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Background: Peer workers are individuals who draw on their personal experiences in a professional capacity to support clients. Existing research on the role of peer workers in mental health, homelessness, and substance use services has primarily focused on their impact on client outcomes. This paper describes the development of peer workers as they transition into, through, and beyond this role. Utilising data from the Supporting Harm Reduction through Peer Support (SHARPS) study, where Peer Navigators supported people experiencing homelessness and substance use challenges, this paper explores the sense-making involved in an intensive peer support worker role, adaptation to organisational culture, and engagement with opportunities for professional advancement., Methods: Semi-structured interviews with three Peer Navigators were conducted by two SHARPS study researchers at four time points in 2018 and 2019 corresponding with the beginning, middle, and end of the intervention. These data were analysed along with entries from the three Peer Navigators' reflective diaries. Analysis followed a multi-stage approach to thematic analysis utilising both inductive and deductive processes. The Peer Navigators' personal reflections have also been incorporated into the recommendations., Results: The foundational training provided to the Peer Navigators before taking up their role helped to ensure readiness and build confidence. This training illuminated the dynamics of supporting individuals with complex health and social challenges. Integrating into diverse organisational environments, the Peer Navigators adapted to new professional expectations and consistently advocated for harm reduction and psychologically informed approaches, sometimes encountering resistance from other professionals. Establishing effective relationships with participants and professionals was essential and involved dealing with challenges such as overcoming personal biases and navigating systemic obstacles. the Peer Navigators benefitted from the specially designed training to support career progress with personal and professional development opportunities which enabled successful transitions beyond the SHARPS study., Conclusions: Pre-work training, coupled with support and adherence to key principles, enabled the Peer Navigators to integrate effectively into diverse organisations. Quality relationships were vital in achieving client outcomes and supporting the professional growth of the Peer Navigators. These findings are important for services employing peer workers and underscore the importance of a commitment to training and continuing professional development., (© 2024. The Author(s).)

Background: Distinct from western Managed Alcohol Programs (MAPs), Indigenous-led alcohol harm reduction programs can be defined by both 'culture as healing' and decolonized harm reduction philosophies. We sought to explore experiences of Indigenous 'family members' (participants) in an Indigenous-led alcohol harm reduction program and culturally supportive housing to identify appropriate supports according to family member perspectives, and to inform delivery of the program., Methods: Situated within an Indigenous-western research partnership, we completed semi-structured interviews with seven family members of an Indigenous-led alcohol harm reduction and culturally supportive housing program. Community-guided protocols informed relational knowledge gathering practices including semi-structured in-depth interviews, qualitative thematic analysis, collaborative interpretation of findings, and development of knowledge products., Results: Family members highlighted the importance of tailored Indigenous-led alcohol harm reduction in shifting their relationships to alcohol from survival to having choice and control of their drinking (It's a choice I'm making right now). The provision of varied and incremental culture-based opportunities (Multiple pathways for connecting to culture) facilitated engagement with culture as healing. Policies that honour respect and autonomy were identified as supportive to healing and harm reduction, countering family members' experiences in western spaces (Give me the reigns of taking care of myself with a home)., Conclusions: An Indigenous-led alcohol harm reduction program within a model of culture as healing facilitated shifts in relationships to alcohol, providing a space where family members could explore long term goals of healing and connection to culture. Family members' experiences and recommendations offer key considerations for the design of Indigenous-led harm reduction and culture as healing models. Recommendations emphasize the provision of tailored alcohol harm reduction plans in parallel to multiple and accessible opportunities for connection to culture as healing in order to meet diverse participant goals and relationships to alcohol and culture., (© 2024. The Author(s).)

Background: In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model., Methods: This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study., Results: Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability., Conclusions: Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets., (© 2024. The Author(s).)

Importance: At the onset of the COVID-19 pandemic, the government of British Columbia, Canada, released clinical guidance to support physicians and nurse practitioners in prescribing pharmaceutical alternatives to the toxic drug supply. These alternatives included opioids and other medications under the risk mitigation guidance (RMG), a limited form of prescribed safer supply, designed to reduce the risk of SARS-CoV-2 infection and harms associated with illicit drug use. Many clinicians chose to coprescribe opioid medications under RMG alongside opioid agonist treatment (OAT)., Objective: To examine whether prescription of hydromorphone tablets or sustained-release oral morphine (opioid RMG) and OAT coprescription compared with OAT alone is associated with subsequent OAT receipt., Design, Setting, and Participants: This population-based, retrospective cohort study was conducted from March 27, 2020, to August 31, 2021, included individuals from 10 linked health administrative databases from British Columbia, Canada. Individuals who were receiving OAT at opioid RMG initiation and individuals who were receiving OAT and eligible but unexposed to opioid RMG were propensity score matched at opioid RMG initiation on sociodemographic and clinical variables. Data were analyzed between January 2023 and February 2024., Exposure: Opioid RMG receipt (≥4 days, 1-3 days, or 0 days of opioid RMG dispensed) in a given week., Main Outcome and Measures: The main outcome was OAT receipt, defined as at least 1 dispensed dose of OAT in the subsequent week. A marginal structural modeling approach was used to control for potential time-varying confounding., Results: A total of 4636 individuals (2955 [64%] male; median age, 38 [31-47] years after matching) were receiving OAT at the time of first opioid RMG dispensation (2281 receiving ongoing OAT and 2352 initiating RMG and OAT concurrently). Opioid RMG receipt of 1 to 3 days in a given week increased the probability of OAT receipt by 27% in the subsequent week (adjusted risk ratio, 1.27; 95% CI, 1.25-1.30), whereas receipt of opioid RMG for 4 days or more resulted in a 46% increase in the probability of OAT receipt in the subsequent week (adjusted risk ratio, 1.46; 95% CI, 1.43-1.49) compared with those not receiving opioid RMG. The biological gradient was robust to different exposure classifications, and the association was stronger among those initiating opioid RMG and OAT concurrently., Conclusions and Relevance: This cohort study, which acknowledged the intermittent use of both medications, demonstrated that individuals who were coprescribed opioid RMG had higher adjusted probability of continued OAT receipt or reengagement compared with those not receiving opioid RMG.

Background: Within North America and worldwide, drug related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply to replace unregulated substances and to reduce toxicity and overdoses. Service providers play an integral role in the delivery of safer supply but there is little empirical evidence that conceptualizes effective safer supply from their perspectives. This study explored early implementation and impacts of a safer supply program, capturing the perspectives of an interdisciplinary team of service providers on tensions and issues encountered in the development of the SAFER program., Methods: Using a community-based participatory approach, we conducted individual interviews with program providers (n = 9). The research team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The Consolidated Framework for Implementation Research (CFIR) informed the interview guide. Data was analyzed using thematic analysis., Results: There are six themes describing early implementation: (1) risk mitigation prescribing as context for early implementation; (2) developing SAFER specific clinical protocols; (3) accessibility challenges and program innovations; (4) interdisciplinary team and wraparound care; (5) program tensions between addiction medicine and harm reduction; (6) the successes of safer supply and future visions., Conclusion: Early implementation issues and tensions included prescriber concerns about safer supply prescribing in a highly politicized environment, accessibility challenges for service users such as stigma, encampment displacement, OAT requirements, program capacity and costs, and tensions between addiction medicine and harm reduction. Navigating these tensions included development of clinical protocols, innovations to reduce accessibility challenges such as outreach, wraparound care, program coverage of medication costs and prescribing safer supply with/without OAT. These findings contribute important insights for the development of prescribed safer supply programs., (© 2024. The Author(s).)

