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Competing Interests: Intérêts concurrents : Thomas Brothers déclare avoir reçu une bourse de recherche des Instituts de recherche en santé du Canada (IRSC) et de la Fondation de recherche en médecine interne de l’Université Dalhousie, dans le cadre des travaux présentés ici. Jane Buxton déclare avoir reçu une subvention de l’IRSC à l’Initiative canadienne de recherche sur l’abus de substances (ICRAS) pour le travail supervisé et géré par le Centre de toxicomanie et de santé mentale, dans le cadre des travaux présentés ici. Elle a également reçu des honoraires du Centre canadien sur les dépendances et l’usage de substances (CCDUS) pour la rédaction du préambule d’un rapport, du Centre de contrôle des maladies de la Colombie-Britannique et de l’Université calédonienne de Glasgow; et elle a reçu des honoraires de l’Association des infirmières et infirmiers du Canada et de l’Association canadienne des Infirmières d’hépatologie pour donner des présentations, dans chaque cas indépendamment des travaux soumis. Katherine Rittenbach était une employée des Services de santé de l’Alberta pendant la tenue de l’étude. Pendant la même période, Pamela Leece déclare avoir reçu des subventions des institutions publiques suivantes, administrées par Santé publique Ontario (Agence ontarienne de protection et de promotion de la santé) : IRSC, Santé Canada, Agence de la santé publique du Canada. Tara Elton-Marshall déclare avoir reçu une subvention de l’IRSC, indépendamment des travaux soumis. Charlene Burmeister est directrice générale de la Coalition des toxicomanes du Nord (Coalition of Substance Users of the North). Aucun autre intérêt concurrent n’a été déclaré.

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., Competing Interests: Competing interests: Thomas Brothers reports receiving a research fellowship from the Canadian Institutes of Health Research (CIHR), Dalhousie University Internal Medicine Research Foundation, in support of the present manuscript. Jane Buxton reports receiving a CIHR grant to the Canadian Research Initiative in Substance Misuse (CRISM) for the work overseen and managed by the Centre for Addictions and Mental Health, in support of the present manuscript. Dr. Buxton has also received fees from the Canadian Centre on Substance Use and Addiction to write a foreword for a report, from the British Columbia Centre for Disease Control, and Glasgow Caledonian University; and received honoraria from the Canadian Association of Nurses and the Canadian Association of Hepatitis Nurses for invited presentations, all outside the present work. Katherine Rittenbach was an employee of Alberta Health Services, during the conduct of the study. During the conduct of the study, Pamela Leece reports receiving grants from the following public institutions, administered at Public Health Ontario (Ontario Agency for Health Protection and Promotion): CIHR, Health Canada, Public Health Agency of Canada. Tara Elton-Marshall reports receiving a grant from CIHR, outside the submitted work. Charlene Burmeister is executive director of the Coalition of Substance Users of the North. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Background and Aim: The rate of drug poisoning (or overdose) deaths in England and Wales has risen annually since 2010. We aimed to measure seasonal and other cyclical changes in these deaths within years., Methods: We used the daily count of deaths due to drug poisoning in England and Wales between 1 January 1993 and 31 December 2018 to investigate variation by season, weekday, week-of-month and public holiday. We used Poisson regression to estimate the count of deaths per day for each of these variables and peak-to-low ratios. We also stratified the analysis by time period and whether an opioid was mentioned on the death certificate., Results: 78 583 deaths occurred between 1993 and 2018, increasing from 5.50 (95% confidence interval [CI] = 5.24-5.77) per day in 1993 to 13.18 (95% CI = 12.66-13.72) per day in 2018. The rate peaked in Spring and was 1.07 (95% CI = 1.04-1.09) times higher in April than in October. This seasonal pattern emerged in the past decade and was only present for opioid-related deaths. The rate at New Year was 1.28 (95% CI = 1.17-1.41) times higher than on non-holidays; and this peak was only present for deaths that were not related to opioids. The rate was higher on Saturday than on other weekdays. We did not find evidence that the number of deaths varied by week-of-month., Conclusions: Deaths due to drug poisoning in England and Wales are seasonal and peak in Spring and briefly at New Year. This suggests a role of external triggers. These seasonal variations are small compared with long-term increases in drug-related deaths., (© 2023 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background: People who use heroin and other illicit opioids are at high risk of fatal overdose in the days after hospital discharge, but the reasons for this risk have not been studied., Methods: We used the National Programme on Substance Abuse Deaths, a database of coroner reports for deaths following psychoactive drug use in England, Wales, and Northern Ireland. We selected reports where the death occurred between 2010 and 2021, an opioid was detected in toxicology testing, the death was related to nonmedical opioid use, and death was either during an acute medical or psychiatric hospital admission or within 14 days after discharge. We used thematic framework analysis of factors that may contribute to the risk of death during hospital admission or after discharge., Results: We identified 121 coroners' reports; 42 where a patient died after using drugs during hospital admission, and 79 where death occurred shortly after discharge. The median age at death was 40 (IQR 34-46); 88 (73%) were male; and sedatives additional to opioids were detected at postmortem in 88 cases (73%), most commonly benzodiazepines. In thematic framework analysis, we categorised potential causes of fatal opioid overdose into three areas: (a) hospital policies and actions. Zero-tolerance policies mean that patients conceal drug use and use drugs in unsafe places such as locked bathrooms. Patients may be discharged to locations such as temporary hostels or the street while recovering. Some patients bring their own medicines or illicit opioids due to expectations of low-quality care, including undertreated withdrawal or pain; (b) high-risk use of sedatives. People may increase sedative use to manage symptoms of acute illness or a mental health crisis, and some may lose tolerance to opioids during a hospital admission; (c) declining health. Physical health and mobility problems posed barriers to post-discharge treatment for substance use, and some patients had sudden deteriorations in health that may have contributed to respiratory depression., Conclusion: Hospital admissions are associated with acute health crises that increase the risk of fatal overdose for patients who use illicit opioids. Hospitals need guidance to help them care for this patient group, particularly in relation to withdrawal management, harm reduction interventions such as take-home naloxone, discharge planning including continuation of opioid agonist therapy during recovery, management of poly-sedative use, and access to palliative care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lewer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The COVID-19 pandemic has impacted supervised consumption site (SCS) operations in Montréal, Canada, potentially including changes in SCS visits, on-site emergency interventions, injection of specific drugs, and distribution of harm reduction materials., Method: We used administrative data from all four Montréal SCS from 1 March 2018 - 28 February 2021 to conduct an interrupted time series study with 13 March 2020 as the intervention point. We employed segmented regression using generalised least squares fit by maximum likelihood. We analysed monthly SCS visits and materials distributed as counts, and emergency interventions and drugs injected as proportions of visits., Results: SCS visits (level change = -1,286; 95% CI [-1,642, -931]) and the proportion of visits requiring emergency intervention (level = -0.27% [-0.47%, -0.06%]) decreased immediately in March 2020, followed by an increasing trend in emergency interventions (slope change = 0.12% [0.10%, 0.14%]) over the ensuing 12 months. Over the same period, the proportion of injections involving opioids increased (slope = 0.05% [0.03%, 0.07%]), driven by increasing pharmaceutical opioid and novel synthetic opioid injections. Novel synthetic opioids were the drugs most often injected prior to overdose. The proportion of injections involving unregulated amphetamines increased immediately (level = 7.83% [2.93%, 12.73%]), then decreased over the next 12 months (slope = -1.86% [-2.51%, -1.21%]). There was an immediate increase in needle/syringe distribution (level = 16,552.81 [2,373, 30,732]), followed by a decreasing trend (slope = -2,398 [-4,218, -578]). There were no changes in pre-existing increasing trends in naloxone or fentanyl test strip distribution., Conclusion: Reduced SCS use and increasing emergency interventions at SCS are cause for serious concern. Findings suggest increased availability of novel synthetic opioids in Montréal, heightening overdose risk., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

