People who use drugs' prioritization of regulation amid decriminalization reforms in British Columbia, Canada: A qualitative study.

BACKGROUND: North America and the province of British Columbia (BC), Canada, is experiencing an unprecedented number of overdose deaths. In BC, overdose has become the leading cause of death for people between the ages of 10-59 years old. In January 2023, BC decriminalized personal possession of a number of illegal substances with one aim being to address overdose deaths through stigma reduction and promoting access to substance use services. METHODS: We conducted a qualitative study to understand people who use drugs' (PWUD) perceptions of the new decriminalization policy, immediately prior to its' implementation (October-December 2022). To contextualize decriminalization within broader drug policy, we also asked PWUD what they perceived as the priority issues drug policy ought to address and the necessary solutions. Our final sample included 38 participants who used illegal drugs in the past month. RESULTS: We identified four themes: 1) The illicit drug supply as the main driver of drug toxicity deaths 2) Concerns about the impact of decriminalization on drug toxicity deaths 3) Views towards decriminalization as a policy response in the context of the drug toxicity crisis 4) Regulation as a symbol of hope for reducing drug toxicity deaths. CONCLUSION: From our data it became clear that many anticipated that decriminalization would have minimal or no impact on the overdose crisis. Regulation was perceived as the necessary policy approach for effectively and candidly addressing the drivers of the ongoing overdose crisis. These findings are important as jurisdictions consider different approaches to moving away from prohibition-based drug policy.

Awareness and knowledge of drug decriminalization among people who use drugs in British Columbia: a multi-method pre-implementation study.

BACKGROUND: In January 2023, British Columbia implemented a three-year exemption to Controlled Drugs and Substances Act, as granted by the federal government of Canada, to decriminalize the personal possession of small amounts of certain illegal drugs. This decriminalization policy, the first in Canada, was announced in response to the overdose emergency in British Columbia as a public health intervention that could help curb overdose deaths by reducing the impact of criminalization and increasing access to health and social services through stigma reduction. METHODS: The current multi-method study examines people who use drugs' awareness and knowledge of British Columbia's decriminalization model through cross-sectional quantitative surveys and qualitative interviews among people who use drugs from September-November 2022, immediately prior to the implementation of decriminalization. RESULTS: Quantitative findings show that two-thirds (63%) of people who use drugs were aware of the policy, but substantial knowledge gaps existed about the legal protections afforded (threshold amount, substances included, drug trafficking, confiscation). The qualitative findings suggest that people who use drugs misunderstood the details of the provincial decriminalization model and often conflated it with regulation. Results suggest that information sharing about decriminalization were minimal pre-implementation, highlighting areas for knowledge dissemination about people who use drugs' rights under this policy. CONCLUSIONS: Given that decriminalization in British Columbia is a new and landmark reform, and that the success of decriminalization and its benefits may be undermined by poor awareness and knowledge of it, efforts to share information, increase understanding, and empower the community, may be required to promote its implementation and benefits for the community.

Feeling safer: effectiveness, feasibility, and acceptability of continuous pulse oximetry for people who smoke opioids at overdose prevention services in British Columbia, Canada.

BACKGROUND: Smoking is the most common mode of unregulated opioid consumption overall and implicated in fatal overdoses in British Columbia (BC). In part, perception of decreased risk (e.g., fewer who smoke carry naloxone kits) and limited smoking-specific harm reduction services contribute to overdose deaths. Overdose prevention services (OPS) offer supervised settings for drug use. Continuous pulse oximetry, common in acute care, allows real-time, remote oxygen monitoring. We evaluated the effectiveness of a novel continuous pulse oximetry protocol aimed at allowing physical distancing (as required by COVID-19, secluded spaces, and to avoid staff exposure to vaporized opioids), its feasibility, and acceptability at OPS for people who smoke opioids. METHODS: This was a mixed methods survey study. We developed a continuous pulse oximetry protocol in collaboration with clinical experts and people with lived/living experience of substance use. We implemented our protocol from March to August 2021 at four OPS in BC permitting smoking. We included adults (≥ 18 years) presenting to OPS to smoke opioids. Peer researchers collected demographic, health, and substance use information, and conducted structured observations. OPS clients participating in our study, OPS staff, and peer researchers completed post-monitoring surveys. We analyzed responses using a thematic inductive approach and validated themes with peer researchers. RESULTS: We included 599 smoking events. OPS clients participating in our study had a mean age of 38.5 years; 73% were male. Most (98%) reported using "down", heroin, or fentanyl; 48% concurrently used other substances (32% of whom reported stimulants); 76% reported smoking alone in the last 3 days; and 36% reported an overdose while smoking. Respondents reported that the protocol facilitated physical distancing, was easy to use, high satisfaction, improved confidence, improved sense of safety, and that they would use it again. CONCLUSIONS: Continuous pulse oximetry allowed safe physical distancing, was feasible, and acceptable in monitoring people who smoke opioids at OPS.

