Characterizing Use of Supervised Consumption Services among Street-involved Youth and Young Adults in the Context of an Overdose Crisis.

In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.

Performance of the Medical Priority Dispatch System® in Identifying Patients Requiring Chest Compressions at Overdose Prevention Services: A Retrospective Cohort Study.

BACKGROUND AND AIMS: The Medical Priority Dispatch System (MPDS)® is used to triage 9-1-1 calls according to acuity, with certain coding receiving telecommunicator cardiopulmonary resuscitation (T-CPR) for suspected out-of-hospital cardiac arrest (OHCA). However, this may be challenging for those with drug poisoning emergencies, who may resemble OHCA. We sought to examine the performance of the system to correctly identify cases requiring T-CPR, specifically at overdose prevention services (OPS). METHODS: This retrospective cohort study included patients attended by the provincial emergency medical system (EMS) (May 1, 2019-January 31, 2023). We calculated the diagnostic performance of MPDS® assessment of whether the case required T-CPR instructions against the gold standard of whether the patient was found pulseless on EMS clinician arrival. We compared performance among subgroups, specifically OPS vs other locations and drug poisoning-classified cases vs other case classifications. RESULTS: Comparing OPS to other locations, the sensitivity of MPDS® was similar (66.7% vs 62.4%, p = 0.4), with lower specificity (87.3% vs 98.1%, p < 0.01) and positive predictive value (0.3% vs 35.7%, p < 0.01) and higher negative predictive value (99.9% vs 99.4%, p < 0.01). The negative likelihood ratio of MPDS® was 0.381 at OPS locations, compared with 0.383 at other locations, while the positive likelihood ratio was 5.24, compared with 32.36. In patients with drug poisoning emergencies, compared with other 9-1-1 events, MPDS® had higher sensitivity (83.6% vs 60.6%, p < 0.01) but lower specificity (77.6% vs 98.9%, p < 0.01) and positive predictive value (10.5% vs 48.5%, p < 0.01), and similar negative predictive value (99.33% vs 99.35%, p = 0.03). The negative likelihood ratio of MPDS® was 0.212 in drug poisoning emergencies compared with 0.398 for all other presentations, and the positive likelihood ratio was 3.73 compared with 57.88. DISCUSSION AND CONCLUSIONS: The ability of MPDS® to correctly identify patients needing telecommunicator cardiopulmonary resuscitation instructions differed between OPS settings and other locations, frequently recommending T-CPR for patients not suffering OHCA at an OPS. Different strategies developed in collaboration with people who use substances are required to better tailor dispatch instructions prior to EMS arrival to avoid delays in life-saving interventions.

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

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

Addressing overdose risks and fatalities in public bathrooms: insights from the development of a Safer Bathroom Toolkit in British Columbia, Canada.

SETTING: In British Columbia (BC), over 11,000 people have died of an overdose since 2016. Recently, an all-party standing committee on health tabled a report identifying several gaps in BC's overdose response. Chief among these is the inequitable distribution of supervised consumption and overdose prevention services across BC and barriers to accessing services that are currently available. In this context, public bathrooms continue to act as consumption spaces and contribute to overdose-related risks and fatalities. INTERVENTION: The Safer Bathroom project sought to address long-standing policy and practice gaps by developing a toolkit to improve bathroom overdose prevention and response. Activities included a literature review and cross-sectoral, province-wide consultation (Fall 2021), the creation and launch of the Safer Bathroom Toolkit (Fall 2022), and knowledge transfer activities (ongoing). OUTCOMES: The toolkit meets four objectives. First, it provides a bathroom safety checklist that helps identify and, most importantly, mitigate safety risks. Second, it offers organizational guidance on developing a bathroom safety policy and procedure. Third, it includes practical resources such as staff training material and signs that communicate bathroom safety messages in a non-stigmatizing manner. Finally, it identifies bathroom architecture and design features that can increase or decrease overdose-related risks. IMPLICATIONS: The Safer Bathroom Toolkit is a highly comprehensive resource developed in response to the overdose crisis. However, significant reporting, research, policy, and practice gaps remain. This paper concludes with an overview of recommendations for advancing overdose prevention and response efforts within and beyond the bathroom context.

