Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey.

BACKGROUND: With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply. METHODS: Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply. RESULTS: A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00-2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20-3.60)) of prescribed safer supply access, compared to people who did not access these services. CONCLUSIONS: Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.

Motivators of and barriers to drug checking engagement in British Columbia, Canada: Findings from a cross-sectional study.

OBJECTIVE: Responding to increasing rates of illicit drug toxicity mortality in British Columbia, regional health authorities introduced various types and models of drug checking services starting in 2016. Uptake has been gradual yet consistent, but motivators and barriers of service use have not been well-described. METHODS: The British Columbia Harm Reduction Client Survey is a cross-sectional survey conducted at harm reduction sites across British Columbia. Data for the present findings were collected between March 2021 and January 2022. Participants (n = 537) were asked about their use of drug checking services and what prevented them from using available services. Responses were analyzed with descriptive statistics and multivariable logistic regression. RESULTS: Of all participants, 519 (96.6 %) answered the survey question on drug checking with 144 (27.7 %) reporting having used services within six months. Participants highlighted barriers such as not knowing where to access services (21.0 %), or not having services in their area (10.0 %). Among people who did not report recent use of fentanyl, 49.6 % stated they would not use their drugs if they tested positive for fentanyl. Other harm reduction behaviors were positively associated with drug checking, such as use of overdose prevention sites (adjusted odds ratio [AOR]: 2.75, 95 % confidence interval [CI]: 1.65, 4.59) and having a naloxone kit (AOR: 2.67, 95 %CI: 1.14, 6.28). Receipt of opioid agonist therapy in the previous six months was also positively associated with drug checking (AOR: 1.72, 95 %CI: 1.05, 2.83). DISCUSSION: Drug checking uptake remains low in British Columbia, however this study identified desire for services among participants, suggesting a need for expanded drug checking services. Behavioral change was reported among a high proportion of people who said they would not use their drugs if they tested positive for fentanyl, meaning that immunoassay strips alone have utility in the context of a pervasive fentanyl supply.

Peer-led safer supply and opioid agonist treatment medication distribution: a case study from rural British Columbia.

BACKGROUND: British Columbia (BC) has been facing a public health emergency of overdose since 2016, with rural regions of the province facing the highest rates of death. Peers (in this case, people with lived experience of substance use) are known to be effective patient navigators in health systems and can play a role in connecting patients to care and reducing overdose risk. CASE PRESENTATION: We outline a peer-led program focused on opioid agonist treatment and prescribed safe supply medication delivery that began in March 2020 at a clinic in rural BC. The peer takes an Indigenous harm reduction approach and is focused on meeting the needs of the whole person. The peer has regular contact with approximately 50 clients and navigates medication delivery and appointments for approximately 10-15 people each day. Clients have been retained on the medication, and experienced improvement in other outcomes, including securing housing, employment and managing acute and chronic health conditions. The peer has established contact with clients since March 2020 to support engagement with health care and continuity of medication access. This program highlights the importance and value of peer-led work and need for further investments in peer-led programs to respond to the unregulated drug poisoning crisis. CONCLUSIONS: This peer-led intervention is a promising approach to engaging people who remain disconnected from health services in care in a rural community. This model could be adapted to other settings to support patient contact with the health system and medication access and continuity, with the ultimate goal of reducing overdose risk.

Doing community-based research during dual public health emergencies (COVID and overdose).

Meaningful engagement and partnerships with people who use drugs are essential to conducting research that is relevant and impactful in supporting desired outcomes of drug consumption as well as reducing drug-related harms of overdose and COVID-19. Community-based participatory research is a key strategy for engaging communities in research that directly affects their lives. While there are growing descriptions of community-based participatory research with people who use drugs and identification of key principles for conducting research, there is a gap in relation to models and frameworks to guide research partnerships with people who use drugs. The purpose of this paper is to provide a framework for research partnerships between people who use drugs and academic researchers, collaboratively developed and implemented as part of an evaluation of a provincial prescribed safer supply initiative introduced during dual public health emergencies (overdose and COVID-19) in British Columbia, Canada. The framework shifts from having researchers choose among multiple models (advisory, partnership and employment) to incorporating multiple roles within an overall community-based participatory research approach. Advocacy by and for drug users was identified as a key role and reason for engaging in research. Overall, both academic researchers and Peer Research Associates benefited within this collaborative partnerships approach. Each offered their expertise, creating opportunities for omni-directional learning and enhancing the research. The shift from fixed models to flexible roles allows for a range of involvement that accommodates varying time, energy and resources. Facilitators of involvement include development of trust and partnering with networks of people who use drugs, equitable pay, a graduate-level research assistant dedicated to ongoing orientation and communication, technical supports as well as fluidity in roles and opportunities. Key challenges included working in geographically dispersed locations, maintaining contact and connection over the course of the project and ensuring ongoing sustainable but flexible employment.