"Shared experience makes this all possible": documenting the guiding principles of peer-led services for people released from prison.

BACKGROUND: There is a growing body of evidence demonstrating the effectiveness of peer-led services in supporting community reintegration for people released from prison. This study aims to document the guiding principle of a peer-led service for people released from prison, from the perspective of peer mentors. METHODS: Data were collected using focus groups (N = 10; 2 groups with 5 participants each) and one-on-one interviews (N = 5) including a total of 13 people, representing all UTGSS staff at the time of the study. An inductive thematic analysis was used to identify patterns in the data. Initial coding was done by using "in-vivo" codes (i.e. applying codes to terms used by participants). This informed the direction of the next stage of analysis, which focused on identifying categories that synthesized the codes and data across transcripts. In this stage, broad themes and sub-themes were developed. FINDINGS: Six themes were constructed to reflect the guiding principles of UTGSS staff. This includes four central themes: 1) Offering hope; 2) Building respectful relationships; 3) Providing consistent support; 4) Meeting people where they are at. Two connected themes are also reported: 1) Relying on shared experience, which participants reported serves as the foundation for practicing these guiding principles and 2) Bridging connections to services, which reflects the outcome of practicing these guiding principles. CONCLUSION: The principles identified in this study can be used by UTGSS staff as a guide for checking-in on progress with clients and may be considered as a model for reflection on practice by staff providing similar peer-led services. These principles should not be applied in a prescriptive way, as relationship building is at the centre of peer support, and different applications will be required depending on clients' goals and the range of supports available within their community.

Preferred stimulant safer supply and associations with methamphetamine preference among people who use stimulants in British Columbia: Findings from a 2021 cross-sectional survey.

BACKGROUND: As safer supply programs expand in Canada, stimulant safer supply is often overlooked despite the harms and criminalization faced by people who use stimulants. METHODS: The 2021 Harm Reduction Client Survey was administered at 17 harm reduction sites around British Columbia, Canada. The survey included a question about what specific substance participants would want to receive as stimulant safer supply. We investigated preference of stimulant safer substance by looking at frequency of stated preference and by using multivariable logistic regression to understand factors associated with the most frequently chosen substance. RESULTS: Of 330 participants who reported a stimulant safer supply preference, 58.5% (n = 193) chose crystal methamphetamine, 13% (n = 43) crack cocaine and 12.4% (n = 41) cocaine powder. The options that were available by prescription at the time of data collection were chosen by under 11% of participants (dextroamphetamine n = 21, methylphenidate n = 15). A preference for crystal methamphetamine was associated with being 29 and under compared to 50 and over (AOR: 3.96, 95% CI: 1.42-11.07, p-value: 0.01); self-identifying as a cis man versus a cis woman (AOR: 1.75, 95% CI: 1.03-2.97, p-value: 0.04); and using drugs every day (AOR: 15.43, 95% CI: 3.38-70.51, p-value: < 0.01) or a few times a week (AOR: 8.90, 95% CI: 1.78-44.44, p-value: 0.01) compared to a few times a month. CONCLUSIONS: Preference of stimulant safer supply is associated with age, gender, and substance use characteristics. Safer supply programs that offer limited substances risk being poorly accessed, resulting in a continued reliance on an unregulated supply. Moreover, programs that do not offer a range of substances can contribute to health inequities.

Smoking identified as preferred mode of opioid safe supply use; investigating correlates of smoking preference through a 2021 cross-sectional study in British Columbia.

