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Bud Osborn (1947-2014) was an American poet and activist who arrived in Vancouver, Canada in 1986. He landed in Vancouver's oldest neighbourhood, the Downtown Eastside (DTES), while struggling with heroin addiction. The DTES is a complex and politically active neighbourhood and site of intersecting social crises. Osborn would spend the remainder of his life capturing this community in his poetry, which is often understood solely through activism for harm reduction and against gentrification. In this article, I engage with his poetry to understand the politics which motivate his activism. This exploration will include a variety of textual mediums, voices, and analytic perspectives to capture the complex politics contained in his words. I believe that by reading his words we can examine his complicated self-positionality as a PWUD (people who use drugs) and a member of the lumpenproletariat who occupied sociocultural spaces that often excluded those from his social standing. This examination shows how he constitutes the DTES as a space of material and discursive struggle. What emerges from this examination is how his poetic resistance at the level of the signifier intertwines with his street-level resistance. That is, how the act of writing and reading poetry can be an act of defiance. [ABSTRACT FROM AUTHOR]

Background: British Columbia, Canada, is experiencing an overdose crisis that has pushed drug liberalization policies to the forefront of the response. This study examines police officers' perceptions of enforcement and drug liberalization policies, including support for decriminalization and regulation or 'safer supply', in this context. Methods: Qualitative interview data were collected in September-November 2020 from active police officers involved in drug law enforcement in British Columbia, prior to decriminalization reforms being introduced in the province. We conducted a thematic analysis of this data with a focus on police officer views towards drug enforcement and drug liberalization policies. Results: Policing and reforms amid the overdose crisis has shaped officer perceptions and actions towards illegal drugs and drug policies. Although officers saw overdose as a health issue, these views coincided with a strong emphasis on supply-side policing, such as drug trafficking investigations. Policing continues to be entrenched in the overdose crisis, which has impacted the way police officers view drugs and drug use, particularly, their belief that current interventions to disrupt the illegal drug market are not working. Conclusion: This study advances knowledge on the motivations for promoting drug enforcement, and enacting drug policies, in the context of an overdose crisis. [ABSTRACT FROM AUTHOR]

Background: Missouri's Overdose Field Report (ODFR) is a community-based reporting system which intends to capture overdoses which may not be otherwise recorded. Objectives: Describe the factors related to non-fatal overdoses reported to Missouri's ODFR. Methods: This study used a descriptive epidemiological approach to examine the demographics and circumstances of overdoses reported to the ODFR. We used binary logistic regression to evaluate factors associated with survival and ordinal logistic regression to evaluate factors associated with number of doses used. Factors were chosen based on their relevance to overdose education and survival, and naloxone distribution. Results: Between 2018 and 2022, 12,225 overdoses (67% male; 78% White) were reported through the ODFR, with a 96% (n = 11,225) survival rate. Overdose survival (ps <.02) was associated with younger age (OR =.58), no opioid and stimulant co-involvement (OR =.61), and private location (OR =.48). Intramuscular naloxone in particular was associated with a significantly higher odds of survival compared to nasal naloxone (OR = 2.11). An average of 1.6 doses of naloxone per incident were administered. Additional doses were associated (ps <.02) with being older (OR =.45), female (OR =.90), nasal naloxone (versus intravenous) (OR =.65), and the belief fentanyl was present (OR = 1.49). Conclusion: Our reporting form provides a comprehensive picture of the events surrounding reported overdoses, including factors associated with survival, how much naloxone was used, and the effects of respondents believing fentanyl was involved. Missouri's report can provide support for current naloxone dosing, contextualize refusing post-overdose transport, and can be used to improve overdose response by community and first responders. [ABSTRACT FROM AUTHOR]

This research article will contextualize drug testing and conditions of supervision by analyzing eight original in-depth interview and survey narratives provided by persons are in treatment for substance use disorder. We identify a gap in the literature surrounding drug testing as part of community supervision. Specifically, the practice of drug testing from the perspective of the person ordered to test is not well documented. We consider how these experiences diverge from the intention of drug testing by supervising agencies as described in the prior scholarship. This cleavage between the expectations, experiences, and understanding of persons being tested relative to those of supervision agencies presents an avenue for the government to improve community relations, and specifically, improve trust among formerly incarcerated persons towards the supervision process, thereby increasing its legitimacy while enacting procedural justice. The persons under supervision describe broad criminal justice experiences and histories with illicit substances that resulted in drug screenings. The opinions from persons who use drugs towards drug testing and related conditions also vary and suggest evidence-based practices involving drug screening could be helpful to improve compliance with conditions and increase trust towards supervision agencies and courts. Opinions towards obligatory drug screens ranged from fear to one of gratitude. A common theme emerged: when drug tests were viewed as avoidable, respondents described changing their behavior to avoid testing—such as avoiding employers who may test for drug use; when screenings were understood as obligatory, like in the context of court ordered community-based addiction treatment, some respondents identified the broader context of the testing as helpful to their abstinence from drug use. Respondents described drug screenings as impacting their employment, economic well-being, and freedom—in particular, failed drug screens on community supervision, including drug court and other specialized supervision caseloads, could result in punitive action including incarceration and other adverse outcomes like job loss. The risk acknowledgement, however, of consequences of a failed drug screen, had not up to the point of our interview, resulted in long-term abstinence from substances for any of the respondents under community-based supervision. [ABSTRACT FROM AUTHOR]

