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The authors discuss an article by Chandra and colleagues, published in the issue, which described the excess drug-related deaths attributable to the COVID-19 pandemic in the U.S. at a local scale. Topics include main factors proposed by Chandra and colleagues, a significant risk factor for illicit drug-related mortality, and the evolution of unregulated drug supply in British Columbia.

Introduction: Lives lost in North America due to the unregulated drug poisoning emergency are preventable and those who survive an opioid overdose may suffer long-term disability. Rates of opioid overdose more than doubled following the onset of the COVID-19 pandemic in British Columbia, Canada. Materials and methods: Our analytical sample was comprised of 1447 participants from the 2018, 2019, and 2021 Harm Reduction Client Survey who responded yes or no to having experienced an opioid overdose in the past 6 months. Participants were recruited from harm reduction sites from across British Columbia. We used logistic regression to explore associations of experiencing an opioid overdose. Results: Overall, 21.8% of participants reported experiencing an opioid overdose in the last six months (18.2% in 2019 and 26.6% in 2021). The following factors were positively associated with increased adjusted odds of experiencing a non-fatal opioid overdose: cis men relative to cis women (AOR 1.49, 95% CI 1.10–2.02), unstably housed compared to people with stable housing (AOR 1.87, 95% CI 1.40–2.50), and participants from 2021 compared to those from 2019 (AOR 3.06, 95% CI 1.57–5.97). The effects of both previous experience of a stimulant overdose and having witnessed an opioid overdose depended on the year of study, with both effects decreasing over subsequent years. Conclusions: Overdoses have increased over time; in 2021 more than one in four participants experienced an overdose. There is an urgent need for policy and program development to meaningfully address the unregulated drug poisoning emergency through acceptable life-saving interventions and services to prevent overdoses and support overdose survivors. [ABSTRACT FROM AUTHOR]

Background: Despite the implementation and expansion of public health and harm reduction strategies aimed at preventing and reversing overdoses, rates of overdose-related events and fatalities continue to rise in British Columbia. The COVID-19 pandemic created a second, concurrent public health emergency that further exacerbated the illicit drug toxicity crisis, reinforced existing social inequities and vulnerabilities, and highlighted the precariousness of systems in place that are meant to protect the health of communities. By exploring the perspectives of people with recent experience of illicit substance use, this study sought to characterize how the COVID-19 pandemic and associated public health measures influenced risk and protective factors related to unintentional overdose by altering the environment in which people live and use substances, influencing the ability of people who use substances to be safe and well. Methods: One-on-one semi-structured interviews were conducted by phone or in-person with people who use illicit substances (n = 62) across the province. Thematic analysis was performed to identify factors shaping the overdose risk environment. Results: Participants pointed to factors that increased risk of overdose, including: [1] physical distancing measures that created social and physical isolation and led to more substance use alone without bystanders nearby able to respond in the event of an emergency; [2] early drug price spikes and supply chain issues that created inconsistencies in drug availability; [3] increasing toxicity and impurities in unregulated substances; [4] restriction of harm reduction services and supply distribution sites; and [5] additional burden placed on peer workers on the frontlines of the illicit drug toxicity crisis. Despite these challenges, participants highlighted factors that protected against overdose and substance-related harm, including the emergence of new programs, the resiliency of communities of people who use substances who expanded their outreach efforts, the existence of established social relationships, and the ways that individuals consistently prioritized overdose response over concerns about COVID-19 transmission to care for one another. Conclusions: The findings from this study illustrate the complex contextual factors that shape overdose risk and highlight the importance of ensuring that the needs of people who use substances are addressed in future public health emergency responses. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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

Introduction: British Columbia (BC) declared an overdose public health emergency in 2016. Since then, BC has consistently reported the highest overdose death rates of any province in Canada. In the context of the COVID‐19 pandemic, overdose deaths in BC reached a record high in 2020. This analysis reports on changes in the profile of people who have died of overdose since BC's declaration of COVID‐19 as a public health emergency on 17 March 2020. Methods: Using BC Coroners Service data, Chi‐square tests and multivariable logistic regression were conducted to compare demographic, geographic and post‐mortem toxicology data between people who died of overdose before (17 March–31 December 2019) and after (17 March–31 December 2020) BC's declaration of COVID‐19 as a public health emergency. Results: Overdose deaths observed since 17 March 2020 (n = 1516) more than doubled those observed in the same period in 2019 (n = 744). In the adjusted logistic regression model, odds of death in the post compared to pre‐COVID‐19 period was significantly higher among males compared to females, among all older age groups compared to people aged 30–39, and was lower in public buildings compared to private residences. Discussion and Conclusions: Alongside a significant increase in overdose deaths since BC's declaration of COVID‐19 as a public health emergency, the demographic profile of people who have died of overdose has changed. Ongoing overdose prevention efforts in BC must seek to reach people who remain most isolated, including older adults, who during dual public health emergencies are facing compounded risk of preventable mortality. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aim: To capture pandemic experiences of people with opioid use disorder (OUD) to better inform the programs that serve them. Design: We designed, conducted, and analyzed semi-structured qualitative interviews using grounded theory. We conducted interviews until theme saturation was reached and we iteratively developed a codebook of emerging themes. Individuals with lived experience of substance use provided feedback at all steps of the study. Setting: We conducted phone or in-person interviews in compliance with physical distancing and public health regulations in outdoor Vancouver parks or well-ventilated indoor spaces between June to September 2020. Participants: Using purposive sampling, we recruited participants (n = 19) who were individuals with OUD enrolled in an intensive community outreach program, had visited one of two emergency departments, were over 18, lived within catchment, and were not already receiving opioid agonist therapy. Measurements: We audio-recorded interviews, which were later transcribed verbatim and checked for accuracy while removing all identifiers. Interviews explored participants' knowledge of COVID-19 and related safety measures, changes to drug use and healthcare services, and community impacts of COVID-19. Results: One third of participants were women, approximately two thirds had stable housing, and ages ranged between 23 and 59 years old. Participants were knowledgeable on COVID-19 public health measures. Some participants noted that fear decreased social connection and reluctance to help reverse overdoses; others expressed pride in community cohesion during crisis. Several participants mentioned decreased access to housing, harm reduction, and medical care services. Several participants reported using drugs alone more frequently, consuming different or fewer drugs because of supply shortages, or using more drugs to replace lost activities. Conclusion: COVID-19 had profound effects on the social lives, access to services, and risk-taking behaviour of people with opioid use disorder. Pandemic public health measures must include risk mitigation strategies to maintain access to critical opioid-related services. [ABSTRACT FROM AUTHOR]

