Perceptions of provider awareness of traditional and cultural treatments among Indigenous people who use unregulated drugs in Vancouver, Canada.

INTRODUCTION: Indigenous people who use unregulated drugs (IPWUD) face significant barriers to care, including sparse availability of culturally safe health services. Integrating Indigenous traditional and cultural treatments (TCT) into health service delivery is one way to enhance culturally safe care. In a Canadian setting that implemented cultural safety reforms, we sought to examine the prevalence and correlates of client perceptions of primary care provider awareness of TCT among IPWUD. METHODS: Data were derived from two prospective cohort studies of PWUD in Vancouver, Canada between December 2017 and March 2020. A generalized linear mixed model with logit-link function was used to identify longitudinal factors associated with perceived provider awareness of TCT. RESULTS: Among a sample of 507 IPWUD who provided 1200 survey responses, a majority (n = 285, 56%) reported their primary care provider was aware of TCT. In multiple regression analyses, involvement in treatment decisions always (Adjusted Odds Ratio [AOR] = 3.6; 95% confidence interval [CI]: 1.6-7.8), involvement in treatment decisions most or some of the time (AOR = 3.3; 95% CI: 1.4-7.7), comfort with provider or clinic (AOR = 2.7; 95% CI: 1.5-5.0), and receiving care from a social support worker (AOR = 1.5; 95% CI: 1.0-2.1) were positively associated with provider awareness of TCT. CONCLUSION: We found high levels of perceived provider awareness of TCT and other domains of culturally safe care within a cohort of urban IPWUD. However, targeted initiatives that advance culturally safe care are required to improve healthcare and health outcomes for IPWUD, who continue to bear a disproportionate burden of substance use harms.

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

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

Combining photoperiod and thermal responses to predict phenological mismatch for introduced insects.

A wide variety of organisms use the regular seasonal changes in photoperiod as a cue to align their life cycles with favorable conditions. Yet the phenological consequences of photoperiodism for organisms exposed to new climates are often overlooked. We present a conceptual approach and phenology model that maps voltinism (generations per year) and the degree of phenological mismatch that can arise when organisms with a short-day diapause response are introduced to new regions or are otherwise exposed to new climates. Our degree-day-based model combines continent-wide spatialized daily climate data, calculated date-specific and latitude-specific day lengths, and experimentally determined developmental responses to both photoperiod and temperature. Using the case of the knotweed psyllid Aphalara itadori, a new biological control agent being introduced from Japan to North America and Europe to control an invasive weed, we show how incorporating a short-day diapause response will result in geographic patterns of attempted voltinism that are strikingly different from the potential number of generations based on degree-days alone. The difference between the attempted and potential generations represents a quantitative measure of phenological mismatch between diapause timing and the end of the growing season. We conclude that insects moved from lower to higher latitudes (or to cooler climates) will tend to diapause too late, potentially resulting in high mortality from inclement weather, and those moved from higher to lower latitude (to warmer climates) may be prone to diapausing too early, therefore not fully exploiting the growing season and/or suffering from insufficient reserves for the longer duration in diapause. Mapped output reveals a central region with good phenology match that shifts north or south depending on the geographic source of the insect and its corresponding critical photoperiod for diapause. These results have direct relevance for efforts to establish populations of classical biocontrol agents. More generally, our approach and model could be applied to a wide variety of photoperiod- and temperature-sensitive organisms that are exposed to changes in climate, including resident and invasive agricultural pests and species of conservation concern.

Expansion history and environmental suitability shape effective population size in a plant invasion.

The margins of an expanding range are predicted to be challenging environments for adaptation. Marginal populations should often experience low effective population sizes (Ne ) where genetic drift is high due to demographic expansion and/or census population size is low due to unfavourable environmental conditions. Nevertheless, invasive species demonstrate increasing evidence of rapid evolution and potential adaptation to novel environments encountered during colonization, calling into question whether significant reductions in Ne are realized during range expansions in nature. Here we report one of the first empirical tests of the joint effects of expansion dynamics and environment on effective population size variation during invasive range expansion. We estimate contemporary values of Ne using rates of linkage disequilibrium among genome-wide markers within introduced populations of the highly invasive plant Centaurea solstitialis (yellow starthistle) in North America (California, USA), and within native Eurasian populations. As predicted, we find that Ne within the invaded range is positively correlated with both expansion history (time since founding) and habitat quality (abiotic climate). History and climate had independent additive effects with similar effect sizes, indicating an important role for both factors in this invasion. These results support theoretical expectations for the population genetics of range expansion, though whether these processes can ultimately arrest the spread of an invasive species remains an unanswered question.

