Publications by authors named "Jane A Buxton"

129 Publications

Towards cross-Canada monitoring of the unregulated street drug supply.

BMC Public Health 2021 Sep 15;21(1):1678. Epub 2021 Sep 15.

British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.

Background: The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions.

Methods: The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018-March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use.

Results: The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal.

Conclusions: This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.
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http://dx.doi.org/10.1186/s12889-021-11757-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8441944PMC
September 2021

Police officers' knowledge, understanding and implementation of the Good Samaritan Drug Overdose Act in BC, Canada.

Int J Drug Policy 2021 Aug 23;97:103410. Epub 2021 Aug 23.

British Columbia Center for Disease Control,655 W 12th Avenue, Vancouver, BC, V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z8, Canada. Electronic address:

Introduction: In May 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted in Canada - amending the Controlled Drugs and Substances Act. For people present at an overdose, the GSDOA offers legal protection from simple drug possession as well as breach of charges related to simple possession including probation, pre-trial release, conditional sentences, and parole. It is unclear if the GSDOA has been fully implemented by police officers.

Methods: We conducted 22 key informant interviews with police officers across British Columbia, Canada. Convenience sampling was initially employed, followed by purposeful sampling to ensure diversity in jurisdictions and participant demographics (e.g. age, sex, policing experience). A thematic analysis was conducted RESULTS: Our findings show that awareness and knowledge of the GSDOA vary among police officers. Many officers reported being unaware of the GSDOA or could not correctly define for whom and when the GSDOA applies. Information about the GSDOA was largely disseminated via email. Many officers expressed concerns with this dissemination method given the potential that key legal information would be overlooked. Police officers reported that not arresting for simple possession at an overdose was common practice, even before the enactment of the GSDOA. Thus, some officers did not believe that the GSDOA considerably changed police practices. Finally, police officers reported that they exercised discretion applying the GSDOA. Police officer interpretation of the intention and content of the GSDOA had critical implications for how they applied it in practice.

Conclusion: Effective education for law enforcement, including the dissemination of information beyond email, is needed to improve officers' awareness and understanding of the GSDOA. Given officers' use of discretion when applying the GSDOA, greater legal reforms, such as de jure decriminalization, may be required to fully protect persons at an overdose from simple possession for controlled substances.
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http://dx.doi.org/10.1016/j.drugpo.2021.103410DOI Listing
August 2021

Multivariable modelling of factors associated with criminal convictions among people experiencing homelessness and serious mental illness: a multi-year study.

Sci Rep 2021 Aug 16;11(1):16610. Epub 2021 Aug 16.

Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11830 - 8888 University Dr., Burnaby, BC, V5A 1S6, Canada.

People experiencing homelessness and serious mental illness exhibit high rates of criminal justice system involvement. Researchers have debated the causes of such involvement among people experiencing serious mental illness, including what services to prioritize. Some, for example, have emphasized mental illness while others have emphasized poverty. We examined factors associated with criminal convictions among people experiencing homelessness and serious mental illness recruited to the Vancouver At Home study. Participants were recruited between October 2009 and June 2011. Comprehensive administrative data were examined over the five-year period preceding study baseline to identify risk and protective factors associated with criminal convictions among participants (n = 425). Eight variables were independently associated with criminal convictions, some of which included drug dependence (RR = 1.53; P = 0.009), psychiatric hospitalization (RR = 1.44; P = 0.030), an irregular frequency of social assistance payments (compared to regular payments; 1.75; P < 0.001), and prior conviction (RR = 3.56; P < 0.001). Collectively, findings of the present study implicate poverty, social marginalization, crises involving mental illness, and the need for long-term recovery-oriented services that address these conditions to reduce criminal convictions among people experiencing homelessness and serious mental illness.
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http://dx.doi.org/10.1038/s41598-021-96186-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8368183PMC
August 2021

Smoke Gets in the Eye: A systematic review of case reports of ocular complications of crack cocaine use.

Drug Alcohol Rev 2021 Aug 1. Epub 2021 Aug 1.

Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.

Issues: Use of crack cocaine and associated medical complications persists globally. Some reports in medical literature describe a sight-threatening condition commonly referred to as 'crack eye' or 'crack eye syndrome'. The purpose of this review is to describe what is known about crack eye from case reports in peer-reviewed literature.

Approach: A structured search was completed in MEDLINE, TOXLINE, EMBASE, PsychInfo, Scopus and Biomed Central, to collect case reports and case series on corneal complications attributed to crack cocaine smoking.

Key Findings: Of 111 articles screened, 11 contained case reports or series. Thirty individual cases of 'crack eye' were reported. The majority (63%) of cases had bilateral involvement; 83% of all cases with microbial culture results had corneal infections. Aggressive treatment caused an improvement in 95% of all cases and 23% of all cases were lost to follow up. Of those who received treatment for corneal complications associated with crack cocaine, 22% remained with significant visual impairment (hand motions only) in the affected eye.

Implications: Clinicians should consider crack cocaine involvement in patients presenting with corneal disease without known predisposing factors, and elicit comprehensive drug histories to prevent a reduction in visual acuity.

Conclusion: Corneal complications of crack cocaine smoking are caused by a number of synergistic factors, including direct toxicity of crack cocaine vapours to surface cells, impairment of neurogenic support to corneal epithelial integrity, desiccation of the eye surface due to diminished blinking reflex, low level chemical burns and mechanical denudement of surface cells through eye rubbing.
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http://dx.doi.org/10.1111/dar.13366DOI Listing
August 2021

Experiences of people with opioid use disorder during the COVID-19 pandemic: A qualitative study.

