On 31 January 2023, the province of British Columbia (BC), Canada implemented a three-year “Decriminalization Pilot” in response to a toxic drug supply public health emergency, which removed criminal sanctions for the personal possession of some drugs below a cumulative total of 2.5 g. We sought to measure frequency of police drug seizures without arrest before and during the Decriminalization Pilot, and to determine potential relationships between police drug seizures and nonfatal overdose in the urban setting of Vancouver, BC. We drew from a prospective cohort study and employed multivariable generalized estimating equations models. We used data collected between March 2022 and February 2024 among a prospective cohort of people who use drugs. Among study participants (n = 490), the quarterly prevalence of police-enforced drug seizures without arrest in the past month ranged from 0.8

Healthcare professionals' wellbeing is crucial for healthcare system functioning and population health. Prolonged moral distress may result in burnout, undermining healthcare professionals' wellbeing, negatively impacting quality of patient care, and resulting in considerable healthcare system costs. We conducted 36 interviews with healthcare professionals working with patients with concurrent mental and substance use disorders in British Columbia, Canada, exploring their perceptions of the institutional constraints which shaped their experiences and caring practices. We conducted a reflexive thematic analysis of the interviews guided by the theoretical concept of responsibilization. While most participants found their work rewarding, many encountered institutional constraints which limited their ability to provide the standard of care to which they felt morally and ethically obligated. Prolonged exposure to such morally uninhabitable working environments resulted in participants' moral distress and burnout. Central to participants' narratives was the role of responsibilization in both contributing to and exacerbating moral distress and burnout. On top of their caring duties, participants perceived a need to over-function to offset institutional constraints within healthcare, and address their and their colleagues' moral distress and burnout without adequate institutional support. Findings demonstrate how individual-centered interventions are inadequate without proper institutional support, and have the potential to re-enact rather than rectify moral distress and burnout. Structural interventions are paramount to redress these occupational harms and protect healthcare professionals' wellbeing.

BackgroundPeople living with HIV (PLHIV) who use drugs face overlapping social-structural inequities that contribute to suboptimal adherence to antiretroviral therapy (ART). Recent research suggests that long-acting antiretroviral therapy (LA-ART) can offer an important alternative to daily oral ART by mitigating adherence barriers, but this work has largely excluded PLHIV who use drugs. We, therefore, explored the acceptability of injectable and transdermal LA-ART among PLHIV who use drugs in Canada, which has no-cost universal access to oral ART. Greater understanding of PLHIV who use drugs' perspectives on LA-ART will be essential to fully leverage treatment advances and maximize its individual- and population-level benefits.MethodsFrom February 2019 to February 2020, we conducted in-depth interviews with 33 PLHIV who use drugs in Vancouver, Canada with suboptimal ART adherence (i.e., ≦ 50%). Participants were recruited for interviews through a prospective cohort study. Interviews were audio-recorded, transcribed, and analyzed using inductive and deductive approaches.ResultsOur analysis identified key factors shaping LA-ART acceptability. First, LA-ART enthusiasm was highest among participants who were less satisfied with oral ART regimens due to pill burden or adverse side effects for oral ART and participants who struggled with daily adherence due substance use and social-structural factors (e.g., homelessness, incarceration). Moreover, participants who had physicians they trusted identified their physicians as credible sources of information on LA-ART, and indicated a desire for informed and shared decision-making regarding treatment changes. Finally, participants emphasized that there is no one-size-fits-all treatment approach for PLHIV who use drugs and highlighted the importance of access to a full range of available treatment options, including LA-ART.ConclusionsThere is potential for high LA-ART uptake among PLHIV who use drugs, particularly those who experience adherence barriers due to their substance use and structural vulnerability. While our findings are limited by the specific population and setting, they nevertheless underscore the need for efforts to ensure universal and equitable access to LA-ART.