RéSUMé: LIEU: En Colombie-Britannique (C.-B.), plus de 11 000 personnes sont décédées d'une surdose depuis 2016. Un comité multipartite en santé a récemment déposé un rapport identifiant plusieurs écarts dans la réponse du gouvernement de la C.-B. face aux surdoses. La distribution inéquitable des services de consommation supervisée et de prévention des surdoses ainsi que les barrières d'accès aux services qui sont disponibles constituent un écart important. Dans ce contexte, les toilettes publiques servent d'espaces de consommation et contribuent au risque de surdoses ainsi qu'aux surdoses mortelles. INTERVENTION: Le projet visant à améliorer la sécurité dans les toilettes publiques avait pour but de répondre à des lacunes de longue date en matière de politiques et de pratiques et ce, en proposant des outils pour prévenir les surdoses et faciliter les réponses aux surdoses en cas d'urgence. Les activités réalisées dans le cadre de ce projet incluent une revue de la littérature et une consultation intersectorielle à l'échelle provinciale (automne 2021), la création et le lancement d'une trousse d'outils (automne 2022), et les activités de transfert des connaissances (en cours). RéSULTATS: La trousse d'outils répond à quatre objectifs. Premièrement, elle contient une liste de vérification permettant d'identifier, et surtout, de diminuer les risques à la sécurité dans les toilettes publiques. Deuxièmement, elle offre des directives aux organisations qui souhaitent développer une politique et une procédure pour améliorer la sécurité dans leurs toilettes publiques. Troisièmement, elle propose des ressources pratiques pour la formation du personnel et des affiches permettant de communiquer des messages ayant pour but de promouvoir la sécurité sans toutefois stigmatiser. Finalement, elle décrit les caractéristiques architecturales pouvant augmenter ou diminuer les risques associés aux surdoses par le biais d'une fiche d'information. CONSéQUENCES: La trousse d'outils que nous avons développée contient des ressources complètes qui répondent à la crise des surdoses. Toutefois, des lacunes importantes en matière de surveillance, de recherche, de politiques, et de pratiques demeurent. Nous proposons certaines recommandations pour améliorer la réponse aux surdoses et les efforts de prévention dans les toilettes publiques et de façon plus large en conclusion de cet article.

Concurrent use of opioids and stimulants and risk of fatal overdose: A cohort study.

BACKGROUND: Stimulant use has been rising among people with opioid use disorder in recent years in North America, alongside a parallel rise in illicit drug toxicity (overdose) deaths. This study aimed to examine the association between stimulant use and overdose mortality. METHODS: Data from a universal health insurance client roster were used to identify a 20% random general population sample (aged ≥12) in British Columbia, Canada between January 1 2015 and December 31 2018 (N = 1,089,682). Provincial health records were used to identify people who used opioids and/or stimulants. Fatal overdose observed during follow-up (January 12,015- December 312,018) was retrieved from Vital Statistics Death Registry and BC Coroners Service Data. Potential confounders including age, sex, health region, comorbidities and prescribed medications were retrieved from the provincial client roster and health records. RESULTS: We identified 7460 people who used stimulants and or opioids. During follow-up there were 272 fatal overdose events. People who used both opioids and stimulants had more than twice the hazard of fatal overdose (HR: 2.02, 95% CI: 1.47-2.78, p < 0.001) compared to people who used opioids only. The hazard of death increased over time among people who used both opioids and stimulants. CONCLUSIONS: There is an urgent need to prioritize the service needs of people who use stimulants to reduce overdose mortality in British Columbia. Findings have relevance more broadly in other North American settings, where similar trends in opioid and stimulant polysubstance use have been observed.

Association of Opioid and Stimulant Use Disorder Diagnoses With Fatal and Nonfatal Overdose Among People With a History of Incarceration.

