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Background: Overdose prevention sites (OPS) are a harm reduction strategy that offer people who use drugs a variety of resources including but not limited to sterile supplies, linkage to healthcare resources, and intervention if an overdose occurs. OPS operate in over 120 countries and evidence has demonstrated they are an effective harm reduction strategy. Despite their success elsewhere, OPS remain federally illegal in the United States and thus there is limited research on their implementation and outcomes in the United States. This study aimed to identify Colorado healthcare providers' knowledge and attitudes about OPS and determine if there is a correlation between healthcare providers with more knowledge about OPS having a more positive attitude about OPS. Methods: An electronic survey was distributed to healthcare providers in Colorado. Responses were collected in early 2022 and recorded on a 5-point Likert scale. Mean scores between 1 and 5 were calculated for each participant and analysis of variance methods were used to determine correlating demographic factors. A p value of ≤ 0.05 was used to determine statistical significance of all findings. Results: This study included 698 participants. A Pearson correlation analysis revealed a strong positive relationship (r = 0.76, p < 0.0001) between provider knowledge and attitudes about OPS. Emergency medicine providers scored the highest in mean knowledge and attitude scores in comparison to all other specialties. Respondents affiliated with a harm reduction center exhibited the highest mean knowledge and attitude scores. Mean knowledge and attitude scores generally rose with respondents' increasing encounters with people who inject drugs in a typical workday, except when reaching nine or more encounters, where a sharp decline occurred. Conclusions: Our study highlights the importance of education, exposure to harm reduction strategies, and inter-specialty collaboration in shaping healthcare providers' knowledge and attitudes about OPS. The positive correlation between providers' knowledge and attitudes about OPS suggests that educating healthcare providers on harm reduction strategies, specifically OPS, may lead to reduced stigmatization of OPS among healthcare professionals. [ABSTRACT FROM AUTHOR]

Abstract Background Overdose prevention sites (OPS) are a harm reduction strategy that offer people who use drugs a variety of resources including but not limited to sterile supplies, linkage to healthcare resources, and intervention if an overdose occurs. OPS operate in over 120 countries and evidence has demonstrated they are an effective harm reduction strategy. Despite their success elsewhere, OPS remain federally illegal in the United States and thus there is limited research on their implementation and outcomes in the United States. This study aimed to identify Colorado healthcare providers’ knowledge and attitudes about OPS and determine if there is a correlation between healthcare providers with more knowledge about OPS having a more positive attitude about OPS. Methods An electronic survey was distributed to healthcare providers in Colorado. Responses were collected in early 2022 and recorded on a 5-point Likert scale. Mean scores between 1 and 5 were calculated for each participant and analysis of variance methods were used to determine correlating demographic factors. A p value of ≤ 0.05 was used to determine statistical significance of all findings. Results This study included 698 participants. A Pearson correlation analysis revealed a strong positive relationship (r = 0.76, p

BackgroundA staff e-learning course was developed to prepare for scaling up a national take-home naloxone (THN) program in Norway. The aims of the study were to (a) describe participant characteristics for those that completed a THN e-learning course, (b) compare opioid overdose knowledge scores before and after e-learning course completion, and (c) to explore subsequent THN distribution by those trained.MethodsThis was a quasi-experimental pre-test, post-test longitudinal cohort study of individuals completing a THN e-learning course from April 2021 to May 2022. Frequency analyses were performed for participant characteristics and subsequent naloxone distributions at 1-week and 1-month follow-up. The opioid overdose knowledge scale (OOKS) was used to measure pre-test-post-test knowledge among participants. Wilcoxon signed-rank test was performed for comparison between pre-test and post-test. Effect size was calculated using Cohen criteria.ResultsIn total, 371 individuals were included in this study. Most were either nurses or social workers (n = 277, 75%). Participant knowledge increased by medium or large effect for all items measured. At 1-month follow-up, 15% reported naloxone distribution. During the study period, 94 naloxone kits were distributed. Major reasons for not distributing were “clients not interested”, “workplace not distributing” and “workplace in process of distributing”.ConclusionsOur findings suggest that an e-learning course is equally effective in terms of knowledge transfer as an in-person classroom setting, and may provide engagement in terms of naloxone distribution. However, our findings also emphasize the importance of clear implementation routines, including support from central coordinators to optimize the implementation process.

Abstract Background The United States (US) continues to experience unprecedented rates of overdose mortality and there is increased need to identify effective harm reduction practices. Research from Canada describes cannabis donation through harm reduction agencies as an adjunctive strategy to mitigate the negative consequences of more harmful drugs. This case study describes the operational logistics, feasibility, and potential benefits of a cannabis donation program that was operated through a harm reduction program in rural Michigan. Case presentation We applied a community driven research approach to gather information from harm reduction program staff about the implementation and evolution of cannabis donation efforts in Michigan. We also examined 20-months (September 2021 through May 2023) of administrative data from a cannabis company to compare the sale and donation of cannabis products. Ten cannabis-experienced harm reduction clients received cannabis donations, with clinical staff determining client interest and appropriateness, and providing weekly pick-up or delivery. To expand product availability and sustainability, we examined administrative data from a commercialcannabis company that volunteered to provide donations. This administrative data suggests that while flower products constitute most of the adult and medical sales, edible, oil, and topical products predominated donations. Further, cost analysis suggests that donations represent only 1% of total gross sales and account for much less than the expected yearly donation amount. Conclusions Research suggests there is potential to reduce alcohol and drug use related harms of more dangerous substances through substitution with cannabis. This case study is the first to document cannabis donation as a harm reduction practice in the US and suggests potential for sustainability dependent on state laws. Findings from this case study provide a starting point for inquiry into cannabis donation as a harm reduction strategy in the US; future research is needed to fully understand the individual-level outcomes, public health impacts, necessary legal regulations, and best practices for cannabis donation programs through harm reduction organizations.