BACKGROUND: The increasing number of illicit drug toxicity deaths in British Columbia (BC) has led to calls for a regulated (pharmaceutical grade) supply of substances ("safe supply"). In order to inform safe supply recommendations, we aimed to identify why people currently smoke opioids and assess the preferred mode of consumption if people who use opioids were provided with opioid safe supply. METHODS: The BC Harm Reduction Client Survey (HRCS) is an annual survey that gathers information about people who use drugs' (PWUD) substance use characteristic with the goal of contributing to evidence-based policy. This study utilized data from the 2021 HRCS. The outcome variable was "prefer smoking opioid safe supply" ('yes/no'). Explanatory variables included participants' demographics, drug use, and overdose characteristics. Bivariate and hierarchical multivariable logistic regressions were conducted to identify factors associated with the outcome. RESULTS: Of 282 total participants who indicated a preference for a mode of consumption for opioid safe supply, 62.4% preferred a smokable option and 19.9% preferred to inject if provided with opioid safe supply. Variables significantly associated with the outcome (preferred smoking) included: being 19-29 years old (AOR=5.95, CI =1.93 - 18.31) compared to >50 years old, having witnessed an overdose in the last 6 months (AOR=2.26, CI=1.20 - 4.28), having smoked opioids in the last 3 days (AOR=6.35, CI=2.98 - 13.53) and having a preference to smoke stimulants safe supply (AOR=5.04, CI=2.53 - 10.07). CONCLUSION: We found that over half of participants prefer smokable options when accessing opioid safe supply. Currently in BC, there are limited smokable opioid safe supply options as alternatives to the toxic street supply. To reduce overdose deaths, safe supply options should be expanded to accommodate PWUD that prefer smoking opioids.

"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.

An evaluation of nine culturally tailored interventions designed to enhance engagement in HIV care among transgender women of colour in the United States.

INTRODUCTION: Transgender women (TW) worldwide have a high prevalence of HIV, and TW with HIV encounter numerous healthcare barriers. It is critical to develop evidence-informed interventions to improve their engagement in healthcare to achieve durable viral suppression (VS). We evaluated whether participation in one of nine interventions designed specifically for TW was associated with improved engagement in HIV care among transgender women of colour (TWC). METHODS: Between 2013 and 2017, nine US organizations implemented nine distinct and innovative HIV care engagement interventions with diverse strategies, including: individual and group sessions, case management and navigation, outreach, drop-in spaces, peer support and/or incentives to engage TWC with HIV in care. The organizations enrolled 858 TWC, conducted surveys, captured intervention exposure data and extracted medical record data. Our evaluation of the interventions employed a pre-post design and examined four outcomes-any HIV care visit, antiretroviral therapy (ART) prescription, retention in HIV care and VS (both overall and among those with a clinic visit and viral load test), at baseline and every 6 months for 24 months. We employed logistic generalized estimating equations to assess the relative odds of each outcome at 12 and 24 months compared to baseline. RESULTS: Overall, 79% of participants were exposed to at least one intervention activity. Over 24 months of follow-up, participants received services for a median of over 6 hours (range: 3-69 hours/participant). Compared to baseline, significantly (p<0.05) greater odds were demonstrated at both 12 and 24 months for three outcomes: prescription of ART (ORs: 1.42 at 12 months, 1.49 at 24 months), VS among all participants (ORs: 1.49, 1.54) and VS among those with a clinic visit and viral load test (ORs: 1.53, 1.98). The outcomes of any HIV care visit and retention in HIV care had significantly greater odds (ORs: 1.38 and 1.58, respectively) only at 12 months compared to baseline. CONCLUSIONS: These evaluation results illustrate promising approaches to improve engagement in HIV care and VS among TWC with HIV. Continued development, adaptation and scale-up of culturally tailored HIV care interventions for this key population are necessary to meet the UNAIDS 95-95-95 goals.

Intention to seek emergency medical services during community overdose events in British Columbia, Canada: a cross-sectional survey.

INTRODUCTION: Canada and the United States continue to experience increasing overdose deaths attributed to highly toxic illicit substances, driven by fentanyl and its analogues. Many bystanders report being hesitant to call 9-1-1 at an overdose due to fears around police presence and arrests. In Canada, a federal law was enacted in 2017, the Good Samaritan Drug Overdose Act (GSDOA), to provide protection from simple drug possession and related charges when 9-1-1 is called to an overdose. There is limited evidence, however, that the GSDOA has improved rates of intention to call 9-1-1 at overdose events. We therefore sought to examine intent to call 9-1-1 among persons who received GSDOA education and were at risk of witnessing an overdose. METHODS: A cross-sectional survey was conducted with people at risk of witnessing an overdose recruited at 19 Take Home Naloxone (THN) program sites across British Columbia as well as online through Foundry from October 2020 to April 2021. Descriptive statistics were used to examine intention to call 9-1-1 at future overdoses. Multivariable logistic regression models were built in hierarchical fashion to examine factors associated with intention to call 9-1-1. RESULTS: Overall, 89.6% (n = 404) of the eligible sample reported intention to call 9-1-1. In the multivariable model, factors positively associated with intention to call 9-1-1 included identifying as a cisgender woman (adjusted odds ratio [AOR]: 3.37; 95% CI: 1.19-9.50) and having previous GSDOA awareness ([AOR]: 4.16; 95% CI: 1.62-10.70). Having experienced a stimulant overdose in the past 6 months was negatively associated with intention to call 9-1-1 ([AOR]: 0.24; 95% CI: 0.09-0.65). CONCLUSION: A small proportion of the respondents reported that, despite the enactment of GSDOA, they did not intend to call 9-1-1 and those who were aware of the act were more likely to report an intention to call at future overdose events. Increasing GSDOA awareness and/or additional interventions to support the aims of the GSDOA could address ongoing reluctance to seek emergency medical care by people who use drugs.

