'I don't chase drugs as much anymore, and I'm not dead': Client reported outcomes associated with safer opioid supply programs in Ontario, Canada.

INTRODUCTION: The ongoing opioid overdose crisis, which has killed over 30,000 people in Canada since 2016, is driven by the volatility of an unregulated opioid drug supply comprised primarily of fentanyl. The Canadian government has recently funded safer opioid supply (SOS) programs, which include off-label prescriptions of pharmaceutical-grade opioids to high risk individuals with the goal of reducing overdose deaths. METHODS: In 2021, we examined the implementation and adaption of four SOS programs in Ontario. These programs use a primary care model and serve communities experiencing marginalisation. We conducted semi-structured interviews with program clients. We present the results of a thematic analysis with the aim of describing clients' self-reported impact of these programs on their health and well-being. RESULTS: We interviewed 52 clients between June and October 2021 (mean age 47 years, 56% men, 17% self-identified Indigenous, 14% living with HIV). Our results indicate multifaceted pathways to improved self-reported health and well-being among clients including changes to drug use practices, fewer overdoses, reduced criminalised activity, improved trust and engagement in health care, and increased social stability (e.g., housing). DISCUSSION AND CONCLUSION: Most clients reported that the intervention saved their life because of the reduced frequency of overdoses. Findings suggest that SOS programs improved clients' health outcomes and increase opportunities for engagement in health services. Our results provide insight into the mechanisms behind some of the emergent evidence on the impact of safer supply prescribing.

Spotting as a risk mitigation method: A qualitative study comparing organization-based and informal methods.

OBJECTIVES: To explore the similarities and differences of organization-based and informal spotting (remote supervision of substance use) from the perspectives of spotters and spottees across Canada. METHODS: Spotters and spottees who spot informally and for organizations were recruited across Ontario and Nova Scotia. We interviewed 20 informal and 10 organization-based participants by phone using semi-structured interviews between 08/2020 and 11/2020. Participants were asked about each methods benefits and limitations. Interviews were audio-recorded, transcribed, and analyzed thematically. RESULTS: Benefits of informal spotting included its ability to strengthen social connections and foster autonomy in overdose response planning. The lack of support for informal spotters created stress and burnout. Organization-based spotters enjoyed the spotting training and support provided. However, regulations surrounding having to call ambulance in overdose events deterred many people from wanting to work for or call these services. CONCLUSIONS: Both organization-based and informal spotting have a role in mitigating harms associated with the overdose crisis. Moving forward, further research is needed on how to optimize these services for all people who use drugs in varying jurisdictions internationally.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone.

BACKGROUND: Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees. METHODS: Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used. RESULTS: We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings. CONCLUSION: Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

Challenges, Skepticism, and Recommendations from Police about Working in Collaboration with Supervised Consumption Services.

BACKGROUND: The operation of supervised consumption services (SCS), programs that offer supervised locations for the consumption of drugs such as heroin, other opioids, cocaine, other stimulants, and other drugs, is contingent on cooperative relationships with police. In this manuscript, we focus on an under studied topic: how active duty police officers understand their role with respect to SCS, and their recommendations for improving relationships with these programs. Methods: During 2018, we audio-recorded and transcribed focus group discussions conducted in four police divisions with 26 police constables and 3 officers of other ranks in Toronto, Canada. Officers were asked about their roles relative to SCS, perceived training needs, and how to build cooperative relationships with SCS. We followed an iterative thematic approach to analyze the data. Results: Participants in three divisions were unclear about their roles, duties, and policy governing policing of SCS. Participants in the fourth division had received instructions from the division commander to observe a "distance and discretion policy". However, these participants believed that developing familiarity with the new SCS, instead of keeping a distance, would be a more effective approach to building working relationships with staff, clients, and the local community. There was nearly unanimous skepticism about the willingness of SCS workers to work cooperatively with the police. These perceptions were commonly linked to previous negative experiences with harm reduction workers and, in some cases, staff at the new SCS. Several participants also linked problems in communication to fundamental differences between the philosophies or worldviews of SCS staff versus those of police. Conclusions: Building collaborative SIS-police relationships can be assisted by demystifying the operation of SCS for police, articulating policies, and working toward mutual respect.

A clinical practice guide: What HIV care providers need to know about HIV pregnancy planning to optimize preconception care for their patients.