In Canada, there has been a substantial increase of opioid overdoses in recent years. PROFAN, a peer-led overdose prevention initiative, was successfully implemented in Montreal, Quebec, for people who use drugs (PWUD), or those likely to witness overdoses. The worsening of the situation during the COVID-19 pandemic sparked the need to expand the program across the province. Individual interviews were conducted with 17 key informants from 12 health regions to identify implementation facilitators and barriers. A thematic analysis was conducted based on emerging themes. Four main facilitators were reported: 1) presence of an active peer network involved with harm reduction in the region, 2) collaboration among community and public health sectors, 3) stakeholders' awareness of opioid situation, and 4) perceived appropriateness of training. Six main barriers also emerged: 1) geographical isolation, 2) existing offer of similar services, 3) difficulty reaching isolated PWUD, 4) stigmatization of PWUD, 5) unwillingness of stakeholders to address situation, and 6) lack of funding stability. The expansion achieved by the PROFAN program highlights the ability of a peer-driven community organization to lead an overdose prevention program when provided with funding and support from government health agencies and partnerships with other organizations such as addiction worker associations. [ABSTRACT FROM AUTHOR]

Background: The United States (US) continues to experience unprecedented rates of overdose mortality and there is increased need to identify effective harm reduction practices. Research from Canada describes cannabis donation through harm reduction agencies as an adjunctive strategy to mitigate the negative consequences of more harmful drugs. This case study describes the operational logistics, feasibility, and potential benefits of a cannabis donation program that was operated through a harm reduction program in rural Michigan. Case presentation: We applied a community driven research approach to gather information from harm reduction program staff about the implementation and evolution of cannabis donation efforts in Michigan. We also examined 20-months (September 2021 through May 2023) of administrative data from a cannabis company to compare the sale and donation of cannabis products. Ten cannabis-experienced harm reduction clients received cannabis donations, with clinical staff determining client interest and appropriateness, and providing weekly pick-up or delivery. To expand product availability and sustainability, we examined administrative data from a commercialcannabis company that volunteered to provide donations. This administrative data suggests that while flower products constitute most of the adult and medical sales, edible, oil, and topical products predominated donations. Further, cost analysis suggests that donations represent only 1% of total gross sales and account for much less than the expected yearly donation amount. Conclusions: Research suggests there is potential to reduce alcohol and drug use related harms of more dangerous substances through substitution with cannabis. This case study is the first to document cannabis donation as a harm reduction practice in the US and suggests potential for sustainability dependent on state laws. Findings from this case study provide a starting point for inquiry into cannabis donation as a harm reduction strategy in the US; future research is needed to fully understand the individual-level outcomes, public health impacts, necessary legal regulations, and best practices for cannabis donation programs through harm reduction organizations. [ABSTRACT FROM AUTHOR]

Providing family members of individuals with opioid use disorders (OUD) naloxone is a cost-effective way to prevent overdose deaths. However, misconceptions and negative attitudes towards naloxone hinder family engagement with naloxone programs. This study examines factors associated with knowledge and attitudes toward naloxone among adults with close family members who misused opioids. Adults with family members (parent, step-parent, child, spouse, sibling, or step-sibling) who misused opioids (N = 299) completed a web-based survey. Participants were recruited through treatment providers, community groups, and social media. Surveys assessed naloxone knowledge, attitudes toward overdose response, demographics, completion of naloxone training, attitude toward medications for OUD, and family members' overdose history. Multiple regression was used to identify factors associated with naloxone knowledge (Model 1) and attitudes toward overdose response (Model 2). A graduate degree (B =.35, p <.003) and a history of overdose (B = 0.21, p =.032) were associated with greater naloxone knowledge. Age (B =.11, p <.001), race/ethnicity (B = -1.39, p =.037), naloxone training (B = 2.70, p <.001), and more positive attitude toward medications for OUD (B = 1.50, p =.003) were associated with attitudes toward overdose response. Family members are potential allies in reducing drug overdose deaths, and families may need broader education about naloxone. Awareness of previous overdose was associated with greater naloxone knowledge. Findings related to race/ethnicity suggest the need to reach family members of minoritized racial groups to provide access to naloxone training. Findings point to where education and distribution efforts may focus on increasing knowledge and improving attitudes among those closest to people with OUD. [ABSTRACT FROM AUTHOR]

Abstract Background With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply. Methods Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply. Results A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00–2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20–3.60)) of prescribed safer supply access, compared to people who did not access these services. Conclusions Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.

Abstract Background Shifts in the US drug supply, including the proliferation of synthetic opioids and emergence of xylazine, have contributed to the worsening toll of the overdose epidemic. Drug checking services offer a critical intervention to promote agency among people who use drugs (PWUD) to reduce overdose risk. Current drug checking methods can be enhanced to contribute to supply-level monitoring in the USA, overcoming the selection bias associated with existing supply monitoring efforts and informing public health interventions. Methods As a group of analytical chemists, public health researchers, evaluators, and harm reductionists, we used a semi-structured guide to facilitate discussion of four different approaches for syringe service programs (SSPs) to offer drug checking services for supply-level monitoring. Using thematic analysis, we identified four key principles that SSPs should consider when implementing drug checking programs. Results A number of analytical methods exist for drug checking to contribute to supply-level monitoring. While there is likely not a one-size-fits-all approach, SSPs should prioritize methods that can (1) provide immediate utility to PWUD, (2) integrate seamlessly into existing workflows, (3) balance individual- and population-level data needs, and (4) attend to legal concerns for implementation and dissemination. Conclusions Enhancing drug checking methods for supply-level monitoring has the potential to detect emerging threats in the drug supply and reduce the toll of the worsening overdose epidemic.