Abstract Background The Canadian drug supply has significantly increased in toxicity over the past few years, resulting in the worsening of the overdose crisis. A key initiative implemented during this crisis has been data monitoring and reporting of substance use-related harms (SRH). This literature review aims to: (1) identify strategies used for the meaningful engagement of people who use drugs (PWUD) in local, provincial, and national SRH data system planning, reporting, and action and (2) describe data monitoring and reporting strategies and common indicators of SRH within those systems. Methods We searched three academic and five gray literature databases for relevant literature published between 2012 and 2022. Team members who identify as PWUD and a librarian at Public Health Ontario developed search strings collaboratively. Two reviewers screened all search results and applied the eligibility criteria. We used Microsoft Excel for data management. Results Twenty-two articles met our eligibility criteria (peer-reviewed n = 10 and gray literature reports n = 12); most used qualitative methods and focused on the Canadian context (n = 20). There were few examples of PWUD engaged as authors of reports on SRH monitoring. Among information systems involving PWUD, we found two main strategies: (1) community-based strategies (e.g., word of mouth, through drug sellers, and through satellite workers) and (2) public health-based data monitoring and communication strategies (e.g., communicating drug quality and alerts to PWUD). Substance use-related mortality, hospitalizations, and emergency department visits were the indicators most commonly used in systems of SRH reporting that engaged PWUD. Conclusion This review demonstrates limited engagement of PWUD and silos of activity in existing SRH data monitoring and reporting strategies. Future work is needed to better engage PWUD in these processes in an equitable manner. Building SRH monitoring systems in partnership with PWUD may increase the potential impact of these systems to reduce harms in the community.

Objectives: Fentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use. Methods: The search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with databasespecific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included. Results: The search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability. Conclusions: Among PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder. [ABSTRACT FROM AUTHOR]

The article discusses the current overdose crisis, which is a significant public health challenge in the field of mental health and substance use disorder care. The increase in mortality is primarily due to changing drug markets and patterns of substance use, as well as an ill-prepared system of care. Fentanyl has become the dominant drug of choice among many people who use drugs, and the rise in overdose deaths in North America has been dramatic. The article explores the concept of "safe supply," which involves providing high-potent psychotropic substances outside of a therapeutic context to reduce overdose risk. However, there is a lack of large-scale effectiveness studies on safe supply, and caution is expressed by experts regarding the potential risks and lack of evidence for its benefits. The article emphasizes the importance of integrating pharmacotherapy and psychosocial care, as well as learning from successful approaches in other countries such as Portugal and Switzerland. It also highlights the lessons that can be learned from the COVID-19 pandemic, emphasizing the importance of evidence-based approaches in addressing public health crises. Overall, the article calls for a comprehensive and evidence-based strategy to address the overdose crisis, taking into account the complexities and diverse needs of individuals with substance use disorders. [Extracted from the article]

ObjectivesFentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use.MethodsThe search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included.ResultsThe search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability.ConclusionsAmong PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42021272111.

Background: The Canadian drug supply has significantly increased in toxicity over the past few years, resulting in the worsening of the overdose crisis. A key initiative implemented during this crisis has been data monitoring and reporting of substance use-related harms (SRH). This literature review aims to: (1) identify strategies used for the meaningful engagement of people who use drugs (PWUD) in local, provincial, and national SRH data system planning, reporting, and action and (2) describe data monitoring and reporting strategies and common indicators of SRH within those systems. Methods: We searched three academic and five gray literature databases for relevant literature published between 2012 and 2022. Team members who identify as PWUD and a librarian at Public Health Ontario developed search strings collaboratively. Two reviewers screened all search results and applied the eligibility criteria. We used Microsoft Excel for data management. Results: Twenty-two articles met our eligibility criteria (peer-reviewed n = 10 and gray literature reports n = 12); most used qualitative methods and focused on the Canadian context (n = 20). There were few examples of PWUD engaged as authors of reports on SRH monitoring. Among information systems involving PWUD, we found two main strategies: (1) community-based strategies (e.g., word of mouth, through drug sellers, and through satellite workers) and (2) public health-based data monitoring and communication strategies (e.g., communicating drug quality and alerts to PWUD). Substance use-related mortality, hospitalizations, and emergency department visits were the indicators most commonly used in systems of SRH reporting that engaged PWUD. Conclusion: This review demonstrates limited engagement of PWUD and silos of activity in existing SRH data monitoring and reporting strategies. Future work is needed to better engage PWUD in these processes in an equitable manner. Building SRH monitoring systems in partnership with PWUD may increase the potential impact of these systems to reduce harms in the community. [ABSTRACT FROM AUTHOR]