This clinical practice guide has been developed to support human immunodeficiency virus (HIV) care providers' use of the 2018 Canadian HIV Pregnancy Planning Guidelines (CHPPG) in their work with people and couples affected by HIV. HIV pregnancy planning has changed considerably in the last decade and requires a multidisciplinary team, and HIV care providers are often at the forefront of the team. It is, therefore, important to have clear guidance on how to provide HIV pregnancy planning care. This Clinical Practice Guide is intended for both primary and specialty HIV care providers, including doctors, nurses, and nurse practitioners. We have repackaged the 2018 CHPPG's 36 recommendations into five standards of care for ease of use. We have also included an initial algorithm that can be used with each patient to direct discussions about their reproductive goals. Pregnancy and parenting are increasingly normalized experiences in the lives of people and couples affected by HIV. While conception used to be a complicated decision, often heavily focused on minimizing the risk of HIV transmission, the current evidence supports more universal counselling and supports for HIV pregnancy planning. HIV care providers have a responsibility to be familiar with the unique considerations for pregnancy planning when supporting their patients. This counselling is critical to optimizing reproductive health outcomes for all people affected by HIV, including those who wish to prevent pregnancy.

Les présentes directives de pratique clinique visent à soutenir l'utilisation des Lignes directrices canadiennes en matière de planification de la grossesse en présence du VIH 2018 par les dispensateurs de soins aux personnes et aux couples touchés par le virus d'immunodéficience humaine (VIH). La planification de grossesse en présence du VIH a considérablement évolué depuis dix ans. Elle exige l'apport d'une équipe multidisciplinaire, et les dispensateurs de soins aux personnes infectées par le VIH y occupent souvent le premier rang. Il est donc important de disposer de directives claires sur le mode de prestation des soins pendant la planification de la grossesse en présence de VIH. Les directives de pratique clinique sont conçues pour les dispensateurs de soins primaires et spécialisés en matière de VIH, y compris les médecins, les infirmières et les infirmières praticiennes. Les Lignes directrices de 2018 contiennent 36 recommandations que les auteurs ont regroupées en cinq normes de soins pour en faciliter l'utilisation. Ils ont également inclus un premier algorithme à utiliser avec chaque patient pour orienter les échanges sur leurs objectifs de reproduction. La grossesse et le rôle de parent sont des expériences de plus en plus normalisées dans la vie des personnes et des couples touchés par le VIH. La conception a déjà été une décision complexe, souvent axée fortement sur la réduction du risque de transmission du VIH, mais les données à jour appuient la transmission de conseils plus universels et une aide à la planification de grossesse en présence du VIH. Il incombe aux dispensateurs de soins aux personnes touchées par le VIH de connaître les particularités de la planification de grossesse auprès de ces patients. Ces conseils sont cruciaux pour optimiser les résultats en santé génésique de toutes les personnes en cause, y compris la prévention des grossesses non désirées.

Using concept mapping to inform the development of a transitional reintegration intervention program for formerly incarcerated people with HIV.

BACKGROUND: Accessing HIV-related care is challenging for formerly incarcerated people with HIV. Interventions informed by the perspectives of these individuals could facilitate engagement with care and address competing priorities that may act as barriers to this process. METHODS: We used concept mapping to identify and prioritize the main obstacles to engaging with HIV-related care following prison release. In brainstorming sessions, formerly incarcerated people with HIV generated responses to a focused prompt regarding the main barriers to reengaging with care. These were consolidated in 35 statements. Next, participants sorted the consolidated list of responses into groups and rated each from lowest to highest in terms of its importance and feasibility of being addressed. We used cluster analysis to generate concept maps that were interpreted with participants. RESULTS: Overall, 39 participants participated in brainstorming sessions, among whom 18 returned for rating and sorting. Following analysis, a seven-cluster map was generated, with participants rating the 'Practical Considerations' (e.g. lack of transportation from prison) and 'Survival Needs' (e.g. securing housing and food) clusters as most important. Although ratings were generally similar between women and men, women assigned greater importance to barriers related to reconnecting with children. CONCLUSIONS: Using concept mapping, we worked with formerly incarcerated people with HIV to identify and prioritize key challenges related to accessing health and social services following prison release. Transitional intervention programs should include programs and processes that address meeting basic subsistence needs and overcoming logistical barriers related to community re-entry.