Background: Shifts in the US drug supply, including the proliferation of synthetic opioids and emergence of xylazine, have contributed to the worsening toll of the overdose epidemic. Drug checking services offer a critical intervention to promote agency among people who use drugs (PWUD) to reduce overdose risk. Current drug checking methods can be enhanced to contribute to supply-level monitoring in the USA, overcoming the selection bias associated with existing supply monitoring efforts and informing public health interventions. Methods: As a group of analytical chemists, public health researchers, evaluators, and harm reductionists, we used a semi-structured guide to facilitate discussion of four different approaches for syringe service programs (SSPs) to offer drug checking services for supply-level monitoring. Using thematic analysis, we identified four key principles that SSPs should consider when implementing drug checking programs. Results: A number of analytical methods exist for drug checking to contribute to supply-level monitoring. While there is likely not a one-size-fits-all approach, SSPs should prioritize methods that can (1) provide immediate utility to PWUD, (2) integrate seamlessly into existing workflows, (3) balance individual- and population-level data needs, and (4) attend to legal concerns for implementation and dissemination. Conclusions: Enhancing drug checking methods for supply-level monitoring has the potential to detect emerging threats in the drug supply and reduce the toll of the worsening overdose epidemic. [ABSTRACT FROM AUTHOR]

Background: With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply. Methods: Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply. Results: A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00–2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20–3.60)) of prescribed safer supply access, compared to people who did not access these services. Conclusions: Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia. [ABSTRACT FROM AUTHOR]

Background: To help prevent overdose deaths involving prescription drugs, accurate linkage of prescription drug monitoring program (PDMP) records for individual patients is essential. Objectives: To compare the accuracy of the linkage program used by California's PDMP against various record linkage programs with respect to accuracy in deduplicating patient identities in the PDMP, with implications for identifying high‐risk opioid use and outlier behaviors. Research Design: We evaluated California's program, Link Plus, LinkSolv, and The Link King on 557 861 PDMP identity records with addresses in two 3‐digit zip code areas for patients who filled a controlled substance prescription in 2013. Manual review was performed on a stratified sample of 720 paired records identified as matches by at least one program. Measures: We estimated sensitivity and positive predictive value, and computed PDMP patient alerts for the patient entities identified by each program. Results: Sensitivity was 95% for LinkSolv and The Link King, 84% for Link Plus, and 73% for California's program; positive predictive value was ≥93% for all programs. The number of patient entities prompting a PDMP alert was similar among the programs for all alerts except multiple provider episodes (obtaining prescriptions from ≥6 prescribers or ≥6 pharmacies in the last 6 months), which were 10.9%, 26.6%, and 16.9% greater using The Link King, Link Plus, and LinkSolv, respectively, compared to California's program. Conclusions: PDMPs should assess the accuracy of record linkage algorithms and the impacts of these algorithms on patient safety alerts and develop national best practices for PDMP record linkage. [ABSTRACT FROM AUTHOR]

The opioid overdose epidemic continues to disproportionately impact underserved rural areas throughout the nation, with many of these rural areas experiencing greater opioid-related mortality rates than their urban counterparts. With limited treatment infrastructure and resources, two rural communities in Southeast Utah utilized community-based participatory research collaboration principles to develop, implement, and evaluate a series of evidence-based community opioid education events. This practical and quantitative study surveying 123 participants describes the collaborative efforts of two rural communities in addressing the devastating impacts of the opioid overdose epidemic and reflects on the success of the events via descriptive analysis of summary data. These events increased participants' reported perceptions of and knowledge in four main education areas: stigma reduction, prevention and treatment awareness, naloxone education and use, and resource location awareness. Post-event surveys further supported these results, revealing improved learning in each of these four areas, indicating increased knowledge toward opioid use disorder treatments and stigma reduction. In addition, participants identified key takeaways such as local resource awareness and dismantling stigma as effective strategies to reduce the negative effects of the opioid overdose epidemic. This model for rural community education supports previous research and serves as an effective strategy of public health practice to address the opioid overdose epidemic on a local level. [ABSTRACT FROM AUTHOR]

Abstract Background The potential public health benefits of supervised smoking facilities (SSFs) are considerable, and yet implementation of SSFs in North America has been slow. We conducted this study to respond to significant knowledge gaps surrounding SSF utilization and to characterize substance use, harm reduction practices, and service utilization following the onset of the COVID-19 pandemic. Methods A questionnaire was self-administered at a single site by 175 clients using an outdoor SSF in Vancouver, Canada, between October–December 2020. Questionnaire responses were summarized using descriptive statistics. Multinomial logistic regression techniques were used to examine factors associated with increased SSF utilization. Results Almost all respondents reported daily substance use (93% daily use of opioids; 74% stimulants). Most used opioids (85%) and/or methamphetamine (66%) on the day of their visit to the SSF. Respondents reported drug use practice changes at the onset of COVID-19 to reduce harm, including using supervised consumption sites, not sharing equipment, accessing medically prescribed alternatives, cleaning supplies and surfaces, and stocking up on harm reduction supplies. Importantly, 45% of SSF clients reported using the SSF more often since the start of COVID-19 with 65.2% reporting daily use of the site. Increased substance use was associated with increased use of the SSF, after controlling for covariates. Conclusions Clients of the SSF reported increasing not only their substance use, but also their SSF utilization and harm reduction practices following the onset of COVID-19. Increased scope and scale of SSF services to meet these needs are necessary.

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Objectives: Overdose is a major cause of preventable death among persons living with HIV. This study aimed to increase HIV clinicians' naloxone prescribing, which can reduce overdose mortality. Methods: We enrolled 22 Ryan White–funded HIV practices and implemented onsite, peer-to-peer training, posttraining academic detailing, and pharmacy peer-to-peer contact around naloxone prescribing in a nonrandomized stepped wedge design. Human immunodeficiency virus clinicians completed surveys to assess attitudes toward prescribing naloxone at preintervention and 6 and 12 months postintervention. Aggregated electronic health record data measured the number of patients with HIV prescribed and the number of HIV clinicians prescribing naloxone by site over the study period. Models controlled for calendar time and clustering of repeated measures among individuals and sites. Results: Of 122 clinicians, 119 (98%) completed a baseline survey, 111 (91%) a 6-month survey, and 93 (76%) a 12-month survey. The intervention was associated with increases in self-reported “high likelihood” to prescribe naloxone (odds ratio [OR], 4.1 [1.7-9.4]; P = 0.001). Of 22 sites, 18 (82%) provided usable electronic health record data that demonstrated a postintervention increase in the total number of clinicians who prescribed naloxone (incidence rate ratio, 2.9 [1.1-7.6]; P = 0.03) and no significant effects on sites having at least one clinician who prescribed naloxone (OR, 4.1 [0.7-23.8]; P = 0.11). The overall proportion of all HIV patients prescribed naloxone modestly increased from 0.97% to 1.6% (OR, 2.2 [0.7-6.8]; P = 0.16). Conclusion: On-site, practice-based, peer-to-peer training with posttraining academic detailing was a modestly effective strategy to increase HIV clinicians' prescribing of naloxone. [ABSTRACT FROM AUTHOR]

Abstract Background Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs. Methods Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically. Results TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk. Conclusions This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.

