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Introduction: When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated., Methods: In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed a priori . Low dose naloxone (LDN; ≤0.15 mg) and high dose naloxone (HDN; >0.15 mg) patients were matched in a 1:4 ratio based upon initial respiratory rate (RR). The proportion of patients who developed OW and who met reversal criteria were compared between those treated initially with LDN or HDN. Odds ratios (OR) for OW and opioid reversal were obtained via logistic regression stratified by matched sets and adjusted for age, sex, pre-naloxone GCS, and presence of non-opioid drugs or alcohol., Results: Eighty LDN patients were matched with 299 HDN patients. After adjustment, HDN patients were more likely than LDN patients to have OW after initial dose (OR = 8.43; 95%CI: 1.96, 36.3; p  = 0.004) and after any dose (OR = 2.56; 95%CI: 1.17, 5.60; p  = 0.019). HDN patients were more likely to meet reversal criteria after initial dose (OR = 2.73; 95%CI: 1.19, 6.26; p  = 0.018) and after any dose (OR = 6.07; 95%CI: 1.81, 20.3; p  = 0.003)., Conclusions: HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.

Background: As the overdose emergency continues in British Columbia (BC), paramedic-attended overdoses are increasing, as is the proportion of people not transported to hospital following an overdose. This study investigated risk of death and subsequent healthcare utilization for people who were and were not transported to hospital after a paramedic-attended non-fatal overdose., Methods: Using a linked administrative health data set which includes all overdoses that come into contact with health services in BC, we conducted a prospective cohort study of people who experienced a paramedic-attended non-fatal overdose between 2015 and 2016. People were followed for 365 days after the index event. The primary outcomes assessed were all-cause mortality and overdose-related death. Additionally, we examined healthcare utilization after the index event., Results: In this study, 8659 (84%) people were transported and 1644 (16%) were not transported to hospital at the index overdose event. There were 279 overdose deaths (2.7% of people, 59.4% of deaths) during follow-up. There was no significant difference in risk of overdose-related death, though people not transported had higher odds of a subsequent non-fatal overdose event captured in emergency department and outpatient records within 90 days. People transported to hospital had higher odds of using hospital and outpatient services for any reason within 365 days., Conclusions: Transport to hospital after a non-fatal overdose is an opportunity to provide care for underlying and chronic conditions. There is a need to better understand factors that contribute to non-transport, particularly among people aged 20-59 and people without chronic conditions., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: North American communities are severely impacted by the overdose crisis, particularly in British Columbia (BC), which has the highest toxic drug overdose death rate in Canada. Most fatal overdoses in BC occurred among individuals using alone and in private residences. This study aimed to assess prevalence and reasons for using drugs alone among people accessing harm reduction services in BC., Methods: We recruited harm reduction supply distribution site clients from 22 communities across BC. Descriptive statistics and multivariable logistic regression were used to describe factors associated with using alone. Thematic analysis of free-text responses providing reasons for using alone were grouped with survey data and additional themes identified., Results: Overall, 75.8% (n = 314) of the study sample (N = 414) reported using drugs alone within the last week. Those that reported using alone did not differ from those that did not by gender, age, urbanicity, or preferred drug use method. Among those that used alone, 73.2% (n = 230) used opioids, 76.8% (n = 241) used crystal meth, 41.4% (n = 130) used crack/cocaine, and 44.6% (n = 140) used alcohol in the past week. Polysubstance use involving stimulants, opioids, and/or benzodiazepines was reported by 68.5% (n = 215) of those that used alone. Additionally, 22.9% (n = 72) of those that used alone had experienced an opioid and/or stimulant overdose in the past 6 months. In a multivariable logistic regression model, having no regular housing and past week crack/cocaine use were associated with using alone (adjusted odds ratio (AOR): 2.27; 95% CI 1.20-4.27 and AOR: 2.10; 95% CI 1.15-3.82, respectively). The most common reason reported for using alone was convenience and comfort of using alone (44.3%). Additional reasons included: stigma/hiding drug use (14.0%); having no one around (11.7%); safety (9.6%); and not wanting to share drugs with others (8.6%)., Conclusions: Using drugs alone, particularly for convenience and comfort, is ubiquitous among people accessing harm reduction services. Overdose prevention measures that go beyond individual behaviour changes, including providing a safer supply of drugs and eliminating stigma, are paramount to mitigate harms. These interventions are especially necessary as emergence of coronavirus disease may further exacerbate unpredictability of illicit drug content and overdose risk.

Background: Overdose response has become an increasingly relevant component of paramedic practice, particularly in light of increased opioid overdose globally. Previous studies have noted gaps in our understanding regarding the unique challenges which paramedics face during this form of pre-hospital emergency care. The aim of this study is to explore and describe the ways in which paramedics experience overdose response, specifically within a community markedly affected by the overdose crisis., Methods: Ten participants were recruited from a single ambulance station located in an urban center in Western Canada. Two rounds of semi-structured individual interviews were conducted, and data saturation was found to have been reached. Verbatim transcripts were produced and subject to two rounds of descriptive and pattern coding. A second researcher reviewed all of the codes, with disagreements being handled by discussion until agreement was obtained. Themes were identified, along with a Core Category which seeks to describe the underlying dynamics of overdose response represented in our data. The concept of a Core Category was borrowed from Grounded Theory methodology., Findings: Five major themes were identified: Connecting with patients' lived experiences; Occupying roles as clinicians and patient advocates; Navigating on-scene hazards; Difficulties with transitions of care; and Emotional burden of the overdose crisis. A core category was identified as One's capacity to help., Conclusions: This research contributes to existing literature on overdose response by specifically examining paramedic experiences during this form of emergency care. While paramedics felt highly confident in providing clinical care, their capacity to address underlying causes of drug use was understood as much more limited. Participants found ways to address this lack of control, along with feelings of frustration, by trying to understand patient perspectives and adopting empathetic attitudes., Competing Interests: The authors have declared that no competing interests exist.

Introduction: British Columbia's (BC) Take-Home Naloxone (THN) program provides naloxone to bystanders for use in cases of suspected opioid overdose. This study seeks to provide trends and analysis from the provincial BC THN program since inception in 2012 to the end of 2018., Materials and Methods: BC THN shipment and distribution records from 2012-2018 were retrieved. Frequency distributions were used to describe characteristics of individuals accessing the program. To evaluate correlates of distribution after the addition of hundreds of pharmacy distribution sites, an analytic sample was limited to records from 2018, and multivariate logistic regression was used to evaluate correlates of collecting naloxone at a pharmacy site., Results: Since program inception to the end of 2018, there were 398,167 naloxone kits shipped to distribution sites, 149,999 kits reported distributed, and 40,903 kits reported used to reverse an overdose in BC. There was a significant increasing trend in the number of naloxone kits used to reverse an overdose over time (p<0.01), and more than 90% of kits that were reported used were distributed to persons at risk of an overdose. Individuals not personally at risk of overdose had higher odds of collecting naloxone at a pharmacy site, compared to other community sites (including harm reduction supply distribution sites, peer led organizations, drop-in centers, and supportive housing sites) (Adjusted Odds Ratio (AOR): 2.69; 95% CI: 2.50-2.90)., Conclusions: This study documents thousands of opioid overdose reversals facilitated through the BC THN program. While those at highest risk of overdose may preferentially access naloxone through community sites, naloxone distribution through pharmacies has allowed the BC THN program to expand dramatically, increasing naloxone availability through longer opening hours on evenings and weekends. and in rural and remote regions. A diversity of naloxone distribution sites and strategies is crucial to prevent rising opioid overdose deaths., Competing Interests: The authors have declared that no competing interests exist.

