Reducing drug-related harms
What is the situation?
Alberta is in the midst of dual public health crises — the continuing overdose emergency and the COVID-19 pandemic. At the intersection of these dual public health emergencies are a number of challenging issues that increase the risk of drug-related harms, including overdose deaths.
Many persons who use drugs (PWUD) are at increased risk of developing severe COVID-19 symptoms because of existing clinical, psychological, and psychosocial conditions (Baillargeon et al., 2020; Lagisetty et al., 2017; Peacock et al., 2018). Plus, the social and living conditions of many PWUD make them vulnerable to COVID-19 infection: tented encampments, emergency shelters, and rough sleeping are not conducive to reducing COVID-19 risk (Tyndall, 2020). The public health measures to reduce the risk of COVID-19 infection have, however, had unintended consequences for PWUD and placed them at increased risk for overdose or other drug-related harms.
The number of deaths (n=583) caused by non-pharmaceutical opioids in Alberta declined in 2019 for the first time since comprehensive data on acute substance deaths began reporting in 2016 (Government of Alberta, 2022). Any signs of the overdose crisis abating were quickly reversed in 2020, however, with Alberta recording the greatest number (n=1180) of deaths caused by illicit drugs on record, only to be surpassed further in 2021 (n=1623) (Government of Alberta, 2022).
Public health measures to prevent the spread of COVID-19 may be partly to blame for this increase. Efforts to increase social distancing restricted access to care and harm reduction services that people rely on (Dunlop et al., 2020; Glick et al., 2020). Border closures disrupted supply chains and interrupted the flow of existing sources of illicit drugs, resulting in increased drug adulteration and toxicity (Becker & Fiellin, 2020; CCENDU, 2020). Meanwhile, contradictory public health messaging simultaneously encouraged PWUD to remain physically distant yet discourages using drugs alone. Social distancing and isolation have been associated with anxiety, fear, sadness, anger, or boredom (Ornell et al., 2020a), which themselves have been known to intensify drug consumption (Serafini et al., 2016). Additionally, efforts to limit the strain on the health system to maintain surge capacity for patients infected with COVID-19 limited the ability of individuals managing these issues to seek assistance (Dunlop et al., 2020; Ornell et al., 2020b). The confluence of these issues have created an environment where already problematic drug-related harms, including deaths, are further exacerbated.
Who is affected?
The burden of drug-related deaths is primarily carried by middle-aged males, with 73.4% of all drug poisoning deaths in 2021 (the last full year with data available) occurring among males, and the greatest number of those deaths (n=207 or 11.5%) occurring among males aged 35 to 39 (Government of Alberta, 2022).
While the public face of the overdose crisis is often portrayed as those displaying visible signs of poverty, or as persons who may be street entrenched, the reality is that more than half (52.75%) of all opioid poisoning deaths in 2021 occurred in a person’s own private residence (Government of Alberta, 2022), many of whom were alone at the time of overdose (Aware360, n.d.).
To begin to understand, then, how we might address the issue of overdose-related deaths for those most affected by it, the following persona for persons who use substances was composed:
So what is the problem?
To understand the roots of the problem, I utilized the “Five Whys Worksheet”, focusing on the problem statements that have been identified through the literature (as outlined above).
This represents only three root causes for three problem statements that, together, may still only partially explain the issue of drug-related overdose deaths. The reality is that this issue is what Rittel and Webber (1974) might call a “wicked problem” insofar as it is unique, difficult to define, a symptom of other problems, and met with solutions that are neither immediately apparent nor set.
What solutions exist?
The personas building exercise identified that there are various reasons why people use illicit substances, and individuals are at different stages of change with regards to their interest and/or readiness to reduce (or quit) their substance use. In addition, we must also accept that any one solution to the issue of drug-related overdose deaths may only be a partial solution. In considering these limitations, the following are suggested:
Problem statement 1: How might we reduce the toxicity of the drug supply?
The toxicity of the drug supply is intimately linked to the financial incentivization of an adulterated drug supply for suppliers. Basically, by mixing street drugs the suppliers can get more ‘bang for their buck,’ particularly in a context of disrupted supply chains. One mechanism to disrupt this is the provision of medical-grade alternatives to illicit drugs, otherwise referred to as “safe supply.” In 2020, Health Canada issued a temporary exemption under the Controlled Drugs and Substances Act that allows nurse practitioners and physicians to prescribe pharmaceutical alternatives for illicit and licit substances, including opioids, alcohol, and amphetamines, to counteract some of the potential secondary effects of the public health response to COVID-19 (Health Canada, n.d.).
Safe supply helps support PWUD in adhering to public health guidance and better enable physical distancing and self-isolation to reduce the spread of COVID-19 by permitting the prescribing of prescription alternatives for illicit drugs to PWUD that are at high-risk of contracting COVID-19 and with a high likelihood of withdrawal, overdose, or other drug related harms. In essence, these measures help PWUD access non-toxic drugs that will reduce their reliance on, and need to access street drugs, thereby enabling PWUD to follow measures to reduce COVID-19 infection while simultaneously reducing their risk of drug-related overdoses and other harms.
Problem statement 2: How might we reduce the use of unsafe consumption methods?
Deaths attributed to substance use are one of several drug-related harms that PWUD are at risk for, along with blood-borne infections (e.g., HIV, HCV) (Kerr et al., 2005) and other physical health problems related to consumption practices (e.g., wounds, abscesses) (Kerr et al., 2005; Krusi et al., 2009), amongst others. Supervised consumption sites (SCS) are an evidence-based harm reduction intervention aimed at reducing mortality and morbidity associated with substance use (Keer et al., 2006; Milloy et al, 2008). Various forms of SCS exist, but most entail health services where PWUD can consume their pre-obtained substances in a safe and clean environment, under the supervision of staff who are trained to respond to drug overdoses and provide education on safer consumption, as well as first aid related to drug consumption (e.g., wound care).
Problem statement 3: How might we reduce the frequency of overdoses occurring while people use alone?
The Government of Alberta has recently scaled a new intervention, the Digital Overdose Response System (DORS). DORS is a free mobile application that can prevent overdose deaths among people who use drugs alone (Aware360, n.d.). DORS users can start a timer on the app and confirm their location prior to using substances alone. The timer can be cancelled or extended by the user, and if there is no response from the user when the timer runs out an alarm will sound, and an emergency alert is sent to a response centre who will be provided with the user’s location in order to displace medical help. This intervention helps fill the gap for those individuals who use substances alone.
References
Aware 360. (n.d.). Digital Overdose Response System (DORS). https://www.dorsapp.ca/
Baillargeon, J., Polychronopoulou, E., Kuo, Y. F., & Raji, M. A. (2020). The Impact of Substance Use Disorder on COVID-19 Outcomes. Psychiatric Services, appi-ps.
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CCENDU. (2020). Changes Related to COVID-19 in the Illegal Drug Supply and Access to Services and Resulting Health Harms. Retrieved fromhttps://ccsa.ca/sites/default/files/2020-05/CCSA-COVID-19-CCENDU-Illegal-Drug-Supply-Alert-2020-en.pdf.
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Health Canada. (n.d.) Government of Canada supports a safer drug supply project in Toronto. https://www.canada.ca/en/health-canada/news/2020/08/government-of-canada-supports-a-safer-drug-supply-project-in-toronto.html
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Serafini, K., Toohey, M. J., Kiluk, B. D., & Carroll, K. M. (2016). Anger and its association with substance use treatment outcomes in a sample of adolescents. Journal of child & adolescent substance abuse, 25(5), 391–398.
