“It's like super structural” – Overdose experiences of youth who use drugs and police in three non-metropolitan cities across British Columbia

Harm reduction is an important public health factor for people who use drugs. It is recommended by United Nations agencies and implemented in many countries around the world. In this article, we present a study of local harm reduction policies in Denmark. Historically, harm reduction has developed at the local level due to local stakeholders’ concerns about the health of people who use drugs. Therefore, it is a key site for studying harm reduction policies. In Denmark, harm reduction policy implementation is delegated to 98 municipalities. National legislation obliges municipalities to implement some harm reduction services and makes it optional for them to implement others. The latter services include heroin-assisted treatment (HAT) and drug consumption rooms (DCRs). In this article, we present a study of local harm reduction policy processes in relation to implementation of HAT and DCRs—or not—in three municipalities in Denmark based on document analysis and qualitative interviews with local stakeholders. One municipality had implemented a DCR, one has implemented HAT, and one had implemented neither. Analytically we apply Kingdon's multiple streams approach to policy analysis and Stone's ideas about moral and emotional engagement in policy processes. We show how local problem constructions and justifications influence the implementation of harm reduction services, and that moral engagement with core policy values like equity in such processes. We conclude that the Danish harm reduction model, which at the same time makes it optional for municipalities to implement certain harm reduction services and gives them a monopoly on implementing them, creates geographical differences in access to harm reduction services in Denmark. To characterize harm reduction in Denmark on the basis of national policy and legislation would therefore be a misrepresentation, local differences need to be taken into account.

A growing body of evidence suggests that news media which includes a sympathetic portrayal of a mother bereaved by substance use can increase public support for harm reduction initiatives. However, the extent to which such news media coverage occurs in Canada is unknown, and research has not documented how the news media in Canada covers such stories. We undertook a mixed-method secondary analyses of 5681 Canadian newspaper articles on harm reduction (2000–2016). Quantitative analyses described the volume and content of harm reduction reporting featuring a mother whose child’s death was related to substance use while qualitative thematic analysis provided in-depth descriptions of the discourses underlying such news reporting. Newspaper articles featuring a mother whose child’s death was related to substance use were rarely published (n = 63; 1.1% of total harm reduction media coverage during the study period). Deductive content analysis of these 63 texts revealed that coverage of naloxone distribution (42.9%) and supervised drug consumption services (28.6%) were prioritized over other harm reduction services. Although harm reduction (services or policies) were advocated by the mother in most (77.8%) of these 63 texts, inductive thematic analysis of a subset (n = 52) of those articles revealed that mothers’ advocacy was diminished by newspaper reporting that emphasized their experiences of grief, prioritized individual biographies over structural factors contributing to substance use harms, and created rhetorical divisions between different groups of people who use drugs (PWUD). Bereaved mothers’ advocacy in support of harm reduction programs and services may be minimized in the process of reporting their stories for newspaper readers. Finding ways to report bereaved mothers’ stories in ways that are inclusive of all PWUD while highlighting the role of broad, structural determinants of substance use has the potential to shift public opinion and government support in favour of these life-saving services.

On January 31st 2023, the Canadian province of British Columbia temporarily decriminalized the personal possession of certain illegal drugs up to 2.5 g, cumulatively, for adults. A stated aim of this policy directive was to reduce the stigmatization of people who use drugs and increase access to health and harm reduction services. The aim of this study was to capture the prevalence and nature of potential barriers to such services under drug decriminalization. We employed a mixed-methods study design, triangulating survey data from harm reduction service users in 2022 (n = 503) and 2023 (n = 433) alongside qualitative interviews with people who use drugs in British Columbia (n = 78) collected in 2023. Qualitative and quantitative findings were analysed convergently. Findings across both datasets suggest that reported barriers to health and harm reduction services persisted during British Columbia’s decriminalization pilot. Quantitative and qualitative data reflecting these barriers are presented in parallel under four themes: (1) stigma and fear of substance use disclosure, (2) stigma and access to services, (3) service-specific barriers, and (4) police-related barriers. Decriminalization alone may be insufficient to address and/or mitigate the barriers that continue to constrain people who use drugs’ access to care. If the policy goal is to reduce barriers to health and harm reduction services, additional structural and institutional supports may be required. Barriers to accessing health and harm reduction services persisted during BC’s decriminalization pilot. Perceived stigma limited access to health and harm reduction services. Inhalation services remain limited at observed consumption sites across BC. Despite the legal reform, policing practices discouraged health service attendance. Decriminalization alone may be insufficient in eliminating service barriers.