Background: People who smoke drugs (PWSD) are at high risk of both infectious disease and overdose. Harm reduction activities organized by their peers in the community can reduce risk by providing education, safer smoking supplies, and facilitate access to other services. Peers also provide a network of people who provide social support to PWSD which may reinforce harm reducing behaviors. We evaluated the numbers of supportive network members and the relationships between received support and participants' harm-reducing activities., Methods: Initial peer-researchers with past or current lived drug use experience were employed from communities in Abbotsford and Vancouver to interview ten friends from their social networks who use illegal drugs mainly through smoking. Contacts completed a questionnaire about people in their own harm reduction networks and their relationships with each other. We categorized social support into informational, emotional, and tangible aspects, and harm reduction into being trained in the use of, or carrying naloxone, assisting peers with overdoses, using brass screens to smoke, obtaining pipes from service organizations and being trained in CPR., Results: Fifteen initial peer researchers interviewed 149 participants who provided information on up to 10 people who were friends or contacts and the relationships between them. People who smoked drugs in public were 1.46 (95% CI, 1.13-1.78) more likely to assist others with possible overdoses if they received tangible support; women who received tangible support were 1.24 (95% CI; 1.02-1.45) more likely to carry and be trained in the use of naloxone. There was no relationship between number of supportive network members and harm reduction behaviors., Conclusions: In this pilot study, PWSD who received tangible support were more likely to assist peers in possible overdoses and be trained in the use of and/or carry naloxone, than those who did not receive tangible support. Future work on the social relationships of PWSD may prove valuable in the search for credible and effective interventions.

Background: There have been significant efforts to respond to the two public health emergencies of coronavirus disease 2019 (COVID-19) and overdose in British Columbia (BC), Canada. The purpose of this study was to quantify the prevalence of known risk factors associated with mortality due to COVID-19 for persons who have had a non-fatal overdose during 2015-2017 in comparison to persons who have not had an overdose., Methods: Data were extracted from the BC Provincial Overdose Cohort which includes a 20 % random sample of BC residents and persons who have had a non-fatal overdose in BC from January 2015 to December 2017. Chi-square tests and logistic regression were used to compare risk factors by overdose history., Results: Persons who had a non-fatal overdose were significantly more likely to have three (chronic pulmonary disease, diabetes, coronary heart disease) of the four known chronic conditions associated with the development of severe illness due to COVID-19 compared to persons who did not have a previous non-fatal overdose event., Conclusion: Persons who had an overdose were more likely to have several chronic conditions associated with the development of severe illness due to COVID-19. The increased likelihood of having these risk factors is reflective of the social and health inequities experienced by persons who have a history of overdose., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Evaluate the relationship between naloxone dose (initial and cumulative) and opioid toxicity reversal and adverse events in undifferentiated and presumed fentanyl/ultra-potent opioid overdoses., Methods: We searched Embase, MEDLINE, Cochrane Central Register of Controlled Trials, DARE, CINAHL, Science Citation Index, reference lists, toxicology websites, and conference proceedings (1972 to 2018). We included interventional, observational, and case studies/series reporting on naloxone dose and opioid toxicity reversal or adverse events in people >12 years old., Results: A total of 174 studies (110 case reports/series, 57 observational, 7 interventional) with 26,660 subjects (median age 35 years; 74% male). Heterogeneity precluded meta-analysis. Where reported, we abstracted naloxone dose and proportion of patients with toxicity reversal. Among patients with presumed exposure to fentanyl/ultra-potent opioids, 56.9% (617/1,085) responded to an initial naloxone dose ≤0.4 mg compared with 80.2% (170/212) of heroin users, and 30.4% (7/23) responded to an initial naloxone dose >0.4 mg compared with 59.1% (1,434/2,428) of heroin users. Among patients who responded, median cumulative naloxone doses were higher for presumed fentanyl/ultra-potent opioids than heroin overdoses in North America, both before 2015 (fentanyl/ultra-potent opioids: 1.8 mg [interquartile interval {IQI}, 1.0, 4.0]; heroin: 0.8 mg [IQI, 0.4, 0.8]) and after 2015 (fentanyl/ultra-potent opioids: 3.4 mg [IQI, 3.0, 4.1]); heroin: 2 mg [IQI, 1.4, 2.0]). Where adverse events were reported, 11% (490/4,414) of subjects experienced withdrawal. Variable reporting, heterogeneity and poor-quality studies limit conclusions., Conclusions: Practitioners have used higher initial doses, and in some cases higher cumulative naloxone doses to reverse toxicity due to presumed fentanyl/ultra-potent opioid exposure compared with other opioids. High-quality comparative naloxone dosing studies assessing effectiveness and safety are needed.

Introduction: In response to North America's opioid crisis, access to naloxone has increased. However, our understanding of the correlates of possessing a naloxone kit is limited. This study seeks to determine the prevalence and correlates of kit possession among people who use drugs (PWUD) in British Columbia (BC) Canada., Methods: This analysis used cross-sectional survey data collected in 2018 from 27 harm reduction sites in BC. Descriptive statistics and Poisson regression with robust error variance were used to examine factors associated with naloxone kit possession., Results: Overall, 70.7% (n = 246) of the total sample (n = 348) reported having a naloxone kit. Having a kit was significantly associated with self-reported opioid use in comparison with non-opioid use (Adjusted Prevalence Ratio (APR): 2.39; 95% CI: 1.33-4.32). Those reporting 'injection' as their preferred drug administration method were also more likely to possess a kit compared to those that predominantly preferred inhalation, smoking, or snorting (APR: 2.39; 95% CI: 1.25-4.58). Urbanicity, age, gender, and having regular housing were not significantly associated with possessing a kit., Conclusions: This study is the first to examine naloxone kit possession across geographies, including non-urban areas. Lower kit possession among those that preferred inhaling, smoking or snorting drugs may reflect misconceptions around overdose risk of non-injection drug administration. Our study supports the need for enhanced awareness around the risk of opioid overdose with non-injection administration and suggests a need for comprehensive public health messaging that aims to address overdose risk and response., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: This study describes the 2016 expansion of the British Columbia Take Home Naloxone (BCTHN) programme quantitatively and explores the challenges, facilitators and successes during the ramp up from the perspectives of programme stakeholders., Design: Mixed-methods study., Setting: The BCTHN programme was implemented in 2012 to reduce opioid overdose deaths by providing naloxone kits and overdose recognition and response training in BC, Canada. An increase in the number of overdose deaths in 2016 in BC led to the declaration of a public health emergency and a rapid ramp up of naloxone kit production and distribution. BCTHN distributes naloxone to the five regional health authorities of BC., Participants: Focus groups and key informant interviews were conducted with 18 stakeholders, including BC Centre for Disease Control staff, urban and rural site coordinators, and harm reduction coordinators from the five regional health authorities across BC., Primary and Secondary Outcome Measures: Take Home Naloxone (THN) programme activity, qualitative themes and lessons learnt were identified., Results: In 2016, BCTHN responded to a 20-fold increase in demand of naloxone kits and added over 300 distribution sites. Weekly numbers of overdose events and overdose deaths were correlated with increases in THN kits ordered the following week, during 2013-2017. Challenges elicited include forecasting demand, operational logistics, financial, manpower and policy constraints. Facilitators included outsourcing kit production, implementing standing orders and policy changes in naloxone scheduling, which allowed for easier hiring of staff, reduced paperwork and expanded client access., Conclusion: For THN programmes preparing for potential increases in naloxone demand, we recommend creating an online database, implementing standing orders and developing online training resources for standardised knowledge translation to site staff and clients., Competing Interests: Competing interests: None declared., (© 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.)

