Publications by authors named "Thomas Kerr"

667 Publications

Increasing preference for fentanyl among a cohort of people who use opioids in Vancouver, Canada, 2017-2018.

Subst Abus 2021 Jul 20:1-7. Epub 2021 Jul 20.

British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, BC, Canada.

Despite increasing prevalence of illicit fentanyl use in the US and Canada, preference for fentanyl over other illicit opioids has not been fully characterized. Therefore, we sought to describe changes in illicit opioid preferences over time among people who inject drugs (PWID). Data were obtained from two prospective cohort studies between 2017 and 2018. Trends in opioid preference over time were examined using bivariable generalized estimating equation (GEE) analysis. Multivariable models were used to identify factors associated with fentanyl preference. Among 732 eligible participants, including 425 (58%) males, the prevalence of preference for fentanyl increased from 4.4% in 2017 to 6.6% in 2018 (Odds Ratio [OR] = 1.27, 95% Confidence Interval [CI]: 1.05-1.52). In a multivariable analysis, younger age (Adjusted Odds Ratio [AOR] = 0.94, 95% CI: 0.92-0.96) and daily crystal methamphetamine injection (AOR = 1.68, 95% CI: 1.01-2.78) were independently associated with preference for fentanyl. The most common reasons for preferring fentanyl included "better high than other opioids" (45%), and "lasts longer than heroin" (27%). The current study has demonstrated that preference for fentanyl has been increasing over time among our sample of PWID who use opioids. Further work is needed to clarify risk factors surrounding transitions to illicit fentanyl.
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http://dx.doi.org/10.1080/08897077.2021.1946892DOI Listing
July 2021

The relationship between crystal methamphetamine use and methadone retention in a prospective cohort of people who use drugs.

Drug Alcohol Depend 2021 Aug 24;225:108844. Epub 2021 Jun 24.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada. Electronic address:

Background: The efficacy of methadone in reducing morbidity and mortality associated with opioid use disorder is supported by a wealth of evidence, yet methadone retention is often poor. While crystal methamphetamine (methamphetamine) use has been recently increasing in many countries, the effect of frequency of methamphetamine use on methadone discontinuation has not been investigated. We aimed to examine whether frequency of methamphetamine use is associated with increased rates of methadone discontinuation among individuals on methadone.

Design: Two harmonized ongoing open prospective cohort studies of community-recruited people who use illicit drugs with semi-annual follow-ups between 2014 and 2018.

Setting: Vancouver, Canada.

Participants: A community recruited sample of people who use drugs.

Intervention: A time-varying variable of self-reported methamphetamine use frequency within the past six months.

Measurements: The primary outcome was time to discontinuation of methadone, defined as reporting not being on methadone at the time of a follow-up interview during the study period. We employed multivariable extended Cox regression analysis to examine the relationship between frequency of methamphetamine use and time to methadone discontinuation after adjusting for potential confounders.

Findings: Of 875 eligible participants who contributed 2319 person-years of follow-up, 284 (32.5 %) discontinued methadone at least once during follow-up and 135 (15.4 %) reported more than weekly methamphetamine use at study baseline. In a multivariate analysis, in comparison to no use, ≥weekly use of methamphetamine remained independently associated with methadone discontinuation (adjusted hazard ratio [aHR] = 1.38, 95 % CI = 1.03-1.85).

Conclusions: A significant proportion of participants on methadone in this study reported more than weekly crystal methamphetamine use, which was associated with an increased risk of methadone discontinuation. Closer follow up, education, and treatment of methamphetamine use may be needed for this group to improve methadone retention.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108844DOI Listing
August 2021

The impact of PSTD on service access among people who use drugs in Vancouver, Canada.

Subst Abuse Treat Prev Policy 2021 Jun 26;16(1):53. Epub 2021 Jun 26.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.

Background: Settings throughout the United States and Canada are contending with high rates of drug-related overdose. This in turn has prompted efforts to more effectively engage people who use drugs (PWUD) in treatment and care. However, while co-morbid mental disorders are prevalent among PWUD and can undermine access to services, the impact of post-traumatic stress disorder (PTSD) on service access is not known. Therefore, we sought to assess whether PTSD is associated with difficulties accessing health and social services among PWUD in Vancouver, Canada.

Methods: Survey data was derived from two prospective cohorts of PWUD in Vancouver, Canada for the period of April 2017 to November 2018. PTSD was assessed using the PTSD Checklist for the DSM-V (PCL-5). Generalized estimating equations (GEE) was used to estimate the relationship between PTSD and self-reported inability to access health and social services, after adjustment for confounders.

Results: Among 810 participants included in our analysis, 316 (39.0%) participants qualified for a provisional PSTD diagnosis, and 117 (14.4%) reported difficulties accessing services. In a multivariable GEE analysis, a PTSD diagnosis (adjusted odds ratio = 1.69, 95% confidence interval: 1.12-2.55) was independently associated with difficulties accessing services.

Conclusions: We found high rates of PTSD and self-reported difficulties accessing services among PWUD in Vancouver, as well as a positive association between PTSD and difficulties with service access. These findings highlight the need for trauma-informed approaches to service delivery for PWUD, as well as enhanced provider training specific to PTSD.
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http://dx.doi.org/10.1186/s13011-021-00390-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233608PMC
June 2021

Examining factors that shape use and access to diverted prescription opioids during an overdose crisis: A qualitative study in Vancouver, Canada.

J Subst Abuse Treat 2021 Apr 20;130:108418. Epub 2021 Apr 20.

Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver V6Z 1Y6, BC, Canada; British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver V6Z 2A9, BC, Canada.

Objective: Prescription opioid (PO) diversion is widely regarded as a driver of overdose mortality. However, less is known about the rationale for using diverted POs during an overdose epidemic and how contextual factors (e.g., poverty, drug policies) may affect this practice. Therefore, we sought to examine this phenomenon.

Method: We conducted qualitative interviews with 24 participants who accessed diverted POs in Vancouver, Canada. Participants were recruited from ongoing cohort studies of people who use drugs (PWUD).