Objective: To determine the effect of opioid and stimulant Risk Mitigation Guidance (RMG) dispensations on mortality and acute care visits during the dual public health emergencies of overdose and covid-19., Design: Population based retrospective cohort study., Setting: British Columbia, Canada., Participants: 5882 people with opioid or stimulant use disorder who received RMG prescriptions for opioids (n=5356) and/or stimulants (n=1061) (535 received both) from 27 March 2020 to 31 August 2021., Main Outcome Measures: All cause and overdose specific mortality and acute care visits in the week after RMG opioid or stimulant dispensation. RMG recipients were matched 1:1 with controls through use of high dimensional propensity score matching. Marginal structural models, executed on weekly time steps, were used to measure the effect of dispensations on outcomes., Results: RMG opioid dispensations of one day or more were associated with reduced all cause mortality (adjusted hazard ratio 0.39, 95% confidence interval 0.25 to 0.60) and overdose related mortality (0.45, 0.27 to 0.75) in the subsequent week. Dispensations of RMG stimulants (≥1 days) were not significantly associated with reduced all cause mortality (adjusted hazard ratio 0.50, 0.20 to 1.23) or overdose related mortality (0.53, 0.18 to 1.56). The protective effect of RMG opioid dispensations increased with the number of days the medications were dispensed in a given week. People who received four or more days of RMG opioid dispensations had reduced all cause mortality (adjusted hazard ratio 0.09, 0.04 to 0.21) and overdose related mortality (0.11, 0.04 to 0.32) compared with the control group. Opioid RMG dispensations did not significantly modify the odds of all cause or overdose related acute care visits. Dispensations of RMG stimulants were associated with a significant decrease in the odds of acute care visits for any cause but did not affect the odds of overdose related acute care visits., Conclusions: RMG opioid dispensations were associated with reduced overdose related and all cause mortality among a sample of people with opioid use disorder. Pharmaceutical alternatives to the illegal drug supply are promising interventions to reduce mortality in people with opioid use disorder., Competing Interests: Competing interests: All authors have completed ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: support for the submitted work from the Canadian Institutes for Health Research (CIHR), Michael Smith Foundation for Health Research, and National Institutes of Health; AKS holds a Michael Smith Research BC Scholar Award and project grant funding from CIHR, Public Health Agency of Canada, Health Canada, and Providence Health Care; AKS is a volunteer (unpaid) board member of Unlocking the Gates Non-Profit Service Society; KU is supported by a Canada Research Chair through CIHR; HP is supported by postdoctoral awards from Michael Smith Research BC and CIHR; BP is supported by the Island Health Scholar in Residence Program; AC has received consulting fees from the Canadian Research Initiative in Substance Misuse Ontario Node and is a past board member of the SRO Collaborative; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A small but growing body of research has suggested the potential for cannabis substitution to support Managed Alcohol Program (MAP) service users to reduce acute and chronic alcohol-related harms. In 2022, researchers from the Canadian Managed Alcohol Program Study (CMAPS) noted a dearth of accessible, alcohol-specific educational resources to support service users and program staff to implement cannabis substitution pilots at several MAP sites in Canada. In this essay, we draw on over 10-years of collaboration between CMAPS, and organizations of people with lived experience (the Eastside Illicit Drinkers Group for Education (EIDGE) and SOLID Victoria) to describe our experiences co-creating cannabis education resources where none existed to support MAP sites interested in beginning to provide cannabis to participants. The research team relied on the unique lived experiences and informal cannabis-related harm reduction strategies described by EIDGE and SOLID members to create cannabis education resources that were accurate and relevant to MAP sites. EIDGE was familiar with creating peer-oriented educational resources and convened meetings and focus groups to engage peers. CMAPS research team members created standard cannabis unit equivalencies to support program delivery, and clinical advisors ensured that the stated risks and benefits of cannabis substitution, as well as tapering guidance for withdrawal management, were safe and feasible. The collaboration ultimately produced tailored client-facing and provider-facing resources. Our experience demonstrates that the lived expertise of drinkers can play an integral role in creating alcohol harm reduction informational materials, specifically those related to cannabis substitution, when combined with data from rigorous, community-based programs of research like CMAPS. We close by listing additional considerations for cannabis substitution program design for MAP settings emerging from this process of collaboration between illicit drinkers, service providers, clinicians, and researchers for consideration by other programs., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A. Bailey and B. Graham are employed by the Vancouver Area Network of Drug Users (VANDU) and Canadian Managed Alcohol Programs Study (CMAPS)., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Meaningful engagement and partnerships with people who use drugs are essential to conducting research that is relevant and impactful in supporting desired outcomes of drug consumption as well as reducing drug-related harms of overdose and COVID-19. Community-based participatory research is a key strategy for engaging communities in research that directly affects their lives. While there are growing descriptions of community-based participatory research with people who use drugs and identification of key principles for conducting research, there is a gap in relation to models and frameworks to guide research partnerships with people who use drugs. The purpose of this paper is to provide a framework for research partnerships between people who use drugs and academic researchers, collaboratively developed and implemented as part of an evaluation of a provincial prescribed safer supply initiative introduced during dual public health emergencies (overdose and COVID-19) in British Columbia, Canada. The framework shifts from having researchers choose among multiple models (advisory, partnership and employment) to incorporating multiple roles within an overall community-based participatory research approach. Advocacy by and for drug users was identified as a key role and reason for engaging in research. Overall, both academic researchers and Peer Research Associates benefited within this collaborative partnerships approach. Each offered their expertise, creating opportunities for omni-directional learning and enhancing the research. The shift from fixed models to flexible roles allows for a range of involvement that accommodates varying time, energy and resources. Facilitators of involvement include development of trust and partnering with networks of people who use drugs, equitable pay, a graduate-level research assistant dedicated to ongoing orientation and communication, technical supports as well as fluidity in roles and opportunities. Key challenges included working in geographically dispersed locations, maintaining contact and connection over the course of the project and ensuring ongoing sustainable but flexible employment., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Across North America, overlapping overdose and COVID-19 emergencies have had a substantial impact on young people who use drugs (YPWUD). New risk mitigation guidance (RMG) prescribing practices were introduced in British Columbia, Canada, in 2020 to allow people to decrease risk of overdose and withdrawal and better self-isolate. We examined how the prescribing of hydromorphone tablets specifically impacted YPWUD's substance use and care trajectories. Between April 2020 and July 2021, we conducted virtual interviews with 30 YPWUD who had accessed an RMG prescription of hydromorphone in the previous six months and 10 addiction medicine physicians working in Vancouver. A thematic analysis was conducted. YPWUD participants highlighted a disjuncture between RMG prescriptions and the safe supply of unadulterated substances such as fentanyl, underscoring that having access to the latter is critical to reducing their reliance on street-based drug markets and overdose-related risks. They described re-appropriating these prescriptions to meet their needs, stockpiling hydromorphone so that it could be used as an "emergency backup" when they were unable to procure unregulated, illicit opioids. In the context of entrenched poverty, hydromorphone was also used to generate income for the purchase of drugs and various necessities. For some YPWUD, hydromorphone prescriptions could be used alongside opioid agonist therapy (OAT) to reduce withdrawal and cravings and improve adherence to OAT. However, some physicians were wary of prescribing hydromorphone due to the lack of evidence for this new approach. Our findings underscore the importance of providing YPWUD with a safe supply of the substances they are actively using alongside a continuum of substance use treatment and care, and the need for both medical and community-based safe and safer supply models., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Background: In response to the rise in opioid-related deaths, communities across Ontario have developed opioid or overdose response plans to address issues at the local level. Public Health Ontario (PHO) leads the Community Opioid / Overdose Capacity Building (COM-CAP) project, which aims to reduce overdose-related harms at the community level by working with communities to identify, develop, and evaluate capacity building supports for local needs around overdose planning. The 'From Design to Action' co-design workshop used a participatory design approach to engage communities in identifying the requirements for capacity building support., Methods: A participatory approach (co-design) provided opportunity for collaborative discussion around capacity building needs at the community level. The co-design workshop included three structured collaborative activities to 1) prioritize scenarios that illustrated various challenges associated with community overdose response planning, 2) prioritize the challenges within each scenario and 3) prioritize the supports to address each of these challenges. It was conducted with fifty-two participants involved in opioid/overdose-related response plans in Ontario. Participatory materials were informed by the results of a situational assessment (SA) data gathering process, including survey, interview, and focus group data. A voting system, including dot stickers and discussion notes, was applied to identify priority supports and delivery mechanisms., Results: At the workshop, key challenges and top-priority supports were identified, for development and implementation. The prioritized challenges were organized into five categories of capacity building supports addressing: 1) stigma & equity; 2) trust-based relationships, consensus building & on-going communication; 3) knowledge development & on-going access to information and data; 4) tailored strategies and plan adaptation to changing structures and local context; and 5) structural enablers and responsive governance., Conclusion: Using a participatory approach, the workshop provided an opportunity for sharing, generating, and mobilizing knowledge to address research-practice gaps at the community level for opioid response planning. The application of health design methods such as the 'From Design to Action' co-design workshop supports teams to gain a deeper understanding of needs for capacity building as well as illustrating the application of participatory approaches in identifying capacity building needs for complex public health issues such as the overdose crisis., (© 2023. The Author(s).)

