"Everybody is impacted. Everybody's hurting": Grief, loss and the emotional impacts of overdose on harm reduction workers.

BACKGROUND: The emotional impacts of witnessing and responding to overdose and overdose-related deaths have been largely overlooked during the drug toxicity overdose crisis in North America. Scarce research has analyzed these impacts on the health and well-being of harm reduction workers, and the broader determinants of harm reduction work. Our study investigates the experiences and impacts of witnessing and responding to frequent and escalating rates of overdose on harm reduction workers in Toronto, Canada. METHODS: Using semi-structured interviews, 11 harm reduction workers recruited from harm reduction programs with supervised consumption services in Toronto, Canada, explored experiences with and reactions to overdose in both their professional and personal lives. They also provided insights on supports necessary to help people cope with overdose-related loss. We used thematic analysis to develop an initial coding framework, subsequent iterations of codes and emergent themes. RESULTS: Results revealed that harm reductions workers experienced physical, emotional, and social effects from overdose-related loss and grief. While some effects were due to the toll of overdose response and grief from overdose-related losses, they were exacerbated by the lack of political response to the scale of the drug toxicity overdose crisis and the broader socio-economic-political environment of chronic underfunding for harm reduction services. Harm reduction workers described the lack of appropriate workplace supports for trauma from repeated overdose response and overdose-related loss, alongside non-standard work arrangements that resulted in a lack of adequate compensation or access to benefits. CONCLUSIONS: Our study highlights opportunities for organizational practices that better support harm reduction workers, including formal emotional supports and community-based supportive care services. Improvement to the socio-economic-political determinants of work such as adequate compensation and access to full benefit packages are also needed in the harm reduction sector for all workers.

Initiations of safer supply hydromorphone increased during the COVID-19 pandemic in Ontario: An interrupted time series analysis.

AIMS: Calls to prescribe safer supply hydromorphone (SSHM) as an alternative to the toxic drug supply increased during the COVID-19 pandemic but it is unknown whether prescribing behaviour was altered. We aimed to evaluate how the number of new SSHM dispensations changed during the pandemic in Ontario. METHODS: We conducted a retrospective interrupted time-series analysis using provincial administrative databases. We counted new SSHM dispensations in successive 28-day periods from March 22, 2016 to August 30, 2021. We used segmented Poisson regression methods to test for both a change in level and trend of new dispensations before and after March 17, 2020, the date Ontario's pandemic-related emergency was declared. We adjusted the models to account for seasonality and assessed for over-dispersion and residual autocorrelation. We used counterfactual analysis methods to estimate the number of new dispensations attributable to the pandemic. RESULTS: We identified 1489 new SSHM dispensations during the study period (434 [mean of 8 per 28-day period] before and 1055 [mean of 56 per 28-day period] during the pandemic). Median age of individuals initiating SSHM was 40 (interquartile interval 33-48) with 61.7% (N = 919) male sex. Before the pandemic, there was a small trend of increased prescribing (incidence rate ratio [IRR] per period 1.002; 95% confidence interval [95CI] 1.001-1.002; p<0.001), with a change in level (immediate increase) at the pandemic date (relative increase in IRR 1.674; 95CI 1.206-2.322; p = 0.002). The trend during the pandemic was not statistically significant (relative increase in IRR 1.000; 95CI 1.000-1.001; p = 0.251). We estimated 511 (95CI 327-695) new dispensations would not have occurred without the pandemic. CONCLUSION: The pandemic led to an abrupt increase in SSHM prescribing in Ontario, although the rate of increase was similar before and during the pandemic. The absolute number of individuals who accessed SSHM remained low throughout the pandemic.

Disease-related stigma among people who inject drugs in Toronto amidst the COVID-19 pandemic.

