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To learn about the experiences of people who use drugs, specifically opioids, in the Halifax Regional Municipality (HRM), in Nova Scotia, Canada during the COVID-19 pandemic through qualitative interviews with people who use drugs and healthcare providers (HCP). This study took place within the HRM, a municipality of 448,500 people [1]. During the pandemic many critical services were interrupted while overdose events increased. We wanted to understand the experiences of people who use drugs as well as their HCPs during the first year of the pandemic. We conducted a qualitative study using semi-structured interviews with 13 people who use drugs and 6 HCPs, including physicians who work in addiction medicine (3), a pharmacist, a nurse, and a community-based opioid agonist therapy (OAT) program staff member. Participants were recruited within HRM. Interviews were held via phone or videoconference due to social distancing directives. Interviews focused on the challenges people who use drugs and HCPs faced during the pandemic as well as elicited perspectives on a safe supply of drugs and the associated barriers and facilitators to the provision of a safe supply. Of the 13 people who use drugs who participated in this study, ages ranged from 21-55 years (mean 40). Individuals had spent on average 17 years in HRM. Most people who use drugs (85%, n = 11) utilized income assistance, the Canadian Emergency Response Benefit, or disability support. Many had experienced homelessness (85%, n = 11) and almost half (46%, n = 6) were currently precariously housed in the shelter system. The main themes among interviews (people who use drugs and HCPs) were housing, accessing healthcare and community services, shifts in the drug supply, and perspectives on safe supply. We identified several challenges that people who use drugs face in general, but especially during the COVID-19 pandemic. Access to services, housing support, and interventions to use safely at home were limited. As many challenges faced by people who use drugs exist outside of COVID-19, we concluded that the formal and informal interventions and changes in practice that were made to support people who use drugs should be sustained well past the end of the pandemic. The need for enhanced community supports and a safe supply of drugs, despite its complicated nature, is essential for the health and safety of people who use drugs in HRM, especially during COVID-19.

Background Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI’s) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees. Methods Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used. Results We interviewed 20 individuals between 08/2020–11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings. Conclusion Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI’s prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

Background In May 2022, Health Canada approved a three-year exemption from the Controlled Drugs and Substances Act decriminalizing possession of certain illegal substances for personal use among adults in the province of British Columbia. The exemption explicitly includes a cumulative threshold of 2.5 g of opioids, cocaine, methamphetamine, and MDMA. Threshold quantities are commonly included in decriminalization policies and justified within law enforcement systems to delineate personal use among people who use drugs versus drug dealers who are carrying for trafficking purposes. Understanding the impact of the 2.5g threshold can help define the extent to which people who use drugs will be decriminalized. Methods From June-October 2022, 45 people who use drugs from British Columbia were interviewed to gain an understanding of their perceptions on decriminalization, particularly on the proposed threshold of 2.5 g. We conduced descriptive thematic analyses to synthesize common interview responses. Results Results are displayed under two categories: 1) Implications for substance use profiles and purchasing patterns, including implications on the cumulative nature of the threshold and impacts on bulk purchasing, and 2) Implications of police enforcement, including distrust of police use of discretion, potential for net widening and jurisdictional discrepancies in enforcing the threshold. Results illustrate the need for the decriminalization policy to consider diversity in consumption patterns and frequency of use among people who use drugs, the inclination to purchase larger quantities of substances for reduced costs and to guarantee a safe and available supply, and the role police will play in delineating between possession for personal use or trafficking purposes. Conclusions The findings underscore the importance of monitoring the impact of the threshold on people who use drugs and whether it is countering the goals of the policy. Consultations with people who use drugs can help policymakers understand the challenges they may face when trying to abide by this threshold.