Background: Persons with hepatitis C virus (HCV) infection are at risk of mortality from both chronic liver disease and HCV acquisition risk activities. We compared causes of death among HCV positive and negative individuals to characterize contributions of acquisition risks and viral sequelae., Methods: The British Columbia (BC) Hepatitis Testers Cohort (BC-HTC) includes all individuals tested for HCV or reported as a HCV case since 1992, linked to health administrative data. ICD-10 codes were used to classify deaths as: 1) liver-related (LR); 2) HCV acquisition risk-related (AR); and 3) other causes. Mortality proportions and trends were assessed among HCV positive and negative individuals overall and by birth cohort (born <1945, 1945-64 and ≥1965)., Results: As of December 31, 2018, of 1,300,204 HCV-tested individuals, 20,049 (27.5%) HCV positive and 132,999 (10.2%) HCV negative individuals had died (median age at death: 56.4 vs. 74.5 years, respectively). HCV positive individuals were more likely than negatives to die from both AR (24.7%/4.2%) and LR (23.4%/6.2%) causes. Deaths among older HCV positive individuals were more likely to be LR while younger individuals were more likely AR: 1) birth cohort <1945 (25.3%/2.7%); 2) 1945-64 (26.5%/23.7%) and ≥1965 (7.7%/59.9%). Among HCV positives, LR mortality increased from 1992 to 2014, then declined sharply, coinciding with the introduction and uptake of direct-acting antiviral drugs. AR mortality increased from 1992 to 2000, declined slowly until 2013, then rapidly increased, coinciding with the recent surge in opioid overdose deaths., Conclusions: Curative HCV treatments reduce LR mortality, but typically will not impact AR mortality. This will need to be addressed if the World Health Organization 2030 HCV mortality reduction goals are to be achieved., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: British Columbia (BC), Canada, is experiencing an unprecedented number of opioid overdoses mainly due to the contamination of illicit drugs with fentanyl and its analogues. Reluctance to seek emergency medical help (i.e., by calling 9-1-1) has been identified as a barrier to optimal care for overdose victims. This study aimed to identify the correlates of seeking help during an overdose event when naloxone was administered via BC's Take Home Naloxone (THN) program., Methods: In this cross-sectional study, we reviewed administrative records (from July 2015 to December 2017) about overdose events submitted by THN participants when they received their replacement naloxone kits (n = 2350). The primary outcome of the study was reported calling 9-1-1 and modified Poisson regression models were built to investigate the factors associated with help-seeking during an overdose event., Results: Most overdose victims were men (69.0%) and >30 years old (61.5%). Overall, participants reported calling 9-1-1 in 1310 (55.7%) overdose events. In the multivariable model, the likelihood of calling 9-1-1 was significantly and positively associated with the overdose victim being male and receiving rescue breathing. The likelihood of calling 9-1-1 was significantly and negatively associated with the overdoses occurring in private residences and health regions other than Vancouver Coastal which delivers services to mostly urban residents., Conclusion: Overall, medical help was sought for 55.7% of overdoses where naloxone was administered. Overdoses occurring among male victims as well as those receiving higher doses of naloxone and mouth-to-mouth rescue breathing were associated with a higher likelihood of help-seeking by responders. Future interventions need to encourage people who witness an overdose to seek emergency medical help., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and Aims: The province of British Columbia (BC) Canada has experienced a rapid increase in illicit drug overdoses and deaths during the last 4 years, with a provincial emergency declared in April 2016. These deaths have been driven primarily by the introduction of synthetic opioids into the illicit opioid supply. This study aimed to measure the combined impact of large-scale opioid overdose interventions implemented in BC between April 2016 and December 2017 on the number of deaths averted., Design: We expanded on the mathematical modelling methodology of our previous study to construct a Bayesian hierarchical latent Markov process model to estimate monthly overdose and overdose-death risk, along with the impact of interventions., Setting and Cases: Overdose events and overdose-related deaths in BC from January 2012 to December 2017., Interventions: The interventions considered were take-home naloxone kits, overdose prevention/supervised consumption sites and opioid agonist therapy MEASUREMENTS: Counterfactual simulations were performed with the fitted model to estimate the number of death events averted for each intervention and in combination., Findings: Between April 2016 and December 2017, BC observed 2177 overdose deaths (77% fentanyl-detected). During the same period, an estimated 3030 (2900-3240) death events were averted by all interventions combined. In isolation, 1580 (1480-1740) were averted by take-home naloxone, 230 (160-350) by overdose prevention services and 590 (510-720) were averted by opioid agonist therapy., Conclusions: A combined intervention approach has been effective in averting overdose deaths during British Columbia's opioid overdose crisis in the period since declaration of a public health emergency (April 2016-December 2017). However, the absolute numbers of overdose deaths have not changed., (© 2019 Society for the Study of Addiction.)

Background: North America is in the midst of an unabated opioid overdose epidemic due to the increasing non-medical use of fentanyl and ultra-potent opioids. Naloxone is an effective antidote to opioid toxicity, yet its optimal dosing in the context of fentanyl and ultra-potent opioid overdoses remains unknown. This review aims to determine the relationship between the first empiric dose of naloxone and reversal of toxicity, adverse events, and the total cumulative dose required among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. Secondary objectives include evaluating the relationship between the cumulative naloxone dose and toxicity reversal and adverse events, among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids., Methods: To identify studies, we will search MEDLINE, Embase, CENTRAL, DARE, CDAG, CINAHL, Science Citation Index, multiple trial registries, and the gray literature. Included studies will evaluate patients with suspected or confirmed opioid toxicity from undifferentiated opioids and ultra-potent opioids, who received an empiric and possibly additional doses of naloxone. The main outcomes of interest are the relationship between naloxone dose and toxicity reversal and adverse events. We will include controlled and non-controlled interventional studies, observational studies, case reports/series, and reports from poison control centers. We will extract data and assess study quality in duplicate with discrepancies resolved by consensus or a third party. We will use the Downs and Black and Cochrane risk of bias tools for observational and randomized controlled studies. If we find sufficient variation in dose, we will fit a random effects one-stage model to estimate a dose-response relationship. We will conduct multiple subgroup analyses, including by type of opioid used and by suspected high and low prevalence of ultra-potent opioid use based on geographic location and time of the original studies., Discussion: Our review will include the most up-to-date available data including ultra-potent opioids to inform the current response to the opioid epidemic, addressing the limitations of recent reviews. We anticipate limitations relating to study heterogeneity. We will disseminate study results widely to update overdose treatment guidelines and naloxone dosing in Take Home Naloxone programs.