Background: Emerging evidence indicates that illicit drug overdoses are increasing throughout the COVID-19 pandemic. There is a paucity of evidence on the causative pathways for this trend, but expert opinions, commentaries, and some reviews offer theoretical underpinnings.Methods: In this rapid review, we collate the available published evidence, expert opinions, commentaries, and reviews on the unintended pathways between COVID-19 public health responses and increasing illicit drug overdoses. Using tenets of thematic analyses and grounded theory, we also offer a visual conceptual framework for these unintended pathways.Results: Our framework focuses on five particular public health responses, namely social isolation/physical distancing/quarantine; staff/resource reallocations and reductions; closures of businesses and other places of employment; border closures and transportation restrictions; and the early release of people from prisons. As argued in the literature reviewed here, these public health responses have unintentionally created increased overdose risks by producing high risk use scenarios; increased risks of relapsing; disrupted addictions services and treatment; an increasingly toxic supply of drugs; and the risk of using with lowered tolerance.Conclusions: Health care systems should respond to these pathways to mitigate the unintended consequences. Furthermore, the COVID-19 pandemic may represent an opportunity to enact proactive, progressive, and innovative solutions to an overdose crisis that will surely outlast the current pandemic. [ABSTRACT FROM AUTHOR]

• Understanding the drivers of pandemic-coincident increases in overdose is important. • Emerging research considers the potential role of income support payments. • Ecological analyses found unequal distributions overdose increases across regions. • Results found no correlation between support payments and overdose in BC. • Desynchronized payment structures may explain deviations from previous research. Pandemic income support payments have been speculatively linked to an increased incidence of illicit drug poisoning (overdose). However, existing research is limited. Collating Canadian Emergency Response Benefit (CERB) payment data with data on paramedic attended overdose and illicit drug toxicity deaths for the province of British Columbia at the Local Health Area (LHA) level, we conducted a correlation analysis to compare overdose rates before, during and after active CERB disbursement. There were 20,014,270 CERB-entitled weeks identified among residents of British Columbia for the duration of the pandemic response program. Approximately 52 % of all CERB entitled weeks in the study were among females and approximately 48 % were among males. Paramedic-attended overdoses increased uniformly across the pre-CERB, CERB and post-CERB periods, while illicit drug toxicity deaths sharply increased and then remained high over the period of the study. Correlation analyses between overdose and CERB-entitled weeks approached zero for both paramedic-attended overdoses and illicit drug toxicity deaths. These findings suggest that attributing the pandemic increase in overdose to income support payments is unfounded. Sustained levels of unacceptably high non-fatal and fatal drug poisonings that further increased at the start of the pandemic are reflective of complex pre-existing and pandemic-driven changes to overdose risk. [ABSTRACT FROM AUTHOR]

Background: The province of British Columbia (BC), Canada is amid dual public health emergencies in which the overdose epidemic declared in 2016 has been exacerbated by restrictions imposed by the Coronavirus Disease of 2019 (COVID-19) pandemic. Experiential workers, commonly known as 'peers' (workers with past or present drug use experience) are at the forefront of overdose response initiatives and are essential in creating safe spaces for people who use drugs (PWUD) in harm reduction. Working in overdose response environments can be stressful, with lasting emotional and mental health effects. There is limited knowledge about the personal meaning that experiential workers derive from their work, which serve as motivators for them to take on these often-stressful roles.Methods: This project used a community-based qualitative research design. The research was based at two organizations in BC. Eight experiential worker-led focus groups were conducted (n = 31) where participants spoke about their roles, positive aspects of their jobs, challenges they face, and support needs in harm reduction work. Transcripts were coded and analyzed using interpretative description to uncover the meaning derived from experiential work.Results: Three themes emerged from focus group data that describe the meanings which serve as motivators for experiential workers to continue working in overdose response environments: (1) A sense of purpose from helping others; (2) Being an inspiration for others, and; (3) A sense of belonging.Conclusion: Despite the frequent hardships and loss that accompany overdose response work, experiential workers identified important aspects that give their work meaning. These aspects of their work may help to protect workers from the emotional harms associated with stressful work as well as the stigma of substance use. Recognizing the importance of experiential work and its role in the lives of PWUD can help inform and strengthen organizational supports. [ABSTRACT FROM AUTHOR]