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.

Experiences of Clients in Three Types of Methadone Maintenance Therapy in an Atlantic Canadian City: A Qualitative Study.

BACKGROUND: Methadone maintenance therapy remains the most common form of substitution therapy for opioid use disorder in Canada. Effectiveness of methadone maintenance therapy has been established, but recently newer treatment delivery models have emerged. Differences across these treatment models have not been examined. PURPOSE: This descriptive qualitative study used semi-structured interviews to assess client experiences in three methadone maintenance therapy treatment delivery models: (a) comprehensive programs, (b) low-threshold/high-tolerance programs, and (c) fee-for-service programs. METHODS: A total of 32 participants were recruited from methadone maintenance therapy clinics in an Atlantic Canadian city and grouped into three models of care (na = 9, nb = 11, nc = 12). Content analysis was performed on interview data to assess the frequency of relevant themes in the data. RESULTS: Participants from all groups stressed the importance of supportive staff and having access to some form of counselling. However, low-threshold/high-tolerance and fee-for-service clients voiced a need for more formal counselling and programming at their clinics. Methadone was reported as the most helpful aspect of the methadone maintenance therapy programs; however, participants also expressed negative views about the substance. CONCLUSIONS: These findings have important implications for the development and implementation of methadone maintenance therapy, specifically pertaining to further integration of addiction and mental health services.

Impact of Substance Use and Mental Health Comorbidity on Health Care Access in Canada.

Objective: Psychological disorders and substance use comorbidity is associated with greater symptomatology and a worse prognosis. Previous research has highlighted discrepancies in the level of use of health care services in individuals experiencing comorbidity compared to those with mental disorders or substance use disorders alone. The purpose of the current study was to compare mental health service use (i.e., access, number of professionals accessed, helpfulness of services received, and number of hours of services received) among individuals with mental disorders, substance use disorders, and comorbid disorders. Methods: Participants consisted of respondents to the 2012 Canadian Community Health Survey-Mental Health (N = 25,133). The researchers used a mixture of binary logistic regressions, Poisson regressions, linear regressions, and ordinal logistic regression to explore the impact of demographic variables, psychological distress, and clinical categories on health care access. Results: The mental disorders group, OR = 0.52, p = .008, 95% CI [0.32, 0.85], d = 0.36, and the substance use disorders group, OR = 0.31, p = .001, 95% CI [0.16, 0.60], d = 0.65, were significantly less likely than the comorbid group to report having accessed a professional in the past year. There were no significant differences in the perceived level of helpfulness for interventions received or in the time spent in professional consultation when comparing the substance use disorders and mental disorders groups to the comorbid group. Conclusions: Although the level of access to health care was low overall, those with concurrent disorders were more likely to access mental health services than those with substance use disorders or mental disorders only. The findings of this study reveal various treatment gaps, especially in those experiencing substance use disorders, and reaffirm the importance of improving treatment accessibility for these individuals.

Substance use in incarcerated male offenders: Predictive validity of a personality typology of substance misusers.

INTRODUCTION: Substance use and misuse is highly prevalent in offenders, and a significant proportion of convicted offenders continue to use controlled substances during incarceration. Few studies have focused on the identification of variables, especially personality characteristics, that may be predictive of institutional substance use. The purpose of this study is to assess the validity of the Substance Use Risk Profile (SURP) personality typology in a sample of male offenders and to determine whether it may have utility in identifying offenders at risk for substance use during incarceration. METHODS: A total of 118 offenders across all provincial and federal institutions in New Brunswick, Canada completed questionnaires assessing personality, mental health symptoms, substance use motives, and substance use. RESULTS: Latent class cluster analysis revealed the presence of three distinct clusters of offenders based on severity of substance use, personality, and mental health symptoms. Survival analysis indicated a significant effect of levels of sensation seeking, a trend of cluster membership, and anxiety sensitivity on days until first institutional substance use. CONCLUSION: High levels of sensation seeking and low anxiety sensitivity appear to indicate increased risk for substance misuse in this population.

Personality mediators of psychopathy and substance dependence in male offenders.