Background: Stigma overwhelmingly affects people who inject drugs. The COVID-19 pandemic posed unique challenges for people who inject drugs, who are already stigmatized as being "dangerous and spreading disease." The present study explored ways in which stigma was experienced by a sample of people who inject drugs in Toronto, Canada following COVID-related public health precaution measures. Methods: Qualitative interviews were conducted with people who inject drugs (n = 24) recruited from supervised consumption sites in Toronto, Canada. The semi-structured interview guide focused on the impact of COVID-19 on participants' health and social well-being. Interviews took place six-months after initial COVID-19 precautions (September-October 2020). We used thematic analysis to examine findings, with stigma being an emergent theme. Results: Participants described heightened acts of stigma after COVID-19 restrictions were implemented, including feeling treated as "diseased" and the cause of COVID-19's spread. They reported being less likely to receive emergency care during events such as overdoses. Participants perceived increased disease-related stigma evident through actions of stigma, including amplified dehumanization by the public, others avoiding all contact with them, and more discrimination by police and hospital systems. Conclusion: Participants provided specific examples of how stigmatizing behaviors harmed them after COVID-19 precautions began. It is plausible that stigma contributed to the dramatic increase in fatal overdoses, difficulty accessing housing, and further difficulty accessing needed healthcare in our setting. Integrating evidence-based harm reduction approaches in areas where stigma is evident might offset harms stemming from disease-related stigma and mitigate these harms during future public health emergencies.

Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto, Canada: A cross-sectional analysis.

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.

"They have their security, we have our community": Mutual support among people experiencing homelessness in encampments in Toronto during the COVID-19 pandemic.

Unaffordable housing is a growing crisis in Canada, exacerbated by the COVID-19 pandemic, yet perspectives of people living outdoors in encampments have primarily gone unheard. We conducted qualitative interviews with encampment residents to explore how mutual support occurred within the social context of encampments. We found that mutually supportive interactions helped residents meet basic survival needs, as well as health and social needs, and reduced common health and safety risks related to homelessness. The homelessness sector should acknowledge that encampment residents form their own positive communities, and ensure policies and services do not isolate people from these beneficial social connections.

Frequency of fatal and non-fatal overdoses and response to grief and loss among people who inject drugs: An unexplored dimension of the opioid overdose crisis.

BACKGROUND: We investigated the relationship between overdose events and grief and loss responses among people who inject drugs. METHODS: We conducted a cross-sectional, tablet-based survey with a convenience sample of people who inject drugs (n = 249) from four community-based harm reduction programs in Toronto in 2019. We examined the association between frequency and types of overdose events (own, witnessed, death of significant person) in the last 6 months with grief and loss responses, identified using latent class analysis. RESULTS: Among respondents, 70 (48.6 %) reported 2 or more personal overdoses, 173 (79.5 %) witnessed 2 or more overdoses, and 69 (41.4 %) experienced overdose deaths of 2 or more significant persons in the last 6 months. We identified 2 latent classes with probability of membership of 38.6 % (95 % confidence interval [CI]=31.0, 46.7) for medium/low intensity of responses to grief/loss and 61.4 % (95 % CI= 53.3, 69.0) for severe responses to grief/loss. In adjusted Poisson regression models with robust standard error estimators, severe responses to grief/loss were associated with exposure to two or more own overdoses (prevalence ratio [PR] = 1.44; 95 % CI=1.12, 1.84, p-value=0.004), and having witnessed one (PR=2.09; 95 % CI=1.05, 4.15, p-value=0.04) or witnessed two or more overdoses (PR=2.25; 95 % CI=1.24, 4.09, p-value=0.008). Severe grief/loss responses were also more common in individuals exposed to all three types of overdose events (PR=2.42; 95 % CI=1.08, 5.41, p-value=0.03). CONCLUSIONS: Cumulative overdose events were associated with severe responses to grief and loss. Bereavement interventions should consider the complex nature of grief and loss following overdoses.

Prescribing trends in direct-acting antivirals for the treatment of hepatitis C in Ontario, Canada.

Background: Direct-acting antivirals (DAA) offer an opportunity to cure hepatitis C. Reimbursement for DAAs has changed on two occasions since their inclusion on the Ontario public formulary. Whether these changes have appreciably modified prescribing patterns and increased access to DAAs is unknown. Methods: We conducted a repeated cross-sectional study of DAA reimbursement by the Ontario Public Drug Programs from January 1, 2012, to December 31, 2018, to summarize the use of DAAs in Ontario and describe changes in DAA prescribing physician specialties over this period. We measured the total number of users quarterly. Results are reported overall and by prescriber type. Results: A total of 27,116 individuals received a publicly funded prescription for a DAA from the first quarter (Q1) of 2012 to the fourth quarter (Q4) of 2018. Nearly two-thirds (n = 17,813; 65.7%) of all DAAs were prescribed by gastroenterologists, hepatologists, or infectious disease specialists. Use of DAAs over time appears to have had three major phases in uptake: (1) the introduction of DAA treatments on the Ontario public drug formulary as a prior authorization benefit in Q1 2015, (2) expanded listing of all DAAs as limited-use products on the formulary in Q1 2017, and (3) the introduction of newer DAAs in Q2 2018. Conclusions: Changes in listing of these agents had a direct impact on the use of DAAs overall. Generally, broader listing expanded access but did not appear to shift utilization patterns to primary care prescribers. Further understanding of who is not receiving treatment is needed.