Results: Participants preferred a variety of POs due to their known contents and lower overdose risk compared to street drugs and used them for pain relief and pleasure. Participants reported barriers in accessing POs from physicians, with some being cut off or having insufficient prescriptions. Prices for diverted POs varied and affected access among impoverished participants. These access challenges led some to acquire fentanyl. Some participants reported concerns over the contents of counterfeit pills, while others relied on trusted sources or using visual cues to identify legitimate pills.

Conclusions: Our findings demonstrate that diverted POs are being used by PWUD with the goal of reducing opioid-related harms, although PO use comes with challenges associated with limited accessibility and risks posed by counterfeit pills. Poverty also limited PO accessibility, leading some to purchase more toxic, yet affordable, street drugs. Given the risks and barriers affecting people seeking to use diverted POs, our findings emphasize the need for the continued implementation and evaluation of safer drug supply initiatives, including those providing access to various drug types.
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http://dx.doi.org/10.1016/j.jsat.2021.108418DOI Listing
April 2021

Current Management and Future Treatment of Alcoholic Hepatitis.

Gastroenterol Hepatol (N Y) 2020 Apr;16(4):178-189

Dr Mitchell is the Nancy S. and Jeremy L. Halbreich Professor of Gastroenterology and vice president of medical affairs at the University of Texas Southwestern Medical Center in Dallas, Texas. Dr Kerr is an associate professor and Dr Herlong is a professor in the Division of Digestive and Liver Diseases at the University of Texas Southwestern Medical Center.

Excessive alcohol consumption is responsible for approximately 50% of all deaths due to cirrhosis. Although the duration and amount of alcohol consumption are the primary factors responsible for the liver injury caused by consuming alcohol, the pathogenesis of the 3 stages of alcohol-associated liver disease (ALD)-fatty liver, alcoholic hepatitis (AH), and cirrhosis- is likely multifactorial. Preexisting obesity, dysbiosis of the gut microbiome, activation of proinflammatory cytokines, and genetic factors can all contribute to the risk of developing ALD. The cornerstone of therapy for all stages of ALD is abstinence from drinking alcoholic beverages. Severe AH, defined by a Maddrey discriminant function greater than 32, warrants additional therapy. The results of multiple studies evaluating the use of glucocorticoids in the treatment of severe AH led to guidelines from international societies that recommend glucocorticoid therapy in patients with severe AH without active infection. Liver transplantation provides an effective treatment option for patients who fail glucocorticoid therapy. Recent advances in understanding the pathogenesis of AH have led to the investigation of potential therapies directed at preventing the development of steatosis, inhibiting the innate immune response, modifying the gut microbiome, and stimulating liver regeneration.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132686PMC
April 2020

High-intensity cannabis use and hospitalization: a prospective cohort study of street-involved youth in Vancouver, Canada.

Harm Reduct J 2021 May 17;18(1):53. Epub 2021 May 17.

BC Centre on Substance Use, University of British Columbia, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.

Background: There is concern that cannabis use negatively affects vulnerable groups such as youth; however, the relationship between cannabis use and health care utilization has not been well characterized in this population. We longitudinally evaluated the association between daily cannabis use and hospitalization among a prospective cohort of street-involved youth.

Methods: Data were collected from the At-Risk Youth Study (ARYS) in Vancouver, Canada, from September 2005 to May 2015. Participants were interviewed semi-annually and multivariable generalized estimating equation (GEE) logistic regression was used to examine the relationship between daily cannabis use and hospitalization.

Results: A total of 1216 participants (31.2% female) were included in this analysis, and 373 (30.7%) individuals reported hospitalization at some point during the study period. In a multivariable GEE analysis, daily cannabis use was not significantly associated with hospitalization (Adjusted Odds Ratio [AOR] = 1.17, 95% Confidence interval [CI] = 0.84, 1.65). We did observe a significant interaction between daily cannabis use and sex (AOR = 0.51, 95% CI = 0.34, 0.77), whereby cannabis use was associated with a decreased odds of hospitalization among males (AOR = 0.60, 95% CI = 0.47, 0.78), yet was not significantly associated with hospitalization among females (AOR = 1.19, 95% CI = 0.84, 1.67).

Conclusions: The finding that daily cannabis use was not associated with hospitalization among street-involved youth is encouraging given the high rates of cannabis use in this population and the expansion of cannabis legalization and regulation. Future studies, however, are warranted to monitor possible changes in the consequences of cannabis use as cannabis legalization and regulation increase internationally.
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http://dx.doi.org/10.1186/s12954-021-00501-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130127PMC
May 2021

"People need them or else they're going to take fentanyl and die": A qualitative study examining the 'problem' of prescription opioid diversion during an overdose epidemic.

Soc Sci Med 2021 06 3;279:113986. Epub 2021 May 3.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.
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http://dx.doi.org/10.1016/j.socscimed.2021.113986DOI Listing
June 2021

High Neutrophil-Lymphocyte Ratio and Delta Neutrophil-Lymphocyte Ratio Are Associated with Increased Mortality in Patients with Hepatocellular Cancer.

Dig Dis Sci 2021 May 3. Epub 2021 May 3.

Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd, POB 1, Suite 420, Dallas, TX, 75390-8887, USA.

Background: The neutrophil-lymphocyte ratio (NLR) has been proposed as a prognostic biomarker for cirrhosis and non-liver malignancies. We aimed to evaluate the prognostic value of NLR in a diverse cohort of patients with hepatocellular carcinoma (HCC).

Methods: We performed a retrospective study of patients diagnosed with HCC between 2008 and 2017 at two large US health systems. We used Cox proportional hazard and multivariable ordinal logistic regression models to identify factors associated with overall survival and response to first HCC treatment, respectively. Primary variables of interest were baseline NLR and delta NLR, defined as the difference between pre- and post-treatment NLR.

