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Introduction: To address the increase in opioid-related overdoses and deaths in Canada the Good Samaritan Drug Overdose Act (GSDOA) was enacted in May 2017. The GSDOA aims to reduce concerns of police attending overdose events and encourage bystanders to call emergency services. This study explores GSDOA awareness and understanding and the factors associated with GSDOA awareness among people who use drugs (PWUD). Methods: A cross-sectional drug and harm reduction service use survey containing GSDOA-specific questions wasconducted from October to December 2019 at 22 harm reduction supply distribution sites across British Columbia.Descriptive analysis and multivariable logistic regression were conducted to assess correlates of GSDOA awareness. Results: Overall, 54.2% (n = 315) of the eligible study sample (n = 581) reported being aware of the GSDOA. Of respondents reporting awareness, 45.2% and 61.3%, respectively, had a full understanding of when and to whom the GSDOA provides legal protection. In the multivariable model, GSDOA awareness was significantly associated with respondents identifying as cis-men (adjusted odds ratio (AOR) = 2.03 [95% CI: 1.30–3.19]); and those who obtained harm reduction supplies frequently (at least a few times/week) compared with those who did not obtain supplies or obtained them less frequently (AOR = 1.78 [95% CI: 1.14–2.76]). Conclusion: More than 2 years after its introduction, approximately half of harm reduction site clients reported being aware of the GSDOA, and, of these, less than two-thirds had a complete understanding of who is legally protected by the GSDOA. Future GSDOA knowledge dissemination should target PWUD who are less engaged with harm reduction services to improve GSDOA awareness and understanding.

Introduction Rising overdose deaths are a devastating problem across the United States and Canada. Despite the availability of observed consumption sites in British Columbia (BC), data suggest people who use drugs (PWUD) alone in private residences are most at risk of overdose death. These individuals may not use consumption sites due to fear of stigmatization, lack of privacy, or personal preference. It is this population that would benefit from overdose monitoring alternatives. Methods This 2018 study employed two sources of data. (1) A provincial harm reduction distribution site client survey administered at 27 sites across BC asked about cell phone possession and functionality. (2) Structured interviews with PWUD in Vancouver gathered perspectives regarding monitoring devices and alerting systems. Results The client survey was administered to 486 individuals. Among 443 respondents, 48% ( n = 212) owned a cellphone and 68% ( n = 115) of individuals with a cellphone with access to internet ( n = 168) would use an application to mitigate opioid-related overdose deaths. Thirty qualitative interviews were performed; thematic analysis of the responses identified three major themes – safety, public versus private drug use, and technological monitoring and function. The relevance of technological devices was affected by the inconsistent availability of cellphones, concerns about anonymity, as well as personal comfort while using drugs. Conclusions Technological applications may not be suitable for clients with transient lifestyles, no permanent home, and lack of consistent access to a mobile device. Thorough needs assessments, considerations of lifestyle limitations, and understanding perceptions around cellphone and overdose monitoring can increase the potential that devices will be used. Highlights • 45% ( n = 219) of client survey respondents owned a cellphone • Out of cellphone owners, 59% ( n = 102) of client survey respondents had access to internet • Of 168 with internet access, 68% willing to use any applications for overdose response • Applications not suitable for transient lifestyles, no permanent home, and lack of consistent access to cellphone