Abstract Background The global burden of mental illness is substantial, with depression impacting close to 300 million people worldwide. This has been exacerbated within the context of the COVID-19 pandemic. Yet, in many low- and middle-income countries including Vietnam, there is a substantial treatment gap, with many requiring mental health care unable to access it. Task-shifting is an evidence-based approach that seeks to address this gap by utilizing non-specialist providers to provide care. While there is a large body of literature exploring task-shifting, there is little that explores the client experience. This paper describes the facilitators and barriers impacting the client experience of a task-shifting supported self-management (SSM) intervention for depression in Vietnam. SSM involves a client workbook and supportive coaching by non-specialist providers. Methods This paper is situated within a randomized controlled trial that demonstrated the effectiveness of the SSM intervention in adult populations across eight provinces in Vietnam. Semi-structured interviews were conducted with a convenience sample of clients (recipients of the intervention) with depression caseness as measured by the Self-Report Questionnaire-20 depression screening measure, and providers (non-specialist “social collaborators”) to explore SSM’s acceptability and factors influencing participation and adherence. This paper presents the qualitative findings from an analysis of the interviews, focusing on the client perspective. Qualitative descriptive methods and thematic analysis were used. Results Forty-five clients were interviewed. Sub-themes reported for the facilitators and benefits for the client experience of the SSM intervention were client-provider relationship building and family and community connections. Sub-themes reported for the barriers were clients’ responsibilities, clients’ health conditions, and consequences of stigma. Conclusions Due to challenges with sustaining and scaling up the in-person SSM intervention in Vietnam, the research team has pivoted to delivering the SSM intervention digitally through a smartphone-based app adapted from SSM, with direction from the Government of Vietnam. Findings from this study suggest that while digital interventions may support accessibility and convenience, they may neglect the critical human contact component of mental health care. Ultimately, a model that combines digital delivery with some form of human contact by a support person may be important.

Background Chronic pain is a common comorbidity among people living with HIV (PLHIV) who use drugs. However, in-depth understanding of how chronic pain is managed among PLHIV who use drugs remains limited, especially in the aging population. We sought to explore how older PLHIV who use drugs manage chronic pain and situate these experiences within their social and structural contexts. Methods This study draws on semi-structured, in-depth interviews conducted with 27 PLHIV who use drugs and were living with chronic pain in Vancouver, Canada. Participants were recruited through outreach at an integrated HIV care facility and from an open prospective cohort study of PLHIV who use drugs. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using an inductive-deductive approach to coding. Results Three themes emerged from our data analysis. First, chronic pain influenced daily life and functioning, including ability to manage HIV and other health conditions. Second, provider-related barriers, including anti-drug stigma and discrimination, impeded access to pain management. Third, illicit drugs were often used to self-manage pain. Conclusions This study advances our understanding of the everyday experiences of living with chronic pain among older PLHIV who use drugs. Inadequately managed pain may contribute to an array of health- and drug-related harms among this population. Our findings underscore the need for equitable access to pain care, and safer alternatives to the toxic illicit drug supply in the context of the illicit drug poisoning epidemic, to relieve suffering and improve quality of life for older PLHIV who use drugs.

Background: Decriminalization of personal possession of drugs has been proposed as an approach to mitigate the harms of drug prohibition. Despite growing interest, particularly in Canadian settings, analyses of approaches to defining the parameters of what constitutes personal possession within decriminalization models are lacking. Using the Province of British Columbia, Canada, as a case study, we undertook an evidence-based multi-criteria policy analysis of three models for defining personal possession: 1) a model that defines personal possession as the absence of evidence of drug trafficking; 2) a cumulative threshold of 15 grams; and 3) a cumulative threshold of 2.5 grams. Methods: We utilized data from four sources: qualitative interviews with 16 experts, including representatives from government and law enforcement; Vancouver Police drug seizure data; self-reported drug consumption data from longitudinal cohorts of people who use drugs in Vancouver; and publicly available government documents (e.g., the Government of BC's submission for decriminalization). Data was used to identify and define evaluation criteria which reflect the stated policy objectives of decriminalization alongside other policy considerations. This framework was used to conduct a multi-criteria policy analysis of the three different models. Results: The seven evaluation criteria included: 1) reduction in interactions with police; 2) reduction of police drug seizures; 3) coverage for those with high consumption; 4) impact on equity-deserving groups; and acceptance on the part key stakeholders, including: 5) people who use drugs; 6) law enforcement; and 7) the public. The model that performed the best was the cumulative threshold model of 15 grams. Conclusion: Findings highlight that different threshold models advance and constrain the stated policy objec-tives of drug decriminalization to varying degrees. This analysis provides a framework that other jurisdictions considering decriminalization could use to help inform determinations of threshold levels based on stated policy objectives.