Background: The drug toxicity crisis has had dramatic impacts on people who use drugs. Peer overdose response workers (peer responders), i.e., individuals with lived/living experience of drug use who work in overdose response settings, are particularly susceptible to negative physical and mental health impacts of the crisis. Despite that, the mental health impacts on peer responders have yet to be studied and measured. Methods: The Professional Quality of Life survey (Version 5) was completed by 47 peer responders at two organizations in British Columbia between September 2020 and March 2021 to assess compassion satisfaction and compassion fatigue. The Likert scale responses were converted into numerical values and scores were calculated for each sub-scale. The mean score was calculated for each sub-scale and categorized as low, medium, or high, based on the instructions for Version 5 of the instrument. Results: Our study uncovered a high mean score for compassion satisfaction, low mean score for burnout, and medium mean score for secondary traumatic stress among peer responders. These results may be due to the participants' strong feelings of pride and recognition from their work, as well as the low number of participants that felt they had too much to do at work. Conclusion: Although peer responders derive pleasure and fulfillment from their jobs, i.e., compassion satisfaction, they also sometimes face burnout and stress due to continuous exposure to the trauma of the people they support. These results shed light on the areas that need to be targeted when creating supports for peer responders.

People experiencing homelessness and alcohol dependence are at increased risk of a range of harms, including from COVID-19. Managed Alcohol Programmes (MAPs) are an alcohol harm reduction intervention specifically for this group. In this paper we report on qualitative findings of a mixed methods study investigating the potential utility of MAPs during the COVID-19 pandemic in Scotland. Interviews, conducted with 40 participants, explored potential views of implementing MAPs during the pandemic. Theoretically, we drew on the Consolidated Framework for Implementation Research (CFIR) to inform data collection and analysis. Six themes were identified which mapped onto three CFIR domains: perceptions of MAPs and the evidence base; necessary components of MAPs; changing culture of alcohol harm reduction; MAPs as a moral and ethical grey area; addressing a service gap; and securing buy-in and partnership working. Participants were generally positive about MAPs and viewed them as a key intervention to address a service gap. Several necessary components were identified for successful implementation of MAPs. Securing buy-in from a range of stakeholders and partnership working were deemed important. Finally, MAPs require careful, long-term planning before implementation. We conclude that MAPs are needed in Scotland and require long-term funding and appropriate resources to ensure they are successful.

Background: Novel public health interventions are needed to address the toxic drug supply and meet the needs of people who use drugs amidst the overdose crisis. Safer supply - low-barrier distribution of pharmaceutical grade substances - has been implemented in some jurisdictions to provide safer alternatives to the unregulated drug supply, yet no studies to date have explored professional stakeholder perspectives on this approach., Methods: We used purposive sampling to recruit professional stakeholders (n = 17) from four locations in British Columbia, Ontario, and Nova Scotia, including program managers, executive directors, political and health authority representatives, and healthcare providers involved in the design, implementation, and/or operation of safer supply programs in their communities. Semi-structured, one-to-one interviews were conducted, and interview data were coded and analyzed using thematic analyses., Results: Participants defined safer supply as low-barrier access to substances of known quality and quantity, offered on a continuum from prescribed to a legal, regulated supply, and focused on upholding autonomy and liberation of people who use drugs. Stakeholders expressed support for safer supply but explained that current iterations do not meet the needs of all people who use drugs and that implementation is limited by a lack of willing prescribers, stigma towards people who use drugs, and precarity of harm reduction programs to political ideology. Stakeholders expressed strong support for wider-reaching approaches such as decriminalization, legalization, and regulation of substances as a way to fully realize a continuum of safer supply, directly address the overdose crisis and toxic drug supply, and ensure equity of access nationally., Conclusion: The results of this study highlight the need for innovative strategies to address the overdose crisis and that safer supply has the potential to benefit certain people who use drugs. A one-size-fits-all approach is not sufficient and the perspectives of professional stakeholders should be considered alongside those of people who use drugs when designing and implementing future safer supply., (© 2022. The Author(s).)

Background: Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD., Methods: The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings., Results: The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors., Conclusions: Structural vulnerability is salient within Canadian policy actors' discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity., Competing Interests: Declarations of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Background: People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers' perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care., Methods: We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model., Results: Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients' ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs., Conclusions: Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care's ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management., (© 2022. The Author(s).)

Introduction: Peer workers (those with lived/living experience of substance use) are at the forefront of overdose response initiatives in British Columbia, Canada. The onset of the coronavirus disease pandemic has significantly compounded the impact of the overdose crisis. Peer workers are integral in supporting people who use substances. However, despite the important work they do, peer workers often lack formalized credibility and do not have the same resources available to them as service providers without lived experience. The peer-led project titled the Peer2Peer Project implemented several support programs for peer workers, including providing pulse oximeters to peer workers to supplement their overdose response procedures., Materials and Methods: This study was a component of a larger evaluation of the pulse oximeter program at two organizations in BC. The study aims to highlight the competencies of peer workers who use pulse oximeters. Telephone interviews were conducted with seven peer workers who were given pulse oximeters. The transcripts were thematically coded using Covert et al.'s framework of core competencies of community health workers to compare our sample with other widely recognized professions., Findings: We found that peer workers who used pulse oximeters described several core competencies in their work and these were aligned with Covert et al.'s core competencies for community health workers, including assessment, community health practice, communication, diversity and inclusion, professional practice, and disease prevention and management., Conclusion: By aligning peer workers' skills to those of community health workers, we create awareness on the competencies of peer workers in using oximeters to supplement overdose response and advocate for them to receive more recognition and respect within the workplace. Further, our findings act as groundwork for future research in identifying the professional proficiencies of peer workers., Competing Interests: The authors have declared that no competing interests exist.