PLoS One 2021 29;16(7):e0255396. Epub 2021 Jul 29.

Department of Emergency Medicine, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.

Aim: To capture pandemic experiences of people with opioid use disorder (OUD) to better inform the programs that serve them.

Design: We designed, conducted, and analyzed semi-structured qualitative interviews using grounded theory. We conducted interviews until theme saturation was reached and we iteratively developed a codebook of emerging themes. Individuals with lived experience of substance use provided feedback at all steps of the study.

Setting: We conducted phone or in-person interviews in compliance with physical distancing and public health regulations in outdoor Vancouver parks or well-ventilated indoor spaces between June to September 2020.

Participants: Using purposive sampling, we recruited participants (n = 19) who were individuals with OUD enrolled in an intensive community outreach program, had visited one of two emergency departments, were over 18, lived within catchment, and were not already receiving opioid agonist therapy.

Measurements: We audio-recorded interviews, which were later transcribed verbatim and checked for accuracy while removing all identifiers. Interviews explored participants' knowledge of COVID-19 and related safety measures, changes to drug use and healthcare services, and community impacts of COVID-19.

Results: One third of participants were women, approximately two thirds had stable housing, and ages ranged between 23 and 59 years old. Participants were knowledgeable on COVID-19 public health measures. Some participants noted that fear decreased social connection and reluctance to help reverse overdoses; others expressed pride in community cohesion during crisis. Several participants mentioned decreased access to housing, harm reduction, and medical care services. Several participants reported using drugs alone more frequently, consuming different or fewer drugs because of supply shortages, or using more drugs to replace lost activities.

Conclusion: COVID-19 had profound effects on the social lives, access to services, and risk-taking behaviour of people with opioid use disorder. Pandemic public health measures must include risk mitigation strategies to maintain access to critical opioid-related services.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255396PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320992PMC
August 2021

The implementation and role of a staff naloxone program for non-profit community-based sites in British Columbia: A descriptive study.

PLoS One 2021 13;16(5):e0251112. Epub 2021 May 13.

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251112PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118334PMC
May 2021

Cohort profile: development and characteristics of a retrospective cohort of individuals dispensed prescription opioids for non-cancer pain in British Columbia, Canada.

BMJ Open 2021 04 13;11(4):e043586. Epub 2021 Apr 13.

BC Centre for Disease Control, Vancouver, British Columbia, Canada.

Purpose: Prescription opioids (POs) are widely prescribed for chronic non-cancer pain but are associated with several risks and limited long-term benefit. Large, linked data sources are needed to monitor their harmful effects. We developed and characterised a retrospective cohort of people dispensed POs.

Participants: We used a large linked administrative database to create the Opioid Prescribing Evaluation and Research Activities cohort of individuals dispensed POs for non-cancer pain in British Columbia (BC), Canada (1996-2015). We created definitions to categorise episodes of PO use based on a review of the literature (acute, episodic, chronic), developed an algorithm for inferring clinical indication and assessed patterns of PO use across a range of characteristics.

Findings To Date: The current cohort includes 1.1 million individuals and 3.4 million PO episodes (estimated to capture 40%-50% of PO use in BC). The majority of episodes were acute (81%), with most prescribed for dental or surgical pain. Chronic use made up 3% of episodes but 88% of morphine equivalents (MEQ). Across the acute to episodic to chronic episode gradient, there was an increasing prevalence of higher potency POs (hydromorphone, oxycodone, fentanyl, morphine), long-acting formulations and chronic pain related indications (eg, back, neck, joint pain). Average daily dose (MEQ) was similar for acute/episodic but higher for chronic episodes. Approximately 7% of the cohort had a chronic episode and chronic pain was the characteristic most strongly associated with chronic PO use. Individuals initiating a chronic episode were also more likely to have higher social/material deprivation and previous experience with a mental health condition or a problem related to alcohol or opioid use. Overall, these findings suggest our episode definitions have face validity and also provide insight into characteristics of people initiating chronic PO therapy.

Future Plans: The cohort will be refreshed every 2 years. Future analyses will explore the association between POs and adverse outcomes.
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http://dx.doi.org/10.1136/bmjopen-2020-043586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051385PMC
April 2021

Pathways between COVID-19 public health responses and increasing overdose risks: A rapid review and conceptual framework.

Int J Drug Policy 2021 07 20;93:103236. Epub 2021 Mar 20.

British Columbia Centre for Disease Control, 655W 12th Ave, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, University of British Columbia, Vancouver, BC V6T 1Z3, Canada.

Background: Emerging evidence indicates that illicit drug overdoses are increasing throughout the COVID-19 pandemic. There is a paucity of evidence on the causative pathways for this trend, but expert opinions, commentaries, and some reviews offer theoretical underpinnings.

Methods: In this rapid review, we collate the available published evidence, expert opinions, commentaries, and reviews on the unintended pathways between COVID-19 public health responses and increasing illicit drug overdoses. Using tenets of thematic analyses and grounded theory, we also offer a visual conceptual framework for these unintended pathways.

Results: Our framework focuses on five particular public health responses, namely social isolation/physical distancing/quarantine; staff/resource reallocations and reductions; closures of businesses and other places of employment; border closures and transportation restrictions; and the early release of people from prisons. As argued in the literature reviewed here, these public health responses have unintentionally created increased overdose risks by producing high risk use scenarios; increased risks of relapsing; disrupted addictions services and treatment; an increasingly toxic supply of drugs; and the risk of using with lowered tolerance.