Purpose: To understand how the Take Home Naloxone (THN) program is implemented in two pilot correctional facilities in British Columbia (BC), Canada, in order to identify areas for program improvement and inform the expansion of the program to other Canadian correctional facilities The paper aims to discuss these issues., Design/methodology/approach: Two focus groups and one interview were conducted with healthcare staff at two pilot correctional facilities. Sessions were audio recorded, transcribed verbatim and divergent and convergent experiences within and between the facilities were explored in an iterative process. Key themes and lessons learned were identified and later validated by focus group participants., Findings: Key themes that emerged included: challenges and importance of the train-the-trainer program for healthcare staff conducting participant training sessions; potential for improved prison population engagement and awareness of the program; tailoring program resources to the unique needs of an incarcerated population; challenges connecting participants to community harm reduction resources following release; and clarifying and enhancing the role of correctional officers to support the program., Research Limitations/implications: The correctional setting presents unique challenges and opportunities for the THN program that must be considered for program effectiveness., Originality/value: This evaluation was conducted to inform program expansion amidst a historic opioid overdose epidemic in BC, and adds to the limited yet growing body of literature on the implementation and evaluation of this program in correctional settings globally.

Objective: Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN., Methods: In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons., Results: Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN., Conclusion: ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others.

Opioid overdoses (OD) cause substantial morbidity and mortality globally, and current emergency management is typically limited to supportive care, with variable emphasis on harm reduction and addictions treatment. Our urban setting has a high concentration of patients with presumed fentanyl OD, which places a burden on both pre-hospital and emergency department (ED) resources. From December 13, 2016, to March 1, 2017, we placed a modified trailer away from an ED but near the center of the expected area of high OD and accepted low-risk patients with presumed fentanyl OD. We provided OD treatment as well as on-site harm reduction, addictions care, and community resources. The primary outcome was the proportion of patients requiring transfer to an ED for clinical deterioration, while secondary outcomes were the proportion of patients initiated on opioid agonists and provided take-home naloxone kits. We treated 269 patients with opioid OD, transferred three (1.1%) to a local ED, started 43 (16.0%) on opioid agonists, and provided 220 (81.7%) with THN. Our program appears to be safe and may serve as a model for other settings dealing with a large numbers of opioid OD.

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

Background: The overdose epidemic has been exacerbated by a dramatic increase in deaths involving illicitly manufactured fentanyl (IMF). Drug checking is a novel strategy to identify IMF in illicit drugs. We examined the uptake and acceptability of rapid fentanyl test strips among young adults., Methods: From May to September 2017, we recruited 93 young adults in Rhode Island who reported injecting drugs or using heroin, cocaine, or illicitly obtained prescription pills in the past 30 days. Participants were asked to test either their urine after drug use (post-consumption) or a drug sample prior to use (pre-consumption) using rapid fentanyl test strips. After a questionnaire and a brief training, participants received ten strips for their personal use and were asked to return for a one-month follow-up visit, which assessed the uptake and acceptability of the rapid strips tests and the behavioral outcomes associated with receipt of a positive test., Results: Of the 81 (87%) participants who returned for follow-up and who had complete data, the mean age was 27, 45 (56%) were male, and 37 (46%) were non-white. A total of 62 participants (77%) reported using at least one test strip. Of these, 31 (50%) received at least one positive result. A positive result was associated with older age, homelessness, heroin use, injection drug use, ever witnessing an overdose, and concern about overdose or drugs being laced with fentanyl (all p < 0.05). Receiving a positive result was significantly associated with reporting a positive change in overdose risk behavior between baseline and follow-up (p ≤  0.01). Among all participants, 79 (98%) reported confidence in their ability to use the test strips and 77 (95%) wanted to use them in the future., Conclusions: Young adults reported high uptake and acceptability of fentanyl test strips to detect IMF in illicit drugs., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Study Objective: Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose., Methods: At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs., Results: There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85% were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient died within 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone., Conclusion: In our cohort of ED patients with uncomplicated presumed fentanyl overdose-typically after injection-deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged after brief observation. Patients with normal triage vital signs are unlikely to require ED naloxone., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Illicit use of high-potency synthetic opioids has become a global issue over the past decade. This misuse is particularly pronounced in British Columbia, Canada, where a rapid increase in availability of fentanyl and other synthetic opioids in the local illicit drug supply during 2016 led to a substantial increase in overdoses and deaths. In response, distribution of take-home naloxone (THN) overdose prevention kits was scaled up (6·4-fold increase) throughout the province. The aim of this study was to estimate the impact of the THN programme in terms of the number of deaths averted over the study period., Methods: We estimated the impact of THN kits on the ongoing epidemic among people who use illicit opioids in British Columbia and explored counterfactual scenarios for the provincial response. A Markov chain model was constructed explicitly including opioid-related deaths, fentanyl-related deaths, ambulance-attended overdoses, and uses of THN kits. The model was calibrated in a Bayesian framework incorporating population data between Jan 1, 2012, and Oct 31, 2016., Findings: 22 499 ambulance-attended overdoses and 2121 illicit drug-related deaths (677 [32%] deaths related to fentanyl) were recorded in the study period, mostly since January, 2016. In the same period, 19 074 THN kits were distributed. We estimate that 298 deaths (95% credible interval [CrI] 91-474) were averted by the THN programme. Of these deaths, 226 (95% CrI 125-340) were averted in 2016, following a rapid scale-up in distribution of kits. We infer a rapid increase in fentanyl adulterant at the beginning of 2016, with an estimated 2·3 times (95% CrI 2·0-2·9) increase from 2015 to 2016. Counterfactual modelling indicated that an earlier scale-up of the programme would have averted an additional 118 deaths (95% CrI 64-207). Our model also indicated that the increase in deaths could parsimoniously be explained through a change in the fentanyl-related overdose rate alone., Interpretation: The THN programme substantially reduced the number of overdose deaths during a period of rapid increase in the number of illicit drug overdoses due to fentanyl in British Columbia. However, earlier adoption and distribution of the THN intervention might have had an even greater impact on overdose deaths. Our findings show the value of a fast and effective response at the start of a synthetic opioid epidemic. We also believe that multiple interventions are needed to achieve an optimal impact., Funding: Canadian Institutes of Health Research Partnerships for Health Systems Improvement programme (grant 318068) and Natural Science and Engineering Research Council of Canada (grant 04611)., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Due to the alarming rise in opioid-related overdose deaths, a public health emergency was declared in British Columbia (BC). In this study, we examined the relationship between illicit fentanyl and heroin found in seized drugs and illicit overdose deaths in BC., Methods: An observational cross-sectional survey was conducted using BC data from Health Canada's Drug Analysis Service, which analyzes drug samples seized by law enforcement agencies, and non-intentional illicit overdoses from the BC Coroner's Service, from 2000 to 2016. Initial scatter plots and subsequent multivariate regression analysis were performed to describe the potential relationship between seized illicit fentanyl samples and overdose deaths and to determine if this differed from seized heroin and overdose deaths. Fentanyl samples were analyzed for other drug content., Results: Fentanyl is increasingly being found combined with other opioid and non-opioid illicit drugs. Strong positive relationships were found between the number of seized fentanyl samples and total overdose deaths (R2 = 0.97) as well as between seized fentanyl and fentanyl-detected overdose deaths (R2 = 0.99). A positive association was found between the number of seized heroin samples and total overdose deaths (R2 = 0.78)., Conclusion: This research contributes to the expanding body of evidence implicating illicit fentanyl use (often combined with heroin or other substances) in overdose deaths in BC. Policy makers and healthcare providers are urged to implement drug treatment and harm reduction strategies for people at risk of overdose associated with current trends in illicit opioid use., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since 2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid test strips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), may help inform people about their exposure risk. The purpose of this study was to determine whether young adults who use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. We hypothesized that those who had ever overdosed would be more willing to use the test strips., Methods: We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September 2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. The survey assessed participant's socio-demographic and behavioral characteristics, overdose risk, as well as suspected fentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine. Participants were then trained to use the test strips and were given ten to take home., Results: Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male, and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%) of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%) participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly all participants (n = 88, 95%) reported that they planned to use the test strips., Conclusions: More than 90% of participants reported willingness to use rapid test strips regardless of having ever overdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young people who use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.