Psychopathy and substance dependence (SUD) is highly prevalent in incarcerated populations and tends to co-occur in the same individuals. The factors underlying this relationship are not clearly understood. The primary purpose of this study was to investigate whether two personality models mediate the relationship between psychopathy and substance misuse in male offenders. Ninety-two inmates in provincial correctional centers in New Brunswick completed questionnaires, including the Sensitivity to Reward Sensitivity to Punishment Questionnaire to measure behavioral activation and behavioral inhibition, the Substance Use Risk Profile Scale to measure anxiety sensitivity, introversion/hopelessness, sensation seeking and impulsivity, and the Psychopathic Personality Inventory-Revised to assess psychopathy levels. Results revealed that high impulsivity indirectly mediated the relationship between psychopathy and stimulant dependence. In addition, low anxiety sensitivity indirectly mediated the relationship between psychopathy and opioid dependence. Finally, impulsivity indirectly and inconsistently mediated the relationship between psychopathy and alcohol dependence. These results suggest that individuals with psychopathic traits are at increased risk of misusing certain drugs due to underlying personality-based differences.

The role of dopamine in alcohol self-administration in humans: individual differences.

OBJECTIVE: To clarify dopamine's role in alcohol self-administration in a heterogeneous sample of drinkers using acute phenylalanine/tyrosine depletion (APTD). METHODS: Sixteen men with variable drinking histories were characterized on their ethanol-induced cardiac response, a marker previously proposed to index dopamine system reactivity and vulnerability to alcohol abuse. During separate sessions participants were administered (i) a nutritionally balanced (BAL) amino acid (AA) mixture, (ii) a mixture lacking the dopamine precursors, phenylalanine and tyrosine, and (iii) APTD followed by the dopamine precursor, L-DOPA. Five hours after AA administration, participants could earn units of alcohol using a progressive ratio breakpoint task. RESULTS: Alcohol self-administration was reduced in the APTD and APTD+L-DOPA conditions relative to the BAL condition. In both cases the changes were predicted by ethanol-induced cardiac change. CONCLUSIONS: The motivation to drink is likely regulated by more than one neurobiological mechanism. Individual differences in cardiac responsivity to ethanol might provide a peripheral marker of responsiveness to pharmacological manipulations of dopamine.

Relationship between the cardiac response to acute intoxication and alcohol-induced subjective effects throughout the blood alcohol concentration curve.

RATIONALE: There is evidence to suggest that individual differences in the subjective response to alcohol exist and exaggerated cardiac response to alcohol has been suggested to be a marker of increased sensitivity to the stimulant properties of alcohol. OBJECTIVES: The present investigation examines the relationship between cardiac reactivity to alcohol measured on the ascending limb of the Blood Alcohol Concentration (BAC) curve and the subjective stimulant and sedative effects of alcohol throughout the BAC curve. METHODS: The stimulant and sedative effects of alcohol anticipatory to alcohol and during the ascending and descending limbs of the BAC curve were evaluated using the Biphasic Alcohol Effects Scale in 39 male social drinkers. RESULTS: Cardiac response to ethanol measured on the ascending limb of the BAC curve was positively correlated with intoxicated stimulant effects at numerous time points during the ascending and descending limbs of the BAC curve (ps < 0.01). No associations were found between cardiac change following alcohol and alcohol-related sedative effects at any time point. CONCLUSIONS: Objective and subjective reports of stimulation post-alcohol ingestion may increase risk for problematic drinking.

Effects of conditioned reward and nonreward cues on the heart rate response to alcohol intoxication in male social drinkers.