Conclusions: Health care systems should respond to these pathways to mitigate the unintended consequences. Furthermore, the COVID-19 pandemic may represent an opportunity to enact proactive, progressive, and innovative solutions to an overdose crisis that will surely outlast the current pandemic.
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http://dx.doi.org/10.1016/j.drugpo.2021.103236DOI Listing
July 2021

Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review.

BMC Public Health 2021 03 26;21(1):597. Epub 2021 Mar 26.

BC Centre for Disease Control, Vancouver, BC, Canada.

Background: Opioid related overdoses and overdose deaths continue to constitute an urgent public health crisis. The implementation of naloxone programs, such as 'take-home naloxone' (THN), has emerged as a key intervention in reducing opioid overdose deaths. These programs aim to train individuals at risk of witnessing or experiencing an opioid overdose to recognize an opioid overdose and respond with naloxone. Naloxone effectively reverses opioid overdoses on a physiological level; however, there are outstanding questions on community THN program effectiveness (adverse events, dosing requirements, dose-response between routes of administration) and implementation (accessibility, availability, and affordability). The objective of this scoping review is to identify existing systematic reviews and best practice guidelines relevant to clinical and operational guidance on the distribution of THN.

Methods: Using the Arksey & O'Malley framework for scoping reviews, we searched both academic literature and grey literature databases using keywords (Naloxone) AND (Overdose) AND (Guideline OR Review OR Recommendation OR Toolkit). Only documents which had a structured review of evidence and/or provided summaries or recommendations based on evidence were included (systematic reviews, meta-analyses, scoping reviews, short-cut or rapid reviews, practice/clinical guidelines, and reports). Data were extracted from selected evidence in two key areas: (1) study identifiers; and (2) methodological characteristics.

Results: A total of 47 articles met inclusion criteria: 20 systematic reviews; 10 grey literature articles; 8 short-cut or rapid reviews; 4 scoping reviews; and 5 other review types (e.g. mapping review and comprehensive reviews). The most common subject themes were: naloxone effectiveness, safety, provision feasibility/acceptability of naloxone distribution, dosing and routes of administration, overdose response after naloxone administration, cost-effectiveness, naloxone training and education, and recommendations for policy, practice and gaps in knowledge.

Conclusions: Several recent systematic reviews address the effectiveness of take-home naloxone programs, naloxone dosing/route of administration, and naloxone provision models. Gaps remain in the evidence around evaluating cost-effectiveness, training parameters and strategies, and adverse events following naloxone administration. As THN programs continue to expand in response to opioid overdose deaths, this review will contribute to understanding the evidence base for policy and THN program development and expansion.
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http://dx.doi.org/10.1186/s12889-021-10497-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004425PMC
March 2021

Supporting people leaving prisons during COVID-19: perspectives from peer health mentors.

Int J Prison Health 2021 02;ahead-of-print(ahead-of-print)

School of Population and Public Health, University of British Columbia, Vancouver, Canada and the Collaborating Centre for Prison Health and Education, University of British Columbia, Vancouver, Canada.

Purpose: Currently, people leaving prisons face concurrent risks from the COVID-19 pandemic and the overdose public health emergency. The closure or reduction of community services people rely on after release such as treatment centres and shelters has exacerbated the risks of poor health outcomes and harms. This paper aims to learn from peer health mentors (PHM) about changes to their work during overlapping health emergencies, as well as barriers and opportunities to support people leaving prison in this context.

Design/methodology/approach: The Unlocking the Gates (UTG) Peer Health Mentoring Program supports people leaving prison in British Columbia during the first three days after release. The authors conducted two focus groups with PHM over video conference in May 2020. Focus groups were recorded and transcribed, and themes were iteratively developed using narrative thematic analysis.

Findings: The findings highlighted the importance of peer health mentorship for people leaving prisons. PHM discussed increased opportunities for collaboration, ways the pandemic has changed how they are able to provide support, and how PHM are able to remain responsive and flexible to meet client needs. Additionally, PHM illuminated ways that COVID-19 has exacerbated existing barriers and identified specific actions needed to support client health, including increased housing and recovery beds, and tools for social and emotional well-being.

Originality/value: This study contributes to our understanding of peer health mentorship during the COVID-19 pandemic from the perspective of mentors. PHM expertise can support release planning, improved health and well-being of people leaving prison and facilitate policy-supported pandemic responses.
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http://dx.doi.org/10.1108/IJPH-09-2020-0069DOI Listing
February 2021

Awareness of fentanyl exposure and the associated overdose risks among people who inject drugs in a Canadian setting.

Drug Alcohol Rev 2021 Sep 18;40(6):964-973. Epub 2021 Feb 18.

British Columbia Centre on Substance Use, Vancouver, Canada.

Introduction: Illicitly manufactured fentanyl continues to fuel the opioid overdose crisis throughout the USA and Canada. However, little is known about factors associated with knowingly or unknowingly using fentanyl. Therefore, we sought to identify the prevalence and correlates of suspected/known and unknown exposure to fentanyl (excluding the prescribed one) among people who inject drugs (PWID), including associated overdose risks.

Methods: Data were derived from three prospective cohort studies of community-recruited people who use drugs in Vancouver, Canada in 2016-2017. Multivariable logistic regression was used to identify correlates of suspected/known exposure (i.e. urine drug screen positive and self-reporting past 3-day exposure) and unknown exposure to fentanyl (i.e. urine drug screen positive and self-reporting no past three-day exposure), respectively.