BackgroundFew longitudinal cohort studies have focused on the impact of substances abused and psychiatric disorders on premature mortality. The aim of the present study was to identify predictors of increased risk of drug related death and non drug related death in substance abusers of opiates, stimulants, cannabis, sedatives/hypnotics, hallucinogens and alcohol over several decades.MethodsFollow-up study of a consecutive cohort of 561 substance abusers, admitted to a detoxification unit January 1970 to February 1978 in southern Sweden, and followed up in 2006. Demographic and clinical data, substance diagnoses and three groups of psychiatric diagnoses were identified at first admission. Causes of death were coded according to ICD-10 and classified as drug related deaths or non drug related deaths. To identify the incidence of some probable risk factors of drug related premature death, the data were subjected to a competing risks Cox regression analysis.ResultsOf 561 patients in the cohort, 11 individuals had either emigrated or could not be located, and 204/561 patients (36.4%) were deceased by 2006. The cumulative risk of drug related death increased more in the first 15 years and leveled out later on when non drug related causes of death had a similar incidence. In the final model, male gender, regular use of opiates or barbiturates at first admission, and neurosis were associated with an increased risk of drug related premature death, while cannabis use and psychosis were associated with a decreased risk. Neurosis, mainly depression and/or anxiety disorders, predicted drug related premature death while chronic psychosis and personality disorders did not. Chronic alcohol addiction was associated with increased risk of non drug related death.ConclusionsThe cohort of drug abusers had an increased risk of premature death to the age of 69. Drug related premature death was predicted by male gender, the use of opiates or barbiturates and depression and anxiety disorders at first admission. The predicted cumulative incidence of drug related death was significantly higher in opiate and barbiturate abusers over the observed period of 37 years, while stimulant abuse did not have any impact. Alcohol contributed to non drug related death.

In January 2023, British Columbia (BC), Canada, piloted a three-year decriminalization policy to address the escalating overdose crisis. The policy seeks to reduce stigma and the fear of criminal prosecution, and foster a safer and more supportive environment, encouraging greater utilization of treatment and harm reduction (HR) services among people who use drugs. There are limited data on the operational characteristics of HR sites in BC, which are essential for monitoring how decriminalization may influence service operations and utilization. This study aimed to characterize HR site operations in BC and assess any operational changes following decriminalization. A cross-sectional, online self-report survey was distributed to HR sites across BC between March and April 2024. The survey was completed by a site representative, and survey questions focused on client demographics and drug use patterns, service uptake and capacity, resource and staffing demands, police activity near sites, and the availability of HR services. Changes pre-and post-decriminalization were analyzed descriptively to identify trends. A total of 33HR sites completed the survey. Almost a third (30%) of sites reported an increase in client's post-decriminalization, and 18% indicated plans to expand or modify services to meet the increasing demand. However, challenges related to staffing and resources were highlighted, with 45% of sites reporting increased staffing demands post-decriminalization, and 33% noting changes to resource needs, most of which increased. Five sites reported an increase in annual operating budgets. Nearly half (43%) of sites that experienced police activity around their site reported increased police activity post-decriminalization. Moreover, approximately one-fifth (21%) of sites received formal decriminalization training. HR sites have experienced an increase in client engagement post-decriminalization, reporting challenges related to site capacity and funding, and emphasizing the need for additional investments to support and expand HR services. Consideration should be given to needs-based planning and providing decriminalization training to HR staff. Moreover, steps are necessary to address the continued police presence near sites, which may hinder service uptake and perpetuate stigma. Addressing these gaps is critical for improving health system engagement for people who use drugs and achieving the goals of decriminalization.

Relative effects of antiretroviral therapy and harm reduction initiatives on HIV incidence in British Columbia, Canada, 1996–2013: a modelling study

IntroductionThe high prevalence of hepatitis C and the persistence of HIV and hepatitis C virus (HCV) risk practices in people who inject drugs (PWID) in France underlines the need for...

BackgroundIn Canada, funding, administration, and delivery of health services—including those targeting people who use drugs—are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach.MethodsWe employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach.ResultsOnly two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use.ConclusionsCurrent provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.