Importance: Studies have suggested a rise in opioid- and stimulant-involved overdoses in recent years in North America. This risk may be acute for individuals who have had contact with the criminal justice system, who are particularly vulnerable to overdose risk. Objective: To examine the association of opioid and/or stimulant use disorder diagnoses with overdose (fatal and nonfatal) among people with histories of incarceration. Design, Setting, and Participants: In this cohort study, population-based health and corrections data were retrieved from the British Columbia Provincial Overdose Cohort, which contains a 20% random sample of residents of British Columbia. The analysis included all people in the 20% random sample who had a history of incarceration between January 1, 2010, and December 31, 2014. Outcomes were derived from 5-years of follow-up data (January 1, 2015, to December 31, 2019). Statistical analysis took place from January 2022 to June 2022. Exposures: Substance use disorder diagnosis type (ie, opioid use disorder, stimulant use disorder, both, or neither), sociodemographic, health, and incarceration characteristics. Main Outcomes and Measures: Hazard ratios (HRs) are reported from an Andersen-Gill model for recurrent nonfatal overdose events and from a Fine and Gray competing risk model for fatal overdose events. Results: The study identified 6816 people (5980 male [87.7%]; 2820 aged <30 years [41.4%]) with histories of incarceration. Of these, 293 (4.3%) had opioid use disorder only, 395 (6.8%) had stimulant use disorder only, and 281 (4.1%) had both diagnoses. During follow-up, 1655 people experienced 4026 overdoses including 3781 (93.9%) nonfatal overdoses, and 245 (6.1%) fatal overdoses. In adjusted analyses, the hazard of both fatal (HR, 2.39; 95% CI, 1.48-3.86) and nonfatal (HR, 2.45; 95% CI, 1.94-3.11) overdose was highest in the group with both opioid and stimulant use disorder diagnoses. Conclusions and Relevance: This cohort study of people with a history of incarceration found an elevated hazard of fatal and nonfatal overdose among people with both opioid and stimulant use disorder diagnoses. This study suggests an urgent need to address the service needs of individuals who have had contact with the criminal justice system and who co-use opioids and stimulants.

Harm reduction calls to action from young people who use drugs on the streets of Vancouver and Lisbon.

Vancouver, Canada, and Lisbon, Portugal, are both celebrated for their world-leading harm reduction policies and programs and regarded as models for other cities contending with the effects of increasing levels of drug use in the context of growing urban poverty. However, we challenge the notion that internationally celebrated places like Lisbon and Vancouver are meeting the harm reduction needs of young people who use drugs (YPWUD; referring here to individuals between the ages of 14 and 29). In particular, the needs of YPWUD in the context of unstable housing, homelessness, and ongoing poverty-a context which we summarize here as "street involvement"-are not being adequately met. We are a group of community and academic researchers and activists working in Vancouver, Lisbon, and Pittsburgh. Most of us identify as YPWUD and have lived and living experience with the issues described in this comment. We make several calls to action to support the harm reduction needs of YPWUD in the context of street involvement in and beyond our settings.

Low awareness of risk mitigation prescribing in response to dual crises of COVID-19 and overdose deaths among people who use unregulated drugs in Vancouver, Canada.