Potential limits to the benefits of admixture during biological invasion.

Species introductions often bring together genetically divergent source populations, resulting in genetic admixture. This geographic reshuffling of diversity has the potential to generate favourable new genetic combinations, facilitating the establishment and invasive spread of introduced populations. Observational support for the superior performance of admixed introductions has been mixed, however, and the broad importance of admixture to invasion questioned. Under most underlying mechanisms, admixture's benefits should be expected to increase with greater divergence among and lower genetic diversity within source populations, though these effects have not been quantified in invaders. We experimentally crossed source populations differing in divergence in the invasive plant Centaurea solstitialis. Crosses resulted in many positive (heterotic) interactions, but fitness benefits declined and were ultimately negative at high source divergence, with patterns suggesting cytonuclear epistasis. We explored the literature to assess whether such negative epistatic interactions might be impeding admixture at high source population divergence. Admixed introductions reported for plants came from sources with a wide range of genetic variation, but were disproportionately absent where there was high genetic divergence among native populations. We conclude that while admixture is common in species introductions and often happens under conditions expected to be beneficial to invaders, these conditions may be constrained by predictable negative genetic interactions, potentially explaining conflicting evidence for admixture's benefits to invasion.

Engagement in Maximally-Assisted Therapy and Adherence to Antiretroviral Therapy Among a Cohort of Indigenous People Who Use Illicit Drugs.

Throughout the world, Indigenous populations experience a disproportionate burden of HIV infection. Maximally-assisted therapy (MAT) is an interdisciplinary care intervention that includes ART dispensation to support individuals with a history of addiction and homelessness. This study sought to longitudinally evaluate the relationship between engagement in MAT and achieving optimal adherence using data from an ongoing cohort of HIV-positive individuals who use drugs in Vancouver, Canada, where HIV/AIDS treatment is offered at no cost. Between December 2005 and November 2016, 354 HIV-positive Indigenous participants were enrolled and data were analyzed using generalized mixed-effects (GLMM) and marginal structural modeling. In both multivariable analyses, engagement in MAT was independently associated with optimal adherence to ART (GLMM: AOR = 4.92, 95% CI 3.18-7.62; marginal structural model: AOR = 5.76, 95% CI 3.34-9.96). MAT-based programmes could be a part of a renewed evidence-base to elevated levels of preventable HIV/AIDS-associated morbidity, mortality and viral transmission among Indigenous peoples in Canada.

Increased burden of suicidality among young street-involved sex workers who use drugs in Vancouver, Canada.

BACKGROUND: The risks of suicidality among street-involved youth who use drugs and engage in sex work are not well described. This study sought to evaluate if street-involved youth who engage in sex work were at an elevated risk for attempting suicide. METHODS: Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth who use drugs in Vancouver, Canada. Multivariable generalized estimating equation analyses were employed to examine whether youth who engaged in sex work were at elevated risk of attempting suicide, controlling for possible confounders. RESULTS: Between September 2005 and May 2015, 1210 youth were recruited into the cohort, of whom, 173 (14.3%) reported recently attempting suicide at some point during the study period. In multivariable analysis, youth who engaged in sex work were significantly more likely to report a recent suicide attempt (adjusted odds ratio = 1.93; 95% confidence interval: 1.28-2.91). CONCLUSIONS: Street-involved youth who engage in sex work were observed to be at a significantly higher risk for suicidality. Systematic discrimination and unaddressed trauma may contribute to the observed increased burden of suicidality among this population. Interventions that support the mental health and well-being of street-involved youth who engage in sex work are urgently needed.

Population genomic analyses reveal a history of range expansion and trait evolution across the native and invaded range of yellow starthistle (Centaurea solstitialis).