Results: Among 1019 HCC patients, baseline NLR was < 5 in 815 (80.0%) and ≥ 5 in 204 (20.0%). Patients with NLR ≥ 5 had a higher proportion of infiltrative tumors (36.2% vs 22.3%), macrovascular invasion (39.6% vs 25.5%), metastatic disease (20.6% vs 11.4%), and AFP > 200 ng/mL (45.6% vs 33.8%). Baseline NLR ≥ 5 was independently associated with higher mortality (median survival 4.3 vs 15.1 months; adjusted HR 1.70, 95%CI 1.41-2.06), with differences in survival consistent across BCLC stages. After adjusting for baseline covariates including NLR, delta NLR > 0.26 was also independently associated with increased mortality (HR 1.42, 95%CI 1.14-1.78). In a secondary analysis, high NLR was associated with lower odds of response to HCC treatment (20.2% vs 31.6%; adjusted OR 0.55, 95%CI 0.32-0.95).

Conclusions: In a large Western cohort of patients with HCC, high baseline NLR and delta NLR were independent predictors of mortality.

Impact: NLR is an inexpensive test that may be a useful component of future HCC prognostic models.
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http://dx.doi.org/10.1007/s10620-021-07001-6DOI Listing
May 2021

The relationship between opioid agonist therapy satisfaction and fentanyl exposure in a Canadian setting.

Addict Sci Clin Pract 2021 04 28;16(1):26. Epub 2021 Apr 28.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.

Background: While patient-reported treatment dissatisfaction is considered an important factor in determining the success of substance use disorder treatment, the levels of dissatisfaction with opioid agonist therapies (OAT) and its relationship with the risk of fentanyl exposure have not been characterized in the context of the ongoing opioid overdose crisis in the US and Canada. Our primary hypothesis was that OAT dissatisfaction was associated with an increased odds of fentanyl exposure.

Methods: Our objective was to examine self-reported treatment satisfaction among OAT patients in Vancouver, Canada and the association with fentanyl exposure. Longitudinal data were derived from 804 participants on OAT enrolled in two community-recruited harmonized prospective cohort studies of people who use drugs in Vancouver between 2016 and 2018 via semi-annual interviews and urine drug screens (UDS). We employed multivariable generalized estimating equations to examine the relationship between OAT dissatisfaction and fentanyl exposure.

Results: Out of 804 participants (57.0% male), 222 (27.6%) reported being dissatisfied with OAT at baseline and 1070 out of 1930 observations (55.4%) had fentanyl exposure. The distribution of OAT reported in the sample was methadone (n = 692, 77.7%), buprenorphine-naloxone (n = 82, 9.2%), injectable OAT (i.e., diacetylmorphine or hydromorphone; (n = 65, 7.3%), slow-release oral morphine (n = 44, 4.9%) and other/study medication (n = 8, 1.0%). In the multivariable analysis, OAT dissatisfaction was positively associated with fentanyl exposure (AOR = 1.34; 95% CI: 1.08-1.66).

Conclusions: A substantial proportion of OAT patients in our sample reported dissatisfaction with their OAT, and more than half were exposed to fentanyl. We also found that those who were dissatisfied with their OAT were more likely to be exposed to fentanyl. These findings demonstrate the importance of optimizing OAT satisfaction in the context of the ongoing opioid overdose crisis.
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http://dx.doi.org/10.1186/s13722-021-00234-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082888PMC
April 2021

Effect of alternative income assistance schedules on drug use and drug-related harm: a randomised controlled trial.

Lancet Public Health 2021 05 12;6(5):e324-e334. Epub 2021 Apr 12.

Department of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Centre on Substance Use, Vancouver, BC, Canada.

Background: The synchronised monthly disbursement of income assistance, whereby all recipients are paid on the same day, has been associated with increases in illicit drug use and serious associated harms. This phenomenon is often referred to as the cheque effect. Because payment variability can affect consumption patterns, this study aimed to assess whether these harms could be mitigated through a structural intervention that varied income assistance payment timing and frequency.

Methods: This randomised, parallel group trial was done in Vancouver, Canada, and enrolled recipients of income assistance whose drug use increased around payment days. The recipients were randomly assigned 1:2:2 to a control group that received monthly synchronised income assistance payments on government payment days, a staggered group in which participants received single desynchronised monthly income assistance payments, or a split and staggered group in which participants received desynchronised income assistance payments split into two instalments per month, 2 weeks apart, for six monthly payment cycles. Desynchronised payments in the intervention groups were made on individual payment days outside the week of the standard government schedules. Randomisation was through a pre-established stratified block procedure. Investigators and statisticians were masked to group allocation, but participants and front-line staff were not. Complete final results are reported after scheduled interim analyses and the resulting early stoppage of recruitment. Under intention-to-treat specifications, generalised linear mixed models were used to analyse the primary outcome, which was escalations in drug use, predefined as a 40% increase in at least one of: use frequency; use quantity; or number of substances used during the 3 days after government payments. Secondary analyses examined analogous drug use outcomes coinciding with individual payments as well as exposure to violence. This trial is registered with ClinicalTrials.gov, NCT02457949.

Findings: Between Oct 27, 2015, and Jan 2, 2019, 45 participants were enrolled to the control group, 72 to the staggered group, and 77 to the split and staggered group. Intention-to-treat analyses showed a significantly reduced likelihood of increased drug use coinciding with government payment days, relative to the control group, in the staggered (adjusted odds ratio 0·38, 95% CI 0·20-0·74; p=0·0044) and split and staggered (0·44, 0·23-0·83; p=0·012) groups. Findings were consistent in the secondary analyses of drug use coinciding with individual payment days (staggered group 0·50, 0·27-0·96, p=0·036; split and staggered group 0·49, 0·26-0·94, p=0·030). However, secondary outcome analyses of exposure to violence showed increased harm in the staggered group compared with the control group (2·71, 1·06-6·91, p=0·037). Additionally, 51 individuals had a severe or life-threatening adverse event and there were six deaths, none of which was directly attributed to study participation.

Interpretation: Complex results indicate the potential for modified income assistance payment schedules to mitigate escalations in drug use, provided measures to address unintended harms are also undertaken. Additional research is needed to clarify whether desynchronised schedules produce other unanticipated consequences and if additional measures could mitigate these harms.

Funding: Canadian Institutes of Health Research, Providence Health Care Research Institute, Peter Wall Institute for Advanced Research, Michael Smith Foundation for Health Research.
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http://dx.doi.org/10.1016/S2468-2667(21)00023-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176782PMC
May 2021

Knowledge of a Drug-Related Good Samaritan Law Among People Who Use Drugs, Vancouver, Canada.