To evaluate the outcomes of patients discharged to involuntary commitment for substance use disorders directly from the hospital. We performed a retrospective chart review of 22 patients discharged to involuntary commitment for substance use disorder from the hospital between October 2016 and February 2020. We collected demographic data, details about each commitment episode, and healthcare utilization outcomes 1 year following involuntary commitment. Nearly all patients had a primary alcohol use disorder (91%) and had additional medical (82%) and psychiatric comorbidities (71%). One year following involuntary commitment, all patients had relapsed to substance use and had at least one emergency department visit while 78.6% had at least one admission. These findings suggest that patients discharged to involuntary commitment directly from the hospital universally relapsed and experienced significant medical morbidity during the first year following their release. This study adds to a growing literature recognizing the harms of involuntary commitment for substance use disorder. [ABSTRACT FROM AUTHOR]

Abstract Background As the overdose crisis in Canada continues to escalate in severity, novel interventions and programs are required. Safer Supply programs offer pharmaceutical-grade medication to people who use drugs to replace and decrease harms related to the toxic illicit drug supply. Given the paucity of research surrounding these programs, we sought to better understand the experience of being part of a Safer Supply program from the perspective of current participants. Methods We completed semi-structured interviews and surveys with Safer Supply participants in Ottawa, Canada. Interviews were audio-recorded, transcribed, and analyzed thematically. Descriptive statistics were used to report survey data. Results Participants most commonly discussed Safer Supply benefits. This included programs offering a sense of community, connection, hope for the future, and increased autonomy. Participants also described program concerns, such as restrictive protocols, inadequate drugs, and diversion. Conclusions Our research demonstrated that participants found Safer Supply to be effective and impactful for their substance use goals. While participants did discuss concerns about the program, overall, we found that this is an important harm reduction-based program for people who use drugs in the midst of the overdose crisis.

Contingency management (i.e. rewarding people, often with money, for achieving their recovery goals) is backed by decades of empirical support yet remains highly underutilized. Rewards are rarely used in real-world clinical practice due to a number of concerns, including most notably, the apparent lack of innovation, as well as moral, philosophical, ethical, and economic concerns, and even federal rules meant to prevent illegal inducements in health care. Still, other opponents argue that some patients will try to "game" the system by simply doing whatever it takes to earn monetary rewards. This paper provides a succinct, up-to-date overview of the current evidence base for contingency management for opioid use disorder. Common barriers and solutions to implementation, as well as implications for future research and clinical practice are discussed. Although important, greater uptake of contingency management interventions is about more than legislation and regulations; it’s about recognizing stigma, shaping attitudes, and increasing awareness. Provider involvement in advocacy efforts at all levels and collaboration involving academic–industry partnerships is necessary to advance the burgeoning digital health care space and improve outcomes for people with opioid use disorder. Key MessagesContingency management is highly effective but highly underutilized.Low uptake is largely attributed to a lack of innovation and moral, ethical, and economic concerns, among other barriers.Technology-enabled solutions and academic–industry partnerships are critical to advance opioid use disorder care.

Abstract Background The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada. Methods Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS. Results Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42–58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28–5.30), active injection drug use (AOR = 4.06; 95% CI 1.38–11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24–4.85), and unstable housing (AOR = 2.14; 95% CI 1.08–4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93–0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%). Conclusions We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

Background: The adulteration of the illicit drug supply with fentanyl and its analogues is driving the ongoing overdose crisis in North America. While various harm reduction interventions address overdose-related risks, there is growing interest in safer supply programs, including the MySafe Project which utilizes a biometric dispensing machine that provides pharmaceutical opioid alternatives to the toxic drug supply. However, the experiences and perspectives of professional community partners on program implementation remain unexplored. This study aims to examine professional community partner perspectives on the feasibility, as well as barriers and facilitators to the implementation of the MySafe program. Methods: Semi-structured qualitative interviews were conducted with 17 professional community partners involved in program implementation across four pilot locations in Canada. Thematic analysis of interviews focused on perspectives on safer supply, barriers and facilitators faced during program implementation, and recommendations to inform future scale-up of low-barrier safer supply models across Canada. Results: Participants identified a variety of barriers, including the dependence on clinician buy-in, coupled with regulatory and logistical constraints. In addition, some participants perceived hydromorphone to be an inadequate substitute to the increasingly toxic street opioid supply. Lastly, technical difficulties were described as barriers to service uptake and delivery. Conversely, having political and community buy-in, availability of wrap-around services, and collaborative communication from the MySafe team served as facilitators to program implementation. Though community partners preferred establishing MySafe machines into existing community organizations, they also discussed benefits of housing-based MySafe programs. The potential role of this program in mid-sized to rural cities was also emphasized. Conclusions: To address the overdose crisis, there is an urgent need to implement and evaluate novel solutions that address supply drivers of crisis. Community partner-informed research plays an integral role in ensuring program acceptability and proper implementation. Our findings identify current gaps and facilitators underlying the efficacy of one such model, together with future directions for improvement. Participant recommendations included a diversification of medications offered and types of locations for MySafe programs, a streamlined national approach to prescribing guidelines coupled with more robust training for healthcare professionals, and an emphasis on service delivery within an integrated services model. Our findings underscore a potential gap between the goals of healthcare providers in ensuring comprehensive care and the necessity for low-barrier models such as MySafe that can function both within and outside of integrated service models. [ABSTRACT FROM AUTHOR]