Creating and sustaining cooperative relationships between supervised injection services and police: A qualitative interview study of international stakeholders.

BACKGROUND: Supervised injection services (SIS) operate with special exemptions from drug law enforcement. Given the expansion of SIS and the opioid overdose crisis in numerous jurisdictions, now is a critical time to examine factors that contribute to cooperative SIS-police relationships. We sought to learn about SIS-police relationships from international jurisdictions with well-established as well as newer SIS. METHODS: We conducted 16 semi-structured telephone interviews with SIS managers (n = 10) and police liaisons (n = 6) from 10 cities in seven different countries (Australia, Canada, Denmark, France, Germany, Netherlands, and Spain). All participants provided informed consent. We focused our coding and analysis on themes that emerged from the data. RESULTS: Five key contributors to cooperative SIS-police relationships emerged from the data: early engagement and dialogues; supportive police chiefs; dedicated police liaisons; negotiated boundary agreements; and regular face-to-face contact. Most participants perceived the less formalised, on-the-ground approach to relationship-building between police and SIS adopted in their city to be working well in general. SIS managers and police participants reported a lack of formal police training on harm reduction, and some thought that training was unnecessary given the relatively positive local SIS-police relationships they reported. CONCLUSION: Our qualitative study provides new, in-depth empirical examples of how police in varied international jurisdictions can come to accept and work cooperatively with, not against, SIS staff and clients. Investing ongoing effort in SIS-police relationships, in a manner that best suits local needs, may hold greater and more sustainable public health value than delivering specific curricula to police.

Developing national best practice recommendations for harm reduction programmes: Lessons learned from a community-based project.

Through promotion of consistent, evidence-based policy and practice, best practice recommendations can improve service delivery. Nationally relevant best practice recommendations, including guidance for programmes that provide service to people who use drugs, are often created and disseminated by government departments or other national organisations. However, funding priorities do not always align with stakeholder- and community-identified needs for such recommendations, particularly in the case of harm reduction. We achieved success in developing and widely disseminating best practice documents for Canadian harm reduction programmes by bringing together a multi-stakeholder, cross-regional team of people with relevant and diverse experience and expertise. In this commentary, we summarise key elements of our experience to contribute to the literature more detailed and transparent dialogue about team processes that hold much promise for developing best practice resources. We describe our project's community-based principles and process of working together (e.g., regularly scheduled teleconferences to overcome geographic distance and facilitate engagement), and integrate post-project insights shared by our team members. Although we missed some opportunities for power-sharing with our community partners, overall team members expressed that the project offered them valuable opportunities to learn from each other. We aim to provide practical considerations for researchers, other stakeholders, and community members who are planning or already engaged in a process of developing best practice recommendations for programmes and interventions that address drug use.

Intensive hog farming operations and self-reported health among nearby rural residents in Ottawa, Canada.

BACKGROUND: In 2004, hog farming operations were introduced in the village of Sarsfield in the eastern part of Ottawa, Canada. This study evaluates the health-related quality of life (HRQOL), and the prevalence of respiratory conditions among adults and children who lived in proximity to this farm. METHODS: A cross-sectional survey was administered to a random sample of residents from seven rural communities in the eastern part of Ottawa, Canada. We analyzed self-reported questionnaire data obtained from 723 adults and 285 children/adolescents. HRQOL was assessed using the SF-36 survey instrument, while data were also collected for sociodemographic characteristics, the prevalence of selected health conditions, and lifestyle related behaviours (e.g., smoking) of participants. Variations in self-reported health according to the residential distance to the hog farm were evaluated using logistic regression and analysis of variance methods. RESULTS: For the most part, the prevalence of selected health conditions among adults and children was not associated with how far they lived from the farm. No associations were observed with migraines, respiratory conditions (asthma, rhinitis, sinusitis, and chronic bronchitis), and allergies. However, a higher prevalence of depression was noted among those who lived within 3 km of the farm relative to those who lived more than 9 km away (odds ratio = 2.01, 95% CI = 1.11, 3.65). Furthermore, individuals who lived closer to the IHF were more likely to worry about environmental issues such as water quality, outdoor and indoor smells, and air pollution. This level of worry also contributed to lower HRQOL scores for individuals who lived closer to the farm. It was also observed that the prevalence of depression was much higher among those who indicated a concern about environmental issues (18.2%) when compared to those who did not (8.0%). CONCLUSION: While our findings suggest that living in close proximity to an IHF may adversely affect HRQOL these should be interpreted cautiously due to a lack of direct measures of environmental exposures, and possible biases inherent in the use of self-reported health measures.