Aims: In March 2020, British Columbia issued Risk Mitigation Guidance (RMG) to support prescribing of pharmaceutical alternatives to illicit drugs, in order to reduce risk for COVID-19, overdose, and withdrawal among people who use drugs. This study evaluated factors associated with 60-day adherence to novel opioid alternatives prescribed at an inner-city health centre in Victoria, Canada., Methods: A chart review was conducted to collect data on sociodemographic information, medical histories, and follow-up services among all clients prescribed novel opioid alternatives from March 2020-August 2020 (n = 286). Bivariable and multivariable regression were used to identify independent and adjusted factors associated with 60-day adherence., Results: Overall, 77% of 286 clients were still receiving opioids after 60 days of follow-up. Medications included hydromorphone (n = 274), sustained-release oral morphine (n = 2), and oxycodone (n = 9). The adjusted odds of 60-day adherence to novel opioid alternatives were significantly higher for those receiving a mental health medication (aOR = 3.49, 95%CI = 1.26, 11.00), a higher maximum daily dosage of RMG prescriptions (aOR = 1.03 per mg increase, 95%CI = 1.01, 1.04), and those with continuous receipt of OAT (aOR = 6.25, 95%CI = 2.67, 15.90)., Conclusions: Higher dosages and co-prescription of mental health medications and OAT may help support better adherence to this form of prescriber-based "safer supply". Further work is needed to identify optimal prescribing practices and the longer term impacts of differing implementation scenarios., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Many young people who use drugs are structurally vulnerable to policing powers given the ongoing criminalization of drug possession. Police authority limits and the expression of that authority may play a significant role in police encounters among young people who use drugs. This qualitative study explores the views of young people who use drugs toward police power and authority in their recent encounters with police officers. Interviews were conducted with 38 young people who recently used illegal drugs in British Columbia, Canada. We found five interrelated themes related to perceptions of police authority: (1) skepticism and distrust toward authority; (2) paternalism and authority over drug use; (3) officer use of force; (4) police as power-hungry; and (5) officers above the law. Participants described police authority as limitless, unpredictable, untethered, easily abused, and lacking accountability. Participants feared holding police officers accountable to power abuses in a criminal justice system that they saw as stacked against them. Moving forward, institutional reforms may consider and account for the expression, limits, and use of police authority among young people who use drugs and other structurally vulnerable communities., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Introduction: Bystanders to drug overdoses often avoid or delay calling 9-1-1 and cite fear of police involvement as a main reason. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted by the Canadian government to provide people present at an overdose with legal protection from charges for simple drug possession, and conditions stemming from simple possession. Few studies have taken a multi-methods approach to evaluating the GSDOA. We used quantitative surveys and qualitative interviews to explore awareness, understanding, and perceptions of the GSDOA in people at risk of witnessing an overdose., Methods: Quantitative cross-sectional surveys and qualitative telephone interviews were conducted with adults and youth at risk of witnessing an overdose across British Columbia. Cross-sectional survey participants were recruited at 19 Take Home Naloxone sites and online through Foundry. Multivariable logistic regression models were constructed hierarchically to determine factors associated with GSDOA awareness. Telephone interview participants were recruited by research assistants with lived/living experience of substance use. Deductive and inductive thematic analyses were conducted to identify major themes., Results: Overall, 52.7% (n = 296) of the quantitative study sample (N = 453) reported being aware of the GSDOA. In multivariable analysis, cellphone possession (adjusted odds ratio [AOR] = 2.19; 95% confidence interval [CI] 1.36, 3.54) and having recently witnessed an opioid overdose (AOR = 2.34; 95% CI 1.45, 3.80) were positively associated with GSDOA awareness. Young adults (25 - 34 years) were more likely to be aware of the Act (AOR = 2.10; 95% CI 1.11, 3.98) compared to youth (16-24 years). Qualitative interviews (N = 42) revealed that many overestimated the protections offered by the GSDOA. To increase awareness and knowledge of the Act among youth, participants recommended adding the GSDOA to school curricula and using social media. Word of mouth was suggested to reach adults., Conclusion: Both awareness and knowledge of the GSDOA remain low in BC, with many overestimating the protections the Act offers. Dissemination efforts should be led by people with lived/living experience and should target those with limited awareness and understanding of the Act as misunderstandings can erode trust in law enforcement and harm reduction policy., (© 2022. The Author(s).)

Introduction: Managed Alcohol Programs (MAPs) are designed to improve health and housing outcomes for unstably housed people with an alcohol use disorder (AUD). The present study assesses the association of MAP participation with healthcare and mortality outcomes., Methods: A retrospective cohort study assessed health outcomes for 205 MAP participants and 128 controls recruited from five Canadian cities in 2006-2017. Survival and negative binomial regression models were used to calculate hazard ratios (HR) of death and emergency room (ER) visits and hospital bed days (HBDs). Covariates included age, sex, AUD severity and housing stability score., Results: In fully adjusted models, compared with times outside MAPs, participants had significantly reduced risk of mortality (HR = 0.37, P = 0.0001) and ER attendance (HR = 0.74, P = 0.0002), and fewer HBDs yearly (10.40 vs 20.08, P = 0.0184). Over the 12 years, people enrolled in a MAP at some point had significantly fewer HBDs per year than controls after MAP enrolment (12.78 vs 20.08, P = 0.0001) but not significantly different rates of death or ER presentation. MAP participants had significantly more alcohol-related but significantly fewer nonalcohol-related ER presentations than controls., Conclusion: Attendance at a MAP was associated with reduced risk of mortality or morbidity and less hospital utilization for individuals with unstable housing and severe AUDs. MAPs are a promising approach to reduce mortality risk and time spent in hospital for people with an AUD and experiencing homelessness., (© The Author(s) 2022. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Background: For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that the development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing., Methods: The study used mixed methods to assess the feasibility, acceptability and accessibility of a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning, for people experiencing homelessness and problem substance use. Four Peer Navigators were employed to support individuals (n = 68 total, intervention participants). They were based in outreach services and hostels in Scotland and England. Qualitative interviews were conducted with intervention participants, Peer Navigators and staff in services, and observations were conducted in all settings. Quantitative outcomes relating to participants' substance use, physical and mental health, and quality of the Peer Navigator relationship, were measured via a 'holistic health check' with six questionnaires completed at two time-points., Results: The intervention was found to be acceptable to, and feasible and accessible for, participants, Peer Navigators, and service staff. Participants reported improvements to service engagement, and feeling more equipped to access services independently. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling trusting, authentic, and meaningful relationships to be developed. Some challenges were experienced in relation to the 'fit' of the intervention within some settings. Among participants there were reductions in drug use and risky injecting practices. There were increases in the number of participants receiving opioid substitution therapy. Overall, the intervention was positively received, with collective recognition that the intervention was unique and highly valuable. While most of the measures chosen for the holistic health check were found to be suitable for this population, they should be streamlined to avoid duplication and participant burden., Conclusions: The study established that a peer-delivered, relational harm reduction intervention is acceptable to, and feasible and accessible for, people experiencing homelessness and problem substance use. While the study was not outcomes-focused, participants did experience a range of positive outcomes. A full randomised controlled trial is now required to assess intervention effectiveness., Trial Registration: Study registered with ISRCTN: 15900054., (© 2022. The Author(s).)