Background: As the overdose crisis in Canada continues to escalate in severity, novel interventions and programs are required. Safer Supply programs offer pharmaceutical-grade medication to people who use drugs to replace and decrease harms related to the toxic illicit drug supply. Given the paucity of research surrounding these programs, we sought to better understand the experience of being part of a Safer Supply program from the perspective of current participants. Methods: We completed semi-structured interviews and surveys with Safer Supply participants in Ottawa, Canada. Interviews were audio-recorded, transcribed, and analyzed thematically. Descriptive statistics were used to report survey data. Results: Participants most commonly discussed Safer Supply benefits. This included programs offering a sense of community, connection, hope for the future, and increased autonomy. Participants also described program concerns, such as restrictive protocols, inadequate drugs, and diversion. Conclusions: Our research demonstrated that participants found Safer Supply to be effective and impactful for their substance use goals. While participants did discuss concerns about the program, overall, we found that this is an important harm reduction-based program for people who use drugs in the midst of the overdose crisis. [ABSTRACT FROM AUTHOR]

Kentucky is one of ten states that require syringe services program (SSP) approval from local officials to operate legally. Public health leaders and local officials participated in semi-structured interviews in 2016 about the barriers and facilitators of SSP adoption and implementation (N = 22). Interviews were transcribed verbatim, and a thematic content analysis was conducted using Nvivo software. Political support, program champions who led education efforts, and access to resources and training facilitated SSP adoption. The most frequently reported barriers to adoption were often rooted in stigma and included the lack of political will to approve SSPs or lack of recognition of the need for a SSP. Requiring approval from local governing authorities could impose significant implementation delays, limits to the range of harm reduction services provided, and threaten harm reduction program sustainability. Removing barriers to the adoption and implementation of harm reduction programs is critical in order to effectively scale up harm reduction services to reduce the risks of infection and fatal overdose. [ABSTRACT FROM AUTHOR]

Contingency management (i.e. rewarding people, often with money, for achieving their recovery goals) is backed by decades of empirical support yet remains highly underutilized. Rewards are rarely used in real-world clinical practice due to a number of concerns, including most notably, the apparent lack of innovation, as well as moral, philosophical, ethical, and economic concerns, and even federal rules meant to prevent illegal inducements in health care. Still, other opponents argue that some patients will try to "game" the system by simply doing whatever it takes to earn monetary rewards. This paper provides a succinct, up-to-date overview of the current evidence base for contingency management for opioid use disorder. Common barriers and solutions to implementation, as well as implications for future research and clinical practice are discussed. Although important, greater uptake of contingency management interventions is about more than legislation and regulations; it's about recognizing stigma, shaping attitudes, and increasing awareness. Provider involvement in advocacy efforts at all levels and collaboration involving academic–industry partnerships is necessary to advance the burgeoning digital health care space and improve outcomes for people with opioid use disorder. Contingency management is highly effective but highly underutilized. Low uptake is largely attributed to a lack of innovation and moral, ethical, and economic concerns, among other barriers. Technology-enabled solutions and academic–industry partnerships are critical to advance opioid use disorder care. [ABSTRACT FROM AUTHOR]

Background: The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada. Methods: Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS. Results: Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42–58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28–5.30), active injection drug use (AOR = 4.06; 95% CI 1.38–11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24–4.85), and unstable housing (AOR = 2.14; 95% CI 1.08–4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93–0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%). Conclusions: We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts. [ABSTRACT FROM AUTHOR]

The marketing and sale of oxycodone (OxyContin) by Purdue Pharma has commanded a great deal of legal and policy attention due to the drug's central role in the ongoing overdose crisis. However, little is known about the basis for OxyContin's approval by regulators, such as Health Canada in 1996. Taking advantage of a recently created online database containing information pertaining to the safety and effectiveness of drugs, we conducted a retrospective analysis of Purdue Pharma's submission to Health Canada, including both published and unpublished clinical trials. None of the trials sponsored by Purdue Pharma sought to meaningfully assess the risks of misuse or addiction associated with OxyContin. The trials were short in duration (maximum length was 24 days) and only assessed safety and efficacy of a 12-h dosing interval. Also, the two trial reports that explicitly mentioned (but did not formally evaluate) the risk of misuse were not published, making it unclear how Health Canada concluded that there was no risk of misuse. In our view, these findings underscore the need for transparency of not only of clinical trial data, but also the regulator's interpretation of such data, which is currently lacking in Canada. Furthermore, they call into question why Health Canada's role in precipitating the overdose crisis has not received greater scrutiny, including in the context of recent litigation surrounding OxyContin. [ABSTRACT FROM AUTHOR]