Reduction in injection-related HIV risk after 6 months in a low-threshold methadone treatment program.

This study assessed injection-related HIV risk behavioral changes among opioid users 6 months after enrollment in low-threshold (harm reduction based) metha-done maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subcohort); and those who continued to inject drugs (injecting subcohort). In this prospective observational cohort study, an interviewer-administered questionnaire examining injection-related HIV risk behaviors was administered to 183 study participants at entry to treatment and 6 months later. Changes in risk behaviors were analyzed using conditional logistic regression which took into account the paired nature of the data. We found that the proportion of participants injecting drugs, sharing needles, sharing drug equipment, indirectly sharing and using shooting galleries declined with follow-up for the whole cohort. Within the drug-using subcohort, there was a decrease in the proportion of individuals who injected drugs, while within the injecting subcohort the sharing of injection equipment and the use of shooting galleries declined. Our findings suggest that low-threshold MMT programs can reduce the risk of HIV without the enforcement of abstinence-based policies.

Determinants of health-related quality of life of opiate users at entry to low-threshold methadone programs.

OBJECTIVE: The aim of this study was to conduct an exploratory analysis of factors associated with poor health-related quality of life (HRQOL) among opiate users at entry to low-threshold methadone treatment. METHODS: The SF-36 questionnaire was administered to 145 opiate users at enrollment into low-threshold methadone maintenance programs. ANOVA and correlational analyses were performed to investigate the determinants of poor physical and mental composite summary scales (PCS and MCS) of the SF-36 among opiate users. Stepwise regression methods were also employed to fit PCS and MCS multivariate models. RESULTS: Age, employment status, chronic medical conditions, hospitalization, emotional abuse, sexual abuse and age at first injection episode were significantly associated with PCS. Mental health problems, sexual abuse, physical abuse, the use of sedatives, the use of cocaine, the number of days of cocaine use, sedative use and multiple substance use in the past month were significantly associated with MCS. The variances in the MCS and PCS were not readily explained by any one factor. CONCLUSION: The multiplicity of factors influencing HRQOL of opiate users suggests the need for a range of services within the context of a methadone program, addressing primary medical care needs as well as treatment for both mental health problems and abuse issues.

Self-perceived health among Canadian opiate users: a comparison to the general population and to other chronic disease populations.

BACKGROUND: There are an estimated 40,000 to 90,000 injection opiate users in Canada. The social, economic and health consequences of opiate addiction have been well documented. However, there are no data on the self-perceived health status of opiate users in Canada. Therefore, the goal of this research is to gain an understanding of the self-perceived health status of opiate users by comparing the health-related quality of life of opiate users to chronic disease populations and to the general population. METHODS: The SF-36 was administered to a nonrandom sample of 143 opiate users entering low-threshold methadone treatment. Two sample t-tests were performed to assess statistical differences, at a 5% level of significance, between population scores across SF-36 dimensions. RESULTS: Opiate users perceived both their mental and physical health as worse than the general population and individuals with minor and serious medical problems, but comparable to those with diagnosed psychiatric illnesses. CONCLUSIONS: Methadone treatment services should incorporate both primary care and psychiatric care into their programs, or at the very least secure appropriate referral mechanisms to ancillary services to ensure that the health concerns of opiate users are dealt with in the context of their treatment program.

Needle exchange programs. Delivery and access issues.

OBJECTIVE: Examine the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts. METHODS: Using a modified ethnographic approach, semi-structured interviews concerning policies and procedures were conducted with staff (n = 59) of NEPs (n = 15) in Ontario. An iterative, inductive analytic process was used. RESULTS: According to workers and managers, effectiveness of NEP prevention efforts depend on client development and retention and service design. Fixed and satellite sites, home visits and mobile services provide varied levels of temporal and spatial accessibility. Combining modes of delivery can offset the disadvantages of individual modes. DISCUSSION: NEP evaluations that do not consider service and resource factors run the risk of concluding that NEPs are ineffective when it may be that the program works for a small proportion of IDUs whom the NEP has the resources to serve.