Health Educ Behav 2021 Mar 4:1090198121999303. Epub 2021 Mar 4.

British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, British Columbia, Canada.

Background: Across the United States and Canada drug-related Good Samaritan laws (GSLs) have been enacted to encourage observers of acute drug overdose events to contact emergency medical services (EMS) without fear of legal repercussions. However, little is known about the working knowledge of GSLs among people who use illicit drugs (PWUD). We sought to evaluate the prevalence and factors associated with accurate knowledge of a GSL among PWUD in Vancouver, Canada, 1 year after the GSL was enacted.

Method: We used data from participants in three community-recruited prospective cohort studies of PWUD interviewed between June and November 2018. Multivariable logistic regression was used to identify factors associated with accurate knowledge of the GSL.

Results: Among 1,258 participants, including 760 males (60%), 358 (28%) had accurate knowledge of the GSL. In multivariable analyses, participants who reported ever having a negative police encounter (defined as being stopped, searched, or detained by the police) were less likely to have accurate knowledge of the GSL (adjusted odds ratio [AOR] = 0.70; 95% CI [0.54, 0.90]), while those involved in drug dealing were more likely to have accurate knowledge of the GSL (AOR = 1.50; 95% CI [1.06, 2.06]).

Discussion: Despite having been enacted for a full year, approximately three quarters of participants did not have accurate GSL knowledge, warranting urgent educational efforts among PWUD. Additional research is needed to understand whether GSLs can mitigate the fears of legal repercussions among those engaged in drug dealing and with past negative experiences with the police.
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http://dx.doi.org/10.1177/1090198121999303DOI Listing
March 2021

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

Drug Alcohol Rev 2021 Feb 18. 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
February 2021

Corrigendum to 'Cannabis use is associated with reduced risk of exposure to fentanyl among people on opioid agonist therapy during a community-wide overdose crisis' [Drug Alcohol Depend. 219 (2021) 108420].

Drug Alcohol Depend 2021 Apr 3;221:108547. Epub 2021 Feb 3.

British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.drugalcdep.2021.108547DOI Listing
April 2021

Non-medical prescription opioid use and in-hospital illicit drug use among people who use drugs.

Drug Alcohol Rev 2021 Feb 4. Epub 2021 Feb 4.

British Columbia Centre on Substance Use, Vancouver, Canada.

Introduction: Illicit drug use while admitted to hospital is common amongst people who use drugs. Furthermore, non-medical prescription opioid use (NMPOU) is increasingly being used by this population. This study was undertaken to investigate the relationship between NMPOU and having ever reported using illicit drugs in the hospital.

Methods: This study was a cross-sectional study design based on data derived from participants enrolled in three Canadian prospective cohort studies between December 2011 and November 2016. Using bivariable and multivariable logistic regression analyses, we examined the relationship between NMPOU and having ever reported illicit drug use in the hospital.

Results: Among the 1865 participants (951 male, 471 female) enrolled in the studies, 1422 (76.25%) met the inclusion criteria of having ever been hospitalised. Of these, 436 (30.7%) had used illicit drugs while in the hospital. In multivariable analyses, after adjusting for various confounders, we found a positive relationship between the percentage of reporting at least daily NMPOU in the past 6 months during the cohort study period and illicit drug use in the hospital (adjusted odds ratio 3.42; 95% confidence interval 1.46-8.02).

Discussion And Conclusions: Among our sample, more persistent NMPOU was positively associated with having reported in-hospital illicit drug use. Our findings point to the need for better identification and management of opioid use disorder in acute care settings to reduce in-hospital illicit drug use, and to offer evidence-based medical treatments to achieve the most optimal outcomes for patients.
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http://dx.doi.org/10.1111/dar.13246DOI Listing
February 2021

A gender comparative analysis of post-traumatic stress disorder among a community-based cohort of people who use drugs in Vancouver, Canada.

Addict Behav 2021 04 5;115:106793. Epub 2021 Jan 5.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada. Electronic address:

Background: While exposure to traumatic events and subsequent post-traumatic stress disorder (PTSD) are common among people who use drugs (PWUD), little is known about gender-based differences associated with PTSD in this population. We explore gender-based differences in factors associated with a probable PTSD diagnosis in a cohort of PWUD from Vancouver, Canada.

Methods: Data were collected through the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), two community-recruited cohorts of PWUD. Participants were administered the PTSD Checklist for DSM-5. Multivariable logistic regression was used to investigate social-structural factors and substance use patterns and behaviours associated with a probable PTSD diagnosis, stratified by self-identified gender. PTSD symptom clusters and brief descriptions of the worst traumatic event experienced were also reported.

Results: Between December 2016 and December 2018, of 797 eligible participants, 295 (37.0%) identified as women. PTSD was more commonly reported in women compared to men (53.2% vs. 31.5%, p < 0.001). In multivariable analysis involving men, no correlates were associated with PTSD. In multivariable analysis involving women, PTSD was positively associated with exposure to violence (AOR: 3.66; 95%CI: 1.14-11.72), daily stimulant use (AOR: 2.32; 95%CI: 1.32-4.08) and heavy alcohol use (AOR: 3.84; 95%CI: 1.84-8.00), and negatively associated with being in a stable relationship (AOR: 0.46; 95%CI: 0.25-0.84).

Conclusions: Gender-based differences in PTSD diagnosis among a cohort of PWUD point to the need to develop gender-focused and trauma-informed health and social services to meet the immediate needs of PWUD living with PTSD.
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http://dx.doi.org/10.1016/j.addbeh.2020.106793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7971763PMC
April 2021

"And we just have to keep going": Task shifting and the production of burnout among overdose response workers with lived experience.

Soc Sci Med 2021 02 5;270:113631. Epub 2021 Jan 5.