Results: Among 590 PWID, 296 (50.2%) tested positive for fentanyl. Of those, 143 (48.3%) had suspected/known and 153 (51.7%) had unknown exposure to fentanyl. In multivariable analyses, using supervised injection sites and possessing naloxone were associated with both suspected/known and unknown exposure (all P < 0.05). Injecting drugs alone (adjusted odds ratio 3.26; 95% confidence interval: 1.72-6.16) was associated with known exposure, but not with unknown exposure.

Discussion And Conclusions: We found a high prevalence of fentanyl exposure in our sample of PWID, with one half of those exposed consuming fentanyl unknowingly. While those exposed to fentanyl appeared more likely to utilise some overdose prevention services, PWID with suspected/known fentanyl exposure were more likely to inject alone, indicating a need for additional overdose prevention efforts for this group.
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http://dx.doi.org/10.1111/dar.13261DOI Listing
September 2021

"Running myself ragged": stressors faced by peer workers in overdose response settings.

Harm Reduct J 2021 02 11;18(1):18. Epub 2021 Feb 11.

BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.

Background: Peer workers or "peers" (workers with past or present drug use experience) are at the forefront of overdose response initiatives, and their role is essential in creating safe spaces for people who use drugs (PWUD). Working in overdose response settings has benefits for peer workers but is also stressful, with lasting emotional and mental health effects. Yet, little is known about the stressors peer workers face and what interventions can be implemented to support them in their roles.

Methods: This project used a community-based sequential mixed-methods research design. Eight peer researcher-led focus groups (n = 31) were conducted between November 2018 and March 2019 to assess needs of peer workers. The transcripts were thematically coded and analysed using interpretative description. These results informed a survey, which was conducted (n = 50) in September 2019 to acquire quantitative data on peer workers' perception of health, quality of life, working conditions and stressors. Frequency distributions were used to describe characteristics of participants. X distribution values with Yates correction were conducted to check for association between variables.

Results: Five themes emerged from the focus groups that point to stressors felt by peer workers: (1) financial insecurity; (2) lack of respect and recognition at work; (3) housing challenges; (4) inability to access and/or refer individuals to resources; and (5) constant exposure to death and trauma. Consistent with this, the factors that survey participants picked as one of their "top three stressors" included financial situation, work situation, and housing challenges.

Conclusion: Peer workers are faced with a diversity of stressors in their lives which often reflect societal stigmatization of drug use. Recognition of these systemic stressors is critical in designing interventions to ease the emotional, physical and financial burden faced by peer workers.
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http://dx.doi.org/10.1186/s12954-020-00449-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877312PMC
February 2021

Emergency department buprenorphine/naloxone: What we can achieve with system-level support and local champions.

CJEM 2020 11;22(6):735-737

British Columbia Centre for Disease Control, Vancouver, BC.

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http://dx.doi.org/10.1017/cem.2020.470DOI Listing
November 2020

Prenatal hepatitis C screening, diagnoses, and follow-up testing in British Columbia, 2008-2019.

PLoS One 2020 31;15(12):e0244575. Epub 2020 Dec 31.

British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Objective: Current guidelines in British Columbia recommend prenatal screening for hepatitis C antibodies (anti-HCV) if risk factors are present. We aimed to estimate frequency of prenatal anti-HCV testing, new diagnoses, repeated and follow-up testing among BC women.

Methods: BC Centre for Disease Control Public Health Laboratory data estimated the number of BC women (assigned female at birth or unknown sex) aged 13-49 who received routine prenatal serological screening (HIV, hepatitis B, syphilis and rubella) from 2008-2019. Anti-HCV tests ordered the same day as routine prenatal screens were considered prenatal anti-HCV tests. Assessment of follow-up was based on HCV RNA and/or genotype testing within one year of new prenatal anti-HCV diagnoses.

Results: In 2019, 55,202 routine prenatal screens were carried out for 50,392 BC women. Prenatal anti-HCV tests increased significantly, from 19.6% (9,704/49,515) in 2008 to 54.6% (27,516/50,392) in 2019 (p<0.001). New prenatal anti-HCV diagnoses (HCV positive diagnoses at first test or seroconversions) declined from 14.3% in 2008 to 10.1% in 2019. The proportion of women with new prenatal anti-HCV diagnoses that were a result of a first HCV test declined from 0.3% (29/9,701) in 2008 to 0.03% (8/27,500) in 2019. For women known to be anti-HCV positive at the time of prenatal screening, the proportion who had a prenatal anti-HCV test increased from 35.6% in 2008 to 50.8% in 2019.

Conclusion: Prenatal anti-HCV testing increased substantially over the study period. However, new HCV diagnoses remained relatively stable, suggesting that a considerable proportion of BC women with low or no risk are being screened as part of prenatal care. The vast majority of women with new HCV diagnoses receive appropriate follow-up HCV RNA and genotype testing, which may indicate interest in HCV treatment. These findings contribute to the discussion around potential for prenatal anti-HCV screening in an effort to eliminate HCV.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244575PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775094PMC
March 2021

A randomized clinical trial of a theory-based fentanyl overdose education and fentanyl test strip distribution intervention to reduce rates of opioid overdose: study protocol for a randomized controlled trial.

Trials 2020 Nov 26;21(1):976. Epub 2020 Nov 26.

Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.

Background: Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs.

Methods: Residents of Rhode Island aged 18-65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses.

Discussion: If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose.

Trial Registration: ClinicalTrials.gov NCT04372238 . Registered on 01 May 2020.
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http://dx.doi.org/10.1186/s13063-020-04898-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690169PMC
November 2020

Convenience and comfort: reasons reported for using drugs alone among clients of harm reduction sites in British Columbia, Canada.