How Structural Violence, Prohibition, and Stigma Have Paralyzed North American Responses to Opioid Overdose.

As of 2020, North America is now into the fifth year of an unprecedented increase in drug overdose deaths driven by a toxic, unpredictable, and unregulated drug supply. While the genesis and drivers of and response to the opioid overdose crisis have wide regional variations, structural violence, prohibitions against illicit drug use, and stigma consistently play a central role. The criminalization of users of illicit drugs has led directly not only to users' incarceration, but also to their marginalization and isolation and to violence, entrenched poverty, and a vicious cycle of trauma. This policy has created an environment wherein any initiatives to prevent and reverse overdoses have been severely restricted. While a war on drugs and the people who use them has been widely criticized as destructive and unwinnable, the criminal policies that support the war on drugs have not changed even in response to this unprecedented crisis.

Critical studies of harm reduction: Overdose response in uncertain political times.

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada.

BACKGROUND: There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender. METHODS: Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender. RESULTS: Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men. CONCLUSION: Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

Reasons for accepting or declining participation in the ASPRE trial: A qualitative study with women at high risk of preterm pre-eclampsia.

OBJECTIVE: To identify factors that affected the decision of pregnant women at high risk for pre-eclampsia (PE) in accepting or declining participation in a medicated clinical trial (ASPRE) for the prevention of preterm PE. METHOD: This was a qualitative, cross-sectional study. A purposive sample of 14 participants and 13 decliners of the ASPRE trial were interviewed using semi-structured interviews. Data were analysed using template analysis. RESULTS: For participants, their high-risk status seems to have motivated them to take part in the trial. This was enabled by their perception that the trial drug aspirin was commonly used, the safety of the procedure, and the belief that they will be in receipt of extra monitoring in pregnancy. Decliners expressed discomfort about taking medications in pregnancy, and about the presence of the placebo arm; they seemed to be motivated by desire to reduce harm. Satisfaction with the information provided by the medical professionals was also influential in women's decision making, and so were the views of their partners and other trusted individuals. CONCLUSION: Pregnant women's motivation to take part or to decline participation in a medicated trail can be understood as an attempt to cope with the threat posed by their high-risk status.

Understanding real-world adherence in the directly acting antiviral era: A prospective evaluation of adherence among people with a history of drug use at a community-based program in Toronto, Canada.

BACKGROUND: Direct acting antiviral (DAA) treatments for Hepatitis C (HCV) are now widely available with sustained virologic response (SVR) rates of >90%. A major predictor of response to DAAs is adherence, yet few real-world studies evaluating adherence among marginalized people who use drugs and/or alcohol exist. This study evaluates patterns and factors associated with non-adherence among marginalized people with a history of drug use who were receiving care through a primary care, community-based HCV treatment program where opiate substitution is not offered on-site. METHODS: Prospective evaluation of chronic HCV patients initiating DAA treatment. Self-report medication adherence questionnaires were completed weekly. Pre/post treatment questionnaires examined socio-demographics, program engagement and substance use. Missing adherence data was counted as a missed dose. RESULTS: Of the 74 participants, who initiated treatment, 76% were male, the average age was 54 years, 69% reported income from disability benefits, 30% did not have stable housing and only 24% received opiate substitution therapy. Substance use was common in the month prior to treatment initiation with, 11% reported injection drug use, 30% reported non-injection drug use and 18% moderate to heavy alcohol use. The majority (85%) were treatment naïve, with 76% receiving sofosbuvir/ledipasvir (8-24 weeks) and 22% Sofosbuvir/Ribarvin (12-24 weeks). The intention to treat proportion with SVR12 was 87% (60/69). In a modified ITT analysis (excluding those with undetectable RNA at end of treatment), 91% (60/66) achieved SVR12. Overall, 89% of treatment weeks had no missed doses. 41% of participants had at least one missed dose. In multivariate analysis the only factor independently associated with weeks with missed doses was moderate to heavy alcohol use (p=0.05). CONCLUSION: This study demonstrates that strong adherence and SVR with DAAs is achievable, with appropriate supports, even in the context of substance use, and complex health/social issues.