Objectives On January 31, 2023, a three-year exemption from the Controlled Drugs and Substances Act was granted to the Canadian province British Columbia (BC), allowing the cumulative possession of 2.5 g of specific unregulated drugs amongst adults. The goals of the policy are to reduce health, social, and economic harms associated with criminalization, stigma, drug overdose deaths, as well as drug seizures, arrests, and associated enforcement and court costs. As the inaugural year has passed, we aimed to assess people who use drugs’ awareness and knowledge of the, as well as the policy’s impact on their drug use patterns and overdose risk. Methods We conducted 100 telephone-based semi-structured interviews with people who use drugs from across BC, exploring changes in drug use experiences and perceived overdose risk since the implementation of the policy. Participants also completed an interviewer-administered survey assessing socio-demographics and substance use patterns. We utilized a qualitative content analysis approach to analyze the interview data. Results Our findings indicate a general awareness of the policy among participants, although some policy details were often misunderstood, and participants expressed the need for more widespread dissemination of policy information. While the majority of participants reported that their drug use patterns remained unchanged after decriminalization, some made subtle adjustments, such as carrying under the 2.5 g threshold to minimize the risk of criminalization. Participants highlighted several policy benefits and concerns, including its potential to reduce criminalization and stigmatization, but also increase public drug consumption. Participants offered suggestions for policy improvement. Conclusion These findings underscore the need for ongoing monitoring of the impacts of decriminalization regarding its potential impact on people who use drugs’ drug use patterns and related risks. Reevaluation of the possession threshold and efforts to enhance education and awareness about the policy could help achieve the policy’s goals.

IntroductionInjecting-related bacterial and fungal infections are a common complication among people who inject drugs (PWID), associated with significant morbidity and mortality. Invasive infections, including infective endocarditis, appear to be increasing in incidence. To date, preventive efforts have focused on modifying individual-level risk behaviours (eg, hand-washing and skin-cleaning) without much success in reducing the population-level impact of these infections. Learning from successes in HIV prevention, there may be great value in looking beyond individual-level risk behaviours to the social determinants of health. Specifically, the risk environment conceptual framework identifies how social, physical, economic and political environmental factors facilitate and constrain individual behaviour, and therefore influence health outcomes. Understanding the social and structural determinants of injecting-related bacterial and fungal infections could help to identify new targets for prevention efforts in the face of increasing incidence of severe disease.Methods and analysisThis is a protocol for a systematic review. We will review studies of PWID and investigate associations between risk factors (both individual-level and social/structural-level) and the incidence of hospitalisation or death due to injecting-related bacterial infections (skin and soft-tissue infections, bacteraemia, infective endocarditis, osteomyelitis, septic arthritis, epidural abscess and others). We will include quantitative, qualitative and mixed methods studies. Using directed content analysis, we will code risk factors for these infection-related outcomes according to their contributions to the risk environment in type (social, physical, economic or political) and level (microenvironmental or macroenvironmental). We will also code and present risk factors at each stage in the process of drug acquisition, preparation, injection, superficial infection care, severe infection care or hospitalisation, and outcomes after infection or hospital discharge.Ethics and disseminationAs an analysis of the published literature, no ethics approval is required. The findings will inform a research agenda to develop and implement social/structural interventions aimed at reducing the burden of disease.PROSPERO registration numberCRD42021231411.