British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, V6Z 1Y6, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Yale School of Medicine, New Haven, CT, United States; Yale School of Public Health, New Haven, CT, United States; Department of Anthropology, Yale University, New Haven, CT, United States. Electronic address:

Overdose response programs in North America increasingly employ task shifting-shifting overdose response tasks to less specialized workers-to increase effectiveness and promote involvement of people with lived/living experience of drug use (PWLE). In Canada, task shifting has occurred through community-driven implementation of overdose response programs staffed primarily by PWLE. The implications of this task shifting on workers' well-being and service delivery has received little scholarly consideration, despite reports of widespread burnout among frontline responders. This study examines experiences and drivers of burnout among PWLE working at low-barrier supervised consumption sites ("Overdose Prevention Sites" or OPSs) in Vancouver, Canada. Between December 2016 and March 2020, we conducted ethnographic fieldwork at four OPSs, including in-depth interviews with 23 overdose response workers, three site-based focus groups with 20 additional workers, and 150 h of naturalistic observation. Data were analyzed to explore how working conditions, labour arrangements, economic insecurity and social disadvantage shaped burnout. We found that overdose response workers commonly reported burnout, which they attributed to the precarious and demanding nature of their work. While casual positions offered low-barrier employment, PWLE often lacked the wages and benefits enjoyed by other frontline workers, with limited supports and opportunities for advancement. Due to their social position within drug-using networks, PWLE's work encompassed hidden care work that participants felt was constant and undervalued. The scarcity of permanent full-time positions, alongside barriers to transitioning into formal employment, prevented many PWLE from earning livable wages or taking time off to 'recharge.' This study highlights how the devaluing and casualization of overdose response labour, compounded by other dimensions of structural vulnerability, are central to burnout among overdose response workers with lived experience. Interventions to address burnout within this setting must extend beyond individual-level interventions (e.g. counselling, self-care) to also strengthen working conditions and economic security of PWLE.
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http://dx.doi.org/10.1016/j.socscimed.2020.113631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168663PMC
February 2021

Pain and Barriers to Accessing Health Services Among People Who Use Drugs.

Pain Manag Nurs 2021 04 24;22(2):133-140. Epub 2020 Dec 24.

British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Background: The opioid overdose crisis underscores the need for health services among people who use drugs (PWUD) with concurrent pain.

Aims: Investigating the effect of pain on barriers to accessing health services among PWUD.

Design: Prospective cohort study.

Settings: A setting of universal access to no-cost medical care in Vancouver, Canada from June 2014 to May 2016.

Participants/subjects: PWUD who completed at least one study interview.

Methods: Data derived from interviewer-administered questionnaires were used for multivariable generalized linear mixed-effects multiple regression (GLMM) analyses.

Results: Among 1,348 PWUD, 469 (34.8%) reported barriers to accessing health services at least once during the study period. The median average pain severity was 3 (IQR: 0-6) out of 10. A dose-response relationship was observed between greater pain and increased odds of reporting barriers to accessing health services (adjusted odds ratio [AOR]: 1.59, 95% confidence interval [CI]: 1.15-2.21, p = .005 for mild versus no pain; AOR: 1.76, 95% CI: 1.30-2.37, p < .001 for moderate versus no pain; AOR: 2.55, 95% CI: 1.92-3.37, p < .001 for severe versus no pain). Common barriers included poor treatment by health professionals, socio-structural barriers such as transportation or mobility, and long wait lists or wait times.

Conclusions: Pain may be a significant risk factor associated with increased barriers to accessing health services among PWUD. Attention to pain management may improve access to health services, and reducing barriers to health services may conversely improve pain management and its related risks and harms.
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http://dx.doi.org/10.1016/j.pmn.2020.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137537PMC
April 2021

Cannabis use is associated with reduced risk of exposure to fentanyl among people on opioid agonist therapy during a community-wide overdose crisis.

Drug Alcohol Depend 2021 02 17;219:108420. Epub 2020 Dec 17.

British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Background: The ongoing opioid overdose crisis is driven largely by exposure to illicitly-manufactured fentanyl. Preliminary observational and experimental research suggests that cannabis could potentially play a role in reducing use of prescription opioids among individuals with chronic pain. However, there is limited data on the effects of cannabis on illicit opioid consumption, particularly fentanyl, especially among individuals on opioid agonist therapy (OAT). We sought to assess the longitudinal association between cannabis use and exposure to fentanyl among people on OAT.

Methods: Data were drawn from two community-recruited prospective cohorts of people who use drugs in Vancouver, Canada. We used generalized linear mixed-effects modeling, adjusted by relevant confounders, to investigate the relationship between cannabis use and recent fentanyl exposure (both assessed by urine drug testing) among participants on OAT between 2016 and 2018.

Results: Among the 819 participants on OAT who contributed 1989 observations over the study period, fentanyl exposure was common. At the baseline interview, fentanyl was detected in a majority of participants (431, 53 %), with lower prevalence among individuals with urine drug tests positive for tetrahydrocannabinol (47 vs. 56 %, p = 0.028). Over all study interviews, cannabis use was independently associated with reduced likelihood of being recently exposed to fentanyl (Adjusted Prevalence Ratio = 0.91, 95 % Confidence Interval: 0.83 - 0.99).

Conclusions: Participants on OAT using cannabis had significantly lower risk of being exposed to fentanyl. Our findings reinforce the need for experimental trials to investigate the potential benefits and risks of controlled cannabinoid administration for people on OAT.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006801PMC
February 2021

Trajectories of Retention in Opioid Agonist Therapy and Overdose Risk During a Community-Wide Overdose Epidemic in a Canadian Setting.

Am J Prev Med 2021 01;60(1):57-63

British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Introduction: Retention in opioid agonist therapy consistently has been linked with improved outcomes among people with opioid use disorder. However, less is known about the links between patterns of engagement in opioid agonist therapy over the long term and overdose risk. This study assesses the association of opioid agonist therapy retention trajectories with nonfatal overdose.

Methods: Data were drawn from 2 community-recruited prospective cohorts of people who use drugs in Vancouver, Canada. Latent class growth analysis was used to identify trajectories of opioid agonist therapy retention among people with opioid use disorder initiating therapy, and generalized estimating equations assessed the association of these trajectories with nonfatal overdose events after opioid agonist therapy initiation.