Background: For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues., Objectives: The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial., Design: A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n  = 12; Peer Navigator interviews (three or four time points), n  = 15; intervention participant interviews: first time point, n  = 24, and second time point, n  = 10], observations and quantitative outcome measures., Setting: The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England., Participants: Participants were people experiencing homelessness and problem substance use ( n  = 68) (intervention)., Intervention: This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support., Main Outcome Measures: Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure., Results: The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies., Limitations: Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited., Conclusions: A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention., Future Work: A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments., Trial Registration: This trial is registered as ISRCTN15900054., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

Background: Promoting health equity and reducing heath inequities is a foundational aim and ethical imperative in public health. There has been limited attention to and research on the ethical issues inherent in promoting health equity and reducing health inequities that public health practitioners experience in their work. The aim of the study was to explore how public health providers identified and navigated ethical issues and their management related to promoting health equity within services focused on mental health promotion and preventing harms of substance use., Methods: Semi-structured individual interviews and focus groups were conducted with 32 public health practitioners who provided public-health oriented services related to mental health promotion and prevention of substance use harms (e.g. harm reduction) in one Canadian province., Results: Participants engaged in the basic social process of navigating conflicting value systems. In this process, they came to recognize a range of ethically challenging situations related to health equity within a system that held values in conflict with health equity. The extent to which practitioners recognized, made sense of, and acted on these fundamental challenges was dependent on the degree to which they had developed a critical public health consciousness. Ethically challenging situations had impacts for practitioners, most importantly, the experiences of responding emotionally to ethical issues and the experience of living in dissonance when working to navigate ethical issues related to promoting health equity in their practice within a health system based in biomedical values., Conclusions: There is an immediate need for practice-oriented tools for recognizing ethical dilemmas and supporting ethical decision making related to health equity in public health practice in the context of mental health promotion and prevention of harms of substance use. An increased focus on understanding public health ethical issues and working collaboratively and reflexively to address the complexity of equity work has the potential to strengthen equity strategies and improve population health., (© 2022. The Author(s).)

Competing Interests: The authors declare no conflicts of interest.

People who experience homelessness and alcohol dependency are more vulnerable than the general population to risks/harms relating to COVID-19. This mixed methods study explored stakeholder perspectives concerning the impact of COVID-19 and the potential utility of introducing managed alcohol programmes (MAPs) in Scotland as part of a wider health/social care response for this group. Data sources included: 12 case record reviews; 40 semi-structured qualitative interviews; and meeting notes from a practitioner-researcher group exploring implementation of MAPs within a third sector/not-for-profit organisation. A series of paintings were curated as a novel part of the research process to support knowledge translation. The case note review highlighted the complexity of health problems experienced, in addition to alcohol dependency, including polysubstance use, challenges related to alcohol access/use during lockdown, and complying with stay-at-home rules. Qualitative analysis generated five subthemes under the theme of 'MAPs as a response to COVID-19': changes to alcohol supply/use including polysubstance use; COVID-19-related changes to substance use/homelessness services; negative changes to services for people with alcohol problems; the potential for MAPs in the context of COVID-19; and fears and concerns about providing MAPs as a COVID-19 response. We conclude that MAPs have the potential to reduce a range of harms for this group, including COVID-19-related harms.

Background: Peer workers (those with lived/living experience of substance use working in overdose response settings) are at the forefront of overdose response initiatives in British Columbia (BC). Working in these settings can be stressful, with lasting social, mental and emotional impacts. Peer workers have also been disproportionately burdened by the current dual public health crises characterized by the onset of the COVID-19 pandemic and rise in illicit drug overdose deaths. It is therefore critical to develop supports tailored specifically to their realities., Methods: We used the six steps outlined in the Intervention Mapping (IM) framework to identify needs of peer workers and design an intervention model to support peer workers in overdose response settings., Results: Eight peer-led focus groups were conducted in community settings to identify peer workers' needs and transcripts were analyzed using interpretive description. The strategies within the intervention model were informed by organizational development theory as well as by lived/living experience of peer workers. The support needs identified by peer workers were categorized into three key themes and these formed the basis of an intervention model titled 'ROSE'; R stands for Recognition of peer work, O for Organizational support, S for Skill development and E for Everyone. The ROSE model aims to facilitate cultural changes within organizations, leading towards more equitable and just workplaces for peer workers. This, in turn, has the potential for positive socio-ecological impact., Conclusions: Centering lived/living experience in the intervention mapping process led us to develop a framework for supporting peer workers in BC. The ROSE model can be used as a baseline for other organizations employing peer workers., (© 2021. The Author(s).)

Overdose prevention for people who use illicit drugs is essential during the current overdose crisis. Peer support is a process whereby individuals with lived or living experience of a particular phenomenon provide support to others by explicitly drawing on these experiences. This review provides a systematic search and evidence synthesis of peer support within overdose prevention interventions for people who use illicit drugs. A systematic search of six databases (CINAHL, SocINDEX, PsycINFO, MEDLINE, Scopus, and Web of Knowledge) was conducted in November 2020 for papers published in English between 2000 and 2020. Following screening and full-text review, 46 papers met criteria and were included in this review. A thematic analysis approach was used to synthesize themes. Important findings include: the value of peers in creating trusted services; the diversity of peers' roles; the implications of barriers on peer-involved overdose prevention interventions; and the stress and trauma experienced by peers. Peers play a pivotal role in overdose prevention interventions for people who use illicit drugs and are essential to the acceptability and feasibility of such services. However, peers face considerable challenges within their roles, including trauma and burnout. Future interventions must consider how to support and strengthen peer roles in overdose settings.

Background: Public health (PH) practitioners have a strong moral commitment to health equity and social justice. However, PH values often do not align with health systems values, making it challenging for PH practitioners to promote health equity. In spite of a growing range of PH ethics frameworks and theories, little is known about ethical concerns related to promotion of health equity in PH practice. The purpose of this paper is to examine the ethical concerns of PH practitioners in promoting health equity in the context of mental health promotion and prevention of harms of substance use., Methods: As part of a broader program of public health systems and services research, we interviewed 32 PH practitioners., Results: Using constant comparative analysis, we identified four systemic ethical tensions: [1] biomedical versus social determinants of health agenda; [2] systems driven agendas versus situational care; [3] stigma and discrimination versus respect for persons; and [4] trust and autonomy versus surveillance and social control., Conclusions: Naming these tensions provides insights into the daily ethical challenges of PH practitioners and an opportunity to reflect on the relevance of PH frameworks. These findings highlight the value of relational ethics as a promising approach for developing ethical frameworks for PH practice., (© 2021. The Author(s).)

Background: While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool., Methods: To determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis., Results: Five themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation., Conclusion: Cannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.