Police officers' work environment is continually changing, with new risks emerging quickly and unpredictably – increasing officer stress and anxiety in the process. The recent emergence of the synthetic opioid fentanyl as an illicit recreational drug has introduced into police work new, potentially life-threatening, but also somewhat ambiguous risks. Police organizations have modified their policies and practices to manage the dangers posed by these potent opioids. Questions remain, however, about how front-line officers themselves perceive these new dangers and if they are altering police practice as a result. Based on interviews and survey data with two major police departments in Canada which are at the epicenter of Canada's overdose crisis, our study empirically examines how police officers perceive the risks of fentanyl and how they might be altering their work practices due to their beliefs about the risks associated with handling and processing fentanyl and interacting with people who sell and consume these drugs. [ABSTRACT FROM AUTHOR]

Canadians take great pride in their social values such as human and civil rights, universal health care and good government. In response to the COVID-19 pandemic, federal and provincial leadership teams forged new partnerships via shared focus, voluntariness, jurisdictional respect, and lowering of barriers. In our analysis focusing on the Province of British Columbia, we compare and contrast how leadership and politics have impacted the response to COVID-19 vs. the response to B.C.'s concurrent public health emergency, the overdose crisis. We argue that these dual epidemics are framed differently in the public discourse, and that a significant disparity emerges in how the two public health emergencies have been handled at every level of government. We further posit that constructing the narrative around a communicable disease outbreak such as COVID-19 is easier than for the overdose crisis, in large part because COVID-19 impacts every person whereas the overdose crisis is perceived to have a narrow impact on the population. We use three key communications indicators in our analysis: a) the primary groups that messaging from leadership needed to reach; b) the programs and initiatives that leadership needed to ensure receive broad dissemination; and c) the messaging and tone required to achieve the desired impact to encourage societal change. On the basis of our analysis, we conclude that Canada needs to be better at building the types of supports it has created to manage the COVID-19 crisis in order to also support individuals who are immersed in the overdose crisis. Many of the policy and communication decisions and insights learned through the COVID-19 pandemic can, and ought to, be put into effect to mitigate the ongoing overdose crisis in B.C. and beyond. Examples include: consistent messaging that emphasizes respect for all and reflects determination from our political leaders as they work together to change the narrative and enact policy change. COVID-19 has shown us that if we are determined and focused, even if we occasionally run into obstacles, we can move the dial forward to mitigate—and perhaps even eliminate—a health crisis.

AbstractAccurately identifying persons with addiction is critically important for effectively targeting treatment and harm reduction interventions. Misdiagnosis of addictive disorders can lead to a cascade of negative outcomes, including stigma, discontinuation of needed medications, undue scrutiny of both patients and physicians, and even criminal consequences. A recent study raises significant concerns about the accuracy of diagnosis code data, likely rooted in confusingly-worded International Classification of Diseases (ICD)-9 and ICD-10 codes and a general misunderstanding of the difference between addiction and physiologic dependence. It is hardly surprising that physicians frequently mislabel patients when the ICD terms used to code for addiction are themselves misleading. ICD codes have not been updated to reflect current understanding of addiction, unlike those in the DSM-5. To explore this issue further, this commentary briefly discusses new information regarding coding data inaccuracies, how coding inaccuracies can lead to misdiagnosis, and the dangers of conflating “addiction” with “dependence.” The commentary concludes with a call for the ICD to update their codes to reflect current understanding of addiction.Key messagesIt is not surprising that physicians frequently conflate patients with “addiction” and “dependence” when the ICD terms used to code for addiction are themselves misleading.ICD codes have not been updated to reflect what we know about the nature of addiction, unlike those in the DSM-5.This commentary calls for the ICD to update their codes to reflect current understanding of addiction.