Results: Between 2005 and 2018, among 438 opioid agonist therapy initiators, 4 retention trajectories were identified: consistently high (35.6%), increasing (26.0%), consistently low (23.3%), and decreasing (15.1%) opioid agonist therapy engagement. During the study period, there were 371 nonfatal overdose events, with 179 (40.1%) participants reporting ≥1. In adjusted analysis, the consistently low (AOR=1.73, 95% CI=1.10, 2.71) and decreasing (AOR=1.87, 95% CI=1.18, 2.95) retention trajectories were positively associated with increased odds of nonfatal overdose compared with the consistently high opioid agonist therapy retention class.

Conclusions: Suboptimal trajectories of opioid agonist therapy retention were associated with an increased likelihood of nonfatal overdose. These findings suggest that reducing the barriers to sustained engagement in opioid agonist therapy will be critical to address North America's overdose epidemic.
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http://dx.doi.org/10.1016/j.amepre.2020.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978040PMC
January 2021

Factors associated with drug checking service utilization among people who use drugs in a Canadian setting.

Harm Reduct J 2020 12 14;17(1):100. Epub 2020 Dec 14.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada.

Background: The United States and Canada are amidst an opioid overdose crisis, with the Canadian province of British Columbia (BC) among the hardest hit. In response, drug checking services (DCS) have been introduced in this setting as a novel pilot harm reduction intervention though little is known about usage rates. Therefore, we sought to identify factors associated with drug checking uptake among people who use drugs (PWUD) in Vancouver, BC.

Methods: Data were derived from three ongoing prospective cohort studies of PWUD in Vancouver between June and November 2018. Multivariable logistic regression was used to determine factors associated with self-reported DCS utilization in the past 6 months among participants at high risk of fentanyl exposure (i.e., those self-reporting illicit opioid use or testing positive for fentanyl via urine drug screen).

Results: Among 828 eligible participants, including 451 (55%) males, 176 (21%) reported recent use of DCS. In multivariable analyses, factors significantly associated with DCS utilization included: homelessness (Adjusted Odds Ratio [AOR] 1.47; 95% Confidence Interval [CI] 1.01-2.13) and involvement in drug dealing (AOR 1.59; 95% CI 1.05-2.39).

Conclusions: In our sample of PWUD, uptake of DCS was low, although those who were homeless, a sub-population known to be at a heightened risk of overdose, were more likely to use the services. Those involved in drug dealing were also more likely to use the services, which may imply potential for improving drug market safety. Further evaluation of drug checking is warranted.
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http://dx.doi.org/10.1186/s12954-020-00454-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737352PMC
December 2020

"I couldn't live with killing one of my friends or anybody": A rapid ethnographic study of drug sellers' use of drug checking.

Int J Drug Policy 2021 01 24;87:102845. Epub 2020 Nov 24.

British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada; Yale School of Medicine, 367 Cedar Street, New Haven, CT, 06510, United States; Social & Behavioral Sciences, Yale School of Public Health, 60 College St, New Haven, CT 06510, United States. Electronic address:

Introduction: Drug sellers are often represented as morally bereft actors and as being, in part, responsible for North America's overdose crisis. In Canada and the United States, drug sellers selling fentanyl and fentanyl-adulterated drugs have been charged with manslaughter when their clients fatally overdose, representing a retrenchment of drug war tactics. However, targeting drug sellers for drug checking interventions may have potential for reducing fentanyl-related harms. This study explores drug sellers' negotiation of and engagement with drug checking technologies in Vancouver, Canada.

Methods: Rapid ethnographic fieldwork was conducted from November 2018 to January 2019, including 26 semi-structured interviews with people who tested their drugs at an overdose prevention site to examine perceptions of the efficacy of drug checking. As drug sellers were also using the drug checking services, we specifically examined their perceptions of drug checking and the market aspects of the overdose crisis. Data were analyzed using Nvivo 12 and interpreted drawing on the concept of structural vulnerability.

Findings: Drug sellers accessing drug checking services were concerned about the safety of their customers, and drug checking was one way of reducing the likelihood of harm. Drug sellers were embedded in the community, thereby, enmeshing practices of community care and ethics with the selling of drugs. When they had access to drug checking knowledge, sellers were able to modify risks related to the fentanyl market, including tailoring drugs sold to clients, returning dangerous batches and modifying fentanyl in order to make it safer to consume.

Conclusions: Our findings reposition drug sellers as embedded within their communities and demonstrate their potential role in alleviating the dangers of the volatile fentanyl market. Policies that target people who sell drugs, particularly murder or manslaughter charges, are likely to make the crisis worse, and serious consideration should be put into harm reduction approaches with drug sellers.
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http://dx.doi.org/10.1016/j.drugpo.2020.102845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020365PMC
January 2021

Applying the lessons of COVID-19 response to Canada's worsening opioid epidemic.

EClinicalMedicine 2020 Dec 20;29:100633. Epub 2020 Nov 20.

Department of Medicine, University of British Columbia, St. Paul's Hospital, 608‒1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.

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http://dx.doi.org/10.1016/j.eclinm.2020.100633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677043PMC
December 2020

"It's Helped Me a Lot, Just Like to Stay Alive": a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada.

J Urban Health 2021 02 28;98(1):59-69. Epub 2020 Oct 28.

British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada.

North America is experiencing an overdose crisis driven by fentanyl, related analogues, and fentanyl-adulterated drugs. In response, there have been increased calls for "safe supply" interventions based on the premise that providing a safer alternative (i.e., pharmaceutical drugs of known quality/quantity, non-adulterated, with user agency in consumption methods) to the street drug supply will limit people's use of fentanyl-adulterated drugs and reduce overdose events. This study examined outcomes of a hydromorphone tablet distribution program intended to prevent overdose events among people who use drugs (PWUD) at high risk of fatal overdose. Semi-structured qualitative interviews were conducted with 42 people enrolled in the hydromorphone distribution program. Additionally, over 100 h of ethnographic observation were undertaken in and around the study site. Transcripts were coded using NVivo and based on categories extracted from the interview guides and those identified during initial interviews and ethnographic fieldwork. Analysis focused on narratives around experiences with the program, focusing on program-related outcomes. Our analysis identified the following positive outcomes of being enrolled in the hydromorphone tablet distribution program: (1) reduced street drug use and overdose risk, (2) improvements to health and well-being, (3) improvements in co-management of pain, and (4) economic improvements. Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people's use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality. Safe supply programs should be further implemented and evaluated in both urban and rural setting across North America as a strategy to reduce exposure to the toxic drug supply and fatal overdose.
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http://dx.doi.org/10.1007/s11524-020-00489-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592642PMC
February 2021

Greater Pain Severity is Associated with Inability to Access Addiction Treatment Among a Cohort of People Who Use Drugs.

