Search

Opioid overdoses have dramatically increased throughout the past 20 years. Overdoses and other harms associated with the use of the unregulated opioid supply have resulted in a consortium of approaches to reduce drug-related harms, which for decades has included heroin-assisted treatment, although there remains widespread reticence to implement this approach in spite of ample evidence to support its effectiveness. Heroin-assisted treatment is often reserved for persons who have attempted standard opioid agonist treatments - such as methadone - unsuccessfully in order to be eligible for heroin-assisted treatment in countries and regions where available. To date, heroin-assisted treatment is only available in nine countries, mostly in Europe. Heroin-assisted treatment has higher retention rates than other forms of opioid agonist treatments, is cost-effective, reduces overdose morbidity and mortality, and improves public order. Nonetheless, regulatory structures impede its implementation. The present chapter herein presents further details of the evidence on heroin-assisted treatment and newer treatment modality iterations, such as injectable opioid agonist treatment and safe opioid supply programs.&nbsp

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.

Drug checking services (DCS) provide information on drug composition to inform consumption practices and monitor unregulated drug markets. We sought to identify correlates of recent informal DCS use (e.g., fentanyl test strips) and willingness to use a formal DCS (co-located within a supervised consumption site and employing laboratory-based analyses) in Toronto, Canada prior to its implementation.We calculated outcome prevalence based on baseline questionnaire data from a cohort of people who inject drugs in downtown Toronto between November 2018-October 2019 and conducted multivariable Poisson regression analyses. Outcomes included recent (i.e., past six-month) informal DCS use and willingness to use a formal DCS, if implemented. We also conducted a sub-analysis assessing willingness to use a formal DCS following an unexpected drug reaction.Among 604 participants, 12% (n=74) reported recent informal DCS use, 73% (n=442) reported willingness to use a formal DCS, and 88% (n=530) reported willingness to use a formal DCS in response to an unexpected drug reaction. Based on 567 participants with complete data, we found that recent injection at a supervised consumption site or overdose prevention site were both associated with recent informal DCS use (respectively, adjusted prevalence ratio [aPR]=2.44, 95% confidence interval [CI]: 1.11-5.35; aPR=1.78, 95% CI: 1.00-3.15). Recent informal DCS use and recent overdose were both associated with willingness to use a formal DCS (respectively, aPR=1.15, 95% CI: 1.02-1.30; aPR=1.10, 95% CI: 1.00-1.22).Although recent informal DCS use was infrequently reported in our study, willingness to use a formal DCS was high. Our findings indicate a potential role for laboratory-based DCS in mitigating overdose risk among individuals accessing the unregulated drug supply. However, barriers that impede service access or reduce interest should be addressed to ensure equitable use among those at heightened risk of overdose.

Diverse health care leadership teams may improve health care experiences and outcomes for patients. We sought to explore the race and gender of hospital and health ministry executives in Canada and compare their diversity with that of the populations they serve.This cross-sectional study included leaders of Canada's largest hospitals and all provincial and territorial health ministries. We included individuals listed on institutional websites as part of the leadership team if a name and photo were available. Six reviewers coded and analyzed the perceived race and gender of leaders, in duplicate. We compared the proportion of racialized health care leaders with the race demographics of the general population from the 2016 Canadian Census.We included 3056 leaders from 135 institutions, with reviewer concordance on gender for 3022 leaders and on race for 2946 leaders. Reviewers perceived 37 (47.4%) of 78 health ministry leaders as women, and fewer than 5 (7%) of 80 as racialized. In Alberta, Saskatchewan, Prince Edward Island and Nova Scotia, provinces with a centralized hospital executive team, reviewers coded 36 (50.0%) of 72 leaders as women and 5 (7.1%) of 70 as racialized. In British Columbia, New Brunswick and Newfoundland and Labrador, provinces with hospital leadership by region, reviewers perceived 120 (56.1%) of 214 leaders as women and 24 (11.5%) of 209 as racialized. In Manitoba, Ontario and Quebec, where leadership teams exist at each hospital, reviewers perceived 1326 (49.9%) of 2658 leaders as women and 243 (9.2%) of 2633 as racialized. We calculated the representation gap between racialized executives and the racialized population as 14.5% for British Columbia, 27.5% for Manitoba, 20.7% for Ontario, 12.4% for Quebec, 7.6% for New Brunswick, 7.3% for Prince Edward Island and 11.6% for Newfoundland and Labrador.In a study of more than 3000 health care leaders in Canada, gender parity was present, but racialized executives were substantially under-represented. This work should prompt health care institutions to increase racial diversity in leadership.