"There are solutions and I think we're still working in the problem": The limitations of decriminalization under the good Samaritan drug overdose act and lessons from an evaluation in British Columbia, Canada.

BACKGROUND: Drug prohibition has been associated with increased risk of overdose. However, drug prohibition remains the dominant drug policy, including in Canada with the Controlled Drugs and Substances Act. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted, to encourage people to contact emergency medical services by providing bystanders at the scene of an overdose with legal protection for simple possession and conditions related to simple possession. METHODS: We conducted an evaluation of the GSDOA in British Columbia, Canada that included one-on-one interviews with people who use illicit drugs (PWUD), to determine peoples' experiences and perceptions surrounding this form of decriminalization. We present findings from a thematic analysis of 37 interviews. RESULTS: We identified limitations of the GSDOA at overdose events; key themes and concerns causing PWUD to hesitate to or avoid contacting emergency medical services included drug confiscation, the thin line between simple possession and drug trafficking, and enforcement of other charges and court ordered conditions that are not legally protected by the GSDOA. Moreover, participants discussed the GSDOA as inequitable; benefiting some while excluding PWUD with intersecting marginalized identities. CONCLUSION: Our findings are pertinent in light of many jurisdictions across the world considering dejure decriminalization, including BC and Vancouver. The GSDOA and associated limitations that emerged in our evaluation can serve to guide jurisdictions implementing or amending dejure decriminalization policies.

Awareness and knowledge of the Good Samaritan Drug Overdose Act among people at risk of witnessing an overdose in British Columbia, Canada: a multi-methods cross sectional study.

INTRODUCTION: Bystanders to drug overdoses often avoid or delay calling 9-1-1 and cite fear of police involvement as a main reason. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted by the Canadian government to provide people present at an overdose with legal protection from charges for simple drug possession, and conditions stemming from simple possession. Few studies have taken a multi-methods approach to evaluating the GSDOA. We used quantitative surveys and qualitative interviews to explore awareness, understanding, and perceptions of the GSDOA in people at risk of witnessing an overdose. METHODS: Quantitative cross-sectional surveys and qualitative telephone interviews were conducted with adults and youth at risk of witnessing an overdose across British Columbia. Cross-sectional survey participants were recruited at 19 Take Home Naloxone sites and online through Foundry. Multivariable logistic regression models were constructed hierarchically to determine factors associated with GSDOA awareness. Telephone interview participants were recruited by research assistants with lived/living experience of substance use. Deductive and inductive thematic analyses were conducted to identify major themes. RESULTS: Overall, 52.7% (n = 296) of the quantitative study sample (N = 453) reported being aware of the GSDOA. In multivariable analysis, cellphone possession (adjusted odds ratio [AOR] = 2.19; 95% confidence interval [CI] 1.36, 3.54) and having recently witnessed an opioid overdose (AOR = 2.34; 95% CI 1.45, 3.80) were positively associated with GSDOA awareness. Young adults (25 - 34 years) were more likely to be aware of the Act (AOR = 2.10; 95% CI 1.11, 3.98) compared to youth (16-24 years). Qualitative interviews (N = 42) revealed that many overestimated the protections offered by the GSDOA. To increase awareness and knowledge of the Act among youth, participants recommended adding the GSDOA to school curricula and using social media. Word of mouth was suggested to reach adults. CONCLUSION: Both awareness and knowledge of the GSDOA remain low in BC, with many overestimating the protections the Act offers. Dissemination efforts should be led by people with lived/living experience and should target those with limited awareness and understanding of the Act as misunderstandings can erode trust in law enforcement and harm reduction policy.