Identifying sources of genetic variation and reconstructing invasion routes for non-native introduced species is central to understanding the circumstances under which they may evolve increased invasiveness. In this study, we used genome-wide single nucleotide polymorphisms to study the colonization history of Centaurea solstitialis in its native range in Eurasia and invasions into the Americas. We leveraged this information to pinpoint key evolutionary shifts in plant size, a focal trait associated with invasiveness in this species. Our analyses revealed clear population genomic structure of potential source populations in Eurasia, including deep differentiation of a lineage found in the southern Apennine and Balkan Peninsulas and divergence among populations in Asia, eastern Europe and western Europe. We found strongest support for an evolutionary scenario in which western European populations were derived from an ancient admixture event between populations from eastern Europe and Asia, and subsequently served as the main genetic 'bridgehead' for introductions to the Americas. Introductions to California appear to be from a single source region, and multiple, independent introductions of divergent genotypes likely occurred into the Pacific Northwest. Plant size has evolved significantly at three points during range expansion, including a large size increase in the lineage responsible for the aggressive invasion of the California interior. These results reveal a long history of colonization, admixture and trait evolution in C. solstitialis, and suggest routes for improving evidence-based management decisions for one of the most ecologically and economically damaging invasive species in the western United States.

ORIGINS AND GENETIC DIVERSITY OF INTRODUCED POPULATIONS OF THE PUERTO RICAN RED-EYED COQUÍ, ELEUTHERODACTYLUS ANTILLENSIS, IN SAINT CROIX (U.S. VIRGIN ISLANDS) AND PANAMÁ.

The Red-eyed Coquí, Eleutherodactylus antillensis, is a terrestrial frog endemic to the Puerto Rican Bank (Puerto Rico and numerous islands and cays off its eastern coast), in the eastern Caribbean Sea. The species was likely introduced in Saint Croix, an island c. 100 km southeast of Puerto Rico, in the late 1930s, and in Panamá City, Panamá, in the late 1950s or early 1960s, but the source(s) of these introductions are unknown. We analyzed sequence data from one mtDNA locus and four nuDNA introns to infer the origin(s) of the Saint Croix and Panamá City populations and quantify their genetic diversity. Saint Croix and Panamanian populations do not share any haplotypes, and they cluster with different native populations, suggesting that they are derived from separate sources in the Puerto Rican Bank. Patterns of population structure trace the probable sources of E. antillensis in Saint Croix to islands off Puerto Rico's eastern coast, which include Vieques, Culebra, Saint Thomas, Saint John, Tortola, and Virgin Gorda, and possibly to eastern Puerto Rico as well. In contrast, Panamá City E. antillensis probably originated from either western or eastern Puerto Rico. Genetic diversity in the introduced populations is similar to or lower than in populations in the species' native range, indicating that genetic diversity has not increased in the alien frogs. Our findings may facilitate the development of preventive measures to minimize introductions of non-native amphibians in the Caribbean and Central America.

Initiation of drug dealing among a prospective cohort of street-involved youth.

BACKGROUND: Street-involved youth who use drugs may have limited income-generation options and are known to commonly become immersed in illicit drug markets to generate funds. However, little attention has been given to factors that may drive drug dealing initiation among this vulnerable population. OBJECTIVES: This longitudinal study examines drug dealing initiation among street-involved youth. METHODS: Data were derived from the At-Risk Youth Study from September 2005 to November 2014; a prospective cohort of 194 street-involved youth who use drugs aged 14-26, in Vancouver, Canada. Extended Cox model was used to identify factors independently associated with time to first drug dealing. RESULTS: Among street-involved youth who had never dealt drugs at baseline, 56 (29%) individuals initiated drug dealing during the study period for an incidence density of 13.0 per 100 person-years (95% confidence interval [CI]: 9.9-17.2). In multivariable Cox regression analysis, male gender (adjusted hazard ratio [AHR] = 1.90, 95% CI: 1.06-3.42), homelessness (AHR = 1.88, 95% CI: 1.05-3.35), crystal methamphetamine use (AHR = 2.48, 95% CI: 1.47-4.20), and crack cocaine use (AHR = 2.35, 95% CI: 1.38-4.00) were positively and independently associated with initiating drug dealing. CONCLUSION: Homelessness and stimulant drug use were key risk factors for drug dealing initiation among street-involved youth. Findings indicate that evidence-based and innovative interventions, including youth-centric supportive housing, low threshold employment programs, and stimulant addiction treatment should be implemented and evaluated as strategies to help prevent this vulnerable population from engaging in risky illegal income generation practices.

Elevated risk of incarceration among street-involved youth who initiate drug dealing.