Objectives: America's overdose crisis spurred rapid expansion in the number and scope of prescription drug monitoring programs (PDMPs). As their public health impact remains contested, little is known about PDMP user experiences and perspectives. We explore perspectives of PDMP end-users in Massachusetts. Methods: Between 2016 and 2017, we conducted semi-structured qualitative interviews on overdose crisis dynamics and PDMP experiences with a purposive sample of 18 stakeholders (prescribers, pharmacists, law enforcement, and public health regulators). Recordings were transcribed and double-coded using a grounded hermeneutic approach. Results: Perspectives on prescription monitoring as an element of overdose crisis response differed across sectors, but narratives often critiqued PDMPs as poorly conceived to serve end-user needs. Respondents indicated that PDMP: (1) lacked clear orientation towards health promotion; (2) was not optimally configured or designed as a decision support tool, resulting in confusion over interpreting data to guide health care or law enforcement actions; and, (3) problematized communication and relationships between prescribers, pharmacists, and patients. Conclusions: User insights must inform design, programmatic, and policy reform to maximize PDMP benefits while minimizing harm. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic exposed nurses to new and more severe workplace stressors; exposure to these workplace stressors has exacerbated nurse turnover. Nurses working in mental health and substance use (MHSU) have also experienced the unique stressor of the overdose crisis in British Columbia (BC). MHSU nurses have been at the forefront of working to manage these dual emergencies. There is limited evidence related to the compounding effect of COVID-19 and the overdose crisis on nursing turnover. Understanding the unique conditions that MHSU nurses are currently experiencing and what factors influence a nurse's intention to stay in or leave a healthcare facility is essential in developing strategies to minimize turnover and maximize retention., Purpose: To explore the factors that affect nurse turnover while working through the dual emergencies within a MHSU facility in BC, Canada., Methods: A qualitative descriptive approach with an inductive, descriptive thematic analysis guided this quality improvement project., Results: Findings were grouped into two main themes: reasons for leaving and reasons for staying. Reasons for leaving included workplace safety, seeking new opportunities, lack of support, and being short-staffed. Reasons to stay encompassed connections with clients, leaders and colleagues, support from colleagues and leaders, and feeling valued, safe, and heard., Conclusions: Perceived personal safety and protection from workplace violence were found to increase the likelihood of intent to leave and turnover among nurses. Further, psychosocial safety and connection among nurses and health leaders were found to decrease the likelihood of turnover., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Accurately identifying persons with addiction is critically important for effectively targeting treatment and harm reduction interventions. Misdiagnosis of addictive disorders can lead to a cascade of negative outcomes, including stigma, discontinuation of needed medications, undue scrutiny of both patients and physicians, and even criminal consequences. A recent study raises significant concerns about the accuracy of diagnosis code data, likely rooted in confusingly-worded International Classification of Diseases (ICD)-9 and ICD-10 codes and a general misunderstanding of the difference between addiction and physiologic dependence. It is hardly surprising that physicians frequently mislabel patients when the ICD terms used to code for addiction are themselves misleading. ICD codes have not been updated to reflect current understanding of addiction, unlike those in the DSM-5. To explore this issue further, this commentary briefly discusses new information regarding coding data inaccuracies, how coding inaccuracies can lead to misdiagnosis, and the dangers of conflating "addiction" with "dependence." The commentary concludes with a call for the ICD to update their codes to reflect current understanding of addiction. It is not surprising that physicians frequently conflate patients with "addiction" and "dependence" when the ICD terms used to code for addiction are themselves misleading. ICD codes have not been updated to reflect what we know about the nature of addiction, unlike those in the DSM-5. This commentary calls for the ICD to update their codes to reflect current understanding of addiction. [ABSTRACT FROM AUTHOR]

The United States is facing a drug overdose crisis, and stigma against people who use drugs is a major roadblock to implementing solutions. Despite the public health importance of understanding and mitigating substance use stigma, prior research has focused mainly on perceptions of individuals with substance use disorders and a limited set of demographic traits. This leaves critical gaps in our understanding of stigma against fentanyl overdose decedents, who represent a much broader group, including people who use substances recreationally. This study develops a more robust understanding of these attitudes through an experimental vignette survey fielded to a national sample of American adults (n = 1432). Respondents were shown two fictional fentanyl overdose obituaries where a complex suite of decedent characteristics—including demographic traits and contexts of substance use—were randomly varied in a conjoint design. Respondents then endorsed one of the two decedents for each of several attitudinal outcomes, including blameworthiness and support for various interventions, and justified their choices in an open-ended format. Results indicate that the public assesses victims of fentanyl overdose meritocratically, making judgments based on personal history and life experience rather than traditional race, class, and gender status beliefs. While certainly a signal of progress on some fronts, this meritocratic lens conflicts with the public health model of addressing the overdose crisis and exposes the alarming persistence of explicit stigma against people who use drugs. • Public stigma against fatal overdose depends on decedent characteristics. • Substance use history impacted blame attributions more than demographic traits. • Public health attitudes about drug use may have yet to permeate the US population. [ABSTRACT FROM AUTHOR]

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under-executed and understudied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT. [ABSTRACT FROM AUTHOR]

The article discusses Canada's response to the drug overdose public health crisis in the country. Topics include data on opioid-related deaths in Canada since 2016, the federal government's key areas of response to the crisis such as access to treatment, harm reduction and fighting the tainted drug supply, and the challenges posed by the Covid-19 pandemic for the treatment of opioid use disorder in the country.