Swallowing disorders and associated factors in older adults living in nursing homes.

PURPOSE: The aim of this study was to identify the frequency of swallowing disorders and the associated factors in older adults living in nursing homes. METHODS: This is a cross-sectional study with a sample of 73 older adults (≥ 60 years; mean age = 80 ± 7.49 years; female = 82.2%) living in five non-profit Brazilian nursing homes. Demographic and clinical data were collected. The frequency of swallowing disorders was determined by the Volume-Viscosity Swallow Test (VVS-T). Covariables with a p-value less than 0.20 according to Pearson's chi-square test or Fisher's exact test were included in the multiple logistic regression analysis model. The level of significance was 5%. RESULTS: The frequency of swallowing disorders was 63%. The multiple logistic regression model revealed that the chance of an older adult living in a nursing home presenting with swallowing disorders increased by 8% with each 1-year increase in age. Decreases in oral intake level improved the chance of a negative result in the VVS-T by approximately four times, and an individual with a FOIS level below seven was almost 11 times more likely to have a swallowing disorder. CONCLUSION: The frequency of swallowing disorders in older adults living in nursing homes is high and is associated with age and oral intake. The management care team should be aware of the early detection of these conditions to prevent complications of oropharyngeal dysphagia.

Trends in neonatal mortality in Brazil from 2007 to 2017. / Tendência da mortalidade neonatal no Brasil de 2007 a 2017.

The objective of this study was to analyze the trends in neonatal mortality in Brazil from 2007 to 2017. This is an ecological time series study carried out with data from the Mortality Information System and the Information System on Live Births, analyzed through of Prais-Winsten regression. There was an average neonatal mortality rate of 9.46 deaths/1,000 live births in the analyzed period, with a reduction of 2.15% per year. There was a greater decline in early neonatal mortality compared to late neonatal mortality. There was an upward trend of neonatal deaths among preterm infants, newborns with extremely low birth weight, born by cesarean delivery, children of mothers over 30 years of age and of mothers with more than eight years of schooling. Regarding the causes of death, there was an increasing trend of deaths due to congenital malformations, infectious diseases, endocrine, nutritional and metabolic diseases and external causes. Still, there was an upward trend in preventable deaths by adequate care for women during pregnancy and for other causes that are not clearly preventable. Despite the general reduction in deaths, it is necessary to intensify public policies for adequate care for women during pregnancy to ensure improvement in the other indicators analyzed.

O objetivo deste estudo foi analisar a tendência da mortalidade neonatal no Brasil de 2007 a 2017. Trata-se de um estudo ecológico de série temporal, realizado com dados do Sistema de Informações sobre Mortalidade e do Sistema de Informações sobre Nascidos Vivos, analisados por meio de regressão de Prais-Winsten. Verificou-se uma taxa média de mortalidade neonatal de 9,46/1.000 nascidos vivos no período, com redução de 2,15% ao ano. Houve maior declínio da mortalidade neonatal precoce, comparada com a tardia. Destaca-se tendência crescente dos óbitos neonatais entre neonatos pré-termos, com extremo baixo peso, nascidos de parto cesáreo, filhos de mães com idade superior a 30 anos e escolaridade superior a oito anos de estudo. Em relação às causas de morte, verificou-se tendência crescente dos óbitos por malformações congênitas, doenças infecciosas, doenças endócrinas, nutricionais e metabólicas e causas externas. Constatou-se, ainda, tendência crescente nos óbitos evitáveis por adequada atenção à mulher na gestação e por demais causas não claramente evitáveis. Apesar da redução geral dos óbitos, faz-se necessário intensificar as políticas públicas de assistência adequada à mulher na gestação para garantir melhoria nos demais indicadores analisados.

Handgrip Strength Thresholds are Associated With Malnutrition Inflammation Score (MIS) in Maintenance Hemodialysis Patients.