BACKGROUND: Street-involved youth are known to be an economically vulnerable population that commonly resorts to risky activities such as drug dealing to generate income. While incarceration is common among people who use illicit drugs and associated with increased economic vulnerability, interventions among this population remain inadequate. Although previous research has documented the role of incarceration in further entrenching youth in both the criminal justice system and street life, less is known whether recent incarceration predicts initiating drug dealing among vulnerable youth. This study examines the relationship between incarceration and drug dealing initiation among street-involved youth. METHODS: Between September 2005 and November 2014, data were collected through the At-Risk Youth Study, a cohort of street-involved youth who use illicit drugs, in Vancouver, Canada. An extended Cox model with time-dependent variables was used to examine the relationship between recent incarceration and initiation into drug dealing, controlling for relevant confounders. RESULTS: Among 1172 youth enrolled, only 194 (16.6%) were drug dealing naïve at baseline and completed at least one additional study visit to facilitate the assessment of drug dealing initiation. Among this sample, 56 (29%) subsequently initiated drug dealing. In final multivariable Cox regression analysis, recent incarceration was significantly associated with initiating drug dealing (adjusted hazard ratio = 2.31; 95% confidence interval (CI) 1.21-4.42), after adjusting for potential confounders. Measures of recent incarceration lagged to the prior study follow-up were not found to predict initiation of drug dealing (hazard ratio = 1.50; 95% CI 0.66-3.42). CONCLUSIONS: These findings suggest that among this study sample, incarceration does not appear to significantly propel youth to initiate drug dealing. However, the initiation of drug dealing among youth coincides with an increased risk of incarceration and their consequent vulnerability to the significant harms associated therein. Given that existing services tailored to street-involved youth are inadequate, evidence-based interventions should be invested and scaled up as a public health priority.

Climate as a driver of tropical insular diversity: comparative phylogeography of two ecologically distinctive frogs in Puerto Rico.

The effects of late Quaternary climate on distributions and evolutionary dynamics of insular species are poorly understood in most tropical archipelagoes. We used ecological niche models under past and current climate to derive hypotheses regarding how stable climatic conditions shaped genetic diversity in two ecologically distinctive frogs in Puerto Rico. Whereas the Mountain Coquí, Eleutherodactylus portoricensis, is restricted to montane forest in the Cayey and Luquillo Mountains, the Red-eyed Coquí, E. antillensis, is a habitat generalist distributed across the entire Puerto Rican Bank (Puerto Rico and the Virgin Islands, excluding St. Croix). To test our hypotheses, we conducted phylogeographic and population genetic analyses based on mitochondrial and nuclear loci of each species across their range in Puerto Rico. Patterns of population differentiation in E. portoricensis, but not in E. antillensis, supported our hypotheses. For E. portoricensis, these patterns include: individuals isolated by long-term unsuitable climate in the Río Grande de Loíza Basin in eastern Puerto Rico belong to different genetic clusters; past and current climate strongly predicted genetic differentiation; and Cayey and Luquillo Mountains populations split prior to the last interglacial. For E. antillensis, these patterns include: genetic clusters did not fully correspond to predicted long-term unsuitable climate; and past and current climate weakly predicted patterns of genetic differentiation. Genetic signatures in E. antillensis are consistent with a recent range expansion into western Puerto Rico, possibly resulting from climate change and anthropogenic influences. As predicted, regions with a large area of long-term suitable climate were associated with higher genetic diversity in both species, suggesting larger and more stable populations. Finally, we discussed the implications of our findings for developing evidence-based management decisions for E. portoricensis, a taxon of special concern. Our findings illustrate the role of persistent suitable climatic conditions in promoting the persistence and diversification of tropical island organisms.

High prevalence of exposure to the child welfare system among street-involved youth in a Canadian setting: implications for policy and practice.