Abstract Background Community-based harm reduction vending machines (HRVM) are not new to the field of public health; numerous countries have implemented them in response to the needs of people who use drugs over the last three decades. However, until recently, few existed in the United States. Given the rapidity with which communities are standing up harm reduction vending machines, there is a pressing need for a consolidated examination of implementation evidence. This scoping review summarizes existing literature using multiple implementation science frameworks. Methods The scoping review was conducted in five stages including (1) Identify the research question; (2) Identify relevant studies; (3) Select the publications based on inclusion/exclusion criteria; (4) Review and extract data; and, (5) Summarize results. PubMed, Embase, and Web of Science were searched and authors screened publications in English from any year. Data were extracted by applying implementation constructs from RE-AIM and the Consolidated Framework for Implementation Research (CFIR). Both frameworks provided a useful lens through which to develop knowledge about the facilitators and barriers to HRVM implementation. The review is reported according to PRISMA guidelines. Results After applying the full inclusion and exclusion criteria, including the intervention of interest (“vending machines”) and population of interest (“people who use drugs”), a total of 22 studies were included in the scoping review. None of the studies reported on race, making it difficult to retroactively apply a racial equity lens. Among those articles that examined effectiveness, the outcomes were mixed between clear effectiveness and inconclusive results. Evidence emerged, however, to address all CFIR constructs, and positive outcomes were observed from HRVM’s after-hour availability and increased program reach. Recommendations HRVM implementation best practices include maximizing accessibility up to 24 h, 7 days a week, offering syringe disposal options, ensuring capability of data collection, and allowing for anonymity of use. Organizations that implement HRVM should establish strong feedback loops between them, their program participants, and the broader community upfront. Considerations for future research include rigorous study designs to evaluate effectiveness outcomes (e.g. reduced drug overdose deaths) and examination of HRVM reach among ethnic and racial communities.

People who use drugs (PWUD) are the most directly affected by the overdose epidemic. However, they are not often targets of overdose education and naloxone distribution (OEND) programs. Instead, these programs target friends or family members of people prescribed opioids or general community members. This study aimed to understand the perspectives of PWUD and community naloxone distributors on OEND program design. We used a community-based participatory research model to elucidate participant perspectives on what OEND programs should look like in the context of each individual’s specific risk environment. We conducted semi-structured in-depth interviews with PWUD and naloxone distributors (n = 30) in New Brunswick and Newark, New Jersey between February and November of 2022. We analyzed interviews using thematic analysis and identified the following themes: increasing naloxone knowledge, peer-based naloxone access, increasing PWUD-informed OEND program design, and desired broader OEND program scope. All Participants knew what naloxone was and emphasized that naloxone needed to be ubiquitous in the community. Participants prioritized peer-based distribution, integrating distribution into community organizations, and addressing psychosocial issues related to naloxone administration and drug use. In summary, PWUD and community naloxone distributors emphasized peer-led community naloxone distribution that prioritized novel ways for PWUD to access naloxone. OEND program design should prioritize PWUD’s perspectives and direct community naloxone distribution.

Background: Opioid overdose death rates increased during the COVID-19 pandemic. Disruptions in community-based naloxone trainings could have reduced the likelihood of overdose reversal and increased the chances of a fatal overdose. We investigated changes in the number of people trained in naloxone administration and distribution in Maryland before, during, and after COVID-related stay-at-home orders. Methods: Data on naloxone training are from the Maryland Department of Health. We used interrupted time series models to estimate changes in average monthly number of people trained: [1] pre-interruption (4/2019–3/2020), [2] 1-month post-interruption (4/2020–5/2020), and [3] 12-month post-interruption (4/2020–3/2021). Trainees were classified as lay (e.g., people who use drugs) or occupational (e.g., law enforcement officers and harm reduction workers) responders. Results: There were 101,332 trainees; 54.1% lay, 21.5% occupational, and 23.4% unknown responder status. We observed a decrease in the average monthly number of trainees in the pre-interruption period (-235, p

Background: The potential public health benefits of supervised smoking facilities (SSFs) are considerable, and yet implementation of SSFs in North America has been slow. We conducted this study to respond to significant knowledge gaps surrounding SSF utilization and to characterize substance use, harm reduction practices, and service utilization following the onset of the COVID-19 pandemic. Methods: A questionnaire was self-administered at a single site by 175 clients using an outdoor SSF in Vancouver, Canada, between October–December 2020. Questionnaire responses were summarized using descriptive statistics. Multinomial logistic regression techniques were used to examine factors associated with increased SSF utilization. Results: Almost all respondents reported daily substance use (93% daily use of opioids; 74% stimulants). Most used opioids (85%) and/or methamphetamine (66%) on the day of their visit to the SSF. Respondents reported drug use practice changes at the onset of COVID-19 to reduce harm, including using supervised consumption sites, not sharing equipment, accessing medically prescribed alternatives, cleaning supplies and surfaces, and stocking up on harm reduction supplies. Importantly, 45% of SSF clients reported using the SSF more often since the start of COVID-19 with 65.2% reporting daily use of the site. Increased substance use was associated with increased use of the SSF, after controlling for covariates. Conclusions: Clients of the SSF reported increasing not only their substance use, but also their SSF utilization and harm reduction practices following the onset of COVID-19. Increased scope and scale of SSF services to meet these needs are necessary. [ABSTRACT FROM AUTHOR]

It has been estimated that chronic non cancer pain (CNCP) affects more than 30% of people worldwide. Correspondingly, prescriptions for individuals experiencing CNCP have increased in recent years. While opioids can minimize pain, they also pose a risk of overdose. In 2019 in Scotland, prescription analgesics contributed to, or were implicated in, approximately 19% of drug related deaths. The experiences of those prescribed opioids for CNCP and family members, particularly their perceptions of overdose risk, are under-explored in the literature. This study aimed to address this gap by exploring how individuals and family members perceive the issue of overdose in relation to opioid analgesics, and their views of overdose prevention and potential interventions. Lived experiences from 12 individuals and family members living in Scotland were shared via in-depth qualitative interviews and analysed using NVivo and Framework. Coding was iterative and deductive. Analysis generated five themes: (1) living with pain and experiencing stigma; (2) taking more medication than prescribed; (3) side effects of medication; (4) overdose risk and prevention: the role of prescribers; and (5) attitudes towards naloxone to address overdose risk. Study findings have implications for the development of interventions and broader responses to reduce overdose risk among this group. [ABSTRACT FROM AUTHOR]