Background: Take home naloxone (THN) programs reduce mortality by training bystanders to respond to opioid overdoses. Clinical observation by the health care team at the Inner City Youth (ICY) program indicated that young adults appeared to enthusiastically participate in the THN program and developed improved relationships with staff after THN training. However, we found a dearth of literature exploring the experiences of young adults with THN programs. This study set out to address this gap and identify suggestions from the young adults for program improvement. The primary research question was "How do street-involved young people experience the THN Program in Vancouver, BC?", Methods: The study was undertaken at the ICY Program. Two peer researchers with lived experience of THN were recruited from ICY and were involved in all phases of the study. The peer researchers and a graduate student facilitated two focus groups and five individual interviews with ICY program participants using a semi-structured interview guide. Audio recordings were transcribed verbatim. The cut-up-and-put-in-folders approach was used to identify emerging themes., Results: The themes that emerged were perceptions of risk, altruism, strengthening relationship with staff, access to training, empowerment, and confidence in ability to respond, and suggestions for youth-friendly training. These themes were then situated within the framework of the health belief model to provide additional context. Participants viewed themselves as vulnerable to overdose and spoke of the importance of expanding access to THN training. Following training, participants reported an increase in internal locus of control, an improved sense of safety among the community of people who use drugs, improved self-esteem, and strengthened relationships with ICY staff. Overall, participants found THN training engaging, which appeared to enhance participation in other ICY programming., Conclusions: Young people perceived THN training as a positive experience that improved relationships with staff. Participant recommendations for quality improvement were implemented within the provincial program.

Background: Although income assistance is an important source of support for low income individuals, there is evidence that adverse outcomes may increase when payments are disbursed on the same day for all recipients. The objective of this study was to assess the temporal patterns and causal relation between population-level illicit drug overdose deaths and income assistance payments using daily mortality data for British Columbia over a period of five years., Methods: Retrospective data on daily mortality due to illicit drug overdose, 2009-2013, were provided by the BC Coroners Service. These data were analyzed using regression models and time series tests for causality in relation to dates of income assistance payments., Results: 1343 deaths due to illicit drug overdose were reported in BC during 2009-2013; 394 occurred during cheque weeks (n=60) and 949 occurred during non-cheque weeks (n=202). Average weekly mortality due to illicit drug overdose was 40% higher during weeks of income assistance payments compared to weeks without payments (P<0.001). Consistent increases in mortality appeared the day after cheque disbursement and were significantly higher for two days, and marginally higher after 3 days, even when controlling for other temporal trends. Granger causality testing suggests the timing of cheque issue was causally linked to increased drug overdose mortality (P<0.001)., Conclusions: Our findings clarify the temporal relation and causal impact of income assistance payments on illicit drug deaths. We estimate 77 avoidable deaths were attributable to the synchronized disbursement of income assistance cheques over the five year period. An important consideration is whether varying the timing of payments among recipients could reduce this excess mortality and the related demands on health and social services., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: This study sought to identify factors that may be associated with help-seeking by witnesses during overdoses where naloxone is administered., Setting: Overdose events occurred in and were reported from the five regional health authorities across British Columbia, Canada. Naloxone administration forms completed following overdose events were submitted to the British Columbia Take Home Naloxone programme., Participants: All 182 reported naloxone administration events, reported by adult men and women and occurring between 31 August 2012 and 31 March 2015, were considered for inclusion in the analysis. Of these, 18 were excluded: 10 events which were reported by the person who overdosed, and 8 events for which completed forms did not indicate whether or not emergency medical help was sought., Primary and Secondary Outcome Measures: Seeking emergency medical help (calling 911), as reported by participants, was the sole outcome measure of this analysis., Results: Medical help was sought (emergency services-911 called) in 89 (54.3%) of 164 overdoses where naloxone was administered. The majority of administration events occurred in private residences (50.6%) and on the street (23.4%), where reported rates of calling 911 were 27.5% and 81.1%, respectively. Overdoses occurring on the street (compared to private residence) were significantly associated with higher odds of calling 911 in multivariate analysis (OR=10.68; 95% CI 2.83 to 51.87; p<0.01), after adjusting for other variables., Conclusions: Overdoses occurring on the street were associated with higher odds of seeking emergency medical help by responders. Further research is needed to determine if sex and stimulant use by the person who overdosed are associated with seeking emergency medical help. The results of this study will inform interventions within the British Columbia Take Home Naloxone programme and other jurisdictions to encourage seeking emergency medical help., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Prescription opioid (PO) use by people who inject drugs (PWID) is a growing public health concern. Non-fatal overdose remains a leading source of morbidity among PWID, however, little is known about the relationship between PO injection and non-fatal overdose in this population. In this study we sought to examine the impact of PO injection on non-fatal overdose among PWID from Vancouver, Canada., Methods: Data were derived from two open prospective cohorts of PWID for the period of December, 2005 to May, 2014. Multivariable generalized estimating equations were used to examine the odds of overdose among those who injected: POs; heroin; and POs and heroin., Results: In total, 1660 PWID (33.7% women) participated in this study. In multivariable analyses, in comparison to those who were injecting non-opioid drugs, exclusive PO injection was not significantly associated with non-fatal overdose (adjusted odds ratio [AOR]: 1.17, 95% confidence interval [CI]: 0.74-1.86). The odds of non-fatal overdose were elevated for heroin injection (AOR: 1.72, 95% CI: 1.31-2.27), but were greatest for those who injected both heroin and POs (AOR: 2.46, 95% CI: 1.83-3.30)., Discussion: Compared to injecting non-opioids, injecting POs exclusively did not increase risk of non-fatal overdose; however, injecting both POs and heroin doubled the risk. This may reflect consistencies in drug potency and composition when POs are used, as well as unique characteristics of exclusive PO injectors. Our findings call for the continued scale-up of evidence-based overdose prevention interventions for people who inject opioids, including POs., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: There is growing concern regarding rising rates of prescription drug-related deaths among the general North American population as well as increasing availability of illicitly obtained prescription opioids. Concurrently among people who inject drugs (IDU), illicit prescription opioid use has increased while non-fatal overdose remains a major source of morbidity., Objectives: To evaluate whether the use of prescription opioids was associated with non-fatal overdose among IDU in Vancouver, Canada., Methods: Data was obtained from two open prospective cohorts of IDU between December 2005 and May 2013. We used generalized estimating equation (GEE) logistic regression to evaluate the association between prescription opioid use and non-fatal overdose, adjusting for various social, demographic, and behavioral factors., Results: There were 1614 IDU, including 541 (33.5%) women, who were recruited and included in this analysis. At baseline, 526 (32.6%) reported using prescription opioids and 118 (7.3%) reported experiencing an overdose in the previous six months. In a multivariable analysis, prescription opioid use remained independently associated with non-fatal overdose (adjusted odds ratio: 1.61, 95% confidence interval: 1.32-1.95), after adjusting for confounders., Conclusion: We observed relatively high rates of prescription opioid use among IDU in this setting, and found an independent association between prescription opioid use and non-fatal overdose. Our data is likely representative of riskier substance use associated with those who use prescription opioids within our sample. Interventions to prevent and respond to overdoses should consider the higher risk profiles of IDU who use prescription opioids.