IntroductionAn increase in crystal methamphetamine (methamphetamine) use during the overdose epidemic is being observed in British Columbia (BC), Canada, and across North America. Concurrent use (ie, using uppers and downers one after the other or together) can increase the risk of fatal and non-fatal opioid overdose.ObjectivesWe investigated motivations for concurrent use of uppers and downers, specifically how (eg, in what order) and why people use concurrently, to identify potential interventions to prevent overdose and other harms.Setting and participantsThe 2019 Harm Reduction Client Survey was administered across 22 harm reduction supply distribution sites in BC (n=621). This thematic analysis examined 307 responses by people who affirmed concurrent use to classify order and reasons for using uppers and downers concurrently.ResultsOf the 307 people who responded ‘yes’ to concurrent use, 179 (58.3%) used downers then uppers, 76 (24.8%) used uppers then downers and 184 (59.9%) mixed uppers and downers together. Four main reasons for concurrent use emerged: self-medication, availability and preference, drug effects/properties, and financial and life situation. People who mixed drugs together predominantly wanted to achieve desired drug effects/properties, such as a specific high or balancing stimulating and sedating effects.ConclusionsThe ongoing rise in overdoses in BC is multifactorial, and the recent parallel increases in methamphetamine use and concurrent use with opioids may contribute. Qualitative interviews may further elucidate reasons for concurrent use. Addressing reasons for concurrent use identified in this study through harm reduction strategies and education may affect the rates of overdose morbidity and mortality.

Background British Columbia (BC) is in the midst of an opioid overdose crisis. Since 2017, smoking illicit drugs has been the leading mode of drug administration causing overdose death. Yet, little is known about people who smoke opioids, and factors underlying choice of mode of administration. The study objectives are to identify the prevalence and correlates associated with smoking opioids. Methods The Harm Reduction Client Survey is a monitoring tool used by the BC Centre for Disease Control since 2012. This survey is disseminated to harm reduction sites across BC to understand drug use trends and drug-related harms. We examined data from the survey administered October–December 2019 and performed descriptive, univariate, and multivariate analyses to better understand factors associated with smoking opioids. Results A total of 369 people who used opioids in the past 3 days were included, of whom 251 (68.0%) reported smoking opioids. A total of 109 (29.5%) respondents experienced an overdose in the past 6 months; of these 79 (72.5%) smoked opioids. Factors significantly associated with smoking opioids were: living in a small community (AOR =2.41, CI =1.27–4.58), being a woman (AOR = 1.84, CI = 1.03–3.30), age under 30 (AOR = 5.41, CI = 2.19–13.40) or 30–39 (AOR = 2.77, CI = 1.33–5.78) compared to age ≥ 50, using drugs alone (AOR = 2.98, CI = 1.30–6.83), and owning a take-home naloxone kit (AOR = 2.01, CI = 1.08–3.72). Reported use of methamphetamines within the past 3 days was strongly associated with smoking opioids (AOR = 6.48, CI = 3.51–11.96). Conclusions Our findings highlight important correlates associated with smoking opioids, particularly the recent use of methamphetamines. These findings identify actions to better respond to the overdose crisis, such as targeted harm reduction approaches, educating on safer smoking, advocating for consumption sites where people can smoke drugs, and providing a regulated supply of opioids that can be smoked.

Illicit drug overdose is a public health issue that leads to significant morbidity and mortality. In order to reduce the harm associated with substance use, emergent issues related to substances and substance use must be addressed in a timely manner, which requires inter-sectoral collaboration. We describe the British Columbia Drug Overdose and Alert Partnership, an innovative collaborative model of stakeholders who work in prevention, harm reduction, treatment and enforcement related to psychoactive substance use. We describe the formation, purpose, stakeholders, and operation of the partnership and resultant public health surveillance system. We use the example of fentanyl-associated overdoses and deaths to describe the attributes that make the system effective. These include timeliness, flexibility, acceptability and costs. This model of inter-sectoral collaboration and surveillance can be applied to other organizations involved in assessing and responding to drug-related harms.