BACKGROUND: When the novel coronavirus pandemic emerged in March 2020, many settings across Canada and the USA were already contending with an existing crisis of drug overdoses due to the toxic unregulated drug supply. In response, the Canadian province of British Columbia (BC) released innovative risk mitigation prescribing (RMP) guidelines for medical professionals to prescribe pharmaceutical alternatives to unregulated drugs in an effort to support the self-isolation of people who use unregulated drugs (PWUD) in preventing both SARS-CoV-2 virus infection and overdoses. We sought to assess the level of awareness of RMP and identify factors associated with this awareness among PWUD in Vancouver, BC. METHODS: Cross-sectional data were derived from participants enrolled in three community-recruited prospective cohort studies of PWUD in Vancouver, interviewed between July and November 2020. Multivariable logistic regression analysis was used to identify factors associated with awareness of RMP. RESULTS: Among 633 participants, 302 (47.7%) had heard of RMP. Of those 302 participants, 199 (65.9%) had never tried to access RMP services, ten (3.3%) made an unsuccessful attempt to access RMP, and 93 (30.8%) received RMP. In the multivariable analysis, participants who had awareness of RMP guidelines were more likely to self-identify as white (adjusted odds ratio [AOR] = 1.47; 95% confidence interval [CI]: 1.01, 2.13), to have completed secondary school education or higher (AOR = 1.67; 95% CI: 1.16, 2.39), to have used drugs at a supervised consumption or overdose prevention site in the past six months (AOR = 1.66; 95% CI: 1.10, 2.52), and to have received opioid agonist therapy as treatment for opioid use disorder in the past six months (AOR = 1.51; 95% CI: 1.02, 2.24). CONCLUSION: At least four months after the release of the guidelines, RMP was known to less than half of our study participants, warranting urgent educational efforts for PWUD, particularly among racialized groups and those who were not accessing other harm reduction services. Furthermore, the majority of participants who were aware of RMP guidelines had never tried to access the service, suggesting the need to improve perceived accessibility and knowledge of eligibility criteria.

Factors associated with perceived decline in the quality of drugs during the COVID-19 pandemic: Evidence from community-recruited cohorts of people who use drugs in Vancouver, Canada.

OBJECTIVES: Driven by an increasingly toxic drug supply, drug toxicity deaths in the United States and Canada have risen to unprecedented levels during the COVID-19 pandemic. This study aimed to characterize the prevalence of and the factors associated with a perceived decline in the quality of drugs during the COVID-19 pandemic among community-recruited cohorts of PWUD in Vancouver, Canada. METHODS: Data collection took place between July and November 2020. In adherence with COVID-19 safety protocols, questionnaires were administered by interviewers through remote means (e.g., phone or videoconference). Using multivariable logistic regression, we characterized the prevalence of and factors associated with a perceived decline in drug quality during the start of the COVID-19 pandemic in Vancouver, Canada. RESULTS: Of the 738 individuals included in this analysis, 272 (36.9%) reported that the quality of drugs declined during the COVID-19 pandemic. In multivariable analysis, perceived decline in the quality of drugs was significantly associated with: recent non-fatal overdose (adjusted odds ratio [AOR]=2.01, 95% Confidence Interval [CI]: 1.29-3.15), at least weekly injection drug use (AOR=1.94, 95% CI: 1.40-2.71), at least weekly crack use (AOR=1.61, 95%CI: 1.10-2.36), and at least weekly crystal methamphetamine use (AOR=1.46, 95%CI: 1.03-2.08). DISCUSSION: Over a third of PWUD perceived that the quality of drugs declined during the COVID-19 pandemic and these individuals were significantly more likely to report experiencing a recent non-fatal overdose, engaging in frequent injection drug and stimulant use. Study findings indicate the need for interventions to address the toxic drug supply, including providing a regulated supply.

The generative potential of mess in community-based participatory research with young people who use(d) drugs in Vancouver.

Community-based participatory research (CBPR) is increasingly standard practice for critical qualitative health research with young people who use(d) drugs in Vancouver, Canada. One aim of CBPR in this context is to redress the essentialization, erasure, and exploitation of people who use(d) drugs in health research. In this paper, we reflect on a partnership that began in 2018 between three university researchers and roughly ten young people (ages 17-28) who have current or past experience with drug use and homelessness in Greater Vancouver. We focus on moments when our guiding principles of shared leadership, safety, and inclusion became fraught in practice, forcing us in some cases to re-imagine these principles, and in others to accept that certain ethical dilemmas in research can never be fully resolved. We argue that this messiness can be traced to the complex and diverse positionalities of each person on our team, including young people. As such, creating space for mess was ethically necessary and empirically valuable for our CBPR project.

Opioid agonist therapy trajectories among street entrenched youth in the context of a public health crisis.