Awareness, predictors and outcomes of drug alerts among people who access harm reduction services in British Columbia, Canada: findings from a 2021 cross-sectional survey.

OBJECTIVES: To assess the awareness and predictors of seeing/hearing a drug alert in British Columbia (BC) and subsequent drug use behaviour after seeing/hearing an alert. METHODS: This study analysed the 2021 BC harm reduction client survey (HRCS)-a cross-sectional self-reported survey administered at harm reduction sites throughout the province and completed by participants using the services. RESULTS: In total, n=537 respondents participated and n=482 (89.8%) responded to the question asking if they saw/heard a drug alert. Of those, n=300 (62.2%) stated that they saw/heard a drug alert and almost half reported hearing from a friend or peer network; the majority (67.4%) reported altering their drug use behaviour to be safer after seeing/hearing a drug alert. The proportion of individuals who saw/heard a drug alert increased with each ascending age category. Among health authorities, there were significant differences in the odds of seeing/hearing an alert. In the past 6 months, the odds of participants who attended harm reduction sites a few times per month seeing/hearing an alert were 2.73 (95% CI: 1.17 to 6.52) times the odds of those who did not. Those who attended more frequently were less likely to report seeing/hearing a drug alert. The odds of those who witnessed an opioid-related overdose in the past 6 months seeing/hearing an alert were 1.96 (95% CI: 0.86 to 4.50) times the odds of those who had not. CONCLUSION: We found that drug alerts were mostly disseminated through communication with friends or peers and that most participants altered their drug use behaviour after seeing/hearing a drug alert. Therefore, drug alerts can play a role in reducing harms from substance use and more work is needed to reach diverse populations, such as younger people, those in differing geographical locations, and those who attend harm reduction sites more frequently.

"It's just a perfect storm": Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances.

BACKGROUND: Despite the implementation and expansion of public health and harm reduction strategies aimed at preventing and reversing overdoses, rates of overdose-related events and fatalities continue to rise in British Columbia. The COVID-19 pandemic created a second, concurrent public health emergency that further exacerbated the illicit drug toxicity crisis, reinforced existing social inequities and vulnerabilities, and highlighted the precariousness of systems in place that are meant to protect the health of communities. By exploring the perspectives of people with recent experience of illicit substance use, this study sought to characterize how the COVID-19 pandemic and associated public health measures influenced risk and protective factors related to unintentional overdose by altering the environment in which people live and use substances, influencing the ability of people who use substances to be safe and well. METHODS: One-on-one semi-structured interviews were conducted by phone or in-person with people who use illicit substances (n = 62) across the province. Thematic analysis was performed to identify factors shaping the overdose risk environment. RESULTS: Participants pointed to factors that increased risk of overdose, including: [1] physical distancing measures that created social and physical isolation and led to more substance use alone without bystanders nearby able to respond in the event of an emergency; [2] early drug price spikes and supply chain issues that created inconsistencies in drug availability; [3] increasing toxicity and impurities in unregulated substances; [4] restriction of harm reduction services and supply distribution sites; and [5] additional burden placed on peer workers on the frontlines of the illicit drug toxicity crisis. Despite these challenges, participants highlighted factors that protected against overdose and substance-related harm, including the emergence of new programs, the resiliency of communities of people who use substances who expanded their outreach efforts, the existence of established social relationships, and the ways that individuals consistently prioritized overdose response over concerns about COVID-19 transmission to care for one another. CONCLUSIONS: The findings from this study illustrate the complex contextual factors that shape overdose risk and highlight the importance of ensuring that the needs of people who use substances are addressed in future public health emergency responses.

Outpatient balloon catheter vs inpatient prostaglandin for induction of labor: a randomized trial.