Introduction Increased use of crystal methamphetamine (“crystal meth”) has been observed across North America and international jurisdictions, including a notable increase in the presence of methamphetamines in illicit drug toxicity deaths in British Columbia (BC), Canada. We used data from a cross-sectional survey and urine toxicology screening to report the prevalence, correlates, and validity of self-reported crystal meth use among clients of harm reduction sites in BC. Materials and methods Survey data were collected from 1,107 participants across 25 communities in BC, through the 2018 and 2019 Harm Reduction Client Survey. We described reported substance use and used a multivariate logistic regression model to characterize crystal meth use. Urine samples provided by a subset of participants were used to derive validity of self-reported three-day crystal meth use compared to urine toxicology screening. Results Excluding tobacco, crystal meth was the most frequently reported substance used in the past three days in 2018 and 2019 (59.7% and 71.7%, respectively). Smoking was the dominant route of administration for crystal meth, crack, heroin, and fentanyl. Multivariate analysis determined significantly higher odds of crystal meth use among those who used opioids (Adjusted Odds Ratio [AOR] = 3.13), cannabis (AOR = 2.10), and alcohol (1.41), and among those who were not regularly housed (AOR = 2.08) and unemployed (AOR = 1.75). Age ≥50 was inversely associated with crystal meth use (AOR = 0.63). Sensitivity of self-reported crystal meth use was 86%, specificity was 86%, positive predictive value was 96%, and negative predictive value was 65%. Conclusions Crystal meth was the most commonly used substance among clients of harm reduction sites in BC in 2018 and 2019, and was frequently used concurrently with opioids. Comparison to urine samples demonstrated high validity of self-reported crystal meth use. Understanding evolving patterns of substance use will be imperative in tailoring harm reduction and substance use services for individuals that use crystal meth.

Introduction The BC Centre for Disease Control implemented the Facility Overdose Response Box (FORB) program December 1st, 2016 to train and support non-healthcare service providers who may respond to an overdose in the workplace. The program aims to support staff at non-profit community-based organizations by ensuring policy development, training, practice overdose response exercises, and post-overdose debriefing opportunities are established and implemented. Materials and methods Three data sources were used in this descriptive cross-sectional study: FORB site registration data; naloxone administration forms; and a survey that was distributed to FORB sites in February 2019. FORB program site and naloxone administration data from December 1st, 2016 to December 31st, 2019 were analyzed using descriptive statistics. A Cochran-Armitage test was used to assess trends over time in naloxone administration event characteristics. Site coordinator survey results are reported to supplement findings from administrative data. Results As of December 31st, 2019, FORB was implemented at 613 sites across BC and 1,758 naloxone administration events were reported. The majority (86.3%, n = 1,517) were indicated as overdose reversals. At registration, 43.6% of sites provided housing services, 26.3% offered harm reduction supplies, and 18.6% provided Take Home Naloxone. Refusal to be transported to hospital following overdose events when emergency services were called showed an increasing trend over time. Most respondents (81.3%) reported feeling confident in their ability to respond to the overdose and 59.6% were offered staff debrief. Based on the 89 site survey responses, supports most commonly made available following an overdose were debrief with a fellow staff member (91.0%), debrief with a supervisor (89.9%), and/or counselling services (84.3%). Conclusions The uptake of the FORB program has contributed to hundreds of overdose reversals in community settings in BC. Findings suggest that the FORB program supports developing staff preparedness and confidence in overdose response in community-based settings.

Background North American communities are severely impacted by the overdose crisis, particularly in British Columbia (BC), which has the highest toxic drug overdose death rate in Canada. Most fatal overdoses in BC occurred among individuals using alone and in private residences. This study aimed to assess prevalence and reasons for using drugs alone among people accessing harm reduction services in BC. Methods We recruited harm reduction supply distribution site clients from 22 communities across BC. Descriptive statistics and multivariable logistic regression were used to describe factors associated with using alone. Thematic analysis of free-text responses providing reasons for using alone were grouped with survey data and additional themes identified. Results Overall, 75.8% (n = 314) of the study sample (N = 414) reported using drugs alone within the last week. Those that reported using alone did not differ from those that did not by gender, age, urbanicity, or preferred drug use method. Among those that used alone, 73.2% (n = 230) used opioids, 76.8% (n = 241) used crystal meth, 41.4% (n = 130) used crack/cocaine, and 44.6% (n = 140) used alcohol in the past week. Polysubstance use involving stimulants, opioids, and/or benzodiazepines was reported by 68.5% (n = 215) of those that used alone. Additionally, 22.9% (n = 72) of those that used alone had experienced an opioid and/or stimulant overdose in the past 6 months. In a multivariable logistic regression model, having no regular housing and past week crack/cocaine use were associated with using alone (adjusted odds ratio (AOR): 2.27; 95% CI 1.20–4.27 and AOR: 2.10; 95% CI 1.15–3.82, respectively). The most common reason reported for using alone was convenience and comfort of using alone (44.3%). Additional reasons included: stigma/hiding drug use (14.0%); having no one around (11.7%); safety (9.6%); and not wanting to share drugs with others (8.6%). Conclusions Using drugs alone, particularly for convenience and comfort, is ubiquitous among people accessing harm reduction services. Overdose prevention measures that go beyond individual behaviour changes, including providing a safer supply of drugs and eliminating stigma, are paramount to mitigate harms. These interventions are especially necessary as emergence of coronavirus disease may further exacerbate unpredictability of illicit drug content and overdose risk.

