BACKGROUND:Recent North American trends point towards increased smoking of unregulated drugs and decreased injecting. While supervised consumption sites (SCS) offer a monitored environment for people who use drugs (PWUD), these sites have been less likely to accommodate inhalation in Canada. The objective of this study was to determine the factors associated with willingness to use supervised inhalation sites. METHODS:We performed a cross-sectional survey of 499 PWUD in Edmonton, Canada. We used descriptive statistics to characterize willingness to use a supervised inhalation site and logistic regression to examine factors associated with willingness. RESULTS:Of 467 participants who reported smoking their drugs, the mean age was 43.7 years with 303 (64.9%) identifying as men and 320 (68.5%) identifying as Indigenous. A large proportion (64.9%, n = 303) of participants who smoked their drugs indicated a willingness to use a supervised inhalation site. While having overdosed by accident in the last 6 months (aOR = 2.70, 95% CI: 1.31-5.81) and having borrowed, lent or shared a pipe in the last 6 months (aOR = 2.22, 95% CI: 1.01-4.88) were both positively associated with willingness to use a supervised inhalation site, participants who stated that stimulants were the drugs smoked most frequently in the past 6 months (aOR = 0.43, 95% CI: 0.20-0.88) and those who reported always smoking in public places (aOR = 0.53, 95% CI: 0.28-0.97) were less likely to report willingness to use a supervised inhalation site. CONCLUSIONS:Our results outline significant interest among PWUD in supervised inhalation sites and suggest that individuals who have recently borrowed or shared a pipe or recently experienced an overdose would be more likely to use these sites. Implementation of these sites must include decolonizing approaches that create a welcoming space for Indigenous people.

This paper examines how systems of income support for Canadians living with chronic pain operate as forms of structural violence. Drawing on a secondary analysis of data from an institutional ethnographic study of chronic pain and marginalization, the paper traces the everyday "work" required to access and maintain Long-Term Disability and Workers' Compensation benefits. Through analysis of 28 interviews with people who identified as both socioeconomically marginalized and living with chronic pain, we developed four themes: 1) the work of filling out forms; 2) misalignment between bureaucratic requirements and the ambiguity of chronic pain; 3) bureaucracy as harm and 4) long term disability and the retrenchment of poverty. Overall, participants' accounts demonstrate that bureaucratic processes are labyrinthine, opaque, and frequently harmful - aggravating both physical pain and emotional distress. We show that claimants must continually prove their incapacity while navigating systems that presume claimant deceit, producing suffering that is embedded within institutional design rather than resulting from individual malice. The analysis demonstrates how the very processes intended to provide economic security instead deepen precarity and mistrust, forcing marginalized people with pain to perform narratives of deficiency to access insufficient support. Conceptually, the paper expands the application of structural violence to the chronic pain context, arguing that the bureaucratic management of disability-related income support constitutes a normalized form of harm that sustains social inequities. It portrays Canada's income support systems as a labyrinth that traps people in poverty while demanding proof of worthiness for relief.

Public drug use in urban central business districts (CBDs) presents an urgent public health challenge in Canada. People who use drugs (PWUD) in CBDs navigate intersecting risks related to criminalization, stigma, hostile architecture, urban redevelopment, and limited access to essential services—factors that compound health disparities and increase morbidity and mortality. Yet CBDs also function as sites of informal social networks, mutual aid, and adaptive survival strategies that, while precarious, constitute critical resources for daily safety and belonging. This focused ethnographic study, conducted in Edmonton’s CBD between July 2022 and September 2023, draws on 25 semi-structured interviews and over 170 h of embedded field immersion to investigate how intersecting environmental forces shape the daily lives of PWUD. Using Collins et al.’s (2019) intersectional risk environment framework and Duff’s (2009) enabling environment concept, we analyzed how physical, social, economic, and policy environments—operating across micro and macro levels—produce differential harms and, simultaneously, generate precarious yet meaningful sites of connection, resourcefulness, and collective care. Findings reveal how displacement, over-policing, and gentrification-driven spatial change coexist with participants’ place-based belonging, moral economies of reciprocity, and culturally grounded survival knowledge. We argue that effective interventions must account for this co-production of risk and enabling conditions and that urban governance must center the voices of those most structurally affected.

The COVID-19 pandemic and Canada’s drug poisoning crisis placed exceptional demands on emergency departments (ED). We aimed to explore the impact of these intersecting crises from the perspectives of ED staff to understand how EDs can improve care and protect the health and well-being of patients who use opioids, ED staff, and healthcare providers. We conducted a focused ethnographic study involving 29 semi-structured interviews with ED staff who cared for patients who use opioids during the pandemic. Interviews explored ED staff perspectives on how the pandemic impacted care for patients who use opioids and how EDs can better serve this population. We conducted latent content analysis and main theme generation was informed by the socioecological model. Four main themes emerged. First, there was a change in patient behaviors, which impacted provider–patient relationships. Second, hospital pandemic policies and resource limitations created new barriers to care. Third, community service alterations, including the shift to virtual care and uncertain availability of services, further complicated patient care. Finally, participants highlighted opportunities to strengthen systems of care, including enhanced hospital addiction resources, improved addiction care training, expanded harm reduction services, and more robust community services. The COVID-19 pandemic highlighted significant changes in ED care delivery for patients who use opioids. Efforts to enhance EDs should include anticipating the needs of people who use substances and the healthcare providers who care for them to mitigate unintended harm and ensure a more resilient healthcare system.