Background: Although injection drug use is known to result in a range of health-related harms, including transmission of HIV and fatal overdose, little is known about the possible role of synthetic drugs in injection initiation. We sought to determine the effect of crystal methamphetamine use on risk of injection initiation among street-involved youth in a Canadian setting., Methods: We used Cox regression analyses to identify predictors of injection initiation among injection-naive street-involved youth enrolled in the At-Risk Youth Study, a prospective cohort study of street-involved youth in Vancouver, British Columbia. Data on circumstances of first injection were also obtained., Results: Between October 2005 and November 2010, a total of 395 drug injection-naive, street-involved youth provided 1434 observations, with 64 (16.2%) participants initiating injection drug use during the follow-up period, for a cumulative incidence of 21.7 (95% confidence interval [CI] 1.7-41.7) per 100 person-years. In multivariable analysis, recent noninjection use of crystal methamphetamine was positively associated with subsequent injection initiation (adjusted hazard ratio 1.93, 95% CI 1.31-2.85). The drug of first injection was most commonly reported as crystal methamphetamine (14/31 [45%])., Interpretation: Noninjection use of crystal methamphetamine predicted subsequent injection initiation, and crystal methamphetamine was the most commonly used drug at the time of first injection. Evidence-based strategies to prevent transition to injection drug use among crystal methamphetamine users are urgently needed.

Peers, i.e. people with lived/living experience of substance use, are at the forefront of harm reduction initiatives in British Columbia, yet they often lack recognition for their contributions. This study aims to understand the role of peers in overdose response settings and their experiences interacting with emergency service providers (ESPs) within the context of the Good Samaritan Drug Overdose Act (GSDOA). Telephone interviews were conducted with 42 people aged 16 years and older, who were likely to witness and respond to overdoses. Participants were asked about their experiences witnessing or responding to overdoses, and interactions with ESPs. Interview transcripts were analyzed thematically. Peers were often the first to respond to overdoses due to their positioning and saw themselves as having unique expertise in responding to overdoses and connecting with other people who use substances. However, peers perceived several barriers that impacted their ability to respond, including stigmatizing attitudes toward ESPs, lack of recognition, and lack of adequate resources. While policies, such as the GSDOA are in place to promote calling 9-1-1, peers feel confident and competent in responding to overdoses and often consider calling 9-1-1 a waste of resources. There is a need to better recognize and support peers as first responders in overdose contexts. [ABSTRACT FROM AUTHOR]

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.

Background: The increasing toxicity of opioids in the unregulated drug market has led to escalating numbers of overdoses in Canada and worldwide; takehome naloxone (THN) is an evidence-based intervention that distributes kits containing naloxone to people in the community who may witness an overdose. The purpose of this guidance is to provide policy recommendations for territorial, provincial and federal THN programs, using evidence from scientific and grey literature and community evidence that reflects 11 years of THN distribution in Canada. Methods: The Naloxone Guidance Development Group — a multidisciplinary team including people with lived and living experience and expertise of drug use — used the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument to inform development of this guidance. We considered published evidence identified through systematic reviews of all literature types, along with community evidence and expertise, to generate recommendations between December 2021 and September 2022. We solicited feedback on preliminary recommendations through an External Review Committee and a public input process. The project was funded by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Misuse. We used the Guideline International Network principles for managing competing interests. Recommendations: Existing evidence from the literature on THN was of low quality. We incorporated evidence from scientific and grey literature, and community expertise to develop our recommendations. These were in 3 areas: routes of naloxone administration, THN kit contents and overdose response. Take-home naloxone programs should offer the choice of both intramuscular and intranasal formulations of naloxone in THN kits. Recommended kit contents include naloxone, a naloxone delivery device, personal protective equipment, instructions and a carrying case. Trained community overdose responders should prioritize rescue breathing in the case of respiratory depression, and conventional cardiopulmonary resuscitation in the case of cardiac arrest, among other interventions. Interpretation: This guidance development project provides direction for THN programs in Canada in the context of limited published evidence, with recommendations developed in collaboration with diverse stakeholders. [ABSTRACT FROM AUTHOR]

The Good Samaritan Drug Overdose Act, a federal law enacted in Canada in 2017, aims to increase bystander response to overdoses by offering legal protection for arrests related to simple possession at the scene of an overdose. As this legislation suggests, a shift has occurred to view overdose events as a medical issue, constituting a shift in the role of police officers. Our study aimed to uncover the role police perceive for themselves at overdose events. Twenty-two qualitative interviews were conducted with police officers across British Columbia (BC). A thematic analysis was completed to identify patterns in the data. Police officers perceived their primary role was to ensure the safety of first responders and bystanders at overdose events. Some officers favored enforcing mandatory treatment and used coercive practices to ensure overdose victims received further medical care. Policies which reframe overdose events in terms of a health rather than criminal response put into question whether police officers have a role at overdose events and, if so, what it is. Education and awareness are needed to reduce stigma towards people who use drugs, misunderstandings around naloxone and harmful practices such as coercion, at overdose events. [ABSTRACT FROM AUTHOR]