Introduction: The COVID-19 pandemic was preceded by an ongoing overdose crisis and linked to escalating drug overdose deaths in British Columbia (BC). At the outset of these dual public health emergencies, the BC government announced interim Risk Mitigation Guidance (RMG) that permitted prescribing medication alternatives to substances, including opioids, alcohol, stimulants and benzodiazepines, an intervention sometimes referred to as 'safe supply'. This protocol outlines the approach for a study of the implementation of RMG and its impacts on COVID-19 infection, drug-related and systemic harms, continuity of care for people with substance use disorder (SUD), as well as their behavioural, psychosocial and well-being outcomes., Methods and Analysis: We conducted a parallel mixed-method study that involved both analysis of population-level administrative health data and primary data collection, including a 10-week longitudinal observational study (target n=200), a cross-sectional survey (target n=200) and qualitative interviews (target n=60). We implemented a participatory approach to this evaluation, partnering with people with lived or living expertise of drug use, and researchers and public health decision-makers across the province. Linked population-level administrative databases will analyse data from a cohort of BC residents with an indication of SUD between 1996 and 2020. We will execute high-dimensional propensity score matching and marginal structural modelling to construct a control group and to assess the impact of RMG dispensation receipt on a collaboratively determined set of primary and secondary outcomes., Ethics and Dissemination: Study activities were developed to adhere to the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, recommended COVID-19 research practices, and guided by the Truth and Reconciliation Commission's Calls to Action for public health, data governance and research ethics related to Indigenous people. Results will be disseminated incrementally, on an ongoing basis, through the consortium established for this study, then published in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We described public views toward harm reduction among Canadian adults and tested a social exposure model predicting support for these contentious services, drawing on theories in the morality policy, intergroup relations, addiction, and media communication literatures. A quota sample of 4645 adults (18+ years), randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across Canadian provinces, was recruited in June 2018. Participants completed survey items assessing support for harm reduction for people who use drugs (PWUD) and for seven harm reduction interventions. Additional items assessed exposure to media coverage on harm reduction, and scales assessing stigma toward PWUD (α = .72), personal familiarity with PWUD (α = .84), and disease model beliefs about addiction (α = .79). Most (64%) Canadians supported harm reduction (provincial estimates = 60% - 73%). Five of seven interventions received majority support, including: outreach (79%), naloxone (72%), drug checking (70%), needle distribution (60%) and supervised drug consumption (55%). Low-threshold opioid agonist treatment and safe inhalation interventions received less support (49% and 44%). Our social exposure model, adjusted for respondent sex, household income, political views, and education, exhibited good fit and accounted for 17% of variance in public support for harm reduction. Personal familiarity with PWUD and disease model beliefs about addiction were directly associated with support (βs = .07 and -0.10, respectively), and indirectly influenced public support via stigmatized attitudes toward PWUD (βs = 0.01 and -0.01, respectively). Strategies to increase support for harm reduction could problematize certain disease model beliefs (e.g., "There are only two possibilities for an alcoholic or drug addict-permanent abstinence or death") and creating opportunities to reduce social distance between PWUD, the public, and policy makers., Competing Interests: The authors have declared that no competing interests exist.

This study examines encounters between youth and police to identify individual, contextual, and social factors that predict the outcome of these encounters. Young people aged 16-30 years were surveyed between May 2017 and June 2018 in three non-metropolitan cities across British Columbia, Canada. Outcomes were analysed using multinomial logistic generalized estimating equations. A total of 675 encounters were reported by 360 participants. These outcomes resulted in participants being questioned (n = 227; 33.6%); given warnings (n = 132; 19.6%); being searched (n = 104; 15.4%); being given a ticket (n = 101; 15.0%); and being handcuffed or arrested (n = 111; 16.4%). Young Indigenous people (vs. white) were significantly more likely to be handcuffed or arrested (OR=3.26; 1.43, 7.43). Statistical significance held after adjusting for history of police encounters and contextual factors. Findings suggest that police discretion, which has the potential to benefit youth, may be undermined by discriminatory applications of discretion., Competing Interests: Declarations of Interest None., (Copyright © 2020. Published by Elsevier B.V.)

The illicit drug overdose crisis in North America continues to devastate communities with fentanyl detected in the majority of illicit drug overdose deaths. The COVID-19 pandemic has heightened concerns of even greater unpredictability in the drug supplies and unprecedented rates of overdoses. Portable drug-checking technologies are increasingly being integrated within overdose prevention strategies. These emerging responses are raising new questions about which technologies to pursue and what service models can respond to the current risks and contexts. In what has been referred to as the epicenter of the overdose crisis in Canada, a multi-technology platform for drug checking is being piloted in community settings using a suite of chemical analytical methods to provide real-time harm reduction. These include infrared absorption, Raman scattering, gas chromatography with mass spectrometry, and antibody-based test strips. In this Perspective, we illustrate some advantages and challenges of using multiple techniques for the analysis of the same sample, and provide an example of a data analysis and visualization platform that can unify the presentation of the results and enable deeper analysis of the results. We also highlight the implementation of a various service models that co-exist in a research setting, with particular emphasis on the way that drug checking technicians and harm reduction workers interact with service users. Finally, we provide a description of the challenges associated with data interpretation and the communication of results to a diverse audience., (© 2021 John Wiley & Sons, Ltd.)

Introduction and Aims: Managed alcohol programs (MAP) are a harm reduction approach for those experiencing alcohol use disorders (AUD) and homelessness. These programs were developed in Canada and have had positive results; very few exist in the UK and Ireland. The aim of this study was to scope the feasibility and acceptability of implementing MAPs in Scotland., Design and Methods: Using mixed-methods, we conducted two linked phases of work. Quantitative data were collected from the case records of 33 people accessing eight third sector services in Scotland and analysed in SPSS using descriptive and inferential statistics. Qualitative data were collected in Scotland via semi-structured interviews with 29 individuals in a range of roles, including strategic informants (n = 12), service staff (n = 8) and potential beneficiaries (n = 9). Data were analysed using Framework Analysis in NVivo., Results: The case record review revealed high levels of alcohol use, related health and social harms, illicit drug use, withdrawal symptoms, and mental and physical health problems. Most participants highlighted a lack of alcohol harm reduction services and the potential of MAPs to address this gap for this group., Discussion and Conclusions: Our findings highlight the potential for MAPs in Scotland to prevent harms for those experiencing homelessness and AUDs, due to high levels of need. Future research should examine the implementation of MAPs in Scotland in a range of service contexts to understand their effectiveness in addressing harms and promoting wellbeing for those experiencing AUDs and homelessness., (© 2020 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Background: In Canada, nursing programs have not kept pace with the growing rates and changing patterns of substance use., Method: To get a sense of the current state of substance use education in nursing programs, we conducted a survey of nursing students., Results: Our findings indicate that (a) substance use education is minimal, 1 to 5 hours (43%) or none (20%); (b) students had more working knowledge of legal and prescribed substances than illegal ones; (c) of 22 content areas deemed essential for practice, only seven were covered; (d) students were able to identify statements consistent with a harm reduction philosophy despite limited substance use education; and (e) the majority of students wrongfully believed that illegal substances are more harmful than legal substances., Conclusion: Our findings demonstrate that substance use education in nursing programs is largely insufficient and not keeping up with current issues. [J Nurs Educ. 2020;59(9):510-513.]., (Copyright 2020, SLACK Incorporated.)

Setting: There is a multitude of health equity tools but little guidance on how to effectively use these tools in public health nursing practice. In BC, public health nurses who are certified in sexually transmitted infection care utilize guidelines authorized by the nursing regulatory body., Intervention: As part of the Equity Lens in Public Health (ELPH) research project, an assessment of the nursing guideline, Sexually Transmitted Infection (STI) Assessment Decision Support Tool, was undertaken using the Assessing Equity in Clinical Practice Guidelines health equity assessment tool. The chosen tool is intended for use by health care providers, is broadly applicable to clinical practice guidelines, can be used retrospectively, and falls within the category of equity checklists and audits., Outcomes: Overall, the tool was useful in assessing the inclusion and omission of an equity focus in the guideline. However, there were several challenges: the identification of an appropriate health equity tool; the absence of an evaluation of the chosen tool; the tool's focus on chronic disease versus communicable disease; and the difficulty of obtaining client perspectives., Implications: For an improved equity lens in the STI Assessment Decision Support Tool, future revisions should be equity focused and include perspectives from affected populations, an emphasis on the determinants of health that perpetuate inequities for populations who experience a disproportionate burden of STI, information on provincially available resources, and service delivery models that improve timely and equitable access to treatment and care.

