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During a public health overdose emergency driven by fentanyl in British Columbia (BC), Canada, a parallel increase in concurrent use of methamphetamines may be contributing to the risk of overdose. Concurrent use refers to the use of stimulants and opioids one after the other, or together. Describing substance use practices and elucidating correlates of concurrent use can inform harm reduction service provision and prevent overdose events.This cross-sectional study analyzed the 2019 Harm Reduction Client Survey administered at 22 harm reduction sites across BC and sampled individuals aged 19 and older. Bivariable and multivariable logistic regression models identified correlates of concurrent use of stimulants and opioids in the last three days.The study sample was composed of 574 individuals who used stimulants and/or opioids, among whom 307 (53.5%) reported concurrent use. Compared with individuals who used stimulants and/or opioids separately, the odds of concurrent use were significantly increased (OR=2.74, 95%CI 1.71-4.51) while the adjusted odds were increased (aOR=1.79, 95%CI 0.98-3.34) among individuals who experienced an opioid overdose. Further, the adjusted odds of concurrent use decreased with every one-year increase in age (aOR=0.97, 95%CI 0.95-0.99), among individuals with paid work (aOR=0.58, 95%CI 0.33-0.99), and stable housing (aOR=0.61, 95%CI 0.37-1.02). The adjusted odds of concurrent use increased among individuals who used drugs daily (aOR=3.78, 95%CI 2.28-6.40), used tobacco (aOR=2.03, 95%CI 1.09-3.87), used benzodiazepines (aOR=3.72, 95%CI 1.76-8.41), owned a naloxone kit (aOR=1.94, 95%CI 1.15-3.31), used observed consumption sites (aOR=2.51, 95%CI 1.57-4.07), and were prescribed opioid agonist therapy (aOR=2.92, 95%CI 1.81-4.77).Individuals who used stimulants and opioids concurrently tend to be younger, without paid work or housing. They were engaged in harm reduction and treatment services, yet used illicit drugs with unknown concentration daily. Improving access to age-appropriate services and expanding the availability of both legal and regulated stimulants and opioids may further reduce harms of concurrent use.

The drug toxicity crisis continues to be a significant cause of death. Over 24,600 people died from opioid toxicity in Canada over the last 5 years. Safe supply programs are required now more than ever to address the high rate of drug toxicity overdose deaths caused by illicit fentanyl and its analogues. This study aims to identify opioid preferences and associated variables to inform further phases of safe supply program implementation.The Harm Reduction Client Survey, an annual cross-sectional survey of people who use drugs (PWUD), was administered at harm reduction supply distribution sites in BC in October-December 2019. The survey collects information on substance use patterns, associated harms, stigma, and utilization of harm reduction services. Eligibility criteria for survey participation included aged 19 years or older; self-reported substance use of any illicit substance in the past six months, and ability to provide verbal informed consent. We conducted multivariate logistic regression to investigate associations with opioid preference. We used the dichotomized preference for either heroin or fentanyl as an outcome variable. Explanatory variables of interest included: geographic region, urbanicity, gender, age category, Indigenous identity, housing, employment, witnessing or experiencing an overdose, using drugs alone, using drugs at an observed consumption site, injection as preferred mode of use, injecting any drug, frequency of use, and drugs used in last 3 days.Of the 621 survey participants, 405 reported a preferred opioid; of these 57.8% preferred heroin, 32.8% preferred fentanyl and 9.4% preferred prescription opioids. The proportion of participants who preferred heroin over fentanyl significantly increased with age. The adjusted odds of a participant 50 or older preferring heroin was 6.76 (95% CI: 2.78-16.41, p-value:0.01) times the odds of an individual 29 or under. The adjusted odds of an Indigenous participant reporting a preference for heroin compared to fentanyl was 1.75 (95% CI: 1.03-2.98, p-value: 0.04) the odds of a non-Indigenous participant reporting the same. Adjusted odds of heroin preference also differed between geographic regions within British Columbia, Canada.Opioid preference differs by age, geographic area, and Indigenous identity. To create effective safe supply programs, we need to engage PWUD about their drugs of choice.

Background North America is in the midst of an opioid overdose epidemic and it is commonly suggested that exposure to fentanyl is unknown. Using a provincial survey of harm reduction site clients, we aimed to characterize known and unknown fentanyl use and their correlates among people who use drugs in British Columbia, Canada. Methods We recruited 486 clients who were >18 years old and 316 agreed to provide a urine sample for substance use testing. Reported known fentanyl use was defined as a three-level categorical variable assessing recent (i.e., in the previous three days) fentanyl exposure: (i) known exposure; (ii) unknown exposure; and (iii) no exposure. We also assessed any exposure to fentanyl (Yes vs. No) confirmed by urinalysis. Survey data were summarized using descriptive statistics. Multinomial logistic regression and modified Poisson regression models were built to examine different correlates of exposure to fentanyl. Results Median age of the participants was 40 (IQR: 32–49). Out of the 303 eligible participants, 38.7% (117) reported known fentanyl use, 21.7% (66) had unknown fentanyl use, and 39.6% (120) had no recent fentanyl use. In the adjusted multinomial logistic regression model and in comparison with unknown fentanyl use, recent known fentanyl use was significantly associated with self-report of methadone use (aRRR = 3.18), heroin/morphine use (aRRR = 4.40), and crystal meth use (aRRR = 2.95). Moreover, any recent exposure to fentanyl (i.e., positive urine test for fentanyl) was significantly associated with living in urban settings (aPR = 1.49), and self-reporting recent cannabis use (aPR = 0.73), crystal meth (aPR = 1.45), and heroin/morphine use (aPR = 2.48). Conclusion The landscape of illicit opioid use is changing in BC and more people are using fentanyl knowingly. The increasing prevalence of known fentanyl use is concerning and calls for further investments in public awareness and public policy efforts regarding fentanyl exposure and risks.