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.

Introduction Take-Home Naloxone programs have been introduced across North America in response to rising opioid overdose deaths. There is currently limited real-world data on bystander naloxone administration, overdose outcomes, and evidence related to adverse events following bystander naloxone administration. Methods The research team used descriptive statistics from Take-Home Naloxone administration forms. We explored reported demographic variables and adverse events among people who received by-stander administered naloxone in a suspected opioid overdose event between August 31, 2012 and December 31, 2018 in British Columbia. We examined and contextualized differences across years given policy, program and drug toxicity changes. We used multivariate logistic regression to examine whether an association exists between number of ampoules of naloxone administered and the odds that the recipient will experience withdrawal symptoms. Results A large majority (98.1%) of individuals who were administered naloxone survived their overdose and 69.2% had no or only mild withdrawal symptoms. Receiving three (Adjusted Odds Ratio (AOR) 1.64 (95% Confidence Interval (CI): 1.08–2.48)) or four or more (AOR 2.19 (95% CI: 1.32–3.62)) ampoules of naloxone was significantly associated with odds of moderate or severe withdrawal compared to receiving one ampoule of naloxone. Conclusions This study provides evidence from thousands of bystander reversed opioid overdoses using Take-Home Naloxone kits in British Columbia, and suggests bystander-administered naloxone is safe and effective for opioid overdose reversal. Data suggests an emphasis on titration during bystander naloxone training in situations where the person experiencing overdose can be adequately ventilated may help avoid severe withdrawal symptoms. We identified a decreasing trend in the likelihood of moderate or severe withdrawal over the study period.

Introduction In response to North America’s opioid crisis, access to naloxone has increased. However, our understanding of the correlates of possessing a naloxone kit is limited. This study seeks to determine the prevalence and correlates of kit possession among people who use drugs (PWUD) in British Columbia (BC) Canada. Methods This analysis used cross-sectional survey data collected in 2018 from 27 harm reduction sites in BC. Descriptive statistics and Poisson regression with robust error variance were used to examine factors associated with naloxone kit possession. Results Overall, 70.7% (n = 246) of the total sample (n = 348) reported having a naloxone kit. Having a kit was significantly associated with self-reported opioid use in comparison with non-opioid use (Adjusted Prevalence Ratio (APR): 2.39; 95% CI: 1.33–4.32). Those reporting ‘injection’ as their preferred drug administration method were also more likely to possess a kit compared to those that predominantly preferred inhalation, smoking, or snorting (APR: 2.39; 95% CI: 1.25–4.58). Urbanicity, age, gender, and having regular housing were not significantly associated with possessing a kit. Conclusions This study is the first to examine naloxone kit possession across geographies, including non-urban areas. Lower kit possession among those that preferred inhaling, smoking or snorting drugs may reflect misconceptions around overdose risk of non-injection drug administration. Our study supports the need for enhanced awareness around the risk of opioid overdose with non-injection administration and suggests a need for comprehensive public health messaging that aims to address overdose risk and response.

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.