Background: The current illicit drug overdose crisis within North America and other countries requires expanded and new responses to address unpredictable and potentially lethal substances, including fentanyl analogues, in the unregulated drug market. Community-wide drug checking is being increasingly explored as one such public health response. We explored how drug checking could be implemented as a potential harm reduction response to the overdose crisis, from the perspective of potential service users., Methods: The research was guided by the Consolidated Framework for Implementation Research (CFIR). We conducted a qualitative, pre-implementation study to inform development and implementation of drug checking services that are acceptable to people who use substances and meet their needs. University and community researchers conducted 27 in-depth interviews with potential service users at prospective drug checking sites. We inductively developed emerging themes to inform the implementation of drug checking services within the five domains of the CFIR, and identified the most relevant constructs., Results: Implementing community drug checking faces significant challenges within the current context of criminalization and stigmatization of substance use and people who use/sell drugs, and trauma experienced by potential service users. Participants identified significant risks in accessing drug checking, and that confidential and anonymous services are critical to address these. Engaging people with lived experience in the service can help establish trust. The relative advantage of drug checking needs to outweigh risks through provision of accurate results conveyed in a respectful, non-judgemental way. Drug checking should provide knowledge relevant to using and/or selling drugs and informing one's own harm reduction., Conclusions: For service users, the extent to which the implementation of drug checking can respond to and mitigate the risks of being criminalized and stigmatized is critical to the acceptability and success of community drug checking. The culture and compatibility of the service, setting and staff with harm reduction principles and practices is essential.

Introduction: Youth who use drugs (YWUD) are vulnerable to experience or encounter drug related overdose deaths. Fentanyl has increased the risks, calling greater attention to overdose. In response, there have been increases in harm reduction services and policies such as the Good Samaritan Drug Overdose Act (GSDOA) which exempts people who witness an overdose and call 9-1-1 from being charged for possession of drugs. However, fear of police continues to be a barrier to calling 9-1-1. This paper focuses on the experiences of youth with police in overdose situations and their knowledge of GSDOA., Methods: Youth, aged 16-30, who had used drugs at least weekly, and had encountered police in the past year were recruited between May 2017 and June 2018 in three non-metropolitan cities in British Columbia, Canada. 38 participants completed qualitative interviews asking them about their experiences with police, overdose, decisions to call 9-1-1, and their understanding of the GSDOA. Their responses were coded in NVIVO and analyzed using interpretive description., Results: For many YWUD in this study, overdoses are an ever-present part of their lives and fear of fentanyl has left them concerned for themselves and others. Negative experiences occurred when police used their power without benefit to youth or were rough or disrespectful, without care for the person overdosing. Youth saw police in a positive light if they were compassionate, stepping aside for paramedics or reviving someone experiencing an overdose. Youth had very mixed knowledge of the GSDOA and were concerned about criminalization if they called 9-1-1., Conclusions: Collaboration with police and local stakeholders is required to address the concerns of YWUD and to increase awareness and penetration of policies such as the GSDOA. Changes to policing cultures that prioritize health rather than criminalize YWUD may increase youth's trust of police and increase calls to 9-1-1., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Review Question/objectives: The purpose of this scoping review is to systematically identify and describe literature that uses a health equity-oriented (HEO) approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.The question of the review is: What is currently known about the use of an HEO approach for preventing the harms of stigma or overdose when people use illicit or street drugs, or use prescription opioids for other than their intended purposes?Specifically, the review objectives are.

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: While people who are homeless often experience poor mental and physical health and problem substance use, getting access to appropriate services can be challenging. The development of trusting relationships with non-judgemental staff can facilitate initial and sustained engagement with health and wider support services. Peer-delivered approaches seem to have particular promise, but there is limited evidence regarding peer interventions that are both acceptable to, and effective for, people who are homeless and using drugs and/or alcohol. In the proposed study, we will develop and test the use of a peer-to-peer relational intervention with people experiencing homelessness. Drawing on the concept of psychologically informed environments, it will focus on building trusting and supportive relationships and providing practical elements of support such as access to primary care, treatment and housing options., Methods: A mixed-method feasibility study with concurrent process evaluation will be conducted to explore the feasibility and acceptability of a peer-delivered, relational intervention for people with problem substance use who are homeless. Peer Navigators will be based in homelessness outreach and residential services in Scotland and England. Peer Navigators will work with a small number of participants for up to 12 months providing both practical and emotional support. The sample size for the intervention is 60. Those receiving the intervention must be currently homeless or at risk of homelessness, over the age of 18 years and self-report alcohol/drug problems. A holistic health check will be conducted in the first few months of the intervention and repeated towards the end. Health checks will be conducted by a researcher in the service where the Peer Navigator is based. Semi-structured qualitative interviews with intervention participants and staff in both intervention and standard care settings, and all Peer Navigators, will be conducted to explore their experiences with the intervention. Non-participant observation will be conducted in intervention and standard care sites to document similarities and differences between care pathways., Discussion: The SHARPS study will provide evidence regarding whether a peer-delivered harm reduction intervention is feasible and acceptable to people experiencing homelessness and problem substance use in order to develop a definitive trial., Trial Registration: SRCTN registry ISRCTN15900054, protocol version 1.3, March 12, 2018., Competing Interests: Ethical approval has been granted by the University of Stirling’s NHS, Invasive or Clinical Research Ethics Committee (NICR 17/18 Paper 35) and the Salvation Army’s Research and Development Unit’s Ethics Committee. NHS services are not being used, and the study team has received a view from the South East Scotland Research Ethics Service (NHS Lothian) that it does not need NHS ethical review under the terms of the Governance Arrangements for Research Ethics Committees. Any future minor and substantial amendments will be submitted to these committees for consideration, as well as updating the funder regarding changes to the protocol. Written informed consent will be sought from all participants in the study. The University of Stirling will act as sponsor for the research and will undertake regular audit (RIS, University of Stirling, Stirling, FK94LA researchdevelopment@stir.ac.uk). The Project Management Team is responsible for ensuring the appropriate and timely implementation of the study. An independent Study Steering Committee will provide overall supervision for a trial on behalf of the study sponsor and study funder to ensure that the study is conducted to rigorous standards. A Patient and Public Involvement group (called Experts by Experience group) informs the study throughout and consists of people with lived experience of problem substance use and/or homelessness.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objectives: Globally, engaging people who have used drugs, or peers, in decision-making has been increasingly touted as a best practice approach to developing priorities, programs, and policies. Peer engagement ensures decisions are relevant, appropriate, and effective to the affected community. However, ensuring that inclusion is accessible and equitable for those involved remains a challenge. In this study, we examined the perspectives of people who use or have used illicit drugs (PWUD) on peer engagement in health and harm reduction settings across British Columbia (BC), Canada., Methods: The Peer Engagement and Evaluation Project used a participatory approach to conducting 13 peer-facilitated focus groups (n = 83) across BC. Focus group data were coded and analyzed with five peer research assistants. Themes about the nature of peer engagement were generated. From this analysis, peer engagement barriers and enablers were identified., Results: Barriers to peer engagement included individual, geographical, systemic, and social factors. Issues related to stigma, confidentiality, and mistrust were intensely discussed among participants. Being "outed" in one's community was a barrier to engagement, particularly in rural areas. Participants voiced that compensation, setting, and the right people help facilitate and motivate engagement. Peer networks are an essential ingredient to engagement by promoting support and advocacy., Conclusion: PWUD are important stakeholders in decisions that affect them. This cross-jurisdictional study investigated how PWUD have experienced engagement efforts in BC, identifying several factors that influence participation. Meaningful engagement can be facilitated by attention to communication, relationships, personal capacity, and compassion between peers and other professionals.

