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Background Harm reduction (HR) is a critical response to the pronounced toxicity deaths being experienced in Canada. HR providers report many benefits of their jobs, but also encounter chronic stress from structural inequities and exposure to trauma and death. This research study sought to quantify the emotional toll the toxicity emergency placed on HR providers (Cycle One; 2019). Study objectives were later expanded to determine the impact of the ongoing toxicity as well as the pandemic’s impact on well-being (Cycle Two; 2021). Methods Standardized measures of job satisfaction, burnout, secondary traumatic stress, and vulnerability to grief were used in an online national survey. Open-ended questions addressed resources and supports. HR partners across Canada validated the findings and contributed to alternative interpretations and implications. Results 651 respondents in Cycle One and 1,360 in Cycle Two reported moderately high levels of job satisfaction; they reported finding great meaning in their work. Yet, mean levels of burnout and secondary traumatic stress were moderate, with the latter significantly increasing in Cycle Two. Reported vulnerability to grief was moderate but increased significantly during COVID. When available, supports lacked the quality necessary to respond to the complexities of HR workers’ experiences, or an insufficient number of sessions were covered through benefits. Respondents shared that their professional quality of life was affected more by policy failures and gaps in the healthcare system than it was by the demands of their jobs. Conclusion Both the benefits and the strain of providing harm reduction services cannot be underestimated. For HR providers, these impacts are compounded by the drug toxicity emergency, making the service gaps experienced by them all the more critical to address. Implications highlight the need for integration of HR into the healthcare system, sustainable and reliable funding, sufficient counselling supports, and equitable staffing models. Support for this essential workforce is critical to ensuring the well-being of themselves, the individuals they serve, and the health of the broader healthcare system.

Background Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS. Methods A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned. Results The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use. Conclusions There is no one size fits all response to this crisis, and consideration should be given to the unique needs of different communities and populations, as well as the broader impact of harms on families, communities, and society. A situation so multifaceted requires both immediate and long-term strategies implemented concurrently in order to address the differing and on-going needs of Canadians experiencing opioid harms. The expertise of individuals and families affected by the opioid crisis must be included in consultations and decisions related to different strategies, to ensure responses are not stigmatizing, that they will be effective and acceptable and that unintended consequences are quickly recognized and mitigated.

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. PROSPERO registration CRD42018090761.

The Canadian Centre on Substance Use and Addiction (CCSA) has a mandate to provide national leadership in evidence-informed analysis and knowledge mobilization to advance solutions that reduce substance-related harms. Doing this work effectively requires an understanding of the needs, priorities, perspectives and ideologies of multiple groups. Partnerships across various sectors support a full understanding and acknowledgement of the systems that create differential health outcomes for individuals and communities. CCSA has developed an integrated knowledge mobilization model to guide our work in supporting better substance use health outcomes. Our model begins by understanding the context a particular need (for example, research question and practice improvement) is occurring within. This involves engaging key partners with multiple viewpoints to understand the current situation, constraints and opportunities, including barriers to care, social and structural determinates of health and community strengths and assets. Based on this, the steps that follow involve determining the appropriate action and CCSA’s unique role to respond in alignment with partner and community priorities to advance solutions within the given context. This leads to an iterative process of generating and mobilizing knowledge. This integrated and collaborative approach ensures that responses are relevant to the identified knowledge gap, that recommendations reflect partners’ realities and that our efforts will achieve impact while minimizing the risk of harm. Through an iterative process of generating and mobilizing knowledge (for example, supporting the scale and spread of innovations, developing new tools and generating or tailoring evidence for a specific audience/context/substance/setting, among others), outputs such as increased awareness, knowledge, use of information and strengthened capacity occur. Together, these efforts contribute to the outcome of a healthier society for people living in Canada, where multiple forms of evidence advance substance use health. Meaningful engagement of partners and evaluation of our efforts are ingrained throughout the model to ensure our work has the intended effects. We share our approach for the consideration of other organizations (in the space of substance use health and otherwise) to engage partners in the development of evidence and other resources that can drive impactful programs, practice and policy.

Background Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada. Methods We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey ( N  = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario. Results Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities. Conclusions Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

Background Few studies have systematically examined the barriers and facilitators to buprenorphine uptake, despite increasing opioid-related harms and guideline recommendations for use. The aim of the study was to use behaviour change frameworks to investigate barriers and facilitators to buprenorphine access and use from diverse perspectives in Ontario, Canada. Methods We conducted semi-structured face-to-face or telephone interviews with Ontarians including: people with living/lived expertise of opioid use (including family members), healthcare professionals, and organizational and system-level representatives. We used purposive sampling via existing professional networks to recruit participants with diverse experiences. The Theoretical Domains Framework (TDF) guided the data collection tool and analysis. Interviews were recorded, transcribed, coded, and underwent thematic analysis involving three study team members. Results We interviewed 28 participants between September 2019 and January 2020. Three predominant TDF domains were identified across all 4 levels: (1) environmental context/resources; (2) beliefs about consequences; (3) social influences. Key cross-cutting themes included access to comprehensive care, medication and treatment characteristics, confidence and experiences with buprenorphine, as well as supportive relationships and stigma/discrimination. Conclusions Multi-level barriers to optimal buprenorphine implementation continue in the face of the drug toxicity crisis. To counter the identified barriers and enhance facilitators, there is need for mentorship models of support for prescribing, flexibility in buprenorphine treatment requirements, better recognition of mental health and the social determinants of health in buprenorphine treatment, and comprehensive and integrated systems of care.