There have been increases in prescriptions of high strength opioids for chronic non-cancer pain (CNCP), but CNCP patients perceive themselves as being at low risk of opioid overdose and generally have limited overdose awareness. This study examined how an overdose prevention intervention (opioid safety education, naloxone training, and take-home naloxone (THN)) delivered by community pharmacists for patients prescribed high-strength opioids for CNCP would work in practice in Scotland. Twelve patients received the intervention. CNCP patients and Community Pharmacists were interviewed about their experiences of the intervention and perceptions of its acceptability and feasibility. CNCP patients did not initially perceive themselves as being at risk of overdose but, through the intervention, developed insight into opioid-related risk and the value of naloxone. Pharmacists also identified patients' low risk perceptions and low overdose awareness. While pharmacists had positive attitudes towards the intervention, they outlined challenges in delivering it under time and resource pressures and during the COVID-19 pandemic. Overdose prevention interventions are required in the CNCP population as this group has elevated risk factors for overdose but are commonly overlooked. Customised overdose prevention interventions for CNCP patients attend to gaps in overdose awareness and risk perceptions in this population. [ABSTRACT FROM AUTHOR]

Abstract Background COVID-19 dramatically limited the scale and scope of local health department (LHD) work, redirecting resources to the response. However, the need for essential public health services—including substance use prevention—was not reduced. Methods We examined six quantitative data sources, collected between 2016 and 2021, to explore the impact of the COVID-19 pandemic on LHD substance use-related services. Results Before the pandemic, the proportion of LHDs providing some level of substance use prevention services was increasing, and many were expanding their level of provision. During the pandemic, 65% of LHDs reduced their level of substance use-related service provision, but the proportion of LHDs providing some level of services remained steady from prior to COVID-19. Conclusion We discuss policy recommendations to mitigate the risk of service disruptions during future public health emergencies, including direct and flexible funding for LHDs and federal directives declaring substance use prevention services as essential.

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

Abstract Introduction The majority of opioid-related deaths occur in suburban communities with people who use alone in their homes. Background To reach individuals who use substances alone, Grenfell Ministries, a not for profit agency in Hamilton Ontario created a phone-based supervision service to target individuals who use substances alone. Methodology Grenfell implemented a phone line service initially as a 3-month pilot eventually operationalized to a 24/7 phoneline to determine utilization of the service and test operational feasibility. Metrics such as timing of use, number of unique clients using the service and substances used were measured. Results The line was provincially utilized. Between February 1st and December 10, 2020, the line was used 64 times. Most calls occurred in the evening, with fentanyl being the most used substance. EMS was dispatched 3 times for overdoses, of which 2 individuals were successfully resuscitated, and one individual’s status being unknown. Conclusion The overdose prevention line can be implemented to support individuals who use alone. The service can successfully reduce risk of death from individuals who use alone and could be a valuable tool in addressing the opioid crisis. Further study needs to be conducted to determine its efficacy and safety in supporting clients who use alone.

Abstract Background Emergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription. Methods We conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences. Results Of the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge. Conclusions Naloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings.

Abstract Background People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy. Methods Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to ‘family’ was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique. Results Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care. Conclusions Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

Abstract In Scotland drug policy and consequently the progress of evidence-based treatment options has been struggling for many years. Political inaction is brought about by a complex chain of legal and operational obstructions with local authorities deferring to national Government which in turn is paralysed by international convention. Scotland represents a case study demonstrating the adverse consequences of management by non medical requirements rather than implementation of a clinically proven progressive policy. The difficulty of translating theory and evidence into practice is acknowledged but suggestions are made for pragmatic and humanitarian initiatives.

Background: Community-based harm reduction vending machines (HRVM) are not new to the field of public health; numerous countries have implemented them in response to the needs of people who use drugs over the last three decades. However, until recently, few existed in the United States. Given the rapidity with which communities are standing up harm reduction vending machines, there is a pressing need for a consolidated examination of implementation evidence. This scoping review summarizes existing literature using multiple implementation science frameworks. Methods: The scoping review was conducted in five stages including (1) Identify the research question; (2) Identify relevant studies; (3) Select the publications based on inclusion/exclusion criteria; (4) Review and extract data; and, (5) Summarize results. PubMed, Embase, and Web of Science were searched and authors screened publications in English from any year. Data were extracted by applying implementation constructs from RE-AIM and the Consolidated Framework for Implementation Research (CFIR). Both frameworks provided a useful lens through which to develop knowledge about the facilitators and barriers to HRVM implementation. The review is reported according to PRISMA guidelines. Results: After applying the full inclusion and exclusion criteria, including the intervention of interest ("vending machines") and population of interest ("people who use drugs"), a total of 22 studies were included in the scoping review. None of the studies reported on race, making it difficult to retroactively apply a racial equity lens. Among those articles that examined effectiveness, the outcomes were mixed between clear effectiveness and inconclusive results. Evidence emerged, however, to address all CFIR constructs, and positive outcomes were observed from HRVM's after-hour availability and increased program reach. Recommendations: HRVM implementation best practices include maximizing accessibility up to 24 h, 7 days a week, offering syringe disposal options, ensuring capability of data collection, and allowing for anonymity of use. Organizations that implement HRVM should establish strong feedback loops between them, their program participants, and the broader community upfront. Considerations for future research include rigorous study designs to evaluate effectiveness outcomes (e.g. reduced drug overdose deaths) and examination of HRVM reach among ethnic and racial communities. [ABSTRACT FROM AUTHOR]

Background: Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs. Methods: Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically. Results: TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk. Conclusions: This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs. [ABSTRACT FROM AUTHOR]