Harm Reduct J 2020 11 23;17(1):90. Epub 2020 Nov 23.

British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.

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.
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http://dx.doi.org/10.1186/s12954-020-00436-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682134PMC
November 2020

"It's an emotional roller coaster… But sometimes it's fucking awesome": Meaning and motivation of work for peers in overdose response environments in British Columbia.

Int J Drug Policy 2021 02 9;88:103015. Epub 2020 Nov 9.

BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada. Electronic address:

Background: The province of British Columbia (BC), Canada is amid dual public health emergencies in which the overdose epidemic declared in 2016 has been exacerbated by restrictions imposed by the Coronavirus Disease of 2019 (COVID-19) pandemic. Experiential workers, commonly known as 'peers' (workers with past or present drug use experience) are at the forefront of overdose response initiatives and are essential in creating safe spaces for people who use drugs (PWUD) in harm reduction. Working in overdose response environments can be stressful, with lasting emotional and mental health effects. There is limited knowledge about the personal meaning that experiential workers derive from their work, which serve as motivators for them to take on these often-stressful roles.

Methods: This project used a community-based qualitative research design. The research was based at two organizations in BC. Eight experiential worker-led focus groups were conducted (n = 31) where participants spoke about their roles, positive aspects of their jobs, challenges they face, and support needs in harm reduction work. Transcripts were coded and analyzed using interpretative description to uncover the meaning derived from experiential work.

Results: Three themes emerged from focus group data that describe the meanings which serve as motivators for experiential workers to continue working in overdose response environments: (1) A sense of purpose from helping others; (2) Being an inspiration for others, and; (3) A sense of belonging.

Conclusion: Despite the frequent hardships and loss that accompany overdose response work, experiential workers identified important aspects that give their work meaning. These aspects of their work may help to protect workers from the emotional harms associated with stressful work as well as the stigma of substance use. Recognizing the importance of experiential work and its role in the lives of PWUD can help inform and strengthen organizational supports.
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http://dx.doi.org/10.1016/j.drugpo.2020.103015DOI Listing
February 2021

Comparing mortality and healthcare utilization in the year following a paramedic-attended non-fatal overdose among people who were and were not transported to hospital: A prospective cohort study using linked administrative health data.

Drug Alcohol Depend 2021 01 25;218:108381. Epub 2020 Oct 25.

Faculty of Medicine, University of British Columbia, 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada; Providence Health Care, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.

Background: As the overdose emergency continues in British Columbia (BC), paramedic-attended overdoses are increasing, as is the proportion of people not transported to hospital following an overdose. This study investigated risk of death and subsequent healthcare utilization for people who were and were not transported to hospital after a paramedic-attended non-fatal overdose.

Methods: Using a linked administrative health data set which includes all overdoses that come into contact with health services in BC, we conducted a prospective cohort study of people who experienced a paramedic-attended non-fatal overdose between 2015 and 2016. People were followed for 365 days after the index event. The primary outcomes assessed were all-cause mortality and overdose-related death. Additionally, we examined healthcare utilization after the index event.

Results: In this study, 8659 (84%) people were transported and 1644 (16%) were not transported to hospital at the index overdose event. There were 279 overdose deaths (2.7% of people, 59.4% of deaths) during follow-up. There was no significant difference in risk of overdose-related death, though people not transported had higher odds of a subsequent non-fatal overdose event captured in emergency department and outpatient records within 90 days. People transported to hospital had higher odds of using hospital and outpatient services for any reason within 365 days.

Conclusions: Transport to hospital after a non-fatal overdose is an opportunity to provide care for underlying and chronic conditions. There is a need to better understand factors that contribute to non-transport, particularly among people aged 20-59 and people without chronic conditions.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108381DOI Listing
January 2021

Risk of overdose-related death for people with a history of incarceration.

Addiction 2021 06 27;116(6):1460-1471. Epub 2020 Nov 27.

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

Background And Aims: Reported associations between previous incarceration and the risk of overdose-related death are substantially heterogeneous, and previous studies are limited by an inability to control for confounding factors in risk assessment. This study investigated the associations of overdose-related death with previous incarceration and the number or cumulative duration of previous incarcerations, and individual or neighborhood characteristics that may potentially modify the associations.

Design And Setting: A cohort study using a 20% random sample of residents in British Columbia, Canada.

Participants: A total of 765 690 people aged 23 years or older at baseline as of 1 January 2015. Mean age was 50 years; 49% were males.

Measurements: Previous incarcerations that occurred during the 5-year exposure period (January 2010 to December 2014) were identified using provincial incarceration records. Overdose-related deaths that occurred during the 3-year follow-up period (January 2015 to December 2017) were identified using linked administrative health data. Baseline individual and neighborhood characteristics were retrieved from the provincial health insurance data.

Findings: In the cohort, 5743 people had an incarceration history during the exposure period, and 634 people died from drug overdose during the follow-up period. The mortality rate was 897 and 22 per 100 000 person-years for people who did and did not have an incarceration history, respectively. After adjusting for baseline individual and neighborhood characteristics (without any interaction term), people who had an incarceration history were 4.04 times (95% confidence interval 3.23-5.06) more likely to die from drug overdose compared with people without an incarceration history. The association was stronger for females, people without diagnoses of substance use disorder and people without dispensation of opioids for pain or benzodiazepines (P < 0.001 for each interaction term). There was no discernible linear trend between the number or cumulative duration of previous incarcerations and the risk of overdose-related death.

Conclusions: Previous incarceration appears to be a major risk factor for overdose-related death.
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http://dx.doi.org/10.1111/add.15293DOI Listing
June 2021

Accessing Take-Home Naloxone in British Columbia and the role of community pharmacies: Results from the analysis of administrative data.