IntroductionIn the context of the opioid crisis in North America, the benefits of evidence-based opioid agonist treatments such as buprenorphine/naloxone have not been optimised due to low uptake. Numerous factors contribute to the underuse of buprenorphine, and theory-informed approaches to identify and address implementation barriers and facilitators are needed. This scoping review aims to characterise the barriers and facilitators at the patient, healthcare professional, organisation and system level according to the Theoretical Domains Framework (TDF), and identify gaps to inform practice and policy.Methods and analysisWe will conduct a scoping review using established methods and follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. We will identify English and French-language peer-reviewed literature by searching five electronic bibliographic databases (MEDLINE, Embase, PsychINFO, CINAHL, and SocINDEX), from inception and use Google, websites of key organisations, and two or more custom search engines to identify relevant grey literature. Eligible records will be quantitative or qualitative studies that examine barriers and facilitators to buprenorphine use at the patient, healthcare professional, organisation and system level, and involve participants with diagnosis of opioid use disorder or professionals involved in their care. Two reviewers will be involved in independently screening, reviewing and charting the data and calibration exercises will be conducted at each stage. We will conduct descriptive analysis for the charted data, and deductively code barriers and facilitators using the TDF.Ethics and disseminationAs a scoping review of the literature, this study does not require ethics approval. Our dissemination strategy will focus on developing tailored activities to meet the needs of diverse knowledge user audiences. Barriers and facilitators mapped to the TDF can be linked to evidence-based strategies for change to improve buprenorphine use and access, and enable practice to reduce opioid-related harms.

IntroductionThe opioid crisis has resulted in increasing rates of death caused by problematic opioid use. Current clinical guidelines recommend that individuals with persons with opioid use disorder (OUD) receive pharmacological (eg, opioid agonist therapy) and psychosocial (eg, cognitive behavioural therapy) therapy; however, the best combination of pharmacologic and psychosocial components is not known. Our objective of the planned study is to conduct a comprehensive systematic review to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy among persons with OUD.Methods and analysisA comprehensive search for randomised controlled trials published in English or French will be conducted from database inception to March 2018. The search will be conducted in MEDLINE and translated for Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Two independent reviewers will screen, extract and assess risk of bias of eligible articles. Primary outcomes of interest will be treatment retention and opioid use (based on urinalysis results). Secondary outcomes will include self-reported opioid use, abstinence from illicit drugs, adherence to psychosocial therapy and opioid agonist therapy, risk for sexually transmitted disease, risk for blood borne pathogens, changes in mental health symptoms (eg, depression), measures of craving and changes in patients’ quality of life and relevant adverse events. If sufficient data and adequate homogeneity exists, network meta-analyses (NMA) will be performed.Ethics and disseminationThis will be the first systematic review to incorporate NMA to compare psychosocial treatments used as an adjunct to opioid agonist therapy for OUD. Results of this review will inform clinical management of persons with OUD.Trial registration numberCRD42018090761.

ObjectivesWe sought to understand the implementation of multifaceted community plans to address opioid-related harms.DesignOur scoping review examined the extent of the literature on community plans to prevent and reduce opioid-related harms, characterise the key components, and identify gaps.Data sourcesWe searched MEDLINE, Embase, PsycINFO, CINHAL, SocINDEX and Academic Search Primer, and three search engines for English language peer-reviewed and grey literature from the past 10 years.Eligibility criteriaEligible records addressed opioid-related harms or overdose, used two or more intervention approaches (eg, prevention, treatment, harm reduction, enforcement and justice), involved two or more partners and occurred in an Organisation for Economic Co-operation and Development country.Data extraction and synthesisQualitative thematic and quantitative analysis was conducted on the charted data. Stakeholders were engaged through fourteen interviews, three focus groups and one workshop.ResultsWe identified 108 records that described 100 community plans in Canada and the USA; four had been evaluated. Most plans were provincially or state funded, led by public health and involved an average of seven partners. Commonly, plans used individual training to implement interventions. Actions focused on treatment and harm reduction, largely to increase access to addiction services and naloxone. Among specific groups, people in conflict with the law were addressed most frequently. Community plans typically engaged the public through in-person forums. Stakeholders identified three key implications to our findings: addressing equity and stigma-related barriers towards people with lived experience of substance use; improving data collection to facilitate evaluation; and enhancing community partnerships by involving people with lived experience of substance use.ConclusionCurrent understanding of the implementation and context of community opioid-related plans demonstrates a need for evaluation to advance the evidence base. Partnership with people who have lived experience of substance use is underdeveloped and may strengthen responsive public health decision making.

Task-sharing holds promise for bridging gaps in access to mental healthcare; yet there remain significant challenges to scaling up task-sharing models. This formative study aimed to develop a digital platform for training non-specialist providers without prior experience in mental healthcare to deliver a brief psychosocial intervention for depression in community settings in Texas. A 5-step development approach was employed, consisting of: blueprinting, scripting, video production and digital content creation, uploading digital content to a Learning Management System and user testing. This resulted in the development of two courses, one called Foundational Skills covering the skills to become an effective counselor, and the second called Behavioral Activation covering the skills for addressing adult depression. Twenty-one participants with a range of health-related backgrounds, including 11 with prior training in mental healthcare, completed the training and joined focus group discussions offering qualitative feedback and recommendations for improving the program’s usability. Participant feedback centered around the need to make the content more interactive, to include additional engaging features, and to improve the layout and usability of the platform. The next steps will involve evaluating the training program on developing the skills of non-specialist providers and supporting its uptake and implementation.