Abstract Background Evidence suggests people who inject drugs (PWID) prescribed opioid agonist treatment (OAT) are less likely to provide injection drug use (IDU) initiation assistance. We investigated the association between OAT engagement and providing IDU initiation assistance across poly-drug use practices in Vancouver, Canada. Methods Preventing Injecting by Modifying Existing Responses (PRIMER) is a prospective study seeking to identify structural interventions that reduce IDU initiation. We employed data from linked cohorts of PWID in Vancouver and extended the findings of a latent profile analysis (LPA). Multivariable logistic regression models were performed separately for the six poly-drug use LPA classes. The outcome was recently assisting others in IDU initiation; the independent variable was recent OAT engagement. Results Among participants (n = 1218), 85 (7.0%) reported recently providing injection initiation assistance. When adjusting for age and sex, OAT engagement among those who reported a combination of high-frequency heroin and methamphetamine IDU and low-to-moderate-frequency prescription opioid IDU and methamphetamine non-injection drug use (NIDU) was associated with lower odds of IDU initiation assistance provision (Adjusted Odds Ratio [AOR]: 0.18, 95% CI: 0.05–0.63, P = 0.008). Significant associations were not detected among other LPA classes. Conclusions Our findings extend evidence suggesting that OAT may provide a population-level protective effect on the incidence of IDU initiation and suggest that this effect may be specific among PWID who engage in high-frequency methamphetamine and opioid use. Future research should seek to longitudinally investigate potential causal pathways explaining the association between OAT and initiation assistance provision among PWID to develop tailored intervention efforts.

Background: Expanding access to naloxone is one of the most impactful interventions in decreasing opioid-related mortality. However, state distribution rates of naloxone are insufficient to meet community need. The current study sought to better understand this gap by focusing on state policies that may facilitate or impede naloxone distribution in four states highly impacted by fatal opioid overdoses – Kentucky, Massachusetts, New York, and Ohio. Methods: We provide a descriptive analysis of the policy landscape impacting naloxone distribution through pharmacy and community channels in the four states participating in the HEALing Communities Study (HCS). Publicly available data and the expertise of the research team were used to describe each state's naloxone access laws (NALs), Medicaid coverage of naloxone, and community overdose education and naloxone distribution infrastructure. Data presented in this study represent the most current policy landscape through September 2022. Results: Variation exists between specific components of the NALs of each state, the structure of Medicaid coverage of naloxone, and the community distribution infrastructure networks. Massachusetts and New York have a statewide standing order, but other states use different strategies short of a statewide standing order to expand access to naloxone. Quantity limits specific to naloxone may limit access to Medicaid beneficiaries in some states. Conclusion: States participating in the HCS have developed innovative but different mechanisms to ensure naloxone access. Policies were dynamic and moved towards greater access. Research should consider the policy landscape in the implementation and sustainability of interventions as well as the analysis of outcomes.

Background: Opioid-related overdose deaths recently accelerated. In response, overdose education and naloxone distribution (OEND) has been implemented widely, though access remains sparse in rural Appalachia. Despite increasing OEND, risk factors for non-evidence-based overdose responses among the training-naïve remain unknown. Methods: We enrolled 169 adults who use prescription opioids non-medically and reside in rural West Virginia (August 2014-March 2015). Participants were interviewed about witnessing overdose (lifetime and prior-year), characteristics of the most recent overdose, responses to the overdose, and OEND acceptability. Logistic regression was used to assess factors associated with non-evidence-based responses to overdose. Results: Among the 73 participants who witnessed an opioid-related overdose, the majority (n = 53, 73%) reported any non-evidence-based responses. Participants were significantly more likely to report a non-evidence-based response when victims were unresponsive (OR = 3.36; 95% CI = 1.07, 10.58). Common evidence-based responses included staying with the victim until help arrived (n = 66, 90%) and calling 911 (n = 63, 86%), while the most common non-evidence-based responses were hitting or slapping the victim (n = 37, 51%) and rubbing the victim with ice or placing them in a cold shower or bath (n = 14, 19%). While most (n = 60, 82%) had never heard of OEND, the majority (n = 69, 95%) were willing to train, particularly those reporting non-evidence-based responses (n = 52, 98%). Conclusions: These findings underscore the need to expand access to OEND in rural communities and indicate OEND is acceptable to training-naïve individuals who use opioids in rural Appalachia. Given the "harm reduction deserts" in the region, approaches to expand OEND should be pursued. [ABSTRACT FROM AUTHOR]

Background: The opioid epidemic is a growing crisis worldwide. While many interventions have been put in place to try to protect people from opioid overdoses, they typically rely on the person to take initiative in protecting themselves, requiring forethought, preparation, and action. Respiratory depression or arrest is the mechanism by which opioid overdoses become fatal, but it can be reversed with the timely administration of naloxone. Objective: In this study, we described the development and validation of an opioid overdose detection radar (ODR), specifically designed for use in public restroom stalls. In-laboratory testing was conducted to validate the noncontact, privacy-preserving device against a respiration belt and to determine the accuracy and reliability of the device. Methods: We used an ODR system with a high-frequency pulsed coherent radar sensor and a Raspberry Pi (Raspberry Pi Ltd), combining advanced technology with a compact and cost-effective setup to monitor respiration and detect opioid overdoses. To determine the optimal position for the ODR within the confined space of a restroom stall, iterative testing was conducted, considering the radar's bounded capture area and the limitations imposed by the stall's dimensions and layout. By adjusting the orientation of the ODR, we were able to identify the most effective placement where the device reliably tracked respiration in a number of expected positions. Experiments used a mock restroom stall setup that adhered to building code regulations, creating a controlled environment while maintaining the authenticity of a public restroom stall. By simulating different body positions commonly associated with opioid overdoses, the ODR's ability to accurately track respiration in various scenarios was assessed. To determine the accuracy of the ODR, testing was performed using a respiration belt as a reference. The radar measurements were compared with those obtained from the belt in experiments where participants were seated upright and slumped over. Results: The results demonstrated favorable agreement between the radar and belt measurements, with an overall mean error in respiration cycle duration of 0.0072 (SD 0.54) seconds for all recorded respiration cycles (N=204). During the simulated overdose experiments where participants were slumped over, the ODR successfully tracked respiration with a mean period difference of 0.0091 (SD 0.62) seconds compared with the reference data. Conclusions: The findings suggest that the ODR has the potential to detect significant deviations in respiration patterns that may indicate an opioid overdose event. The success of the ODR in these experiments indicates the device should be further developed and implemented to enhance safety and emergency response measures in public restrooms. However, additional validation is required for unhealthy opioid-influenced respiratory patterns to guarantee the ODR's effectiveness in real-world overdose situations. [ABSTRACT FROM AUTHOR]