Almost 12 people in North Carolina die each day from a drug overdose. Primary care providers are ill-equipped to screen, diagnose, and treat substance use disorders. We must see the humanity in all patients and build a better understand-ing of the root causes of, and truly effective solutions for, addiction., Competing Interests: Disclosure of interests: Amy Ford works with the STAR Network but was not financially compensated for this article. No further interests were disclosed., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

As the impact of the overdose crisis continues to worsen, some interventions are proving to be more impactful than others. This article provides insight on the history of harm reduction as it relates to the overdose crisis, how harm reduction strategies are saving lives in North Carolina, and the challenges that could hinder these efforts., Competing Interests: Disclosure of interests: The authors have no competing interests to declare., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Between January 2016 and June 2019, there were over 13,900 apparent opioid-related deaths in Canada, solidifying the need for appropriate and effective services for people who use drugs (PWUD). Within government initiatives and policies, PWUD are often inappropriately considered a homogeneous group of individuals, with implementation of services nationally often being guided by these governmental bodies without meaningful consultation and collaboration with PWUD. However, recent harm reduction research and best practice guidelines have emphasized the importance of tailoring services to local drug scenes. Despite this, very little research on the cultural norms of PWUD exists in the literature. In an attempt to explore the local culture of drug use in Ottawa, a literature review ultimately uncovered very few articles on this topic. However, by expanding the search beyond Ottawa and using a social determinants of health framework, the factors of culture, income and social status, physical environment, and access to services were revealed as unique experiences for PWUD. Further, through four in-depth interviews with current harm reduction providers in Ottawa, the themes of (1) uncertainty and concerns surrounding the overdose crisis; (2) lack of flexibility in resources and access issues; and (3) diversity in the culture of drug use in Ottawa were explored. Recommendations surrounding partnering with PWUD, policy changes, and a safer supply were subsequently discussed. These findings helped to validate the reality of the unique drug-use culture in Ottawa, and the requirement for harm reduction services to be adapted to the local needs of PWUD. [ABSTRACT FROM AUTHOR]

The North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths occurring in the United States (US) in 2022. Overdose deaths have increasingly been polysubstance-involved, with novel substances (e.g., xylazine) complicating overdose risk and health outcomes. Understanding the effects of—and responses to—a changing drug supply among people who use drugs is critical to modifying harm reduction strategies to be more responsive to people's needs. This qualitative study draws on data collected from May to December 2022 in Rhode Island. Data include in-depth interviews with 50 people who use drugs and observational fieldwork in spaces frequented by participants (e.g., encampments, drop-in centers). Qualitative data were analyzed thematically drawing on concepts of situated rationality. Participants described significant changes in the drug supply, with many attributing these transitions to COVID-19. Most participants characterized the local supply as " synthetic " with textures, color, and taste evolving. Notably, participants emphasized adverse outcomes related to available supplies, including during use (e.g., intense burning sensations) and post-consumption (e.g., heavy sedation, ongoing withdrawal, necrosis). Given the complex supply, participants highlighted the increased risk of overdose and shared how they altered their use practices to manage evolving health risks. Our results underscore how people who use drugs characterized the local drug supply, including perceived changes to supply contents. Implementing and scaling up harm reduction interventions that reduce risk and reinforce the agency of people who use drugs are urgently needed to effectively address the overdose crisis. [ABSTRACT FROM AUTHOR]

Abstract Background North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings. Overdose prevention interventions There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also “supervised” spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated. Conclusions Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death.

Ethical and epidemiological concerns should mobilize addiction care providers to deploy their expertise and collective influence to challenge the use of state power to coerce people into treatment settings--especially when such settings often diverge from best clinical practices. Troublingly, with few notable exceptions, the voices of professional organizations on this issue have been largely lacking. This issue of the Journal includes a timely manuscript that sheds light on this resounding silence: "Civil Commitment for Substance Use Disorders: A National Survey of Addiction Medicine Physicians" by Jain et al. provides important and novel insights into the beliefs of physicians regarding civil commitment statutes. This study distributed a web-based survey to physician-members of the American Society of Addiction Medicine with questions gauging awareness of, attitudes toward, and experiences with civil commitment for individuals with substance use disorder. Surprisingly, the study found that the overwhelming majority of addiction medicine providers supported the application of civil commitment for substance use disorder--60.7% reported being in favor of its use whereas only 21.5% reported being opposed. [ABSTRACT FROM AUTHOR]

