown Eastside - a neighbourhood with an established drug scene - as the illicit drug supply changed. METHODS: Qualitative interviews and geo-spatial data collection were conducted with 56 recently evicted PWUD. Data were analyzed by interfacing qualitative and geo-spatial data, and interpreted focusing on how structural vulnerability shaped spatial practices and drug-related risks post-eviction. RESULTS: Findings demonstrate how post-eviction spatial practices and routines produced risk and harm as participants navigated the uncertainties of housing vulnerability and drug supply changes. Post-eviction disruptions complicated participants' ability to engage with trusted drug sellers. Changes to spatial patterns and access to private spaces rendered public drug use inevitable, though this was mitigated to some degree by harm reduction supports. Abrupt changes to drug use patterns occurred due to post-eviction disruptions and included instrumental uses of methamphetamine to increase alertness and navigate survival amidst severe hardship. CONCLUSIONS: Findings demonstrate how post-eviction changes to routines and spatial patterns are framed by structural vulnerability and can exacerbate drug-related harms, particularly in the context of a changing drug supply. There is an urgent need for structural interventions and harm reduction responses to mitigate harms associated with evictions.

Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs.

BACKGROUND: Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women's experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site. METHODS: Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence. RESULTS: Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women's specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose. CONCLUSIONS: Findings demonstrate the ways in which gendered social and structural environments shape women's daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.

A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs.

Antiretroviral therapy (ART) dispensing is strongly associated with treatment adherence. Among illicit drug-using populations, whom experience greater structural barriers to adherence, directly administered antiretroviral therapy (DAAT) is often regarded as a stronger predictor of optimal adherence over self-administered medications. In Vancouver, Canada, people living with HIV (PLHIV) who use drugs and live in low-income housing are a critical population for treatment support. This group is typically able to access two key DAAT models, daily delivery and daily pickup, in addition to ART self-administration. This ethno-epidemiological qualitative study explores how key dispensing models impact ART adherence among PLHIV who use drugs living in low-income housing, and how this is framed by structural vulnerability. Semi-structured interviews lasting 30-45 minutes were conducted between February and May 2018 with 31 PLHIV who use drugs recruited from an ongoing prospective cohort of PLHIV who use drugs. Interviews were audio-recorded, transcribed verbatim, and analyzed using QSR International's NVivo 12 software. Interviews focused on housing, drug use, and HIV management. Models that constrained agency were found to have negative impacts on adherence and quality of life. Treatment interruptions were framed by structural vulnerabilities (e.g., housing vulnerability) that impacted ability to maintain adherence under certain dispensing models, and led participants to consider other models. Participants using DAAT models which accounted for their structural vulnerabilities (e.g., mobility issues, housing instability), credited these models for their treatment adherence, but also acknowledged factors that constrained agency, and the negative impacts this could have on both adherence, and quality of life. Being able to integrate ART into an established routine is key to supporting ART adherence. ART models that account for the structural vulnerability of PLHIV who use drugs and live in low-income housing are necessary and housing-based supports could be critical, but the impacts of such models on agency must be considered to ensure optimal adherence.