Background: Settings throughout Canada and the USA continue to experience crises of overdose death due to the toxic unregulated drug supply. Injecting drugs alone limits the potential for intervention and has accounted for a significant proportion of overdose deaths, yet the practice remains understudied. We sought to examine the practice of injecting alone among people who inject drugs (PWID) in Vancouver, Canada. Methods: Data were derived from two prospective cohorts of people who use drugs between June 2016 and November 2018. This analysis was restricted to participants who, in the previous 6 months, reported any injection drug use. Rates of injecting alone were categorized as always, usually, sometimes, or occasionally. We fit a multivariable generalized linear mixed model to identify factors associated with injecting drugs alone. Results: Among 1070 PWID who contributed 3307 observations, 931 (87%) reported injecting alone at least once during the study period. In total, there were 729 (22%) reports of always injecting alone, 722 (21.8%) usually, 471 (14.2%) sometimes, 513 (15.5%) occasionally, and 872 (26.4%) never. In a multivariable model, factors positively associated with injecting drugs alone included male sex (adjusted odds ratio [AOR] 1.69; 95% confidence interval [CI] 1.20–2.37), residence in the Downtown Eastside neighbourhood (AOR 1.43; 95% CI 1.08–1.91), binge drug use (AOR 1.36; 95% CI 1.08–1.72), and experiencing physical or sexual violence or both (AOR 1.43; 95% CI 1.00–2.03). Protective factors included Indigenous ancestry (AOR 0.71; 95% CI 0.52–0.98) and being in a relationship (AOR 0.30; 95% CI 0.23–0.39). Conclusion: We observed that injecting alone, a key risk for overdose mortality, was common among PWID in Vancouver. Our findings underline the need for additional overdose prevention measures that are gender-specific, culturally appropriate, violence- and trauma-informed, and available to those who inject alone. [ABSTRACT FROM AUTHOR]

Background: COVID-19 dramatically limited the scale and scope of local health department (LHD) work, redirecting resources to the response. However, the need for essential public health services-including substance use prevention-was not reduced.Methods: We examined six quantitative data sources, collected between 2016 and 2021, to explore the impact of the COVID-19 pandemic on LHD substance use-related services.Results: Before the pandemic, the proportion of LHDs providing some level of substance use prevention services was increasing, and many were expanding their level of provision. During the pandemic, 65% of LHDs reduced their level of substance use-related service provision, but the proportion of LHDs providing some level of services remained steady from prior to COVID-19.Conclusion: We discuss policy recommendations to mitigate the risk of service disruptions during future public health emergencies, including direct and flexible funding for LHDs and federal directives declaring substance use prevention services as essential. [ABSTRACT FROM AUTHOR]

Abstract Objectives In May 2018, St. Paul’s Hospital (SPH) in Vancouver (Canada) opened an outdoor peer-led overdose prevention site (OPS) operated in partnership with Vancouver Coastal Health and RainCity Housing. At the end of 2020, the partnered OPS moved to a new location, which created a gap in service for SPH inpatients and outpatients. To address this gap, which was magnified by the COVID-19 pandemic, SPH opened a nurse-led OPS in February 2021. This paper describes the steps leading to the implementation of the nurse-led OPS, its impact, and lessons learned. Methods Four steps paved the way for the opening of the OPS: (1) identifying the problem, (2) seeking ethics guidance, (3) adapting policies and practices, and (4) supporting and training staff. Results The OPS is open between 10:00 and 20:00 and staffed by two nurses per shift. It is accessible to all patients including inpatients, patients in the Emergency Department, and patients attending outpatient services. Between February 1, 2021 and October 23, 2021, the OPS recorded 1612 visits for the purpose of injection, for an average weekly visit number of 42. A total of 46 overdoses were recorded in that 9-month period. Thirty-seven (80%) required administration of naloxone and 12 (26%) required a code blue response. Conclusions Due to the unique nature of our OPS, we learned many important lessons in the process leading to the opening of the site and the months that followed. We conclude the paper with lessons learned grouped into six main categories, namely engagement, communication, access, staff education and support, data collection, and safety.

Objective. Describe how navigator programs from three New England states (Connecticut, Maine, and Massachusetts) function to connect individuals using court services to community-based treatment and services. Hypothesis. Implementation science frameworks can be used to analyze how multiple court programs function to inform replication and address gaps in the use of overdose prevention strategies. Method. The Template for Intervention Description and Replication (TIDieR) Implementation informed semi-structured interviews as part of an exploratory mixed-methods analysis of court navigator programs. Analysis of interviews based on the TIDieR and administrative data on client contacts (n = 436) were analyzed. A subsample of clients with additional background information (n = 249) was used to examine court navigator recommendations. Results. The TIDieR revealed court navigator programs shared basic intervention characteristics but varied dramatically by resources and organization contexts. Nearly half (46.5%) of clients were self-referred and more than two-thirds (69.1%) approved follow-up but varied by program. Of those allowing follow-up, more than one-third (35.7%) had previously experienced an overdose. Court navigators were significantly more likely to refer clients with a history of overdose to locations where they can receive naloxone (the opioid overdose antidote) though only one program had naloxone on hand. Conclusion. Navigators are employed by community organizations with access to courthouses to provide resources to those passing through. These efforts can be implemented to support linkages to treatment and services but there is a significant gap in the allocation of overdose prevention strategies in court settings and court navigator programs have the potential to address this unmet need. [ABSTRACT FROM AUTHOR]