Background The North American opioid overdose crisis is driven in large part by the presence of unknown psychoactive adulterants in the dynamic, unregulated drug supply. We herein report the first detection of the psychoactive veterinary compound xylazine in Toronto, the largest urban center in Canada, by the city’s drug checking service. Methods Toronto’s Drug Checking Service launched in October 2019. Between then and February 2021, 2263 samples were submitted for analysis. The service is offered voluntarily at harm reduction agencies that include supervised consumption services. Samples were analyzed using gas chromatography–mass spectrometry or liquid chromatography-high resolution mass spectrometry. Targeted and/or untargeted screens for psychoactive substances were undertaken. Results In September 2020, xylazine was first detected by Toronto’s Drug Checking Service. Among samples analyzed from September 2020 to February 2021 expected to contain fentanyl in isolation (610) or in combination with methamphetamine (16), xylazine was detected in 46 samples (7.2% and 12.5% of samples, respectively). Samples were predominantly drawn from used drug equipment. Three of the samples containing xylazine (6.5%) were associated with an overdose. Conclusion We present the first detection of xylazine in Toronto, North America’s fourth-largest metropolitan area. The increased risk of overdose associated with use of xylazine and its detection within our setting highlights the importance of drug checking services in supporting rapid responses to the emergence of potentially harmful adulterants. These data also highlight the clinical challenges presented by the dynamic nature of unregulated drug markets and the concomitant need to establish regulatory structures to reduce their contribution to overdose morbidity and mortality.

Background The increasing incidence of fatal opioid overdose is a public health crisis in Canada. Given growing consensus that this crisis is related to the presence of highly potent opioid adulterants (e.g., fentanyl) in the unregulated drug supply, drug checking services (DCS) have emerged as part of a comprehensive approach to overdose prevention. In Canada’s largest city, Toronto, a network of DCS launched in 2019 to prevent overdose and overdose-related risk behaviors. This network employs mass spectrometry technologies, with intake sites co-located with supervised consumption services (SCS) at three frontline harm reduction agencies. The protocol and rationale for assessing the impact of this multi-site DCS network in Toronto is described herein. The aims of this study are to (1) evaluate the impact of DCS access on changes in and factors influencing overdose and related risk behaviors, (2) investigate the perceived capacity of DCS to prevent overdose, and (3) identify composition (qualitative and quantitative) trends in Toronto’s unregulated drug supply. Methods We will use a parallel-mixed-methods design with complementary data sources (including data from chemical analysis of drug samples, quantitative intake and post-test surveys, SCS, coroners, paramedic services, and qualitative interviews), followed by a meta-inference process wherein results from analyses are synthesized. Results Whereas most DCS globally target “recreational drug users,” in Toronto, this networked DCS will primarily target marginalized people who use drugs accessing frontline services, many of whom use drugs regularly and by injection. This evolution in the application of DCS poses important questions that have not yet been explored, including optimal service delivery models and technologies, as well as unique barriers for this population. Increasing information on the unregulated drug supply may modify the risk environment for this population of people who use drugs. Conclusions This study addresses evidence gaps on the emerging continuum of overdose prevention responses and will generate critical evidence on a novel approach to reducing the ongoing high incidence of drug-related morbidity and mortality in Canada and elsewhere.

