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Tyndall examines the pragmatic and ethical response to overdose crisis. He cites the research by Crabtree and colleagues that provides an important snapshot of the toxic drug supply fuelling an overdose epidemic that has killed more than 6,000 people in British Columbia (BC) since 2014. Their descriptive study of drug overdose deaths involving at least 1 illicit substance identified by the BC Coroners Service from 2015 to 2017 showed that the vast majority were related to synthetic opioids purchased from the illicit market, with prescription opioids playing a minor role. The authors conclude that strategies to address the current overdose crisis in Canada need to go far beyond opioid deprescribing. His argumentation that the only pragmatic and ethical way forward is to offer a regulated, safer supply of opioids, decriminalize drug use, and redeploy resources that are used for drug law enforcement into health and social programs is also highlighted.

Unintentional drug overdoses have rapidly become a public health crisis in Canada. Collecting accurate numbers remains problematic, but it is estimated that 2458 overdose deaths occurred in 2016. In the province of British Columbia--ground zero for the epidemic--more than 1000 overdose deaths were reported in the first eight months of 2017. Although the rates of overdoses vary across the country, no regions have been spared, and communities should be bracing for the worst. The overdose crisis has exposed the large gaps in our drug treatment systems and the uneven access to harm reduction services. At the core of the current crisis is a drug supply that has become contaminated with potent synthetic opioids, mainly in the form of fentanyl and carfentanil. Although communities have periodically experienced increased numbers of overdose deaths owing to transient changes in drug supply, it appears that these highly toxic drugs are here for the foreseeable future.

Background North America has been experiencing a persistent epidemic of opioid-related overdose mortality, which has increasingly been driven by fatalities from illicit, toxic opioids in most recent years. Patterns of synthetic opioid availability and related mortality are heterogeneous across Canada, and differing explanations exist as to their differentiated proliferation. We examined the perspective that heterogeneous province-based variations in prescription opioid availability, facilitated by various control strategies, post-2010 may have created regionally differential supply gaps for non-medical opioid use substituted by synthetic opioid products with differential impacts on mortality risks and outcomes in Canada. Methods We examined annual, prescription opioid dispensing rates and changes in the ten Canadian provinces (for the periods of 1) 2011–2018, 2) ‘peak-year’-to-2018) in Defined Daily Doses/1000 population/day, derived from data from a large representative, stratified sample of community pharmacies projected to a Canada total. Annual, provincial opioid-related mortality rates and changes for years 2016–2018 were calculated from federal data. We computed correlation values (Pearson’s R) between respective province-based change rates for prescription opioid dispensing and opioid-related mortality for the two over-time scenarios. Results All but one province featured reductions in prescription opioid dispensing 2011–2018; seven of the ten provinces had increases in opioid mortality 2016–2018. The correlation between changes in opioid dispensing (2011–2018) and in opioid-mortality (2016–2018) was r  = 0.63 (df = 8, p -value: 0.05); the correlation was r  = 0.57 (df = 8, p-value: 0.09) for changes in opioid dispensing ‘peak year’-to-2018, respectively. Conclusions Quasi-significant results indicate that recent increases in opioid-related deaths driven by illicit, synthetic opioids tended to be larger in provinces where reductions in prescription opioid availability have been more extensive. It is a plausible explanation that these reductions created supply gaps for non-medical opioid use increasingly filled by illicit, synthetic opioids differentially contributing to opioid-related deaths, generating un-intended adverse effects for previous interventions. General prevention measures to reduce opioid availability, and targeted prevention for at-risk opioid users exposed to toxic drug supply may be include counteractive effects and require coordinated reconciliation.

The British Columbia (BC) Hepatitis Testers Cohort (BC-HTC) was established to assess and monitor hepatitis C (HCV) epidemiology, cost of illness and treatment effectiveness in BC, Canada. In this paper, we describe the cohort construction, data linkage process, linkage yields, and comparison of the characteristics of linked and unlinked individuals. The BC-HTC includes all individuals tested for HCV and/or HIV or reported as a case of HCV, hepatitis B (HBV), HIV or active tuberculosis (TB) in BC linked with the provincial health insurance client roster, medical visits, hospitalizations, drug prescriptions, the cancer registry and mortality data using unique personal health numbers. The cohort includes data since inception (1990/1992) of each database until 2012/2013 with plans for annual updates. We computed linkage rates by year and compared the characteristics of linked and unlinked individuals. Of 2,656,323 unique individuals available in the laboratory and surveillance data, 1,427,917(54%) were included in the final linked cohort, including about 1.15 million tested for HCV and about 1.02 million tested for HIV. The linkage rate was 86% for HCV tests, 89% for HCV cases, 95% for active TB cases, 48% for HIV tests and 36% for HIV cases. Linkage rates increased from 40% for HCV negatives and 70% for HCV positives in 1992 to ~90% after 2005. Linkage rates were lower for males, younger age at testing, and those with unknown residence location. Linkage rates for HCV testers co-infected with HIV, HBV or TB were very high (90-100%). Linkage rates increased over time related to improvements in completeness of identifiers in laboratory, surveillance, and registry databases. Linkage rates were higher for HCV than HIV testers, those testing positive, older individuals, and females. Data from the cohort provide essential information to support the development of prevention, care and treatment initiatives for those infected with HCV.