Introduction Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018. Method We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender. Results Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15-24 (162%) and men ages 15-34 (81%) and 85 and older (106%). Conclusion Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications.

Background People who use drugs (PWUD) frequent emergency departments at a higher rate than the general population, and experience a greater frequency of soft tissue infections, pneumonia, and chronic conditions such as, HIV/AIDs and hepatitis C. This population has distinct health care considerations (e.g. withdrawal management) and are also more likely to leave or be discharged from hospital against medical advice. Methods This study examines the experiences of PWUD who have left or been discharged from hospital against medical advice to understand the structural vulnerabilities that shape experiences with emergency departments. Semi-structured qualitative interviews were conducted with 30 PWUD who have left or been discharged from hospital against medical advice within the past two years as part of a larger study on hospital care and drug use in Vancouver, Canada. Results Findings characterize the experiences and perceptions of PWUD in emergency department settings, and include: (1) stigmatization of PWUD and compounding experiences of discrimination; (2) perceptions of overall neglect; (3) inadequate pain and withdrawal management; and (4) leaving ED against medical advice and a lack of willingness to engage in future care. Conclusions Structural vulnerabilities in ED can negatively impact the care received among PWUD. Findings demonstrate the need to consider how structural factors impact care for PWUD and to leverage existing infrastructure to incorporate harm reduction and a structural competency focused care. Findings also point to the need to consider how withdrawal and pain are managed in emergency department settings.

Background Housing environments shape injection drug-related risks and harms and thus represent a critical implementation setting for syringe services programs (SSPs). As critical harm reduction measures, SSPs provide safe injecting equipment to people who inject drugs (PWID). Vancouver, Canada, has well-established syringe distribution programs through which PWID have low-threshold access to unlimited syringes and related injecting equipment, including through non-profit operated supportive housing and single-room occupancy hotels. This study examines the role of housing-based SSPs in distributing injecting equipment to PWID in Vancouver. Methods Between January and March 2020, semi-structured, in-depth interviews were conducted in Vancouver with 26 PWID. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using inductive and deductive approaches. Results Many participants accessed SSPs in housing facilities and expressed preference for these programs over those offered at other locations and through other health and social services. Three major themes emerged to explain this preference. First, most participants injected in the buildings where they resided, and housing-based SSPs made injecting equipment available when and where it was most needed. Second, many participants preferred to avoid carrying syringes outside of the places where they inject due to fears that syringe possession may lead to criminal charges or confiscation of syringes and/or illicit drugs by police. Third, for some participants, anti-drug user stigma and concerns over unwillingly disclosing their drug use hindered access to SSPs outside of housing settings. Programs operated within housing facilities often offered greater client anonymity along with more supportive and less stigmatizing environments, particularly in the presence of peer staff. Conclusion The current study advances understanding of access to injecting equipment in a setting with city-wide syringe distribution programs. Our findings underscore the benefits of housing-based SSPs and encourage the expansion of such services to maximize access to harm reduction supports for PWID.

A substantial body of evidence demonstrates that supervised consumption services (SCS) mitigate a variety of drug-related harms, including decreasing overdose deaths, infectious disease transmission, and connecting people who use drugs (PWUD) to various health and social services. Research on SCS has predominantly been quantitative, though qualitative research on these services has increased substantially over the last decade. Qualitative methods provide a framework for developing a richer and more nuanced understanding of meanings and contexts associated with drug use, health service implementation, and experience. We present findings from a scoping review of qualitative studies on experiences of PWUD with SCS published between 1997 and 2022. In total, forty-two papers were included in this analysis. Four primary themes emerged from our analysis: 1) Influence of SCS on health and wellbeing among PWUD, 2) the physical environment of SCS can be both a facilitator and barrier to use, 3) social resources can shape and reshape the context within which PWUD benefit from SCS, and 4) various intersecting forces at play both support and harm PWUD in relation to their experiences with SCS. We discuss the primary facilitators and barriers of SCS use and conclude with suggestions to inform future qualitative research, SCS implementation, and PWUD-centered approaches to drug policy.