Background Canada’s historical reliance on criminal justice approaches to drug policy has intensified structural and social stigma, and high-risk behaviours among people who use drugs. In response to pressure from local advocates, British Columbia implemented a pilot decriminalization policy in January 2023, permitting adults to possess up to 2.5 g of specified unregulated substances, cumulatively. While not designed to address the toxic drug supply directly, it aimed to reduce stigma and encourage engagement with health and harm reduction services. In May 2024, however, drug possession in public spaces was recriminalized, raising concerns about a return to punitive environments. To date, little is known about how these policy shifts have been experienced by people who use drugs themselves. We conducted a qualitative study exploring the impacts of British Columbia’s decriminalization policy and its subsequent recriminalization amendment on the drug use behaviours of people who use drugs across the province. Methods A cross-sectional qualitative study with 75 people who use drugs across British Columbia, including a socio-demographic survey, and semi-structured interviews. Interviews were transcribed verbatim and analyzed using thematic analysis. The codebook was applied across all transcripts using a comparative approach to identify recurring patterns, divergent experiences, and key themes related to drug use behaviours. Results Participants reported little to no change in their drug use patterns following either decriminalization or recriminalization, as drug use was primarily driven by dependence, routine, and structural factors. Nonetheless, many described a psychological benefit under decriminalization, including reduced shame, internalized stigma, and fear of criminalization. These gains were largely reversed following the recriminalization amendment, which pushed drug use back into hidden, high-risk environments. Participants also noted destabilizing shifts in the drug supply, including increased potency and a rise in less experienced dealers, linked to the 2.5 g threshold. Conclusion Decriminalization did not significantly alter drug use behaviours but offered notable psychological relief for participants. The subsequent recriminalization amendment then reversed these perceived gains, illustrating how this abrupt policy change led to unintended consequences, undermining the original goals of the decriminalization policy. These findings highlight the need for sustained and structurally supported effective policy approaches that center the lived realities of people who use drugs.

Background Canada is in the midst of a worsening overdose crisis, driven largely by the unregulated drug supply. In response, safer opioid supply (SOS) programs were implemented to provide pharmaceutical-grade opioids alongside critical services. However, in August 2024, Ontario’s provincial government introduced restrictions on harm reduction initiatives, coinciding with the expiration of federal funding, forcing many programs to close. In their place, the government announced the implementation of Homelessness and Addiction Recovery Treatment Hubs, which exclude harm reduction programs, including SOS programs. This study explores the experiences of SOS program clients and the anticipated impacts of these program closures on their lives. Methods A qualitative study design was used, involving semi-structured interviews with people who use drugs who were enrolled in six SOS programs across Ontario. Participants were recruited through convenience and snowball sampling. Eligible participants were current SOS clients (≥ 6 months), aged 18 or older, and English-speaking. Interviews were conducted virtually and explored participants’ experiences with SOS programs, anticipated impacts of program closures, and strategies to mitigate risks. Data were thematically analyzed using NVivo. Results Participants reported that SOS programs reduced their reliance on the unregulated drug supply, decreased their overdose risk, and connected them to wraparound services. The impending closures triggered widespread fear, uncertainty, and anxiety, particularly about returning to the unregulated supply. Participants also expressed concerns over the loss of access to critical health and social services and the potential decline in their quality of life. Many expressed frustration over the lack of meaningful alternatives, difficulties in securing new prescribers, and distress over forced medication tapers. Conclusion This study highlights participants’ concerns that SOS program closures may force them back into an increasingly dangerous unregulated market, ultimately putting their lives at risk, along with reversing the many benefits SOS programs provided, such as connections to essential health and social services. By replacing harm reduction programs with treatment services, the government is not reducing the demand for opioid use; instead, it forces a return to the unregulated drug market, ultimately putting individuals at risk of overdose.

Background In response to the ongoing drug toxicity crisis, driven by fentanyl and its analogues in the unregulated drug supply, Canada has funded several safer supply programs, which provide pharmaceutical-grade medications to reduce the reliance on toxic unregulated drug supply for people who use drugs. In this study, we examined barriers and facilitators that influenced the implementation of integrated safer supply pilot programs (ISSPP) across Canada. Methods Between March 2022 and May 2023, we conducted a qualitative study using semi-structured interviews with key informants from ten ISSPP located in three provinces across Canada. Data analysis and interpretation of findings were guided by the Consolidated Framework for Implementation Research (CFIR). Thematic analysis was used to code transcripts and identify themes. Results ISSPP varied greatly in the degree of ancillary and wraparound services provided. Additionally, differences existed across the ten programs in terms of eligibility criteria for enrolling clients and the availability of medication options. We found twelve constructs and three sub-constructs across four domains of CFIR that influenced the implementation of ISSPP. Implementation facilitators included low-barrier and client-centered delivery model, ongoing needs assessment through program monitoring and evaluation, integration of wraparound care, partnership with local services to coordinate client care, community buy-in, clinical protocols and standardized practices, and multidisciplinary care teams with motivated staff. Major barriers to ISSPP implementation were a volatile and toxic unregulated drug supply, complicated policy environments, unsustainable funding models, unsupportive regulatory environments, limited medication options, limited physical space, as well as staff shortage. Conclusions Despite several internal implementation facilitators, ISSPP faced many external and policy-level implementation barriers. Future safer supply programs should be guided by evidence-based planning and implementation, drawing from successful experiences in harm reduction implementation. Implementation facilitators, in particular, evidence-based practice guidelines along with better monitoring of client outcomes can be leveraged to enhance quality of care, address client needs and preferences, and mitigate unintended harms.