J Pain Res 2020 1;13:2443-2449. Epub 2020 Oct 1.

British Columbia Centre on Substance Use, Vancouver, BC V6Z 2A9, Canada.

Aim: Given that co-occurring pain is prevalent among people who use drugs (PWUD), we sought to explore the effect of pain severity on accessing addiction treatment.

Methods: Data were derived from two prospective cohort studies of PWUD in Vancouver, Canada from June 2014 to May 2016. Multivariable generalized linear mixed-effects multiple regression (GLMM) analyses were used to investigate the association between average pain severity and self-reported inability to access addiction treatment.

Results: Among 1348 PWUD, 136 (10.1%) reported being unable to access addiction treatment at least once over the study period. Individuals who reported being unable to access addiction treatment had a significantly higher median average pain severity score (median=5, IQR=0-7) compared to individuals reporting no inability to access addiction treatment (median=3, IQR=0-6, =0.038). Greater pain severity was independently associated with higher odds of reporting inability to access addiction treatment (AOR: 1.75, 95%CI: 1.08-2.82 for mild-moderate vs no pain; AOR: 1.98, 95%CI: 1.27-3.09 for moderate-severe vs no pain).

Conclusion: PWUD with greater pain severity may be at higher risk of being unable to access addiction treatment, or vice versa. While further research is needed to confirm causal associations, these data suggest that there may be underlying pathways or mechanisms through which pain may be associated with access to addiction treatment for PWUD.
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http://dx.doi.org/10.2147/JPR.S255438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534843PMC
October 2020

Assisted injection within supervised injection services: Uptake and client characteristics among people who require help injecting in a Canadian setting.

Int J Drug Policy 2020 Oct 8;86:102967. Epub 2020 Oct 8.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, CANADA, V6Z 2A9; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6.

Background: People who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada.

Methods: Data were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS.

Results: Between June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 - 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 - 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 - 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 - 3.47) were associated with increased odds of receiving injection assistance at SIS.

Conclusion: Although uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.
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http://dx.doi.org/10.1016/j.drugpo.2020.102967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026755PMC
October 2020

Long term pre-treatment opioid use trajectories in relation to opioid agonist therapy outcomes among people who use drugs in a Canadian setting.

Addict Behav 2021 01 15;112:106655. Epub 2020 Sep 15.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, V6Z 2A9 Canada; Department of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3 Canada. Electronic address:

Background: Opioid agonist therapy (OAT) models are generally provided without consideration of how pre-treatment characteristics may be associated with outcome. Therefore, we aimed to first characterize longitudinal trajectories of opioid use before initiating OAT. Then we explored the impact of OAT on opioid use across these pre-treatment trajectories.

Methods: Data were derived from three prospective cohort studies involving people who use drugs in Vancouver, Canada. Latent class growth analysis was applied to identify opioid use trajectories based on individual-level observations three years before starting OAT. Multivariable generalized linear mixed model was used to examine whether engaging in OAT was associated with lower risk of illicit opioid use among participants with different pre-treatment opioid use trajectories.

Results: 464 participants were included in the study between September 2005 and November 2018. Two pre-treatment opioid use trajectories were identified: high frequency users (246, 53.0%) and gradually increasing frequency users (218, 47.0%). We observed different strengths of association between OAT engagement and illicit opioid use among high frequency users (adjusted odds ratio [AOR] = 0.36, 95% Confidence Interval [CI]: 0.20 - 0.63) and gradually increasing frequency users (AOR = 0.91, 95% CI: 0.53 - 1.56). Unstable housing, any stimulant use, experiencing violence, drug dealing, sex work involvement, and incarceration were independently and positively associated with ongoing illicit opioid use.

Conclusions: Distinct pre-treatment opioid use trajectories are likely to influence treatment outcomes. Research is required to determine if tailored strategies specific to people with different pre-treatment opioid use patterns have potential to improve outcomes of OAT.
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http://dx.doi.org/10.1016/j.addbeh.2020.106655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572870PMC
January 2021

Motivations to initiate injectable hydromorphone and diacetylmorphine treatment: A qualitative study of patient experiences in Vancouver, Canada.

Int J Drug Policy 2020 11 16;85:102930. Epub 2020 Sep 16.

British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Internal Medicine, Yale School of Medicine. New Haven, CT, 06510 United States; Yale Program in Addiction Medicine, Yale School of Medicine. New Haven, Connecticut, 06510 United States. Electronic address:

Background: Within the context of the ongoing overdose crisis and limitations of conventional opioid treatments, the scale-up of injectable hydromorphone (HDM) and diacetylmorphine (DAM) as evidenced-based treatments is currently underway in some settings in Canada. Past research has underscored the importance of treatment initiation in shaping onward treatment trajectories, however structural factors that influence participants' motivations to access injectable HDM or DAM have not been fully characterized. This study examines peoples' motivations for accessing HDM/DAM treatment and situates these within the social and structural context that shapes treatment delivery by employing the concept of structural vulnerability.

Methods: Fifty-two individuals enrolled in injectable HDM/DAM programs were recruited from four community-based clinical programs in Vancouver, Canada to participate in qualitative semi-structured interviews. Approximately 50 h of ethnographic fieldwork was also completed in one clinical setting, and one-on-one with participants public spaces. Interview transcripts and ethnographic fieldnotes were analyzed through a structural vulnerability lens with a focus on treatment initiation.