Initiatives including supervised consumption services, access to regulated drug supply and decriminalization could facilitate prevention and improved management of bacterial and fungal injecting-related infections. Harnessing potential synergies between differing types of Safer Environment Interventions could address a broad range of drug-related harms. The examination of social-structural forces influencing incidence and treatment of bacterial and fungal injecting-related infections by Brothers et al. [1] illustrates how particular modifiable environments shape risk for injecting-related infections along a pathway from drug acquisition and injection to health outcomes following infections. This suggests adopting a more social-structural approach to managing bacterial and fungal injecting-related infections is promising, with prioritization of Safer Environment Interventions (SEIs) to reshape environmental drivers. Unsafe consumption spaces, unregulated drug quality and restricted access to risk-reduction equipment and programs are forces driving bacterial and fungal injecting-related infections. These also shape injecting-related harms like blood-borne virus transmission, therefore, the potential of supervised consumption services (SCS), access to regulated drug supply and decriminalization of currently illegal drugs is identified. These initiatives could influence multiple stages along the infection pathway and facilitate prevention and improved management of infections. Harnessing synergies between differing types of SEIs could address an even broader range of drug-related harms than the authors note, including overdose. Decriminalization is discussed as a promising macro-level structural SEI to reform prohibitionist frameworks criminalizing people who inject drugs (PWID) [1], which are implicated in the proliferation of injecting-related harm [2, 3]. Potential public health benefits of decriminalization (resulting from prioritizing public health over criminal justice system responses) include reductions in drug-related harm and increased access to risk-reduction programs and healthcare among PWID [4], partially through reduced stigma and discrimination within healthcare [5]. Healthcare access barriers critically shape suboptimal management of injecting-related infections [1], and this would facilitate improved treatment and reduce reluctance to seek care, which negatively impacts the progression of infections [6]. SEIs are constrained in their operation and coverage by regulatory barriers and prohibition [7], therefore, decriminalization could also support the scale-up of interventions with potential to reduce incidence and improve management of injecting-related infections, like syringe services programs and SCS [8, 9]. Enhanced coverage and optimized operation of SCS, through elimination of legal barriers to their establishment and regulations that impede PWIDs’ access [7], would further influence the infection pathway by preventing occurrence of infections and supporting improved identification and management [6]. Decriminalization may also facilitate efforts to reshape multiple environments identified in the synthesis, through further initiatives focused on hygienic consumption spaces, enhanced healthcare policies and practices and access to regulated drug supply. Unregulated drug quality significantly drives injecting-related infections [1], and regulated supply models for currently illegal psychoactive substances have been identified as a public health priority [10]. Although less ambitious than full regulation, providing restricted access to medically regulated drug supply is being piloted in some Canadian settings [11] to reduce drug-related poisoning fatalities stemming from the toxic drug supply. While cited evaluation research demonstrates reduced infection-related hospitalizations among individuals enrolled in pilot ‘safe supply’ initiatives [12], recent studies also report changes in injecting behavior, such as reduced injection frequency and transitions to oral consumption [13], as well as enhanced engagement and retention in other healthcare services [14]. Such programs may exert beneficial effect on the infection pathway through prevention (as pharmaceutical-grade substances intended for injection are provided) and facilitate prompt intervention to identify and treat injecting-related infections. Overlap in the risk environments relevant to infections and overdose suggests regulated drug supply programs may efficiently address a spectrum of harms, as current ‘safe supply’ initiatives can reduce exposure to the unregulated drug supply [11], and many incorporate supervised hygienic drug consumption settings (like SCS) [15]. The veterinary tranquilizer xylazine as an emerging additive in the unregulated drug supply illustrates how specific contaminants can dramatically increase the prevalence and severity of injecting-related infections [16]. Xylazine is now prevalent in some North American drug markets and is associated with serious soft tissue harm in addition to drug poisoning risks, as it contributes to the incidence and severity of abscesses, skin ulcers and infections through vasoconstriction and decreased skin perfusion [17]. Increasing unpredictability and volatility is now a core feature of the unregulated drug supply and novel additives are likely to appear in future [18], highlighting the potential of regulated drug supply to mitigate injecting-related infections, as well as poisoning risks, by reducing unintended exposure to current (and future) contaminants. Expanding SEIs represents a compelling opportunity to reduce a broad range of drug-related harms, including injecting-related infections, through public health-focused approaches to proactively prevent disease and death. This does not dismiss the necessity of clinical care for infections or challenges to the implementation of ambitious structural SEIs (like decriminalization and drug regulation) because of policy inertia and dependence on prohibition [19], but rather focuses on the potential of upstream interventions modifying risk environments and social-structural forces to reduce the incidence, prevalence and severity of diverse injecting-related harms. Will Small: Conceptualization (lead); writing—original draft (lead); writing—review and editing (equal). Sean O'Callaghan: Conceptualization (supporting); writing—original draft (supporting); writing—review and editing (equal). None. There are no funders to report. W.S. is an Associate Professor in the Faculty of Health Sciences at Simon Fraser University, and a Research Scientist at the British Columbia (BC) Centre on Substance Use. S.O. is an MPH candidate in the Faculty of Health Sciences and a Research Assistant at the BC Centre on Substance Use. Both authors declare no financial or other relevant links to companies with an interest in the topic of this article. N/A.