BackgroundThe opioid overdose crisis has generated innovative harm reduction and drug market monitoring strategies. In Toronto, Ontario, Canada, a multi-site drug checking service (DCS) pilot project was launched in October 2019. The project provides people who use drugs with information on the chemical composition of their substances, thereby increasing their capacity to make more informed decisions about their drug use and avoid overdose. DCS also provides real-time market monitoring to identify trends in the unregulated drug supply. MethodsSample data were obtained through analyses of drug and used paraphernalia samples submitted anonymously and free of charge to DCS in downtown Toronto from October 10, 2019 to April 9, 2020, representing the first six months of DCS implementation. Analyses were conducted in clinical laboratories using ultra high performance liquid chromatography-high resolution mass spectrometry (UPLC-HRMS), and liquid chromatography or gas chromatography-mass spectrometry (LC-MS, GC-MS) techniques. ResultsOverall, 555 samples were submitted, with 49% (271) of samples that were found to contain high-potency opioids, of which 87% (235) also contained stimulants. Benzodiazepines or related drugs were also found in 21% (116) of all samples, and synthetic cannabinoids in 1% (7) of all samples. Negative effects (including overdose) were reported for 12% (69) of samples submitted for analysis.ConclusionsToronto’s DCS identified a range of high-potency opioids with stimulants, benzodiazepines and related drugs, and a synthetic cannabinoid, AMB-FUBINACA. This information can inform a range of evidence-informed overdose prevention efforts.

THIS PREPRINT HAS BEEN UPDATED AND FORMALLY PUBLISHED IN _ADDICTION_ [https://onlinelibrary.wiley.com/doi/10.1111/add.15734] (HTTPS://DOI.ORG/10.1111/ADD.15734 [https://doi.org/10.1111/add.15734]). A ONE-PAGE FACT SHEET [https://cdpe.org/publication/drug-checking-services-for-people-who-use-drugs-a-systematic-review/] IS ALSO AVAILABLE. BACKGROUND AND AIMS: Drug checking services (DCS) provide people who use drugs (PWUD) with chemical analysis results of their drug samples, while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) influence of DCS on behaviour of PWUD; (b) monitoring of drug markets by DCS; and (c) outcomes related to models of DCS. METHODS: This review followed PRISMA guidelines and was pre-registered in PROSPERO (CRD42018105366). A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science, and Dissertations & Theses Global. Eligible studies were peer-reviewed articles and conference abstracts, or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of DCS using National Institutes of Health tools. RESULTS: We screened 2,463 titles and abstracts and 156 full-texts, with 90 studies meeting inclusion criteria. Most (n=65, 72.2%) were from Europe and used cross-sectional designs (n=79, 87.7%). Monitoring of drug markets by DCS (n=63, 70%) was most commonly reported, followed by influence of DCS on behaviour (n=31, 34.4%) and outcomes related to models of DCS (n=17, 18.9%). The most common outcome measures were detection of unexpected substances (n=50, 55.6%), expected substances (n=44, 48.9%), new psychoactive substances_ _(n=40, 44.4%), and drugs of concern (n=32, 36.5%) by DCS. CONCLUSIONS: Monitoring of drug markets by DCS is well established in Europe and increasingly in North America. There is an emerging evidence base demonstrating the capacity of DCS to influence behavioural intention, and a smaller subset of findings on its impact on the enacted behaviour of PWUD. Further research is needed on enacted behaviours and corresponding health outcomes including overdose, particularly among people who inject drugs or use opioids.

BACKGROUND AND AIMS Drug checking services provide people who use drugs with chemical analysis results of their drug samples, while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) influence of drug checking services on behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services. METHODS Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science, and Dissertations & Theses Global. Eligible studies were peer-reviewed articles and conference abstracts, or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools. RESULTS We screened 2,463 titles and abstracts and 156 full-texts, with 90 studies meeting inclusion criteria. Most (n=65, 72.2%) were from Europe and used cross-sectional designs (n=79, 87.7%). Monitoring of drug markets by drug checking services (n=63, 70%) was the most reported domain, followed by influence of drug checking services on behaviour (n=31, 34.4%) including intent to use, actual use, and disposal of the drug, and outcomes related to models of drug checking services (n=17, 18.9%). The most common outcome measures were detection of unexpected substances (n=50, 55.6%), expected substances (n=44, 48.9%), new psychoactive substances (n=40, 44.4%), and drugs of concern (n=32, 36.5%) by drug checking services. CONCLUSIONS Drug checking services appear to influence behavioural intentions and behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe and increasingly in North America. Concerns about drug contents and negative health consequences facilitate use of drug checking services; lack of concern, trust in drug sellers, lack of accessibility of drug checking services, and legal and privacy concerns are barriers to use.