BACKGROUND: An exaggerated heart rate (HR) increase following alcohol intoxication has been suggested to reflect sensitivity to alcohol-induced reward. The goal of this study is to verify whether pairing alcohol ingestion with conditioned reward and nonreward cues can influence HR responses to alcohol in previously identified individuals with a low and a high HR response. METHODS: Fifty-six male social drinkers participated in a 2-day study. On day 1, participants consumed 0.75 g/kg of body weight of pure ethanol. A median split of the alcohol-induced HR responses identified groups of low and high HR responders. On day 2, both groups participated while sober in a computer task where distinct auditory and visual cues were paired either with monetary reward or no monetary reward. Subsequently, participants were randomly assigned to an alcohol challenge, which occurred while they were exposed to either the conditioned cues of reward or to the nonreward cues. RESULTS: The physiological response to alcohol intoxication on day 2 was compared with alcohol-induced HR responses on day 1 (neutral alcohol challenge) for both low and high HR responders. Paired t-tests showed that high HR responders had significantly decreased alcohol-induced HR responses on day 2 in the nonreward condition when compared with day 1. No other relationships between cardiac responses to alcohol and cue conditions were obtained. CONCLUSIONS: The rewarding nature of alcohol can be altered by the context in which it is consumed in a subset of individuals who are sensitive to alcohol's stimulating properties.

Psychostimulant users are sensitive to the stimulant properties of alcohol as indexed by alcohol-induced cardiac reactivity.

One indicator of increased sensitivity to alcohol-induced reward is a heightened heart rate (HR) increase following alcohol intoxication, a characteristic associated with increased alcohol-induced dopamine (DA) release. The goal of this study was to determine whether users of drugs known to induce DA release have higher HR increases after alcohol intoxication than never users have. Sixty-four men with known drug-use histories participated in an alcohol challenge in which HR was measured. Stimulant users had significantly higher ethanol-induced HR increases than never users had, although use of marijuana or hallucinogens was not associated with this marker. Stimulant users obtained superior Sensitivity to Reward scores (R. Torrubia, C. Avila, J. Moltó, & X. Caseras, 2001) compared with never users. Stimulant drug users may be more sensitive to the stimulating properties of alcohol, and this appears to be mediated by superior activity in the Behavioral Approach System (J. A. Gray, 1991).

Heightened heart rate response to alcohol intoxication is associated with a reward-seeking personality profile.

BACKGROUND: The psychomotor stimulant theory of addiction posits that sensitivity to the positively rewarding properties of alcohol puts certain individuals at higher risk for alcohol abuse. A valid and reliable index of overactivation in the reward system has been a heightened baseline heart rate (HR) increase on the ascending limb of the blood alcohol curve. The main goal of this study was to investigate the relationship between this HR response and a questionnaire measuring sensitivity to reward and sensitivity to punishment. Additional goals included looking at (1). the association between a high HR response and various personality traits (hopelessness/introversion, anxiety sensitivity, impulsivity, and sensation-seeking) and (2). the relationship between these personality traits and stimulant use. METHODS: A total of 18 low- and 19 high-HR responders completed the Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSRQ), the Substance Use Risk Profile Scale (SURPS), and a modified version of the Addiction Severity Index. RESULTS: High-HR responders obtained significantly higher scores than low-HR responders on the sensitivity to reward scale of the SPSRQ, as well as increased sensation-seeking scores on the SURPS. High-HR responders were not at significantly higher risk of having used stimulants, but stimulant use was associated with higher impulsivity scores on the SURPS. CONCLUSIONS: Novelty/sensation-seeking is among the personality traits that have been linked to heavy alcohol use. This study suggests that reward sensitivity might mediate the relationship between this personality profile and drinking behavior.

Exaggerated ethanol-induced cardiac reactivity as an indicator of increased risk for gambling.

Pathological gambling and alcohol dependence show a high rate of co-occurrence. Some individuals at risk for alcohol dependence display an exaggerated heart rate (HR) increase following alcohol consumption, a characteristic suggesting sensitivity to reward. This study examined whether exaggerated ethanol-induced cardiac reactivity was associated with increased gambling behaviors. One hundred five young men (M = 20.13 years, SD = 1.07) consumed 1 ml of ethanol (95% volume) per kilogram of body weight. HR was measured and participants completed the South Oaks Gambling Screen (SOGS; H. R. Lesieur & S. B. Blume, 1987). Those with higher intoxicated HRs reported significantly greater scores on the SOGS (p = .02). This suggests that ethanol-induced HR increase is a possible marker for addictive disorders.