BACKGROUND: Street-involved youth are more likely to experience trauma and adverse events in childhood; however, little is known about exposure to the child welfare system among this vulnerable population. This study sought to examine the prevalence and correlates of being in government care among street-involved youth in Vancouver, Canada. METHODS: From September 2005 to November 2012, data were collected from the At-Risk Youth Study, a prospective cohort of street-involved youth aged 14-26 who use illicit drugs. Logistic regression analysis was employed to identify factors associated with a history of being in government care. RESULTS: Among our sample of 937 street-involved youth, 455 (49%) reported being in government care at some point in their childhood. In a multivariate analysis, Aboriginal ancestry (adjusted odds ratio [AOR] = 2.07; 95% confidence interval [CI]: 1.50-2.85), younger age at first "hard" substance use (AOR = 1.10; 95% CI: 1.05-1.16), high school incompletion (AOR = 1.40; 95% CI: 1.00-1.95), having a parent that drank heavily or used illicit drugs (AOR = 1.48; 95% CI: 1.09-2.01), and experiencing physical abuse (AOR = 1.90; 95% CI: 1.22-2.96) were independently associated with exposure to the child welfare system. CONCLUSIONS: Youth with a history of being in government care appear to be at high-risk of adverse illicit substance-related behaviours. Evidence-based interventions are required to better support vulnerable children and youth with histories of being in the child welfare system, and prevent problematic substance use and street-involvement among this population.

COVID-19 vaccination among young people who use drugs in Vancouver, Canada.

OBJECTIVES: SARS-CoV-2 vaccines provide significant protection against severe illness and death from COVID-19, in addition to reducing community transmission. Emerging research has identified factors associated with vaccine uptake among adults who use drugs; however, less is known about youth and young adults who use drugs (YWUD). To address this gap, we sought to characterize factors associated with vaccine uptake and explore vaccine hesitancy among YWUD. METHODS: Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved YWUD in Vancouver, Canada. Using multivariable logistic regression, we characterized factors associated with SARS-CoV-2 vaccine uptake between June and November 2021. Data on vaccine hesitancy were also collected. RESULTS: Among 301 participants enrolled in this study (median age: 29 [min and max: 20-40]), 151 (50.2%) self-reported receipt of at least one dose of a SARS-CoV-2 vaccine. In multivariable analysis, vaccine uptake was significantly associated with recent addiction treatment engagement (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI]: 1.47-4.14) and receiving prescribed safer supply (e.g., opioids, stimulants) (AOR = 2.33, 95% CI: 1.03-5.62). Those who reported at least weekly crack use were significantly less likely to be vaccinated (AOR = 0.35, 95% CI: 0.12-0.92). The most reported reason for vaccine hesitancy was safety concerns, specifically regarding long-term side effects (27.4%). CONCLUSION: Vaccine uptake was significantly lower among YWUD than adults who use drugs in Vancouver and the general population in British Columbia, among whom 75% and 93% received at least one dose during the same period. Study findings suggest connecting YWUD to healthcare and novel harm reduction interventions may increase vaccine uptake. Responses to vaccine hesitancy questions revealed complex perspectives of vaccines that were aligned with sources of vaccine hesitancy among the general population. Broader strategies combatting misinformation and promoting evidence-based vaccine information could be tailored to address the unique needs and barriers experienced by YWUD.

Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia.

BACKGROUND: Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers. METHODS: We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals' peers, defined as the proportion of a prescribers' professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after. RESULTS: Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers. CONCLUSIONS: The uptake of PSS in BC was highly dependent on the behavior of prescribers' peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.

Effect of Risk Mitigation Guidance opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study.

OBJECTIVE: To determine the effect of opioid and stimulant Risk Mitigation Guidance (RMG) dispensations on mortality and acute care visits during the dual public health emergencies of overdose and covid-19. DESIGN: Population based retrospective cohort study. SETTING: British Columbia, Canada. PARTICIPANTS: 5882 people with opioid or stimulant use disorder who received RMG prescriptions for opioids (n=5356) and/or stimulants (n=1061) (535 received both) from 27 March 2020 to 31 August 2021. MAIN OUTCOME MEASURES: All cause and overdose specific mortality and acute care visits in the week after RMG opioid or stimulant dispensation. RMG recipients were matched 1:1 with controls through use of high dimensional propensity score matching. Marginal structural models, executed on weekly time steps, were used to measure the effect of dispensations on outcomes. RESULTS: RMG opioid dispensations of one day or more were associated with reduced all cause mortality (adjusted hazard ratio 0.39, 95% confidence interval 0.25 to 0.60) and overdose related mortality (0.45, 0.27 to 0.75) in the subsequent week. Dispensations of RMG stimulants (≥1 days) were not significantly associated with reduced all cause mortality (adjusted hazard ratio 0.50, 0.20 to 1.23) or overdose related mortality (0.53, 0.18 to 1.56). The protective effect of RMG opioid dispensations increased with the number of days the medications were dispensed in a given week. People who received four or more days of RMG opioid dispensations had reduced all cause mortality (adjusted hazard ratio 0.09, 0.04 to 0.21) and overdose related mortality (0.11, 0.04 to 0.32) compared with the control group. Opioid RMG dispensations did not significantly modify the odds of all cause or overdose related acute care visits. Dispensations of RMG stimulants were associated with a significant decrease in the odds of acute care visits for any cause but did not affect the odds of overdose related acute care visits. CONCLUSIONS: RMG opioid dispensations were associated with reduced overdose related and all cause mortality among a sample of people with opioid use disorder. Pharmaceutical alternatives to the illegal drug supply are promising interventions to reduce mortality in people with opioid use disorder.

Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study.

BACKGROUND: North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS: We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS: Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS: BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.

Opioid Coprescription Through Risk Mitigation Guidance and Opioid Agonist Treatment Receipt.

Importance: At the onset of the COVID-19 pandemic, the government of British Columbia, Canada, released clinical guidance to support physicians and nurse practitioners in prescribing pharmaceutical alternatives to the toxic drug supply. These alternatives included opioids and other medications under the risk mitigation guidance (RMG), a limited form of prescribed safer supply, designed to reduce the risk of SARS-CoV-2 infection and harms associated with illicit drug use. Many clinicians chose to coprescribe opioid medications under RMG alongside opioid agonist treatment (OAT). Objective: To examine whether prescription of hydromorphone tablets or sustained-release oral morphine (opioid RMG) and OAT coprescription compared with OAT alone is associated with subsequent OAT receipt. Design, Setting, and Participants: This population-based, retrospective cohort study was conducted from March 27, 2020, to August 31, 2021, included individuals from 10 linked health administrative databases from British Columbia, Canada. Individuals who were receiving OAT at opioid RMG initiation and individuals who were receiving OAT and eligible but unexposed to opioid RMG were propensity score matched at opioid RMG initiation on sociodemographic and clinical variables. Data were analyzed between January 2023 and February 2024. Exposure: Opioid RMG receipt (≥4 days, 1-3 days, or 0 days of opioid RMG dispensed) in a given week. Main Outcome and Measures: The main outcome was OAT receipt, defined as at least 1 dispensed dose of OAT in the subsequent week. A marginal structural modeling approach was used to control for potential time-varying confounding. Results: A total of 4636 individuals (2955 [64%] male; median age, 38 [31-47] years after matching) were receiving OAT at the time of first opioid RMG dispensation (2281 receiving ongoing OAT and 2352 initiating RMG and OAT concurrently). Opioid RMG receipt of 1 to 3 days in a given week increased the probability of OAT receipt by 27% in the subsequent week (adjusted risk ratio, 1.27; 95% CI, 1.25-1.30), whereas receipt of opioid RMG for 4 days or more resulted in a 46% increase in the probability of OAT receipt in the subsequent week (adjusted risk ratio, 1.46; 95% CI, 1.43-1.49) compared with those not receiving opioid RMG. The biological gradient was robust to different exposure classifications, and the association was stronger among those initiating opioid RMG and OAT concurrently. Conclusions and Relevance: This cohort study, which acknowledged the intermittent use of both medications, demonstrated that individuals who were coprescribed opioid RMG had higher adjusted probability of continued OAT receipt or reengagement compared with those not receiving opioid RMG.

Phenological Mapping of Invasive Insects: Decision Support for Surveillance and Management.

Readily accessible and easily understood forecasts of the phenology of invasive insects have the potential to support and improve strategic and tactical decisions for insect surveillance and management. However, most phenological modeling tools developed to date are site-based, meaning that they use data from a weather station to produce forecasts for that single site. Spatial forecasts of phenology, or phenological maps, are more useful for decision-making at area-wide scales, such as counties, states, or entire nations. In this review, we provide a brief history on the development of phenological mapping technologies with a focus on degree-day models and their use as decision support tools for invasive insect species. We compare three different types of phenological maps and provide examples using outputs of web-based platforms that are presently available for real-time mapping of invasive insects for the contiguous United States. Next, we summarize sources of climate data available for real-time mapping, applications of phenological maps, strategies for balancing model complexity and simplicity, data sources and methods for validating spatial phenology models, and potential sources of model error and uncertainty. Lastly, we make suggestions for future research that may improve the quality and utility of phenological maps for invasive insects.