PLoS One 2020 11;15(9):e0238618. Epub 2020 Sep 11.

BC Centre for Disease Control, Vancouver, BC, Canada.

Introduction: British Columbia's (BC) Take-Home Naloxone (THN) program provides naloxone to bystanders for use in cases of suspected opioid overdose. This study seeks to provide trends and analysis from the provincial BC THN program since inception in 2012 to the end of 2018.

Materials And Methods: BC THN shipment and distribution records from 2012-2018 were retrieved. Frequency distributions were used to describe characteristics of individuals accessing the program. To evaluate correlates of distribution after the addition of hundreds of pharmacy distribution sites, an analytic sample was limited to records from 2018, and multivariate logistic regression was used to evaluate correlates of collecting naloxone at a pharmacy site.

Results: Since program inception to the end of 2018, there were 398,167 naloxone kits shipped to distribution sites, 149,999 kits reported distributed, and 40,903 kits reported used to reverse an overdose in BC. There was a significant increasing trend in the number of naloxone kits used to reverse an overdose over time (p<0.01), and more than 90% of kits that were reported used were distributed to persons at risk of an overdose. Individuals not personally at risk of overdose had higher odds of collecting naloxone at a pharmacy site, compared to other community sites (including harm reduction supply distribution sites, peer led organizations, drop-in centers, and supportive housing sites) (Adjusted Odds Ratio (AOR): 2.69; 95% CI: 2.50-2.90).

Conclusions: This study documents thousands of opioid overdose reversals facilitated through the BC THN program. While those at highest risk of overdose may preferentially access naloxone through community sites, naloxone distribution through pharmacies has allowed the BC THN program to expand dramatically, increasing naloxone availability through longer opening hours on evenings and weekends. and in rural and remote regions. A diversity of naloxone distribution sites and strategies is crucial to prevent rising opioid overdose deaths.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238618PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485887PMC
October 2020

Legal approaches and government policies enacted to address the overdose epidemic: a scoping review protocol.

JBI Evid Synth 2021 01;19(1):184-200

British Columbia Centre for Disease Control, Vancouver, BC, Canada.

Objective: The objective of this scoping review is to map different past and present legal approaches and government policies that have an intended or unintended effect on the ongoing overdose epidemic.

Introduction: In response to the current overdose epidemic, a number of different legal approaches and government policies have been implemented regarding prescription drugs, illicit substances, and drug use. Additionally, other legal approaches and government policies that do not directly target the overdose crisis (eg, cannabis legalization) may have unintentional effects on opioid use-related harms. The findings of this review will inform policy-makers and individuals working at the forefront of the overdose crisis to help them anticipate the consequences of legal approaches already in place or those that have been recently implemented.

Inclusion Criteria: This review will include all legal approaches or government policies that have an intended or unintended effect on the overdose epidemic or on opioid use-related harms or mortality. Only studies published in English from 2000 onward will be included.

Methods: We will search health sciences databases, legal databases, and social sciences databases to ensure comprehensive identification of studies across disciplines. Two independent team members will screen titles and abstracts, and review full-text articles for potential inclusion. One team member will extract data for all studies, and a second team member will verify the data extraction. The results will be presented as a narrative synthesis and in tabular or diagrammatic form.
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http://dx.doi.org/10.11124/JBISRIR-D-19-00296DOI Listing
January 2021

Syndemic profiles of people living with hepatitis C virus using population-level latent class analysis to optimize health services.

Int J Infect Dis 2020 Nov 15;100:27-33. Epub 2020 Aug 15.

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; BC Centre for Disease Control, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada. Electronic address:

Background: Hepatitis C (HCV) affects diverse populations such as people who inject drugs (PWID), 'baby boomers,' gay/bisexual men who have sex with men (gbMSM), and people from HCV endemic regions. Assessing HCV syndemics (i.e.relationships with mental health/chronic diseases) among subpopulations using Latent Class Analysis (LCA) may facilitate targeted program planning.

Methods: The BC Hepatitis Testers Cohort(BC-HTC) includes all HCV cases identified in BC between 1990 and 2015, integrated with medical administrative data. LCA grouped all BC-HTC HCV diagnosed people(n = 73,665) by socio-demographic/clinical indicators previously determined to be relevant for HCV outcomes. The final model was chosen based on fit statistics, epidemiological meaningfulness, and posterior probability. Classes were named by most defining characteristics.

Results: The six-class model was the best fit and had the following names and characteristics: 'Younger PWID'(n =11,563): recent IDU (67%), people born >1974 (48%), mental illness (62%), material deprivation (59%). 'Older PWID'(n =15,266): past IDU (78%), HIV (17%), HBV (17%) coinfections, alcohol misuse(68%). 'Other Middle-Aged People'(n = 9019): gbMSM (26%), material privilege (31%), people born between 1965-1974 (47%). 'People of Asian backgrounds' (n = 4718): East/South Asians (92%), no alcohol misuse (97%) or mental illness (93%), people born <1945 (26%), social privilege (66%). 'Rural baby boomers' (n = 20,401): rural dwellers (32%), baby boomers (79%), heterosexuals (99%), no HIV (100%). 'Urban socially deprived baby boomers' (n = 12,698): urban dwellers (99%), no IDU (100%), liver disease (22%), social deprivation (94%).

Conclusions: Differences between classes suggest variability in patients' service needs. Further analysis of health service utilization patterns may inform optimal service layout.
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http://dx.doi.org/10.1016/j.ijid.2020.08.035DOI Listing
November 2020

Overdose and risk factors for coronavirus disease 2019.