Engagement in Group Psychotherapy Among Marginalized Individuals With Hepatitis C.

This article examines an innovative psychoeducational group model at a community-based hepatitis C treatment program in Toronto, Canada. Group support is increasingly used as part of community-based, interdisciplinary approaches to addressing the complex psychosocial needs and barriers to care of individuals living with and/or undergoing treatment for hepatitis C. This article articulates the theoretical framework and details of one such group model. It also examines group engagement and outcomes using data collected over three group cycles. Psychotherapeutic engagement was higher than might be anticipated for a highly marginalized population. Specifically, group cohesion measures were equivalent or higher compared to norms for other support/psychotherapy groups. This study suggests that individuals with complex psychosocial issues have the ability to engage meaningfully in group therapy.

Beyond viral response: A prospective evaluation of a community-based, multi-disciplinary, peer-driven model of HCV treatment and support.

BACKGROUND: Although the majority of new cases of hepatitis C (HCV) occur among people who inject drugs, very few receive treatment. In response, low-barrier, multidisciplinary models of HCV treatment have emerged in recent years to serve illicit drug users and have demonstrated comparable outcomes to the care delivered in tertiary care settings. However, few studies have measured comprehensive outcomes of these models. METHODS: The Toronto Community Hep C Program (TCHCP) is a community-based partnership between three primary health care centres with integrated specialist support. Program clients were interviewed using standardized questionnaires at three time points (baseline, post completion of HCV support group, and one year post group completion). The primary outcome of this study was self-reported overall health. Secondary outcomes included mental health, substance use, housing and income stability, and access to health care. RESULTS: TCHCP clients reported high rates of poverty, histories of trauma and incarceration. Physical and mental health co-morbidities were also very common; 78% reported having at least one chronic medical problem in addition to HCV and 41% had a lifetime history of hospitalization for mental health reasons. Participation in the program improved access to HCV care. Prior to joining the TCHCP, only 15% had been assessed by a HCV specialist. By the end of the study period this had increased significantly to 54%. Self-reported overall health did not improve during the study period. Housing status and income showed significant improvement. The proportion of participants with stable housing increased from 54% to 76% during the study period (p=0.0017) and the proportion of patients receiving income from provincial disability benefits also increased significantly (55% vs 75%, p=0.0216). CONCLUSION: This study demonstrated that a multi-disciplinary, community-based model of HCV treatment improves participant's lives in ways that extend beyond hepatitis C.

A novel program for treating patients with trimorbidity: hepatitis C, serious mental illness, and active substance use.

BACKGROUND: Advances in hepatitis C virus (HCV) treatment have yielded improved virological response rates, and yet, many individuals with psychiatric illness still fail to receive HCV therapy. Concerns about safety, adherence, and efficacy of HCV treatment are compounded and treatment is further deferred when substance use is also present. This is especially problematic given the disproportionately high rates of both mental health issues and substance use among individuals living with HCV. OBJECTIVE: This study sought to examine HCV treatment outcomes in clients with serious mental illness (SMI) and with high rates of active substance use who were participating in a community-based HCV treatment program. PATIENTS AND METHODS: A retrospective chart review of 129 clients was carried out. Patients were classified as having an SMI if they had a history of bipolar disorder, psychotic disorder, past suicide attempt or mental health related hospitalization. RESULTS: Fifty-one patients were defined as having an SMI. Among the 46 patients with SMI and a detectable HCV viral load, HCV antiviral therapy was initiated in nine (19.6%). A relapse or an increase in substance use was common (77.8% or n=7), as was the requirement for adjustment or initiation of psychotropic medications (66.7% or n=6) during HCV antiviral therapy. Despite these barriers, rates of adherence to antiviral therapy were high and overall sustained virological response rates were comparable with published trials. CONCLUSION: This study is the first to report HCV treatment outcomes in a population in which SMI and active polysubstance use was prevalent and suggests that with appropriate models of care, clients with trimorbidity can be treated safely and effectively.