North America has been contending with an unregulated street drug supply in which opioids are often adulterated with illicitly manufactured fentanyl. The unpredictability of composition may result in an increased risk of overdose due to unexpected elevated concentrations of the high-potency drug. Using data from a community-based drug-checking project, we evaluated trends in fentanyl concentration of illicit opioids in the context of an overdose epidemic. Using a quantification model for fentanyl hydrochloride, historical Fourier-transform infrared spectra from opioid drug-checking samples were analyzed to determine fentanyl concentrations. Median monthly fentanyl concentrations were plotted, and polynomial and autoregressive time-series analyses were performed to examine trends over time. A total of 3,621 fentanyl-positive samples were included in the study, spanning November 2017 to December 2019. Monthly median fentanyl concentrations ranged from 4.5% to 10.4%. Time-series analyses indicated that a third-degree polynomial model fit the data well (R 2 = 0.639), suggesting a cyclical pattern in median concentration over time. Notably, absolute variance in fentanyl concentration decreased by an average 0.1% per month (P  < 0.001). Future research should explore the relationship between fentanyl concentration and overdose to identify potential targeted harm-reduction interventions that can respond to changes in observed fentanyl concentration. [ABSTRACT FROM AUTHOR]

Introduction: Take-Home Naloxone programs have been introduced across North America in response to rising opioid overdose deaths. There is currently limited real-world data on bystander naloxone administration, overdose outcomes, and evidence related to adverse events following bystander naloxone administration. Methods: The research team used descriptive statistics from Take-Home Naloxone administration forms. We explored reported demographic variables and adverse events among people who received by-stander administered naloxone in a suspected opioid overdose event between August 31, 2012 and December 31, 2018 in British Columbia. We examined and contextualized differences across years given policy, program and drug toxicity changes. We used multivariate logistic regression to examine whether an association exists between number of ampoules of naloxone administered and the odds that the recipient will experience withdrawal symptoms. Results: A large majority (98.1%) of individuals who were administered naloxone survived their overdose and 69.2% had no or only mild withdrawal symptoms. Receiving three (Adjusted Odds Ratio (AOR) 1.64 (95% Confidence Interval (CI): 1.08–2.48)) or four or more (AOR 2.19 (95% CI: 1.32–3.62)) ampoules of naloxone was significantly associated with odds of moderate or severe withdrawal compared to receiving one ampoule of naloxone. Conclusions: This study provides evidence from thousands of bystander reversed opioid overdoses using Take-Home Naloxone kits in British Columbia, and suggests bystander-administered naloxone is safe and effective for opioid overdose reversal. Data suggests an emphasis on titration during bystander naloxone training in situations where the person experiencing overdose can be adequately ventilated may help avoid severe withdrawal symptoms. We identified a decreasing trend in the likelihood of moderate or severe withdrawal over the study period. [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]

Illicit drug toxicity (i.e. overdose) is the leading cause of unnatural death in British Columbia, with 2021 recording a 26% increase since 2020, and more deaths than recorded in any prior year. This rise has been largely driven by the increased toxicity of the illicit drug supply. While harm reduction and treatment interventions have reduced deaths, these services alone are insufficient to stop the illicit drug toxicity crisis. Calls are mounting to provide access to a "safe supply" of drugs. One size does not fit all, and a diverse range of substances must be made widely available to separate British Columbians from the illicit drug supply. [ABSTRACT FROM AUTHOR]

Background: The distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdose fatalities among people who use drugs. However, little is known about the use of THN among youth who are street-involved. The present study explores knowledge and possession of THN among street-involved youth in a Canadian setting. Methods: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age 14-28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included items related to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors. Multivariable logistic regression models were used to identify factors independently associated with knowledge and possession of THN. Results: Between December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%). While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/white ethnicity was found to be positively associated with both knowledge and possession of THN (both p < 0.05). Public injection drug use in the last 6 months was found to be positively associated with knowledge of THN, while daily heroin use and daily methamphetamine use were associated with possession of THN (all p < 0.05). Male gender was negatively associated with possession of THN (p < 0.05). Conclusions: These findings highlight important gaps between knowledge and possession of THN among youth and the need to increase participation in THN programs among specific populations including non-white and male youth. Further research is needed to gain a better understanding of the barriers that may prevent certain youth from acquiring THN kits. [ABSTRACT FROM AUTHOR]

Objectives: Although take-home naloxone (THN) programs are integral in strategies to prevent overdose deaths among opioid users, the uptake of THN among people who use drugs (PWUD) (including non-opioid users) is unknown. The objectives of this study were to determine awareness, possession, and use of THN among PWUD in Vancouver, Canada, and identify barriers to adopting this strategy. Methods: From December 1, 2014, to May 29, 2015, participants in 2 prospective cohort studies of PWUD in Vancouver completed a standardized questionnaire, which asked about awareness, possession, and use of THN; sociodemographic characteristics; and drug use patterns. We conducted multivariable logistic regression analyses to determine factors independently associated with awareness and possession of THN. Results: Of 1137 PWUD, 727 (64%) reported at least 1 previous overdose ever, and 220 (19%) had witnessed an overdose in the previous 6 months. Although 769 (68%) participants overall reported awareness of THN, only 88 of 392 (22%) opioid users had a THN kit, 18 (20%) of whom had previously administered naloxone. Factors that were positively associated with awareness of THN included witnessing an overdose in the previous 6 months (adjusted odds ratio [aOR] = 2.23; 95% confidence interval [CI], 1.49-3.34; P <.001), possession of THN (aOR = 1.85; 95% CI, 1.11-3.06; P = .02), younger age (aOR = 1.02; 95% CI, 1.01-1.04; P = .003), white race (aOR = 1.67; 95% CI, 1.27-2.19; P <.001), hepatitis C infection (aOR = 1.63; 95% CI, 1.13-2.36; P = .01), residing in Vancouver's Downtown Eastside neighborhood (aOR = 1.93; 95% CI, 1.47-2.53; P < .001), and at least daily heroin injection (aOR = 1.69; 95% CI, 1.09-2.62; P < .02). Conclusion: Efforts to improve knowledge of and participation in the THN program may contribute to reduced opioid overdose mortality in Vancouver. [ABSTRACT FROM AUTHOR]

Background: The British Columbia take-home naloxone (BCTHN) program has been in operation since 2012 and has resulted in the successful reversal of over 581 opioid overdoses. The study aims to explore BCTHN program participant perspectives about the program, barriers to participants contacting emergency services (calling "911") during an overdose, and perspectives of law enforcement officials on naloxone administration by police officers. Methods: Two focus groups and four individual interviews were conducted with BCTHN program participants; interviews with two law enforcement officials were also conducted. Qualitative analysis of all transcripts was performed. Results: Positive themes about the BCTHN program from participants included easy to understand training, correcting misperceptions in the community, and positive interactions with emergency services. Potential barriers to contacting emergency services during an overdose include concerns about being arrested for outstanding warrants or for other illegal activities (such as drug possession) and confiscation of kits. Law enforcement officials noted that warrants were complex situational issues, kits would normally not be confiscated, and admitted arrests for drug possession or other activities may not serve the public good in an overdose situation. Law enforcement officials were concerned about legal liability and jurisdictional/authorization issues if naloxone administration privileges were expanded to police. Conclusions: Program participants and law enforcement officials expressed differing perspectives about warrants, kit confiscation, and arrests. Facilitating communication between BCTHN program participants and other stakeholders may address some of the confusion and remove potential barriers to further improving program outcomes. Naloxone administration by law enforcement would require policies to address jurisdiction/authorization and liability issues. [ABSTRACT FROM AUTHOR]