Objective: To estimate the prevalence of specific mental and substance use disorders (MSUDs), by age and sex, as a first step toward informing needs-based health systems planning by decision-makers. Methods: We developed a conceptual framework and a systematic methodology for combining available data sources to yield prevalence estimates for specific MSUDs. Data sources used included published, peer-reviewed literature from Canada and comparable countries, Canadian population survey data, and health administrative data from British Columbia. Several well-established methodologies including systematic review and meta-analyses of published prevalence estimates, modelling of age- and sex-specific distributions, and the Global Burden of Disease severity distribution model were incorporated in a novel mode of triangulation. Results: Using this novel approach, we obtained prevalence estimates for 10 MSUDs for British Columbia, Canada, as well as prevalence distributions across age groups, by sex. Conclusion: Obtaining reliable assessments of disorder prevalence and severity is a useful first step toward rationally estimating service need and plan health services. We propose a methodology to leverage existing information to obtain robust estimates in a timely manner and with sufficient granularity to, after adjusting for comorbidity and matching with severity-specific service bundles, inform need-based planning efforts for adult (15 years and older) mental health and substance use services.

People who use illicit drugs (PWUD) face increased exposure to the criminal justice system and disproportionate burdens of HIV infection. This article investigated the effects of incarceration on HIV cascade of care-related measures in a setting with a community-wide seek, test, treat, and retain (STTR) initiative. Using a multivariable logistic regression analysis of 935 HIV-positive PWUD between 2005 and 2017, this article showed a negative relationship between periods of incarceration and two measures of engagement in clinical care for HIV among PWUD: recent dispensation of antiretroviral therapy and suppression of HIV viral load. These findings suggest the benefits of STTR-based efforts are limited by exposure to the criminal justice system and highlight the need for additional supports for PWUD with HIV exposed to the criminal justice system.

Street-involved youth who use drugs (YWUD) face an elevated risk of HIV acquisition and represent a key population for HIV prevention initiatives, including pre-exposure prophylaxis (PrEP). However, little is known regarding the acceptability and feasibility of PrEP uptake and adherence among this multiply-marginalized population. Semi-structured qualitative interviews were conducted with 24 street-involved YWUD (ages 17-24) to examine their perspectives toward PrEP; youth were recruited through a longitudinal prospective cohort study in Vancouver, Canada. Youth reported high levels of ambivalence toward PrEP despite engagement in HIV-related risk behaviors. This ambivalence was driven by misperceptions regarding HIV transmission, including stigmatizing associations between HIV transmission and personal hygiene. Such misperceptions led participants to enact strategies that were ineffective in preventing HIV transmission. Participants contested their inclusion as a "key population" for PrEP, which limited their enthusiasm for PrEP uptake and adherence. Participants also highlighted that wider social-structural inequities (e.g., housing vulnerability, poverty) that produced HIV-related risks were likely to undermine sustained PrEP use. Findings demonstrate the need for tailored implementation strategies to increase PrEP acceptability, including targeted education and anti-stigma interventions to increase awareness about HIV transmission. Interventions should also target structural inequities in order to fully address HIV risk and PrEP ambivalence.