Background People Who Use Drugs (PWUD) have lower vaccination uptake than the general population, and disproportionately experience the burden of harms from vaccine-preventable diseases. We conducted a national qualitative study to: (1) identify the barriers and facilitators to receiving COVID-19 vaccinations among PWUD; and (2) identify interventions to support PWUD in their decision-making. Methods Between March and October 2022, semi-structured interviews with PWUD across Canada were conducted. Fully vaccinated (2 or more doses) and partially or unvaccinated (1 dose or less) participants were recruited from a convenience sample to participate in telephone interviews to discuss facilitators, barriers, and concerns about receiving COVID-19 vaccines and subsequent boosters, and ways to address concerns. A total of 78 PWUD participated in the study, with 50 participants being fully vaccinated and 28 participants partially or unvaccinated. Using thematic analysis, interviews were coded based on the capability, opportunity, and motivation-behavior (COM-B) framework. Results Many partially or unvaccinated participants reported lacking knowledge about the COVID-19 vaccine, particularly in terms of its usefulness and benefits. Some participants reported lacking knowledge around potential long-term side effects of the vaccine, and the differences of the various vaccine brands. Distrust toward government and healthcare agencies, the unprecedented rapidity of vaccine development and skepticism of vaccine effectiveness were also noted as barriers. Facilitators for vaccination included a desire to protect oneself or others and compliance with government mandates which required individuals to get vaccinated in order to access services, attend work or travel. To improve vaccination uptake, the most trusted and appropriate avenues for vaccination information sharing were identified by participants to be people with lived and living experience with drug use (PWLLE), harm reduction workers, or healthcare providers working within settings commonly visited by PWUD. Conclusion PWLLE should be supported to design tailored information to reduce barriers and address mistrust. Resources addressing knowledge gaps should be disseminated in areas and through organizations where PWUD frequently access, such as harm reduction services and social media platforms.

Background This paper explores the perspectives of a group of people with lived and living expertise of unregulated drug use who worked as frontline harm reduction service providers and activists in Canada during the dual public health emergencies of COVID-19 and the toxic drug crisis. Specifically, this paper explores their initial experiences at the onset of the COVID-19 pandemic, their reflections on how these experiences varied one year into the pandemic, and their perspectives on how shifting public health measures and policies shaped their work. Methods Drawing on collaborative research methods, this project was developed with a national working group of people with lived and living expertise of substance use. Three rounds of roundtable discussions along with two sets of semi-structured interviews were conducted with working group members from May 2020 to June 2021. A thematic analysis was co-developed by academic facilitators and the working group through deductive and indictive group coding and reflexive analysis. Results Four themes emerged from the interviews and roundtable sessions: (1) initial negative impacts of COVID-19-related public health measures; (2) societal abandonment, collective anger and grief; (3) navigating constantly shifting public health emergencies over time; and (4) leveraging lived expertise to create positive change. Conclusions The COVID-19 pandemic, in concert with the toxic drug crisis, presented many challenges for working group members on the frontlines to continue their work providing essential services to people who use unregulated drugs in Canada. The experiences shared by this unique group demonstrate these challenges, as well as how the immediate and long-term impacts of these dual public health emergencies provided opportunities for innovating and advocating for sustainable policy changes.