Individuals working in the sex industry continue to experience many negative health outcomes. As such, disentangling the factors shaping poor health access remains a critical public health priority. Within a quasi-criminalised prostitution environment, this study aimed to evaluate the prevalence of occupational stigma associated with sex work and its relationship to barriers to accessing health services. Analyses draw on baseline questionnaire data from a community-based cohort of women in street-based sex work in Vancouver, Canada (2006-2008). Of a total of 252 women, 141 (55.9%) reported occupational sex work stigma (defined as hiding occupational sex work status from family, friends and/or home community), while 125 (49.6%) reported barriers to accessing health services in the previous six months. In multivariable analysis, adjusting for sociodemographic, interpersonal and work environment risks, occupational sex work stigma remained independently associated with an elevated likelihood of experiencing barriers to health access. Study findings indicate the critical need for policy and societal shifts in views of sex work as a legitimate occupation, combined with improved access to innovative, accessible and non-judgmental health care delivery models for street-based sex workers that include the direct involvement of sex workers in development and implementation.

Injecting drug use is an increasingly important cause of HIV transmission in most countries worldwide. Our aim was to determine the prevalence of injecting drug use among individuals aged 15–64 years, and of HIV among people who inject drugs. We did a systematic search of peer-reviewed (Medline, EmBase, and PubMed/BioMed Central), internet, and grey literature databases; and data requests were made to UN agencies and international experts. 11 022 documents were reviewed, graded, and catalogued by the Reference Group to the UN on HIV and Injecting Drug Use. Injecting drug use was identified in 148 countries; data for the extent of injecting drug use was absent for many countries in Africa, the Middle East, and Latin America. The presence of HIV infection among injectors had been reported in 120 of these countries. Prevalence estimates of injecting drug use could be ascertained for 61 countries, containing 77% of the world's total population aged 15–64 years. Extrapolated estimates suggest that 15·9 million (range 11·0–21·2 million) people might inject drugs worldwide; the largest numbers of injectors were found in China, the USA, and Russia, where mid-estimates of HIV prevalence among injectors were 12%, 16%, and 37%, respectively. HIV prevalence among injecting drug users was 20–40% in five countries and over 40% in nine. We estimate that, worldwide, about 3·0 million (range 0·8–6·6 million) people who inject drugs might be HIV positive. The number of countries in which the injection of drugs has been reported has increased over the last decade. The high prevalence of HIV among many populations of injecting drug users represents a substantial global health challenge. However, existing data are far from adequate, in both quality and quantity, particularly in view of the increasing importance of injecting drug use as a mode of HIV transmission in many regions. UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales.

Objectives. We investigated the relationship between environmental–structural factors and condom-use negotiation with clients among female sex workers. Methods. We used baseline data from a 2006 Vancouver, British Columbia, community-based cohort of female sex workers, to map the clustering of “hot spots” for being pressured into unprotected sexual intercourse by a client and assess sexual HIV risk. We used multivariate logistic modeling to estimate the relationship between environmental–structural factors and being pressured by a client into unprotected sexual intercourse. Results. In multivariate analyses, being pressured into having unprotected sexual intercourse was independently associated with having an individual zoning restriction (odds ratio [OR] = 3.39; 95% confidence interval [CI] = 1.00, 9.36), working away from main streets because of policing (OR = 3.01; 95% CI = 1.39, 7.44), borrowing a used crack pipe (OR = 2.51; 95% CI = 1.06, 2.49), client-perpetrated violence (OR = 2.08; 95% CI = 1.06, 4.49), and servicing clients in cars or in public spaces (OR = 2.00; 95% CI = 1.65, 5.73). Conclusions. Given growing global concern surrounding the failings of prohibitive sex-work legislation on sex workers' health and safety, there is urgent need for environmental–structural HIV-prevention efforts that facilitate sex workers' ability to negotiate condom use in safer sex-work environments and criminalize abuse by clients and third parties.