INTRODUCTION:Emergency departments (EDs) are important health care access points for people who use drugs (PWUD), but little is known about whether the onset of the COVID-19 pandemic was associated with changes in opioid-related emergency presentations. We investigated whether (1) the onset of the COVID-19 pandemic was associated with any change in average rates of opioid-related ED visits in Alberta; and (2) this varied across regions with different COVID-19 case rates. METHODS:We conducted maximum-likelihood interrupted time series analyses to compare opioid-related ED visits during the "prepandemic period" (3 March 2019-1 March 2020) and the "pandemic period" (2 March 2020-14 March 2021). RESULTS:There were 8883 and 11 657 opioid-related ED visits during the prepandemic and pandemic periods, respectively. The onset of the COVID-19 pandemic was associated with an increase in opioid-related ED visits (Edmonton: IRR = 1.37, 95% CI: 1.30- 1.44, p < 0.05; Calgary: IRR = 1.14, 95% CI: 1.07-1.20, p < 0.05; Other health zones: IRR = 1.14, 95% CI: 1.07-1.21, p < 0.05). Changing COVID-19 case counts did not correspond with changing rates of opioid-related ED visits across regions. CONCLUSION:The increase in opioid-related ED visits associated with the onset of the COVID-19 pandemic was unrelated to COVID-19 case prevalence in Alberta.

BACKGROUND:A polycrisis of rising drug toxicity, pervasive houselessness, pandemic-related disruptions, coloniality and climate disasters is creating and exacerbating health inequities for People Who Use/Have Used Drugs (PWUD). This confluence of intersecting health, socio-political and environmental issues highlights the need for community-driven and adaptive innovation to address inequities in complex systems of care. To inform service innovations in an inner city social service hub in Edmonton, Alberta, we co-created a process that centres PWUD in health service planning and prioritization. METHODS:Using a community-based participatory research methodology informed by complexity theory, we conducted research with PWUD using SenseMaker micro-narratives and optional arts-based asset-mapping. Academic and peer researchers co-developed the study with input from the PWUD community and collected data at social service hubs and on outreach in the community. An iterative four-phase approach to research design, data collection and analysis guided the study: (i) Pre-data collection, (ii) Formal data collection, (iii) Readjusting, and (iv) Accountability. RESULTS:This methodology paper describes how our four-phase framework guided the study and promoted a dynamic and accountable approach to centering PWUD in health system innovation. Over five months, 215 PWUD participants shared narratives and rich insights into their experiences with healthcare access, harm reduction, and community support. Our results emphasise the importance of taking time to orient to each other and the community, even as a diverse team with many preexisting relationships. An iterative data analysis process allowed for adjustments in real-time to guide research focus, ensuring equity-oriented engagement with structurally vulnerable groups. Accountability began with research design, was maintained throughout data collection by creating safety for participants, and then defined the final phase of the research where we created an accessible final report and are now working with the host nonprofit partner and community members on action-oriented responses to the narratives shared. CONCLUSIONS:Meaningful engagement with PWUD in co-creating health system innovation requires relational and adaptive methodologies. The process-focused results of this study demonstrate how community-based participatory research informed by complexity theory can enable accountable healthcare innovation amidst a changing social and political landscape. We conclude with a set of recommendations for co-creation and other peer-centred approaches that prioritize PWUD voices in developing effective health services.

IntroductionLes services d’urgence sont des points d’accès important aux soins de santé pour les personnes qui consomment des drogues, mais on ne sait pas véritablement si le début de la pandémie de COVID-19 a été associé à des changements dans les visites à l’urgence liées aux opioïdes. Nous avons cherché à savoir si 1) le début de la pandémie de COVID-19 a été associé à un changement quelconque des taux moyens de visites à l’urgence liées aux opioïdes en Alberta et 2) si ces taux moyens variaient selon les zones présentant des taux de cas de COVID-19 différents. MéthodologieNous avons mené des analyses de séries temporelles interrompues par maximum de vraisemblance afin de comparer les visites à l’urgence liées aux opioïdes pendant la « période prépandémique » (du 3 mars 2019 au 1er mars 2020) et pendant la « période pandémique » (du 2 mars 2020 au 14 mars 2021). RésultatsIl y a eu 8 883 visites à l’urgence liées aux opioïdes durant la période prépandémique et 11 657 durant la période pandémique. Le début de la pandémie de COVID-19 a été associé à une augmentation du nombre de visites à l’urgence liées aux opioïdes (Edmonton : rapport des taux d’incidence [RTI] = 1,37, intervalle de confiance [IC] à 95 % : 1,30 à 1,44, p $lt; 0,05; Calgary : RTI = 1,14, IC à 95 % : 1,07 à 1,20, p $lt; 0,05; autres zones sanitaires : RTI = 1,14, IC à 95 % : 1,07 à 1,21, p $lt; 0,05). L’évolution du nombre de cas COVID-19 n’offre pas de correspondance en fonction des zones avec les variations dans les taux de visites à l’urgence liées aux opioïdes. ConclusionIl n’y a aucune association entre l’augmentation du nombre de visites à l’urgence liées aux opioïdes ayant eu lieu au début de la pandémie de COVID-19 et la prévalence des cas de COVID-19 en Alberta.