BackgroundThe global emergence of the Covid-19 pandemic in 2019 posed unprecedented challenges to healthcare systems, disrupting routine services and necessitating swift adaptations. Harm reduction programs, vital for addressing substance use-related health risks, faced unique challenges during the pandemic, impacting vulnerable populations. This study focuses on the repercussions of Covid-19 on harm reduction policies in Iran, specifically examining the distribution of condoms, syringes, and methadone to high-risk individuals attending Triangle Centers.AimThe study aims to assess the impact of the Covid-19 pandemic on harm reduction services in Iran and provide evidence-based insights for policy adjustments. Using Interrupted Time Series Analysis (ITSA), the research analyzes trends in the distribution of condoms, syringes, and methadone before and after the official declaration of the pandemic in February 2020.MethodITSA, a valuable tool for evaluating program impacts, was employed to analyze data collected from Triangle Centers in Lorestan Province, Iran. Monthly records of harm reduction services (condoms, syringes, methadone) from January 2017 to February 2023 were extracted. The pre-intervention period spanned January 2017 to January 2020, with the post-intervention period extending from February 2020 to February 2023. Statistical analyses were conducted using the Newey-West technique, Combi-Huizinga autocorrelation test, and Ordinary Least Squares (OLS) regression, with a significance threshold set at P-value < 0.05.ResultsFollowing the onset of Covid-19, the level change in condom distribution to high-risk individuals showed a significant decline, decreasing by 2,168.87 units per month (95% CI: -2,405.57 to -1,932.15). Methadone dispensation, crucial for opioid harm reduction, also witnessed a substantial level change, decreasing by 5,007.60 cc per month (95% CI: -6,251.75 to -3,763.45). Additionally, the provision of syringes decreased significantly, with a level change of -601.01 units per month (95% CI: -706.39 to -495.62).ConclusionThis study reveals significant disruptions in harm reduction services in Iran post-Covid-19, emphasizing the need for targeted interventions. Factors such as fear, stigma, resource reallocation, and logistical challenges contribute to the observed decreases. Policymakers must prioritize sustaining harm reduction services during pandemics, ensuring continuity for vulnerable populations. The findings underscore the importance of proactive policy development and preparedness to prevent delays and inequalities in accessing essential services for individuals with high-risk behaviors. Overall, integrating harm reduction into pandemic planning is crucial for a resilient and equitable health system.

Correlates of concurrent use of stimulants and opioids among people who access harm reduction services in British Columbia, Canada: Findings from the 2019 Harm Reduction Client Survey.

Previous attitudinal research has found that the way survey questions are asked can influence respondents' answers regarding their support for sensitive issues. This study aimed to explore whether findings regarding community support for harm reduction services could be manipulated through priming of language and information contained within survey items. A convenience sample of 260 university students from Sydney Australia were surveyed during late 2008 about their attitudes towards harm reduction services. Participants were randomly allocated to two groups: one received a questionnaire that provided factual information about harm reduction services (Survey 1), while a second group received a questionnaire that contained no information about harm reduction services and framed heroin use as problematic (Survey 2). Participants who completed Survey 1 expressed significantly higher levels of support for harm reduction services overall than participants who completed Survey 2 (t((249)) = -5.8, P < 0.001). Regression analysis indicated that overall support for harm reduction services was associated with the survey version that participants received and participants' political affiliations. These two factors accounted for 17.5% of the variance in the data. Research findings regarding community support for harm reduction services are influenced by questionnaire design. This has implications for the development and expansion of harm reduction services and policy.

Event-level outcomes of police interactions with young people in three non-metropolitan cities across British Columbia, Canada

BackgroundWith 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.MethodsData 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.ResultsA 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.ConclusionsOverall, 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.

BackgroundHarm reduction programs are often vulnerable to political and vocal opposition despite documented evidence of their effectiveness and economic benefit. It is not well understood if opponents to harm reduction represent the general public’s attitudes.ObjectiveTo understand the attitudes of the people of British Columbia (BC) towards various harm reduction strategies and services, and factors associated with support for harm reduction.MethodsA random-digit dialing telephone survey assessing attitudes towards various harm reduction strategies was administered to British Columbians in August 2011 (n = 2000). We compared the level of support for general harm reduction by sex, age, education level, and area of residence (Health Authority region) (χ2). Multivariate logistic regression was used to assess odds of support for harm reduction.ResultsOverall support for general harm reduction among participants was 76%; needle distribution 72%; needle distribution in one’s local community 65%; and safer inhalation equipment distribution 52%. In the multivariate analysis, those with significantly lower odds of supporting harm reduction were male, older, had equal or less than high school education or completed a certificate/diploma program, and resided in the Fraser Health Authority region. The Health Authority region with a municipality that has introduced a bylaw prohibiting the implementation of harm reduction services was found to have 69% support for harm reduction. Another Health Authority region with a municipality that closed a long-standing needle distribution site was found to have over 78% support.ConclusionIn contrast to some local policies, our results show the British Columbians surveyed in our study support harm reduction. It is unclear whether policy makers are swayed by a vocal minority or block harm reduction activities for other reasons. Tailoring messages towards segments of the public less likely to support harm reduction, as well civic policy-makers and the media, may help to reduce stigma and gain support for harm reduction services designed to protect and improve the health of the individual and the public.

Public health messaging and harm reduction in the time of COVID-19