Objectives: To examine changes in presence of methamphetamine in toxicology testing among outpatients receiving healthcare in Boston, Massachusetts. Methods: A serial cross-sectional study of oral fluid drug test results over a 6-year period of all patient specimens submitted for testing as part of routine care across an academic medical center in Boston, Massachusetts and affiliated primary care practices which has roughly 48,000 admissions and 500,000 primary care visits per year. All samples were subjected to definitive drug testing by liquid chromatography-tandem mass spectrometry for fentanyl, 6-mono- acetylmorphine (6-MAM, metabolite of heroin), benzoylecgonine (metabolite of cocaine), cocaine, and methamphetamine. We compared positive rates and change over time across the same calendar months (February to July) of 6 consecutive years from 2014 to 2019. Results: Total of 17,303 oral fluid samples collected from outpatients receiving routine healthcare across 6 years were analyzed. Samples showing presence of methamphetamine, cocaine, and fentanyl increased over the study period, whereas 6-MAM presence decreased. From 2014 to 2019 samples with methamphetamine present increased from 0.9% to 5.1% and samples with 6-MAM present decreased from 9.5% to 2.8%. Fentanyl was added to the testing panel in 2017. In 2019, 15.7% of samples had fentanyl present. Polysubstance use was common; 44% of samples with methamphetamine also showed cocaine or benzoylecgonine, 25% showed fentanyl, and 3% showed 6-MAM presence. Conclusions: Presence of methamphetamine in oral fluid toxicology tests increased from 2014 to 2019 across a sample of outpatients receiving healthcare in Boston, Massachusetts. Regions of the country with high rates of opioid overdose may need to integrate harm reduction and addiction treatment resources for stimulant use disorder in addition to opioid use disorder. [ABSTRACT FROM AUTHOR]

Background: North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings. Overdose prevention interventions: There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also "supervised" spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated. Conclusions: Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death. [ABSTRACT FROM AUTHOR]

An introduction to a series of articles that attempt to synthesize advice given to the United States from other nations that have experienced drug epidemics is presented.

Introduction: HIV pre-exposure prophylaxis (PrEP) is an effective intervention for preventing HIV infections yet is largely unknown to and underutilized among people who use drugs., Methods: To better provide services to this group, we present a prospective, single-group interventional study involving the creation of a partnership between a safer opioid supply program and an HIV PrEP program, both of which were nurse-led., Results: Overall, HIV PrEP was offered to 42 individuals within the safer opioid supply program, resulting in 55% ( n  = 23) acceptance. Almost half of the group that accepted PrEP identified as female, and nearly all participants were homeless and did not have a primary care provider. While it was challenging to obtain routine PrEP follow-up labs per guideline recommendations due to poor venous access, most participants were able to successfully stay on PrEP and maintained good medication adherence. There were no PrEP discontinuations due to renal impairment and no participants tested positive for HIV., Conclusion: This novel integration of programs appeared to be a highly effective way to expand access to HIV prevention among people who use drugs. Given the historical and current mistreatment of people who use drugs within the healthcare system, rapport and trust were essential to the uptake of HIV PrEP services. Further, the importance of infectious disease screening among people who use drugs is underscored, and built-in program flexibility and low barrier access is essential., Competing Interests: Conflict of interest statement: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2022.)

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.Highlights45% ( n = 219) of client survey respondents owned a cellphoneOut of cellphone owners, 59% ( n = 102) of client survey respondents had access to internetOf 168 with internet access, 68% willing to use any applications for overdose responseApplications not suitable for transient lifestyles, no permanent home, and lack of consistent access to cellphone.

Background: In response to a fentanyl-driven overdose crisis, low-threshold supervised consumption sites, termed overdose prevention sites (OPS), have been rapidly implemented in Vancouver, Canada. Since approximately 88% of fatal overdoses in the province occur indoors, OPS have been integrated into select non-profit-operated single room accommodations (SRA) housing. We examined the social-structural features of these housing-based OPS (HOPS) on women's overdose risk.Methods: Ethnographic research was conducted from May 2017 to December 2018 in Vancouver. Data included 35 in-depth interviews with women who use drugs living in SRAs and approximately 100 h of observational fieldwork in SRAs and surrounding areas. Data were analyzed using an intersectional risk environment approach, with attention to equity and violence.Findings: Findings demonstrate that the social and structural environments of HOPS created barriers for women to access these interventions, resulting in an increased overdose risk. Primary barriers included uncertainty as to who else was accessing HOPS, rules prohibiting smoking, and a lack of trust in staff's abilities to effectively respond to an overdose. Most participants considered HOPS to be unsafe environments, and expressed fear of violence from residents and/or guests. The perceived risk of violence was informed by previous experiences of assault and the witnessing of violence. Many participants thus consumed drugs alone in their rooms to better control their safety, despite heightened overdose risk. Further, most participants did not perceive themselves to be at risk of an overdose due to drug use practices and tolerance levels, and viewed using alone as a safer option than HOPS.Conclusion: Findings highlight how the low-barrier design and operation of HOPS can undermine women's engagement with HOPS. Overdose prevention strategies in SRAs should also include gender-specific models (e.g. women-only HOPS, women peer workers) to help mitigate barriers to these services within the context of the current overdose crisis. [ABSTRACT FROM AUTHOR]