Results: Participants' previous experiences and perceptions of other drug treatments (e.g. methadone) foregrounded their initiation of injectable HDM/DAM. Social and structural factors (e.g. fentanyl-adulterated drug supply, poverty, drug criminalization) influenced participants' motivations to address immediate physical risks and their initial perception of this treatment's ability to align with their opioid use experiences. Similar social and structural factors that drive immediate physical risks, were also evidenced in participants' motivations to make changes in their daily lives and to address broader opioid use goals.

Conclusion: Participants descriptions of their motivations to initiate HDM/DAM highlight how structural vulnerabilities shaped participants' experiences initiating injectable HDM/DAM.
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http://dx.doi.org/10.1016/j.drugpo.2020.102930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901590PMC
November 2020

Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: a qualitative study.

Drug Alcohol Depend 2020 11 15;216:108202. Epub 2020 Sep 15.

British Columbia Centre on Substance Use, 1045 Howe St Suite 400 Vancouver, British Columbia, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall Vancouver, British Columbia, V6T 1Z3, Canada; Program in Addiction Medicine, Yale School of Medicine 333 Cedar St, New Haven, CT 06510, United States; General Internal Medicine, Yale School of Medicine 333 Cedar St, New Haven, CT 06510, United States. Electronic address:

Background: North America is experiencing an overdose crisis driven by illicitly-manufactured fentanyl, related analogues, and fentanyl-adulterated drugs. The concept of 'safe supply' has been suggested as a potential measure to address the overdose crisis by providing a regulated alternative to illicit opioids to people at high risk of fatal overdose. In January 2019, a novel hydromorphone tablet distribution program was implemented within an overdose prevention site in Vancouver, Canada's Downtown Eastside neighbourhood. This study explored barriers and facilitators to engagement with this program.

Methods: In-depth interviews were conducted with 42 participants enrolled in the hydromorphone tablet distribution program, and over 100 h of ethnographic observation were conducted in and around the study site. Thematic analysis of the interviews and ethnographic observation focused on program operation, including barriers and facilitators to program uptake, access, and engagement.

Results: Barriers to program engagement identified include: limited operating hours and dose schedule, co-location within the overdose prevention site (e.g., wait times), and receiving the generic formulation of hydromorphone. Facilitators identified include: having access to a reliable source of opioids, co-location within the overdose prevention site (e.g., low-barrier design), experiences of agency, and program flexibility.

Conclusion: Our findings demonstrate key implementation and operational considerations of safe supply programs. In particular, lower-barrier design and operational features should be considered to improve uptake and engagement. Safe opioid supply programs are a promising intervention to address North America's ongoing overdose crisis by providing people at high risk of fatal overdose an alternative to the toxic drug supply.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490624PMC
November 2020

Long-term benefits of providing transitional services to youth aging-out of the child welfare system: Evidence from a cohort of young people who use drugs in Vancouver, Canada.

Int J Drug Policy 2020 11 1;85:102912. Epub 2020 Sep 1.

B.C. Centre on Substance Use, 1045 Howe St., Vancouver, B.C., V6Z 2A9 Canada; School of Public Policy, Simon Fraser University, 515 W Hastings St., Vancouver, B.C., V6B 5K3 Canada.

Background: Youth aging-out of the child welfare system (CWS) experience numerous vulnerabilities including, elevated rates of substance use and substance use disorders. Calls to improve services to transition youth to independence are common; however, evidence of the long-term impacts associated with transitional service utilization is scarce. Further, existing services frequently lack appropriate supports for substance using youth and it is unknown if youth are able to access such services. In the present study, we assess the relationship between transitional service utilization and health and social outcomes among a cohort of people who use drugs (PWUD) that aged-out of the CWS.

Methods: Data were obtained from two harmonized cohorts of PWUD in Vancouver, Canada. Those who reported aging-out were asked about service utilization, availability, barriers, and interest across seven categories of transitional services. Multivariable logistic regression analyses were conducted to assess the relationship between having previously utilized transitional services and current health and social outcomes.

Results: Between December 2014 and November 2017, 217 PWUD reported having previously aged-out of the CWS. Across service categories, reported service utilization prevalence ranged from 16.6-61.8% while unmet demand ranged from 64.8-78.4%. In multivariable analyses, compared to individuals who utilized ≤1 service while aging-out, having utilized 4-7 services was significantly associated with reduced odds of current homelessness (adjusted odds ratio [AOR]=0.29) and engaging in daily drug use (AOR=0.35) (both p<0.05).

Conclusion: Findings suggest that this understudied high-risk population of PWUD and aged-out of the CWS experience long-term benefits associated with transitional service utilization and are interested and willing to engage in these services. However, given high unmet demand, findings also highlight considerable gaps in service delivery and support calls for extending the age of emancipation for all youth in the CWS and in particular, for additional harm reduction and substance use supports embedded into service models.
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http://dx.doi.org/10.1016/j.drugpo.2020.102912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864665PMC
November 2020

Frequent Cannabis Use and Cessation of Injection of Opioids, Vancouver, Canada, 2005-2018.

Am J Public Health 2020 10 20;110(10):1553-1560. Epub 2020 Aug 20.

All authors are with the British Columbia Centre on Substance Use, Vancouver, BC, Canada.

To evaluate the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID). Three prospective cohorts of PWID from Vancouver, Canada, provided the data for these analyses. We used extended Cox regression analysis with time-updated covariates to analyze the association between cannabis use and injection cessation and injection relapse. Between 2005 and 2018, at-least-daily cannabis use was associated with swifter rates of injection cessation (adjusted hazard ratio [AHR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). A subanalysis revealed that this association was only significant for opioid injection cessation (AHR = 1.26; 95% CI = 1.12, 1.41). At-least-daily cannabis use was not significantly associated with injection relapse (AHR = 1.08; 95% CI = 0.95, 1.23). We observed that at-least-daily cannabis use was associated with a 16% increase in the hazard rate of injection cessation, and this effect was restricted to the cessation of injection opioids. This finding is encouraging given the uncertainty surrounding the impact of cannabis policies on PWID during the ongoing opioid overdose crisis in many settings in the United States and Canada.
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http://dx.doi.org/10.2105/AJPH.2020.305825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483125PMC
October 2020
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