Background: Equity-focused health impact assessment (EFHIA) can function as a framework and tool that supports users to collate data, information, and evidence related to health equity in order to identify and mitigate the impact of a current or proposed initiative on health inequities. Despite education efforts in both the clinical and public health settings, practitioners have found implementation and the use of evidence in completing equity focussed assessment tools to be challenging., Methods: We conducted a realist evaluation of evidence use in EFHIA in three phases: 1) developing propositions informed by a literature scan, existing theoretical frameworks, and stakeholder engagement; 2) data collection at four case study sites using online surveys, semi-structured interviews, document analysis, and observation; and 3) a realist analysis and identification of context-mechanism-outcome patterns and demi-regularities., Results: We identified limited use of academic evidence in EFHIA with two explanatory demi-regularities: 1) participants were unable to "identify with" academic sources, acknowledging that evidence based practice and use of academic literature was valued in their organization, but seen as less likely to provide answers needed for practice and 2) use of academic evidence was not associated with a perceived "positive return on investment" of participant energy and time. However, we found that knowledge brokering at the local site can facilitate evidence familiarity and manageability, increase user confidence in using evidence, and increase the likelihood of evidence use in future work., Conclusions: The findings of this study provide a realist perspective on evidence use in practice, specifically for EFHIA. These findings can inform ongoing development and refinement of various knowledge translation interventions, particularly for practitioners delivering front-line public health services.

Background: In 2016, in the Canadian province of British Columbia, the Provincial Health Officer declared drug-related overdose deaths a public health emergency., Objectives: In this study, we examine factors associated with recent non-fatal overdose during a time of unprecedented rates of overdose and increasing involvement of fentanyl and fentanyl derivatives in overdose deaths., Methods: Between June and September 2016, a cross-sectional survey was conducted among people who inject drugs (PWID) in Victoria, British Columbia, Canada. Bivariable and multivariable logistic regression analyses were used to examine factors associated with recent non-fatal overdose., Results: A total of 187 PWID were included in the present study, of whom 56 (29.9%) reported having overdosed in the previous 6 months. In multivariable analyses, fentanyl injection (Adjusted Odds Ratio [AOR] = 2.60; 95% confidence interval [CI]: (1.08 - 6.27) and public injection (AOR = 2.20; 95% CI: 1.09 - 4.43) were positively associated with recent non-fatal overdose., Conclusions: Fentanyl injection and public injection were associated with an increased likelihood of non-fatal overdose. These findings underscore the need for drug checking, safer sources of opioids and safer injecting interventions as part of overdose prevention strategies.

The process of dying pronounces inequities, particularly for structurally vulnerable populations. Extending recent health geography research, we critically explore how the 'places' of formal healthcare settings shape experiences of, and access to, palliative care for the structurally vulnerable (e.g., homeless, substance users). Drawing on 30 months of ethnographic data, thematic findings reveal how symbolic, aesthetic, and physical elements of formal healthcare 'places' intersect with social relations of power to produce, reinforce, and amplify structural vulnerability and thus, inequities in access to care. Such knowledge may inform decision-makers on ways to enhance equitable access to palliative care for some of societies' most vulnerable population groups., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Both health equity research and Indigenous health research are driven by the goal of promoting equitable health outcomes among marginalized and underserved populations. However, the two fields often operate independently, without collaboration. As a result, Indigenous populations are underrepresented in health equity research relative to the disproportionate burden of health inequities they experience. In this methodological article, we present Xpey' Relational Environments, an analytic framework that maps some of the barriers and facilitators to health equity for Indigenous peoples., Methods: Health equity research needs to include a focus on Indigenous populations and Indigenized methodologies, a shift that could fill gaps in knowledge with the potential to contribute to 'closing the gap' in Indigenous health. With this in mind, the Equity Lens in Public Health (ELPH) research program adopted the Xpey' Relational Environments framework to add a focus on Indigenous populations to our research on the prioritization and implementation of health equity. The analytic framework introduced an Indigenized health equity lens to our methodology, which facilitated the identification of social, structural and systemic determinants of Indigenous health. To test the framework, we conducted a pilot case study of one of British Columbia's regional health authorities, which included a review of core policies and plans as well as interviews and focus groups with frontline staff, managers and senior executives., Conclusion: ELPH's application of Xpey' Relational Environments serves as an example of the analytic framework's utility for exploring and conceptualizing Indigenous health equity in BC's public health system. Future applications of the framework should be embedded in Indigenous research methodologies., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In Canada, funding, administration, and delivery of health services-including those targeting people who use drugs-are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach., Methods: We employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach., Results: Only two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use., Conclusions: Current provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.

Background: Access to harm reduction interventions among substance users across Canada is highly variable, and largely within the policy jurisdiction of the provinces and territories. This study systematically described variation in policy frameworks guiding harm reduction services among Canadian provinces and territories as part of the first national multimethod case study of harm reduction policy., Methods: Systematic and purposive searches identified publicly-accessible policy texts guiding planning and organization of one or more of seven targeted harm reduction services: needle distribution, naloxone, supervised injection/consumption, low-threshold opioid substitution (or maintenance) treatment, buprenorphine/naloxone (suboxone), drug checking, and safer inhalation kits. A corpus of 101 documents written or commissioned by provincial/territorial governments or their regional health authorities from 2000 to 2015 were identified and verified for relevance by a National Reference Committee. Texts were content analyzed using an a priori governance framework assessing managerial roles and functions, structures, interventions endorsed, client characteristics, and environmental variables., Results: Nationally, few (12%) of the documents were written to expressly guide harm reduction services or resources as their primary named purpose; most documents included harm reduction as a component of broader addiction and/or mental health strategies (43%) or blood-borne pathogen strategies (43%). Most documents (72%) identified roles and responsibilities of health service providers, but fewer declared how services would be funded (56%), specified a policy timeline (38%), referenced supporting legislation (26%), or received endorsement from elected members of government (16%). Nonspecific references to 'harm reduction' appeared an average of 12.8 times per document-far more frequently than references to specific harm reduction interventions (needle distribution=4.6 times/document; supervised injection service=1.4 times/document). Low-threshold opioid substitution, safer inhalation kits, drug checking, and buprenorphine/naloxone were virtually unmentioned. Two cases (Quebec and BC) produced about half of all policy documents, while 6 cases - covering parts of Atlantic and Northern Canada - each produced three or fewer., Conclusion: Canada exhibited wide regional variation in policies guiding the planning and organization of Canadian harm reduction services, with some areas of the country producing few or no policies. Despite a wealth of effectiveness and health economic research demonstrating the value of specific harm reduction interventions, policies guiding Canada from 2000 to 2015 did not stake out harm reduction interventions as a distinct, legitimate health service domain., (Copyright © 2017 Elsevier B.V. All rights reserved.)