Quality improvement methods could assist in achieving needed health systems improvements to address mental health and substance use, especially in low-middle-income countries (LMICs). Online learning is a promising avenue to deliver quality improvement training. This Computer-based Drug and Alcohol Training Assessment in Kenya (eDATA-K) study assessed users’ experience and outcome of a blended-eLearning quality improvement course and collaborative learning sessions. A theory of change, developed with decision-makers, identified relevant indicators of success. Data, analyzed using descriptive statistics and thematic analysis, were collected through extensive field observations, the eLearning platform, focus group discussions, and key informant interviews. The results showed that 22 community health workers and clinicians in five facilities developed competencies enabling them to form quality improvement teams and sustain the new substance-use services for the 8 months of the study, resulting in 4591 people screened, of which 575 received a brief intervention. Factors promoting course completion included personal motivation, prior positive experience with NextGenU.org’s courses, and a certificate. Significant challenges included workload and network issues. The findings support the effectiveness of the blended-eLearning model to assist health workers in sustaining new services, in a supportive environment, even in a LMIC peri-urban and rural settings.

PURPOSE:A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work.METHODS:We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature.RESULTS:Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups.CONCLUSION:We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Objectives Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group. Design Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC. Setting BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services. Population All people age >15 with MSUD ED visits during the study period. Measures All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described. Results A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care. Conclusions MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the “problem” of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the “problem” of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.

Antiretroviral therapy (ART) dispensing is strongly associated with treatment adherence. Among illicit drug-using populations, whom experience greater structural barriers to adherence, directly administered antiretroviral therapy (DAAT) is often regarded as a stronger predictor of optimal adherence over self-administered medications. In Vancouver, Canada, people living with HIV (PLHIV) who use drugs and live in low-income housing are a critical population for treatment support. This group is typically able to access two key DAAT models, daily delivery and daily pickup, in addition to ART self-administration. This ethno-epidemiological qualitative study explores how key dispensing models impact ART adherence among PLHIV who use drugs living in low-income housing, and how this is framed by structural vulnerability. Semi-structured interviews lasting 30-45 minutes were conducted between February and May 2018 with 31 PLHIV who use drugs recruited from an ongoing prospective cohort of PLHIV who use drugs. Interviews were audio-recorded, transcribed verbatim, and analyzed using QSR International's NVivo 12 software. Interviews focused on housing, drug use, and HIV management. Models that constrained agency were found to have negative impacts on adherence and quality of life. Treatment interruptions were framed by structural vulnerabilities (e.g., housing vulnerability) that impacted ability to maintain adherence under certain dispensing models, and led participants to consider other models. Participants using DAAT models which accounted for their structural vulnerabilities (e.g., mobility issues, housing instability), credited these models for their treatment adherence, but also acknowledged factors that constrained agency, and the negative impacts this could have on both adherence, and quality of life. Being able to integrate ART into an established routine is key to supporting ART adherence. ART models that account for the structural vulnerability of PLHIV who use drugs and live in low-income housing are necessary and housing-based supports could be critical, but the impacts of such models on agency must be considered to ensure optimal adherence.

INTRODUCTION People living with HIV who use drugs commonly experience chronic pain and often use illicit opioids to manage pain. Recent research suggests people living with HIV use cannabis for pain relief, including as an adjunct to opioids. This underscores the need to better understand how people living with HIV who use drugs use cannabis for pain management, particularly as cannabis markets are undergoing changes due to cannabis legalisation. METHODS From September 2018 to April 2019, we conducted in-depth interviews with 25 people living with HIV who use drugs in Vancouver, Canada to examine experiences using cannabis to manage pain. Interviews were audio-recorded, transcribed and coded. Themes were identified using inductive and deductive approaches. RESULTS Most participants reported that using cannabis for pain management helped improve daily functioning. Some participants turned to cannabis as a supplement or periodic alternative to prescription and illicit drugs (e.g. benzodiazepines, opioids) used to manage pain and related symptoms. Nonetheless, participants' access to legal cannabis was limited and most continued to obtain cannabis from illicit sources, which provided access to cannabis that was free or deemed to be affordable. DISCUSSION AND CONCLUSIONS Cannabis use may lead to reduced use of prescription and illicit drugs for pain management among some people living with HIV who use drugs. Our findings add to growing calls for additional research on the role of cannabis in pain management and harm reduction, and suggest the need for concrete efforts to ensure equitable access to cannabis.