Co-occurrence of social conditions and infections may affect HIV/HCV disease risk and progression. We examined the changes in relationship of these social conditions and infections on HIV and hepatitis C virus (HCV) infections over time in British Columbia during 1990-2013. The BC Hepatitis Testers Cohort (BC-HTC) includes ~1.5 million individuals tested for HIV or HCV, or reported as a case of HCV, HIV, HBV, or tuberculosis linked to administrative healthcare databases. We classified HCV and HIV infection status into five combinations: HIV-/HCV-, HIV+monoinfected, HIV-/HCV+seroconverters, HIV-/HCV+prevalent, and HIV+/HCV+. Of 1.37 million eligible individuals, 4.1% were HIV-/HCV+prevalent, 0.5% HIV+monoinfected, 0.3% HIV+/HCV+ co-infected and 0.5% HIV-/HCV+seroconverters. Overall, HIV+monoinfected individuals lived in urban areas (92%), had low injection drug use (IDU) (4%), problematic alcohol use (4%) and were materially more privileged than other groups. HIV+/HCV+ co-infected and HIV-/HCV+seroconverters were materially most deprived (37%, 32%), had higher IDU (28%, 49%), problematic alcohol use (14%, 17%) and major mental illnesses (12%, 21%). IDU, opioid substitution therapy, and material deprivation increased in HIV-/HCV+seroconverters over time. In multivariable multinomial regression models, over time, the odds of IDU declined among HIV-/HCV+prevalent and HIV+monoinfected individuals but not in HIV-/HCV+seroconverters. Declines in odds of problematic alcohol use were observed in HIV-/HCV+seroconverters and coinfected individuals over time. These results highlight need for designing prevention, care and support services for HIV and HCV infected populations based on the evolving syndemics of infections and social conditions which vary across groups.

HIV prevalence among people who inject drugs (PWID) in Ottawa is estimated at about 10%. The successful integration of peers into outreach efforts and wider access to HIV point-of-care testing (POCT) create opportunities to explore the role of peers in providing HIV testing. The PROUD study, in partnership with Ottawa Public Health (OPH), sought to develop a model for community-based peer-administered HIV POCT. PROUD draws on community-based participatory research methods to better understand the HIV risk environment of people who use drugs in Ottawa. From March-October 2013, 593 people who reported injecting drugs or smoking crack cocaine were enrolled through street-based recruitment. Trained peer or medical student researchers administered a quantitative survey and offered an HIV POCT (bioLytical INSTI test) to participants who did not self-report as HIV positive. 550 (92.7%) of the 593 participants were offered a POCT, of which 458 (83.3%) consented to testing. Of those participants, 74 (16.2%) had never been tested for HIV. There was no difference in uptake between testing offered by a peer versus a non-peer interviewer (OR = 1.05; 95% CI = 0.67-1.66). Despite testing those at high risk for HIV, only one new reactive test was identified. The findings from PROUD demonstrate high uptake of community-based HIV POCT. Peers were able to successfully provide HIV POCT and reach participants who had not previously been tested for HIV. Community-based and peer testing models provide important insights on ways to scale-up HIV prevention and testing among people who use drugs.

Background We characterized the twin epidemics of new and prevalent hepatitis C virus (HCV) infections in British Columbia, Canada to inform prevention, care and treatment programs. Methods The BC Hepatitis Testers Cohort (BC-HTC) includes individuals tested for HCV, HIV or reported as a case of HBV, HCV, HIV or active TB between 1990–2013 linked with data on their medical visits, hospitalizations, cancers, prescription drugs and mortality. Prevalent infection was defined as being anti-HCV positive at first test. Those with a negative test followed by a positive test were considered seroconverters or new infections. Results Of 1,132,855 individuals tested for HCV, 64,634 (5.8 %) were positive and an additional 3092 cases tested positive elsewhere for a total of 67,726. Of 55,781 HCV positive individuals alive at the end of 2013, 7064 were seroconverters while 48,717 had prevalent infection at diagnosis. The HCV positivity rate (11.2 %) was highest in birth cohort 1945–1964 which declined over time. New infections were more likely to be male, 15–34 years of age (born 1965-1984), HIV- or HBV-coinfected, socioeconomically disadvantaged, have problematic drug and alcohol use and a mental health illness. The profile was similar for individuals with prevalent infection, except for lower odds of HBV-coinfection, major mental health diagnoses and birth cohort >1975. Conclusions The HCV positivity rate is highest in birth cohort 1945–1964 which represents most prevalent infections. New infections occur in younger birth cohorts who are commonly coinfected with HIV and/or HBV, socioeconomically marginalized, and living with mental illness and addictions.