OBJECTIVE: The aim is to verify the association between nutritional status and muscle strength, considering handgrip strength (HGS) cutoffs associated with sarcopenia and mortality. METHODS: Cross-sectional analysis, including hemodialysis patients. Malnutrition Inflammation Score (MIS) was used to assess nutritional status. Muscle function was assessed by HGS, and the considered cutoffs were established by other studies. Cutoffs for sarcopenia diagnosis were 27 and 16 kg for males and females, respectively; cutoffs associated with mortality were 22 and 7 kg for males and females, respectively. Two binary logistic regression models were built, with HGS categorized according to the cutoff for sarcopenia and mortality as dependent variables. RESULTS: Of the 218 patients who were included, 56.9% were male, the mean age was 58.3 years, and 44.7% diabetic; 132 patients (60.6%) had HGS <27 or 16 kg. Age, prevalence of diabetes, and MIS were higher, creatinine and albumin were lower in patients with HGS below these values; 77 patients (35.2%) had HGS <22 or 7 kg. Age, male, and diabetes prevalence, CRP and MIS were higher, midarm muscle circumference (MAMC), creatinine, albumin, and urea were lower in patients with HGS below these values. In the logistic regression MIS (OR 1.202; 95% CI 1.073-1.347; P < .01), age, male, diabetes, and MAMC were associated with the risk of HGS below the cutoffs for sarcopenia. MIS (OR 1.322; 95% CI 1.192-1.467; P < .01), age, male, and diabetes were associated with the risk of HGS below the cutoffs associated with mortality. CONCLUSION: Worse nutritional status increases the risk of HGS below the cutoffs associated with sarcopenia and mortality in hemodialysis patients.

Stakeholder preferences for supervised consumption site design, staff, and ancillary services: A scoping review of feasibility studies.

BACKGROUND: Supervised consumption services (SCS) prevent drug related harms for people who use drugs (PWUD) and often require a feasibility study before implementation. While there is a growing feasibility study literature, it has not been synthesized for use by researchers and SCS planners. We conducted a scoping review of feasibility studies reporting on preferred SCS design characteristics, staffing models and ancillary services. MATERIALS AND METHODS: We searched academic databases and grey literature sources with key terms related to SCS and feasibility studies. Team members reviewed search results and included feasibility studies with findings relevant to SCS design, staff, or ancillary services. The research methods and findings from included studies regarding design elements were charted, collated, and reported. RESULTS: The search yielded 1347 results; 26 met eligibility criteria for review. Most reported preferences for SCS location, hours and wait times. Few reported preferences for security, space allocation by type of drug use, and onsite opioid prescribing. PWUD generally preferred aligning design elements with the goal of harm reduction for clients while other stakeholders valued treatment as a goal. Specific considerations varied by implementation context. CONCLUSIONS: These results can be used by SCS planners and researchers to help resolve implementation concerns and improve uptake among PWUD, which is critical during an overdose crisis. Future feasibility studies should ask about design preferences that may be significant to uptake but are not commonly covered in studies. These should also explore how context influences preferences to develop an evidence-based framework for context-specific design decisions.

Tendência da mortalidade neonatal no Brasil de 2007 a 2017 / Trends in neonatal mortality in Brazil from 2007 to 2017

Resumo O objetivo deste estudo foi analisar a tendência da mortalidade neonatal no Brasil de 2007 a 2017. Trata-se de um estudo ecológico de série temporal, realizado com dados do Sistema de Informações sobre Mortalidade e do Sistema de Informações sobre Nascidos Vivos, analisados por meio de regressão de Prais-Winsten. Verificou-se uma taxa média de mortalidade neonatal de 9,46/1.000 nascidos vivos no período, com redução de 2,15% ao ano. Houve maior declínio da mortalidade neonatal precoce, comparada com a tardia. Destaca-se tendência crescente dos óbitos neonatais entre neonatos pré-termos, com extremo baixo peso, nascidos de parto cesáreo, filhos de mães com idade superior a 30 anos e escolaridade superior a oito anos de estudo. Em relação às causas de morte, verificou-se tendência crescente dos óbitos por malformações congênitas, doenças infecciosas, doenças endócrinas, nutricionais e metabólicas e causas externas. Constatou-se, ainda, tendência crescente nos óbitos evitáveis por adequada atenção à mulher na gestação e por demais causas não claramente evitáveis. Apesar da redução geral dos óbitos, faz-se necessário intensificar as políticas públicas de assistência adequada à mulher na gestação para garantir melhoria nos demais indicadores analisados.

Abstract The objective of this study was to analyze the trends in neonatal mortality in Brazil from 2007 to 2017. This is an ecological time series study carried out with data from the Mortality Information System and the Information System on Live Births, analyzed through of Prais-Winsten regression. There was an average neonatal mortality rate of 9.46 deaths/1,000 live births in the analyzed period, with a reduction of 2.15% per year. There was a greater decline in early neonatal mortality compared to late neonatal mortality. There was an upward trend of neonatal deaths among preterm infants, newborns with extremely low birth weight, born by cesarean delivery, children of mothers over 30 years of age and of mothers with more than eight years of schooling. Regarding the causes of death, there was an increasing trend of deaths due to congenital malformations, infectious diseases, endocrine, nutritional and metabolic diseases and external causes. Still, there was an upward trend in preventable deaths by adequate care for women during pregnancy and for other causes that are not clearly preventable. Despite the general reduction in deaths, it is necessary to intensify public policies for adequate care for women during pregnancy to ensure improvement in the other indicators analyzed.