In the context of the US overdose crisis, improving access to medications for opioid use disorder is urgently needed. The Canadian model of methadone treatment, whereby clinicians can prescribe methadone for opioid use disorder in office-based settings and methadone can be dispensed through community pharmacies, offers a compelling model for adoption in the US. Office-based settings in which methadone is prescribed often adopt a rapid-access model, allowing walk-in appointments and same-day initiation of methadone. Prescribing authorization requirements have been relaxed over the past 25 years to improve access to methadone. This paper summarizes the model of office-based methadone prescribing in Canada, highlighting the regulatory structures, prescribing practices, and interprofessional collaborations that enable methadone treatment in office-based settings. Potential implementation strategies for adopting office-based prescribing in the US are discussed., (Copyright © 2022 American Society of Addiction Medicine.)

Background: Take-Home Naloxone (THN) is a core intervention aimed at addressing the toxic illicit opioid drug supply crisis. Although THN programs are available in all provinces and territories throughout Canada, there are currently no standardized guidelines for THN programs. The Delphi method is a tool for consensus building often used in policy development that allows for engagement of stakeholders., Methods: We used an adapted anonymous online Delphi method to elicit priorities for a Canadian guideline on THN as a means of facilitating meaningful stakeholder engagement. A guideline development group generated a series of key questions that were then brought to a 15-member voting panel. The voting panel was comprised of people with lived and living experience of substance use, academics specializing in harm reduction, and clinicians and public health professionals from across Canada. Two rounds of voting were undertaken to score questions on importance for inclusion in the guideline., Results: Nine questions that were identified as most important include what equipment should be in THN kits, whether there are important differences between intramuscular and intranasal naloxone administration, how stigma impacts access to distribution programs, how effective THN programs are at saving lives, what distribution models are most effective and equitable, storage considerations for naloxone in a community setting, the role of CPR and rescue breathing in overdose response, client preference of naloxone distribution program type, and what aftercare should be provided for people who respond to overdoses., Conclusions: The Delphi method is an equitable consensus building process that generated priorities to guide guideline development., (© 2022. The Author(s).)

Background: During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program., Methods: We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol., Results: Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day)., Conclusions: COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)