North America is in the midst of an overdose crisis that is having devastating effects among street entrenched youth (<30 years of age). Opioid agonist therapy (OAT) is a cornerstone of the public health response to this crisis; yet, we struggle to connect youth to OAT across numerous settings. This qualitative study examined perspectives on OAT among street entrenched youth and their providers in Vancouver, Canada. Our findings reveal youth's hopes and fears surrounding making a "full" recovery from past substance use. Youth often equated getting off opioids with "getting back to normal" and the ability to pursue "normal" kinds of futures. While many initiated OAT for short periods of time (

Intergenerational Trauma: The Relationship Between Residential Schools and the Child Welfare System Among Young People Who Use Drugs in Vancouver, Canada.

PURPOSE: This study investigated the relationship between familial residential school system (RSS) exposure and personal child welfare system (CWS) involvement among young people who use drugs (PWUD). METHODS: Data were obtained from two linked cohorts of PWUD in Vancouver, Canada, and restricted to Indigenous participants. Multivariable logistic regression analysis was used to investigate the relationship between three categories of familial RSS exposure (none, grandparent, and parent) and CWS involvement. A secondary analysis assessed the likelihood of CWS involvement between non-Indigenous and Indigenous PWUD with no familial RSS exposure. RESULTS: Between December 2011 and May 2016, 675 PWUD (aged <35 years) were included in this study, 40% identified as Indigenous. In multivariable analyses, compared with Indigenous participants with no RSS exposure (reference), those with a grandparent in the RSS had a higher likelihood of having been in CWS (adjusted odds ratio [AOR] = 1.34, 95% confidence interval [CI]: .67-2.71), as did those with a parent exposed to RSS (AOR = 2.03, 95% CI: 1.03-3.99). In secondary analysis, the odds of CWS involvement was not significantly different between non-Indigenous and Indigenous PWUD with no familial RSS exposure (AOR = .63, 95% CI: .38-1.06). CONCLUSIONS: We observed a dose-response-type trend between familial RSS exposure and personal CWS involvement and a nonsignificant difference in the likelihood of CWS involvement between Indigenous and non-Indigenous PWUD when controlling for RSS exposure. These data demonstrate the intergenerational impact of the RSS on the overrepresentation of Indigenous youth in the CWS. Findings have critical implications for public policy and practice including reconciliation efforts with Indigenous Peoples.

Perceived Devaluation among a Cohort of Street-Involved Youth in Vancouver, Canada.

BACKGROUND: Perceived devaluation is a barrier to seeking mental and physical health services among people who use illicit drugs. OBJECTIVE: Assessing the prevalence and correlates of perceived devaluation within a cohort of street-involved youth. METHODS: Data were drawn from an open prospective cohort of street-involved youth who use illicit drugs (aged 14-26 at study enrollment) between December 2013 and May 2015 in Vancouver, Canada. Perceived devaluation was measured using an adapted version of Perceived Devaluation and Discrimination scale. Multivariable generalized estimating equations were constructed to examine factors independently associated with high perceived devaluation. RESULTS: Among 411 street-involved youth, 95.1% reported high perceived devaluation at some point during the study period. In a multivariable analysis, youth who reported high perceived devaluation were significantly more likely to engage in: unprotected sex (Adjusted Odds Ratio [AOR] = 1.56, 95% Confidence Interval 1.03-2.37); heavy alcohol use (AOR = 2.31, 95% CI 1.22-4.36); and daily heroin use (AOR = 2.07, 95% CI 1.16-3.70). Youth who resided in the Downtown Eastside neighborhood were significantly less likely to report high perceived devaluation (AOR = 0.41, 95% CI 0.26-0.65). CONCLUSIONS: Perceived devaluation was extremely prevalent among street-involved youth in our sample. We also observed that youth most in need of health and social services were significantly more likely to report high levels of perceived devaluation which may result in a reluctance to seek out key services and supports. These findings highlight the need to implement stigma reduction interventions for vulnerable youth in this setting.