In 2022, the Drug User Liberation Frontʼs Compassion Club and Fulfillment Centre emerged as a groundbreaking initiative and research endeavor aimed at addressing the alarming rise in overdose deaths within Vancouverʼs Downtown Eastside. As the first of its kind, this pioneering model operated as a non-profit, low-barrier, and non-medicalized approach to regulating the volatility of the content of the illicit drug market in order to prevent overdose deaths. Going beyond traditional overdose prevention methods, the Drug User Liberation Frontʼs Compassion Club and Fulfillment Centre not only provided supervised consumption services, but also supplied rigorously tested cocaine, heroin, and methamphetamine at cost to club members. This intrinsic case study offers a unique perspective on the operation of Drug User Liberation Frontʼs Compassion Club and Fulfillment Centre, delving into its inception, development, implementation, and the challenges it faced in its operation. Ultimately, the insights garnered from the Drug User Liberation Frontʼs Compassion Club and Fulfillment Centre hold significant value for others interested in establishing similar programs or exploring de-medicalized approaches regulating substances in order to prevent overdose deaths. [ABSTRACT FROM AUTHOR]

Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019–January 2020, May–June 2021, and May–June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (−0.26, 95% confidence interval, CI: −0.48, −0.05, p = 0.015), OEND in Other/Non-traditional Venues (−0.53, 95% CI: - 0.84, −0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (−0.34, 95% CI: −0.62, −0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues. • Scaling up overdose education and naloxone distribution (OEND) is challenging. • Barriers to scaling up medication for opioid use disorder (MOUD) are substantial. • The Communities That HEAL (CTH) intervention reduced perceived barriers to scaling up OEND and MOUD in some venues. • The CTH's impact's on perceived barriers did not vary by rural-urban status. [ABSTRACT FROM AUTHOR]

The United States drug overdose epidemic has reached an all-time high, with 2020 provisional mortality data indicating that over 90,000 lives were lost to drug overdose in the 12-months ending in December 2020. The overdose epidemic has evolved over time with respect to the substances involved in overdose deaths and also with respect to the geographic distribution and epidemiology of deaths involving specific substances. Thus, a nimble approach to addressing the epidemic and preventing future overdoses is needed. CDC’s response to the overdose epidemic supports implementation efforts at the state and local levels, where partners can better detect and respond to the evolving drug overdose landscape and implement prevention measures that meet their needs. CDC’s framework for responding to the overdose epidemic focuses on five areas: (1) conducting surveillance and research; (2) building state, local and tribal capacity; (3) supporting providers, health systems and payers; (4) partnering with public safety; and (5) empowering consumers to make safe choices. Central to informing the implementation of evidence-based strategies to prevent drug overdose is rigorous research that undergirds the evidence. This Commentary describes recent investments in overdose prevention research and outlines opportunities for ensuring that future research efforts allow for the flexibility necessary to effectively respond to the continually evolving epidemic.

Background: The purpose of this study was to identify characteristics of people who respond to two or more overdoses (i.e., multiple overdose responders; MOR) compared to those who respond to zero or one, and the association between MOR status and changes in network size. Methods: Secondary analysis of data from a randomized trial among 199 PWUD in Baltimore, MD (2016-2019). We used cross-tabulation, χ2, and ANOVA models to identify cross-sectional associations between overdose response and demographic, drug use, and network size; and ANCOVA models to examine the relationship between baseline MOR status and change in network size. Results: From the cohort of 199, 185 people provided data on overdose response at baseline; 197 provided data at 6-month follow-up. At baseline, 27.6% of participants were classified as MORs (ever). Correlates of MOR status included homelessness; age; injecting drug use; quality of interactions with police (respectful vs. not); and use of powder cocaine, prescription opioids, and heroin. MORs had larger networks and their network size decreased more over time, but the association was not statistically significant. At follow-up, 16% were classified as MORs (past 6 months); correlates of follow-up MOR status were similar to those at baseline. Conclusions: Overdose prevention interventions rely on PWUD to respond to overdoses. Identifying factors associated with MOR status could increase intervention efficiency and providing MORs with support could increase sustainability. Our findings suggest that PWUD experiencing homelessness, using cocaine and heroin, and demonstrating increased salience of overdose in their lives would benefit from targeted programs.

Objectives: Xylazine is a tranquilizer commonly added into the illicit drug supply and a likely contributor to overdoses because it does not respond to naloxone reversal. The objective of this study was to performa retrospective data analysis on xylazine-positive samples collected from patients in various outpatient healthcare settings to illustrate geographic distribution and common copositive substances, which may also contribute to risk of adverse events. Methods: Samples for which providers ordered testing for xylazinewere subjected to enzymatic hydrolysis, extracted, and analyzed using liquid chromatography-tandem mass spectrometry. Retrospective analysis was performed on xylazine-positive samples collected from April 2021 to March 2022, to include geographic location and copositive substances. Results: Xylazinewas identified in 413 of 59,498 samples from adults aged 20-73 years and originated from 25 of the 39 states where xylazine testing was ordered. The most common routine substances detected with xylazine were fentanyl, buprenorphine, naloxone, cocaine, D-methamphetamine, and delta-9-tetrahydrocannabinol. The most common designer drugs detected included fentanyl analogs, isotonitazene, and designer benzodiazepines. Conclusions: Xylazine is geographically spread throughout the United States, indicative of a wide incorporation into the illicit drug supply. These findings differ from previous studies in that these samples originated from healthcare providers in routine care settings, where other reports typically involve overdose deaths. This analysis illustrates that routine testing for xylazine in outpatient settings can afford providers the opportunity to educate individuals and adjust harm reduction measures to potentially mitigate overdose risk. [ABSTRACT FROM AUTHOR]

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

Background: People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy. Methods: Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique. Results: Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care. Conclusions: Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond. [ABSTRACT FROM AUTHOR]

In Scotland drug policy and consequently the progress of evidence-based treatment options has been struggling for many years. Political inaction is brought about by a complex chain of legal and operational obstructions with local authorities deferring to national Government which in turn is paralysed by international convention. Scotland represents a case study demonstrating the adverse consequences of management by non medical requirements rather than implementation of a clinically proven progressive policy. The difficulty of translating theory and evidence into practice is acknowledged but suggestions are made for pragmatic and humanitarian initiatives. [ABSTRACT FROM AUTHOR]