BACKGROUND: Approximately 1 in 4 pregnant women undergo induction of labor. Meta-analyses have shown that mechanical methods of induction of labor are safe and effective, as is starting induction in an outpatient setting. However, few studies have evaluated outpatient balloon catheter induction in comparison with pharmacologic methods. OBJECTIVE: This study aimed to determine whether women who underwent outpatient induction of labor with a balloon catheter would have a lower cesarean delivery rate than women who underwent inpatient induction of labor with vaginal prostaglandin E2 without an increase in adverse maternal or neonatal events. STUDY DESIGN: This was a superiority randomized controlled trial. The eligibility criteria were pregnant women (nullipara and multipara) with a live singleton fetus in vertex presentation with any medical comorbidity who underwent planned induction of labor at term and who had an initial modified Bishop Score of 0 to 6 at 1 of 11 public maternity hospitals in New Zealand. The intervention groups were outpatient single balloon catheter induction in comparison with inpatient vaginal prostaglandin E2 induction. The primary hypothesis was that participants who started their induction at home with a balloon catheter would have a lower risk for cesarean delivery than participants who started their induction with prostaglandins and remained in hospital throughout. The primary outcome was cesarean delivery rate. Participants were randomized using a centralized secure online randomization website in a 1:1 ratio, stratified by parity and hospital. The participants and outcome assessors were not blinded to group allocation. An intention-to-treat analysis with adjustment for stratification variables was used. RESULTS: A total of 539 participants were randomized to outpatient balloon catheter induction, and 548 participants were randomized to inpatient prostaglandin induction; the mode of birth was reported for all participants. The cesarean delivery rate was 41.0% among participants allocated to outpatient balloon induction and 35.2% among those allocated to inpatient prostaglandin induction (adjusted odds ratio, 1.27; 95% confidence interval, 0.98-1.65). Women in the outpatient balloon catheter group were more likely to have artificial rupture of membranes and to received oxytocin and an epidural. No differences were found in the rates of adverse maternal or neonatal events. CONCLUSION: Outpatient balloon catheter induction was not found to reduce the cesarean delivery rate when compared with inpatient vaginal prostaglandin E2 induction. The use of balloon catheters in an outpatient setting does not seem to increase the rate of adverse events for mothers or babies and can be offered routinely.

Identifying behaviours for survival and wellness among people who use methamphetamine with opioids in British Columbia: a qualitative study.

BACKGROUND: British Columbia (BC) has been in a state of public health emergency since 2016, due to the unprecedented numbers of fatal and non-fatal drug toxicity (i.e. overdose) events. Methamphetamine detection in illicit drug toxicity deaths increased from 14% in 2012 to 43% in 2020 suggesting a concerning trend of concurrent methamphetamine and opioid use in BC, consistent with rising patterns identified across North America. People who use methamphetamine concurrently with opioids face an elevated risk of harm. This study aimed to identify behaviours for survival and wellness practiced by people who concurrently use methamphetamine and opioids. METHODS: One-on-one semi-structured interviews were conducted by peer research assistants in person and by telephone. Thematic analysis was carried out to identify patterns in behaviours participants described as important to their safety in the context of concurrent use of methamphetamine and opioids. RESULTS: Participants (n = 22) were distributed across the province with at least four participants from each of the five geographic health regions: 64% self-identified as men, and 50% self-identified as Indigenous. Daily methamphetamine use was reported by 72.7% of participants, and 67.3% reported using alone either often or always. Participants made several considerations and adaptations in order to balance the perceived benefits and risks of their use of methamphetamine with opioids. Two overarching themes were identified to describe how participants adapted their use for survival and wellness. The first was personal safety behaviours which included self-regulation and self-care behaviours. The second was interpersonal safety behaviours which included using alongside peers, and engaging with peer-led services (e.g. community outreach organizations) and public health-led services (e.g. overdose prevention sites) to reduce the risk of harm. Participants identified many gaps in available services to meet their diverse needs. CONCLUSIONS: This manuscript identified diversity in participants' methamphetamine and opioid use (i.e. frequency, route of administration), and a range of behaviours that were performed to improve wellness and survival while using methamphetamine and opioids. Harm reduction and treatment responses must be robust and adaptable to respond to the diversity of patterns of substance use among people who use methamphetamine and opioids concurrently, so as to not perpetuate harm and leave people behind.

Guideline development in harm reduction: Considerations around the meaningful involvement of people who access services.

Background: Harm reduction seeks to minimizes the negative effects of drug use while respecting the rights of people with lived and living experience of substance use (PWLLE). Guideline standards ("guidelines for guidelines") provide direction on developing healthcare guidelines. To identify essential considerations for guideline development within harm reduction, we examined whether guideline standards are consistent with a harm reduction approach in their recommendations on involving people who access services. Methods: We searched the literature from 2011-2021 to identify guideline standards used in harm reduction and publications on involving PWLLE in developing harm reduction services. We used thematic analysis to compare their guidance on involving people who access services. Findings were validated with two organizations of PWLLE. Results: Six guideline standards and 18 publications met inclusion criteria. We identified three themes related to involving people who access services: Reasons for Involvement, Methods of Involvement, and Factors in Success. Subthemes varied across the literature. We identified five essential considerations for guideline development in harm reduction: establishing a shared understanding of reasons for involving PWLLE; respecting their expertise; partnering with PWLLE to ensure appropriate engagement; incorporating perspectives of populations disproportionately affected by substance use; and securing resources. Conclusion: Guideline standards and the harm reduction literature approach the involvement of people who access services from different perspectives. Thoughtful integration of the two paradigms can improve guidelines while empowering PWLLE. Our findings can support the development of high-quality guidelines that align with the fundamental principles of harm reduction in their involvement of PWLLE.