We were engaged by policy stakeholders to undertake a scoping review of cannabis measurement instruments to inform the evaluation of cannabis legalization impacts. We identified instruments employed in population-based or clinical research to screen and assess cannabis use, including measurement properties. We also identified the content domains included in each instrument and gaps in the measurement of key priority areas as established by policy stakeholders.We followed PRISMA and conducted searches on MEDLINE, PsycINFO, Web of Science, EMBASE, HAPI, Scopus and grey literature. We included publications from the past 15 years that reported the use of an instrument to measure cannabis use. Six study team members calibrated screening and data abstraction, independently identified records and abstracted data.Across 915 included publications, we identified 187 unique instruments covering seven content domains and 35 subdomains. The most identified instruments were the Composite International Diagnostic Interview, the Timeline Follow-Back and the National Epidemiologic Survey on Alcohol and Related Conditions (109/915; 91/915; 64/915). The Canadian Cannabis Survey addressed the most subdomains (22/35). Frequency of use, prevalence of use, and mental health impacts were the most addressed subdomains (110/187; 94/187; 67/187) and storage, growing cannabis, and second-hand exposure were the least addressed (1/187; 4/187; 6/187).This research identified instruments and domains critical to the assessment of public health impacts of cannabis legalization, which can facilitate the harmonization of measures to inform policy development. Future research should develop new instruments for less commonly-addressed constructs and thoroughly explore psychometric properties of existing instruments.

Introduction Novel psychoactive substances (NPS) are increasingly being consumed worldwide, with synthetic cannabinoids and synthetic opioids being the second and third most commonly used NPS, respectively. Certain synthetic cannabinoids can produce significant harms, particularly when used with opioids. The objective of this study was to characterise the presence of synthetic cannabinoids in the unregulated drug supply in three Canadian settings METHODS: In the British Columbia setting, all samples were first analysed at point-of-care using combination Fourier-transform infrared (FTIR) spectroscopy and fentanyl immunoassay strips prior to confirmatory testing using quantitative nuclear magnetic resonance spectroscopy, gas chromatography/mass spectrometry (GC/MS) and/or liquid chromatography/mass spectrometry (LC/MS). In the Toronto, Ontario setting, the samples were analysed directly by GC/MS, LC/MS liquid chromatography-high resolution/mass spectrometry. Results Between January 2018 and December 2019, 38 (2.8%) synthetic cannabinoid samples were detected in the unregulated drug supply (25/909 in British Columbia and 13/440 in Ontario). In British Columbia and Ontario, 76% and 85% of samples, respectively, were expected by individuals to be an opioid. Synthetic cannabinoids detected included AMB-FUBINACA, AB-FUBINACA, 5-fluoro-MDMB-PINACA, and 5-fluoro-MDMB-PICA, and largely co-occurred with fentanyl. In the British Columbia context, Fourier-transform infrared spectroscopy failed to detect synthetic cannabinoid compounds in almost half (48%) of the samples at point-of-care. Discussion and conclusions As point-of-care technologies failed to detect these compounds in many occasions, our findings demonstrate the importance of laboratory confirmatory analysis to identify NPS. Given the high risk of harm associated with the consumption of synthetic cannabinoids, further research should investigate the reasons for adulteration.

ObjectivesTo review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.DesignSystematic review with narrative synthesis.Data sourcesWe searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.Inclusion criteriaPeer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.Data extraction and synthesisTwo independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.ResultsWe screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.ConclusionsStudies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

Drug use is a public health problem associated with high mortality and morbidity, and is often accompanied by suboptimal engagement in health care. Harm reduction is a pragmatic public health approach encompassing all goals of public health: improving health, social well-being, and quality of life. Harm reduction prioritizes improving the lives of people who use drugs in partnership with those served without a narrow focus on abstinence from drugs. Evidence has shown that harm reduction oriented practice can reduce transmission of blood-borne illnesses, and other injection related infections, as well as preventing fatal overdose.