Drug Alcohol Depend 2020 07 8;212:108047. Epub 2020 May 8.

BC Centre for Disease Control, School of Population and Public Health, University of British Columbia, 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.

Background: There have been significant efforts to respond to the two public health emergencies of coronavirus disease 2019 (COVID-19) and overdose in British Columbia (BC), Canada. The purpose of this study was to quantify the prevalence of known risk factors associated with mortality due to COVID-19 for persons who have had a non-fatal overdose during 2015-2017 in comparison to persons who have not had an overdose.

Methods: Data were extracted from the BC Provincial Overdose Cohort which includes a 20 % random sample of BC residents and persons who have had a non-fatal overdose in BC from January 2015 to December 2017. Chi-square tests and logistic regression were used to compare risk factors by overdose history.

Results: Persons who had a non-fatal overdose were significantly more likely to have three (chronic pulmonary disease, diabetes, coronary heart disease) of the four known chronic conditions associated with the development of severe illness due to COVID-19 compared to persons who did not have a previous non-fatal overdose event.

Conclusion: Persons who had an overdose were more likely to have several chronic conditions associated with the development of severe illness due to COVID-19. The increased likelihood of having these risk factors is reflective of the social and health inequities experienced by persons who have a history of overdose.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206446PMC
July 2020

Don't forget our dual public health crises.

CJEM 2020 07;22(4):E8

From the British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC.

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http://dx.doi.org/10.1017/cem.2020.369DOI Listing
July 2020

Supporting women leaving prison through peer health mentoring: a participatory health research study.

CMAJ Open 2020 Jan-Mar;8(1):E1-E8. Epub 2020 Feb 18.

School of Population and Public Health (McLeod, Korchinski, Young, Milkovich, Hemingway, Buxton, Janssen, Elwood Martin) and Collaborating Centre for Prison Health and Education (McLeod, Korchinski, Young, Milkovich, Hemingway, Condello, Fels Buxton, Granger-Brown Ramsden, Elwood Martin), University of British Columbia, Vancouver, BC; First Nations Health Authority (DeGroot), BC; Justice Studies (Condello), Nicola Valley Institute of Technology, Burnaby, BC; Arts Education (Fels), Simon Fraser University; BC Centre for Disease Control (Buxton); Child and Family Research Institute (Janssen), Vancouver, BC; Fielding Graduate University (Granger-Brown), Santa Barbara, Calif.; Department of Academic Family Medicine (Ramsden), University of Saskatchewan, Saskatoon, Sask.; Counselling Psychology Program (Buchanan), Education and Counselling Psychology, Faculty of Education, and Centre for Group Counselling and Trauma (Buchanan), University of British Columbia, Vancouver, BC

Background: During the transition between prison and community, people are at greatly increased risk for adverse health outcomes. This study describes a peer health mentoring program that supports women in the first 3 days after their release from a provincial correctional facility in British Columbia.

Methods: We used a participatory health research framework to develop multimethod processes to describe the Unlocking the Gates Peer Health Mentoring Program. Mentors are women with incarceration experience. Between 2013 and 2018, women released from Alouette Correctional Centre for Women were invited to access the program. All program clients were invited to participate in the surveys and interviews. We analyzed survey and interview data using descriptive analysis for quantitative data and content analysis for qualitative data.

Results: There were 346 program contacts from 340 women over the study period. For every contact, a telephone interview was conducted. Among the 346 contacts, 173 women met their mentor, of whom 172 (99.4%) completed the intake and consent forms. A total of 105 women (61.0%) completed a program activity feedback survey at the end of the mentoring period. Women identified a range of needed supports during the transition from prison to community, including access to clothing, social assistance, housing and health care. Participants described a mix of emotions surrounding release, including excitement, anxiety, hope, and a wish for understanding and support. Within 3 days of release, 49 participants (46.7%) had accessed a family physician, and 89 (84.8%) had accessed at least 1 community resource. Ninety-eight participants (93.3%) reported that their mentor assisted them in accessing community resources.

Interpretation: Peer health mentoring provides valuable, multifaceted support in helping women to navigate health and social services and to meet their basic needs. Strengthening health supports during the transition from prison to community is critical to promoting the health and well-being of women leaving prison.
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http://dx.doi.org/10.9778/cmajo.20190106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028165PMC
February 2021

Known fentanyl use among clients of harm reduction sites in British Columbia, Canada.

Int J Drug Policy 2020 03 18;77:102665. Epub 2020 Jan 18.

School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada; British Columbia Centre for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada. Electronic address:

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.
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http://dx.doi.org/10.1016/j.drugpo.2020.102665DOI Listing
March 2020

Naloxone dosing in the era of ultra-potent opioid overdoses: a systematic review.

CJEM 2020 03;22(2):178-186

Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.

Objectives: Evaluate the relationship between naloxone dose (initial and cumulative) and opioid toxicity reversal and adverse events in undifferentiated and presumed fentanyl/ultra-potent opioid overdoses.

Methods: We searched Embase, MEDLINE, Cochrane Central Register of Controlled Trials, DARE, CINAHL, Science Citation Index, reference lists, toxicology websites, and conference proceedings (1972 to 2018). We included interventional, observational, and case studies/series reporting on naloxone dose and opioid toxicity reversal or adverse events in people >12 years old.