BACKGROUND:People who use drugs (PWUD) frequently seek care in the emergency department (ED). Little is known about ED physician perspectives and experiences integrating a harm reduction approach into care, including interventions that reduce the health, social and legal consequences of drug use without requiring a reduction in drug use. OBJECTIVE:This study aimed to describe the experiences of Canadian emergency physicians caring for PWUD, and facilitators and barriers to implementing harm reduction interventions in the ED. METHODS:Purposive sampling, using an existing national network, and snowball sampling techniques were used to recruit practicing emergency physicians. Semi-structured, one-on-one telephone interviews were conducted until theoretical data saturation was achieved. Interview recordings were transcribed and analyzed using latent content analysis. Interviews took place between June 2019 and February 2020. This work is a secondary analysis specifically focused on harm reduction approaches to care. RESULTS:32 physician interviews were included. Participants had a median of 10 years of experience (range 1-33) and most (29/32) worked in urban EDs. Participants highlighted the complexities of caring for PWUD, including the intersection of structural vulnerability with substance use. The ED environment varied across Canada and either facilitated or hindered the adoption of harm reduction interventions. Additional barriers included a lack of training and experience; lack of community follow-up care; insufficient ED funding and staffing resources; and, tensions over the appropriate scope of emergency medicine practice. Facilitators included tailored education and training; specialized multidisciplinary teams; ED harm reduction champions; and standardized protocols. CONCLUSIONS:Though variability existed in the adoption and practice of harm reduction in Canadian EDs, most interviewed physicians supported a harm reduction approach to care. To facilitate widespread ED adoption of harm reduction interventions, there is a need for standardized guidance, supplemental resources, facilitated culture change, and sufficient community-based services.

BACKGROUND:This article investigates the potential links between housing instability and unregulated drug use at the intersection of the housing affordability crisis, drug poisoning emergency, and the COVID-19 pandemic. METHODS:Data for this study were collected as part of an Edmonton, Alberta survey of people who use drugs (N = 406, April-September 2023). This study examines the associations between housing instability, the severity of individual drug use patterns, as measured through the Drug Use Disorders Identification Test (DUDIT) score, and the risk of accidental overdose using a series of linear and logistic regression models. RESULTS:Results indicate that precarious housing conditions were linked to a higher risk of unregulated drug use across respondents. Being unhoused or living in unstable housing was associated with higher DUDIT scores and an increased probability of accidental overdose. In addition, individuals who reported worsening housing situations during COVID-19 were more likely to report increased drug use. CONCLUSIONS:Contributing to the literature on social determinants of health, findings suggest that integrated housing and drug use interventions are vital for effective harm reduction and the promotion of public health.

BackgroundPeople who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.MethodsWe utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.ResultsParticipants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.ConclusionsAcute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

In Canada, public health measures necessitated by the COVID-19 pandemic resulted in a rapid onset and prolonged, widespread increase in the use of virtual primary care services, including for mental health conditions. Our aim was to develop standards on virtual delivery of mental health services in primary care in Canada using information obtained from an earlier rapid review as well as participant feedback obtained through interviews and a focus group. We developed standards using three interlinked processes. First, we completed a rapid review of guidelines regarding virtual primary mental health care services. We then invited health care workers and people with lived experience of mental health concerns to participate in a focus group and interviews. Finally, members of the study team drafted standards and shared them with an advisory group, who reviewed their feasibility, phrasing, and acceptability through a modified Delphi process. Standards ranked as having less than 100% feasibility and acceptability were brought to a virtual discussion of the advisory group to finalize the list. Seven participants were recruited into the focus group and interviews. We identified three themes: (i) patients’ and providers’ agreement about expectations regarding virtual care, (ii) accessibility and equity, and (iii) safety planning in the delivery of virtual care. We drafted 18 standards on virtual primary mental health care delivery that were reviewed by an advisory group of identified experts. Thirteen standards were included in the final list. The standards bring attention to continuity of care, and resources and information that should be given to patients to further health equity. These standards provide guidance for the organization and delivery of virtual mental health services in Canadian and international primary care, particularly within the context of single payer health systems.

Objectives This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services.Design We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings.Methods Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes.Results The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients’ access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients.Conclusions This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.

The Big Ideas Soapbox at Family Medicine Forum (FMF) showcases concepts that could make a difference to clinical practice, faculty development, postgraduate or undergraduate education, patient care and outcomes, or health policy. This session offers a platform for innovators to share fresh ideas,

La Tribune aux idées audacieuses du Forum en médecine familiale (FMF) met en évidence des concepts qui pourraient faire une différence dans la pratique clinique, le perfectionnement professoral, l’éducation postdoctorale ou prédoctorale, les soins aux patients et leurs résultats ou les