Knowledge of the Good Samaritan Drug Overdose Act and possession of a naloxone kit among people recently released from prison.

PURPOSE: This study aims to describe knowledge of Canada's Good Samaritan Drug Overdose Act (GSDOA) and take home naloxone (THN) training and kit possession among people being released from provincial correctional facilities in British Columbia. DESIGN/METHODOLOGY/APPROACH: The authors conducted surveys with clients of the Unlocking the Gates Peer Health Mentoring program on their release. The authors compared the characteristics of people who had and had not heard of the GSDOA and who were in possession of a THN kit. FINDINGS: In this study, 71% people had heard of the GSDOA, and 55.6% were in possession of a THN kit. This study found that 99% of people who had heard of the GSDOA indicated that they would call 911 if they saw an overdose. Among people who perceived themselves to be at risk of overdose, 28.3% did not have a THN kit. Only half (52%) of participants had a mobile phone, but 100% of those with a phone said they would call 911 if they witnessed an overdose. ORIGINALITY/VALUE: The authors found that people with knowledge of the GSDOA were likely to report that they would call 911 for help with an overdose. Education about the GSDOA should be a standard component of naloxone training in correctional facilities. More than one in four people at risk of overdose were released without a naloxone kit, highlighting opportunities for training and distribution. Access to a cellphone is important in enabling calls to 911 and should be included in discharge planning.

Police officers' knowledge, understanding and implementation of the Good Samaritan Drug Overdose Act in BC, Canada.

INTRODUCTION: In May 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted in Canada - amending the Controlled Drugs and Substances Act. For people present at an overdose, the GSDOA offers legal protection from simple drug possession as well as breach of charges related to simple possession including probation, pre-trial release, conditional sentences, and parole. It is unclear if the GSDOA has been fully implemented by police officers. METHODS: We conducted 22 key informant interviews with police officers across British Columbia, Canada. Convenience sampling was initially employed, followed by purposeful sampling to ensure diversity in jurisdictions and participant demographics (e.g. age, sex, policing experience). A thematic analysis was conducted RESULTS: Our findings show that awareness and knowledge of the GSDOA vary among police officers. Many officers reported being unaware of the GSDOA or could not correctly define for whom and when the GSDOA applies. Information about the GSDOA was largely disseminated via email. Many officers expressed concerns with this dissemination method given the potential that key legal information would be overlooked. Police officers reported that not arresting for simple possession at an overdose was common practice, even before the enactment of the GSDOA. Thus, some officers did not believe that the GSDOA considerably changed police practices. Finally, police officers reported that they exercised discretion applying the GSDOA. Police officer interpretation of the intention and content of the GSDOA had critical implications for how they applied it in practice. CONCLUSION: Effective education for law enforcement, including the dissemination of information beyond email, is needed to improve officers' awareness and understanding of the GSDOA. Given officers' use of discretion when applying the GSDOA, greater legal reforms, such as de jure decriminalization, may be required to fully protect persons at an overdose from simple possession for controlled substances.

Feasibility, acceptability, concerns, and challenges of implementing supervised injection services at a specialty HIV hospital in Toronto, Canada: perspectives of people living with HIV.