Results: A total of 174 studies (110 case reports/series, 57 observational, 7 interventional) with 26,660 subjects (median age 35 years; 74% male). Heterogeneity precluded meta-analysis. Where reported, we abstracted naloxone dose and proportion of patients with toxicity reversal. Among patients with presumed exposure to fentanyl/ultra-potent opioids, 56.9% (617/1,085) responded to an initial naloxone dose ≤0.4 mg compared with 80.2% (170/212) of heroin users, and 30.4% (7/23) responded to an initial naloxone dose >0.4 mg compared with 59.1% (1,434/2,428) of heroin users. Among patients who responded, median cumulative naloxone doses were higher for presumed fentanyl/ultra-potent opioids than heroin overdoses in North America, both before 2015 (fentanyl/ultra-potent opioids: 1.8 mg [interquartile interval {IQI}, 1.0, 4.0]; heroin: 0.8 mg [IQI, 0.4, 0.8]) and after 2015 (fentanyl/ultra-potent opioids: 3.4 mg [IQI, 3.0, 4.1]); heroin: 2 mg [IQI, 1.4, 2.0]). Where adverse events were reported, 11% (490/4,414) of subjects experienced withdrawal. Variable reporting, heterogeneity and poor-quality studies limit conclusions.

Conclusions: Practitioners have used higher initial doses, and in some cases higher cumulative naloxone doses to reverse toxicity due to presumed fentanyl/ultra-potent opioid exposure compared with other opioids. High-quality comparative naloxone dosing studies assessing effectiveness and safety are needed.
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http://dx.doi.org/10.1017/cem.2019.471DOI Listing
March 2020

Correlates of take-home naloxone kit possession among people who use drugs in British Columbia: A cross-sectional analysis.

Drug Alcohol Depend 2019 12 7;205:107609. Epub 2019 Oct 7.

British Columbia Centre for Disease Control, 655 W 12th Ave, V5Z 4R4, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, V6T 1Z8, Vancouver, BC, Canada. Electronic address:

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.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.107609DOI Listing
December 2019

What is killing people with hepatitis C virus infection? Analysis of a population-based cohort in Canada.

Int J Drug Policy 2019 10 20;72:114-122. Epub 2019 Jun 20.

Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: Persons with hepatitis C virus (HCV) infection are at risk of mortality from both chronic liver disease and HCV acquisition risk activities. We compared causes of death among HCV positive and negative individuals to characterize contributions of acquisition risks and viral sequelae.

Methods: The British Columbia (BC) Hepatitis Testers Cohort (BC-HTC) includes all individuals tested for HCV or reported as a HCV case since 1992, linked to health administrative data. ICD-10 codes were used to classify deaths as: 1) liver-related (LR); 2) HCV acquisition risk-related (AR); and 3) other causes. Mortality proportions and trends were assessed among HCV positive and negative individuals overall and by birth cohort (born <1945, 1945-64 and ≥1965).

Results: As of December 31, 2018, of 1,300,204 HCV-tested individuals, 20,049 (27.5%) HCV positive and 132,999 (10.2%) HCV negative individuals had died (median age at death: 56.4 vs. 74.5 years, respectively). HCV positive individuals were more likely than negatives to die from both AR (24.7%/4.2%) and LR (23.4%/6.2%) causes. Deaths among older HCV positive individuals were more likely to be LR while younger individuals were more likely AR: 1) birth cohort <1945 (25.3%/2.7%); 2) 1945-64 (26.5%/23.7%) and ≥1965 (7.7%/59.9%). Among HCV positives, LR mortality increased from 1992 to 2014, then declined sharply, coinciding with the introduction and uptake of direct-acting antiviral drugs. AR mortality increased from 1992 to 2000, declined slowly until 2013, then rapidly increased, coinciding with the recent surge in opioid overdose deaths.

Conclusions: Curative HCV treatments reduce LR mortality, but typically will not impact AR mortality. This will need to be addressed if the World Health Organization 2030 HCV mortality reduction goals are to be achieved.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.003DOI Listing
October 2019

Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs.

Subst Abus 2019 17;40(4):519-526. Epub 2019 Jun 17.

Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA.

From 2011 to 2016, the United States has experienced a 55% increase in overall overdose deaths and a 260% increase in fatal fentanyl-related overdoses. Increasing engagement in harm reduction practices is essential to reducing the rate of fentanyl-related overdoses. This study sought to examine the uptake of harm reduction practices among young adults who reported recent drug use and who were recruited for a study to assess the utility and acceptability of rapid fentanyl test strips. Between May and October 2017, 93 young adults who reported drug use in the past 30 days were recruited through word of mouth, Internet advertising, and public canvasing. Participants completed an interviewer-administered survey that assessed participants' sociodemographic and behavioral characteristics, suspected fentanyl exposure, and overdose history. We assessed harm reduction practices and other correlates associated with experiencing a suspected fentanyl-related overdose. Of 93 eligible participants, 36% ( = 34) reported ever having experienced an overdose, among whom 53% ( = 18) suspected having experienced a fentanyl-related overdose. Participants who had ever experienced a fentanyl-related overdose were more likely to keep naloxone nearby when using drugs compared with those who had never experienced an overdose and those who had experienced an overdose that they did not suspect was related to fentanyl ( < .001). Additionally, experiencing a suspected fentanyl-related overdose was associated with having previously administered naloxone to someone else experiencing an overdose ( < .001). Those who had experienced a suspected fentanyl-related overdose were more likely to carry and administer naloxone. Future overdose prevention interventions should involve persons who have experienced a suspected fentanyl overdose and/or responded to an overdose in order to develop harm reduction programs that meet the needs of those at risk of an overdose.
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http://dx.doi.org/10.1080/08897077.2019.1616245DOI Listing
August 2020
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