Background: Fentanyl-detected illicit drug overdose deaths in British Columbia (BC) recently increased dramatically from 13 deaths in 2012 to 90 deaths in 2014, signaling an emerging public health concern. Illicit fentanyl is sold as pills or powders, often mixed with other substances like heroin or oxycodone; reports from coroners suggested that fentanyl was frequently taken unknowingly by people who use drugs. This study aimed to assess the prevalence and characteristics of fentanyl use among clients accessing harm reduction (HR) services in BC. Methods: Participants attending HR services at 17 sites across BC were invited to complete an anonymous questionnaire describing drugs they have used within the last 3 days and provide a urine sample to test for fentanyl. Data from eligible participants were analyzed using descriptive, bivariate, and multivariate statistical methods. Results: Surveys from 17 HR sites were received, resulting in analysis of responses from 242 eligible participants. Most participants used multiple substances (median = 3), with crystal meth (59 %) and heroin (52 %) use most frequently reported. Seventy participants (29 %) tested positive for fentanyl, 73 % of whom did not report using fentanyl. Controlling for age, gender, and health authority, reported use of fentanyl (odds ratio (OR) = 6.13, 95 % confidence interval (CI) = [2.52, 15.78], p < 0.001) and crystal methamphetamine (OR = 3.82, 95 % CI = [1.79, 8.63], p <0.001)use were significantly associated with fentanyl detection. Conclusions: The proportion of those testing positive who did not report knowingly using fentanyl represents a considerable public health concern. The risk of overdose among this vulnerable population highlights the need for targeted HR strategies, such as increased accessibility to naloxone, overdose education, and urine screens. [ABSTRACT FROM AUTHOR]

Background: In August 2012, the British Columbia Take Home Naloxone (BCTHN) program was introduced to help to reduce opioid overdose and its consequences. This study evaluates the BCTHN program, identifying the successes and challenges of implementing a provincial program in Canada. Methods: In this cross-sectional study, we reviewed the records of the BCTHN administrative program to report on program outcomes (participation and overdose reversals). Focus groups and individual interviews were conducted with 40 clients in Vancouver; 12 individual interviews were completed with service providers, police officers and parents of people who use opioids from both the Vancouver and Interior regions of British Columbia. Qualitative data were analyzed using content analysis and a qualitative descriptive approach. Results: As of March 13, 2014, the BCTHN program had been implemented at 40 sites, trained 1318 participants in overdose prevention, recognition and response, distributed 836 kits to clients and received reports of 85 overdose reversals. Stakeholders were supportive of the program, and clients reported greater confidence in response to overdose. Service providers found the program training materials easy to use and that training increased client engagement. Some of the challenges included difficulty in identifying physician willing to prescribe, recruitment of some at-risk populations (e.g., long-term opioid users and patients with chronic pain), and clients' reluctance to call 911 . We also found that the police had some misconceptions about BCTHN. Interpretation: The BCTHN program was easy to implement, empowering for clients and was responsible for reversing 85 overdoses in its first 20 months. We suggest communities across Canada should consider implementing take-home naloxone programs and evaluate their findings. [ABSTRACT FROM AUTHOR]

Abstract: Background: Injection drug use has been identified as a key source of morbidity and mortality, primarily from overdose and the transmission of blood-borne diseases such as HIV. Experts have therefore called for the prioritization of resources toward the prevention of injection drug use. However, these strategies have not been systematically assessed. Methods: PRISMA guidelines were used to systematically review and extract findings from the peer-reviewed literature evaluating the effectiveness of interventions to prevent injecting initiation. We searched 10 English language electronic databases (PubMed, PsycINFO, EMBASE, Cochrane CENTRAL, CINAHL, Web of Science, TOXNET, AIDSLINE, AMED and ERIC), the Internet (Google, Google Scholar), and article reference lists, from database inception to June 1st, 2012. Results: Overall, out of 384 studies identified in the initial search, eight met the inclusion criteria. Studies evaluated four different types of interventions: social marketing, peer-based behavior modification, treatment, and drug law enforcement. Four studies observed a significant effect of the intervention on reducing rates of injecting initiation. Peer-based behavior modification and addiction treatment interventions were found to be most effective. Two of three studies assessing the impact of drug law enforcement on patterns of injecting initiation found no impact on injecting initiation, while one study reported inconclusive results. Conclusion: There exists a limited scientific literature on strategies to prevent injecting initiation. Resources should be allocated toward increased research and development of effective interventions to prevent this phenomenon. [Copyright &y& Elsevier]

Background: Illicit drug overdose deaths (IDD) relate to individual drug dose and context of use, including use with other drugs and alcohol. IDD peaked in British Columbia (BC) in 1998 with 417 deaths, and continues to be a public health problem. The objective of this study was to examine IDD in 2006 in BC by place of residence, injury and death, decedents' age and sex and substances identified. Methods: IDD data was obtained through the BC Coroners Office and entered into SPSS (version 14). Fisher's exact and Pearson's ?2 were used for categorical data; Mann-Whitney U-test for continuous variables. Rates were calculated using 2006 population estimates. Results: We identified 223 IDD in BC; 54 (24%) occurred in Vancouver. Vancouver decedents (compared to those occurring outside Vancouver) were older (mean age 43.9 vs. 39.2 years; p < 0.01) and more likely to be male (90.7% vs. 77.5%; p = 0.03). Provincially Aboriginal ethnicity was reported for 19 deaths; 13 (30.2%) of 43 females and 6 (3.3%) of 180 males (p = < 0.001). Cocaine was identified in 80.3%, opiates 59.6%, methadone 13.9%, methamphetamine/ amphetamine 6.3%, and alcohol in 22.9% of deaths. Poly-substance use was common, 2 substances were identified in 43.8% and 3 or more in 34.5% of deaths. Opiates were more frequently identified in Vancouver compared to outside Vancouver (74.1% vs. 55.0%) p = 0.015. Conclusion: Collaboration with the Coroner's office allowed us to analyze IDD in detail including place of death; cocaine, opiates and poly-substance use were commonly identified. Poly-substance use should be explored further to inform public health interventions. [ABSTRACT FROM AUTHOR]

Background: Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs.Methods: Residents of Rhode Island aged 18-65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses.Discussion: If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose.Trial Registration: ClinicalTrials.gov NCT04372238 . Registered on 01 May 2020. [ABSTRACT FROM AUTHOR]