BACKGROUND: Substance use significantly impacts health and healthcare of people living with HIV/AIDS (PLHIV), especially their ability to remain in hospital following admission. Supervised injection services (SIS) reduce overdoses and drug-related harms, but are not often provided within hospitals/outpatient programs. Leading us to question, what are PLHIV's perceptions of hospital-based SIS? METHODS: This mixed-methods study explored feasibility and acceptability of implementing SIS at Casey House, a Toronto-based specialty HIV hospital, from the perspective of its in/outpatient clients. We conducted a survey, examining clients' (n = 92) demand for, and acceptability of, hospital-based SIS. Following this, we hosted two focus groups (n = 14) and one-on-one interviews (n = 8) with clients which explored benefits/drawbacks of in-hospital SIS, wherein participants experienced guided tours of a demonstration SIS space and/or presentations of evidence about impacts of SIS. Data were analysed using descriptive statistics and thematic analysis. RESULTS: Among survey participants, 76.1% (n = 70) identified as cis-male and over half (n = 49;54.4%) had been a hospital client for 2 years or less. Nearly half (48.8%) knew about clients injecting in/near Casey House, while 23.6% witnessed it. Survey participants were more supportive of SIS for inpatients (76.1%) than for outpatients (68.5%); most (74.7%) reported SIS implementation would not impact their level of service use at Casey House, while some predicted coming more often (16.1%) and others less often (9.2%). Most focus group/interview participants, believed SIS would enhance safety by reducing health harms (e.g. overdose), increasing transparency between clients and clinicians about substance use, and helping retain clients in care. Debate arose about who (e.g., in/outpatients vs. non-clients) should have access to hospital-based SIS and how implementation may shift organizational priorities/resources away from services not specific to drug use. CONCLUSIONS: Our data showed widespread support of, and need for, hospital-based SIS among client stakeholders; however, attempts to reduce negative impacts on non-drug using clients need to be considered in the balance of implementation plans. Given the increased risks of morbidity and mortality for PLHIV who inject drugs as well as the problems in retaining them in care in a hospital setting, SIS is a key component of improving care for this marginalized group.

Oropharyngeal dysphagia frequency in older adults living in nursing homes: an integrative review. / Frequência de disfagia orofaríngea em idosos institucionalizados: uma revisão integrativa.

PURPOSE: To synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes. RESEARCH STRATEGIES: The study question followed the PECO strategy and the search was performed in the Pubmed/Medline, Web of Science, Scopus, LILACS and SciELO databases, using keywords and specific free terms. SELECTION CRITERIA: articles with no time or language restrictions that reported the frequency of oropharyngeal dysphagia in older adults living in nursing homes and the diagnostic criteria. DATA ANALYSIS: it was analyzed the population characteristics, the concept of "oropharyngeal dysphagia", the methods for identifying the outcome and the frequency of oropharyngeal dysphagia. The evaluation of the methodological quality of the articles followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTS: Fifteen articles were included. There was great variability in relation to the sample size, with a predominance of longevous old women. The concept of dysphagia, when mentioned, was heterogeneous. Diagnostic criteria were diverse and mostly comprised of questionnaires or clinical trials results. No studies used instrumental tests. The frequency of oropharyngeal dysphagia in the studied population ranged from 5.4% to 83.7%, being higher in studies that used clinical tests, but with greater precision of confidence intervals in studies that used questionnaires and large sample size. CONCLUSION: The frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variability. Methodological discrepancies among studies compromise the reliability of frequency estimates and highlight the need for research with better defined and standardized methodological criteria.

OBJETIVO: Sintetizar o estado do conhecimento científico sobre a frequência de disfagia orofaríngea em idosos institucionalizados. ESTRATÉGIA DE PESQUISA: A pergunta de pesquisa foi formulada de acordo com a estratégia PECO e a busca foi realizada nas bases de dados Pubmed/Medline, Web of Science, Scopus, LILACS e SciELO, utilizando descritores e termos livres específicos. CRITÉRIOS DE SELEÇÃO: Artigos sem restrição de tempo ou idioma, que relatassem a frequência de disfagia orofaríngea em idosos institucionalizados e o critério utilizado para diagnóstico. ANÁLISE DOS DADOS: Foram analisadas as características da população, conceito de "disfagia orofaríngea", métodos para identificação do desfecho e a frequência de disfagia orofaríngea. A avaliação da qualidade metodológica dos artigos seguiu os critérios do Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTADOS: Foram incluídos quinze artigos. Houve grande variabilidade quanto ao tamanho da amostra, com predomínio de idosos longevos do sexo feminino. O conceito de disfagia, quando mencionado, foi heterogêneo. Os critérios diagnósticos foram diversos e compostos, em sua maioria, por resultados de questionários ou testes clínicos. Nenhum estudo utilizou exames instrumentais. A frequência de disfagia orofaríngea na população estudada oscilou entre 5.4% e 83.7%, sendo mais elevada nos estudos que utilizaram testes clínicos, porém, com intervalos de confiança mais precisos naqueles que usaram questionários e amostras maiores. CONCLUSÃO: A frequência de disfagia orofaríngea em idosos institucionalizados possui ampla variabilidade. As discrepâncias metodológicas entre os estudos comprometem a confiabilidade das estimativas de frequência e apontam a necessidade de pesquisas com critérios metodológicos mais bem definidos e padronizados.