Preventing overdose deaths Bernie Pauly RN, Ph.D bpauly@uvic.ca - - PowerPoint PPT Presentation

@UVIC IC_CIS ISUR #stopoverdoses

Lessons from British Columbia: Preventing overdose deaths

Bernie Pauly RN, Ph.D bpauly@uvic.ca @Bernie Pauly Bruce Wallace, RSW, Ph.D barclay@uvic.ca @BarclayWallace Canadian Institute for Substance Use Research (CISUR)

Territorial Acknowledgement

Self locations

• We are not impacted by the criminalization and

stigmatization of drug use nor the structural impacts

• f marginalization.
• We are not front-line responders and do not carry
• ut public policy and programmes.
• We are engaged researchers who have worked

closely with these people in community for many years and sought to link research to the efforts of those most impacted by and most actively responding to this crisis.

• We are both academics and activists.
• We are from away

Acknowledgements

April 14, 2016

(File Photo: Global News BC)

BC Declares a Public Health Emergency

Art by Smokey D, DTES, Vancouver BC

BCCS May 15, 2019 (data to Mar 31, 2019)

https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf

*

THN introduced PH Emergency declared

250

DOAP formed

8

BCCS May 15 2019 (data to Mar. 31, 2019)

https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and- divorce/deaths/coroners-service/statistical/illicit-drug.pdf

BCCS May 13, 2019

https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and- divorce/deaths/coroners-service/statistical/illicit-drug.pdf

11

BCCS May 15, 2019 (data to Mar. 31, 2019)

https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage- and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf

BC Drug Overdose & Alert Partnership

12

DOAP

Law Enforcement Testing Labs Coroners Emergency Health Services Health Emergency Depts. Drug & Poison Info Centre Researchers (CISUR, BCCSU) People with Lived Experience

Created, Spring, 2017

Community Action Teams - model

1000 2000 3000 4000 5000 6000 7000 8000 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 1011 2012 2013 2014 2015 2016 2017 2018

THN Kits Distributed per Month through the BC Take Home Naloxone Program, August 2012 to November 2018 (data updated Apr. 15th, 2019)

15

NB: Data is derived from a live environment and is subject to change. Distribution records may take some weeks to receive and enter; thus, data from most recent two months is subject to change. NB: With the introduction of the Facility Overdose Response Box (FORB) Program in late 2016, many shelters, drop-in centres, and supportive housing facilities have access to naloxone supplies, and thus are not using their own or clients’ individual kits. This reduces demand for individual kits.

Public health emergency declared

16

• Apr. 15, 2019

Take home naloxone in BC (Since 2012)

Scale up of Suboxone: July 1, 2016

Opioid Agonist Treatments (OAT)

BCCSU Guidelines for Management of Opioid Use Disorder (June, 2017)

• Harm Reduction! NO Withdrawal alone
• Suboxone and/or Methadone
• Slow Release Morphine
• Injectable OAT

BC Nurse Practitioners can prescribe OAT (April, 2018)

# clients dispensed OAT in BC

19 http://www.bccdc.ca/health-professionals/data-reports/overdose-response-indicators

20

Overdose Prevention Sites:

FROM SAFER SUPPLIES TO SAFER SPACES

Bruce Wallace & Bernie Pauly

May, 2019

April 2016

The Context of Take Home Naloxone

Don’t Use Alone Carry Naloxone

Activist origins and innovations

• Unsanctioned “Pop up” injection sites.
• Initially actions to raise awareness of need and feasibility.
• The Overdose Prevention Society in Vancouver

established an ongoing service under a tent in an alley.

“…we don't have to wait for red tape and bureaucratic anything. We can just do this and save lives"

Context

Unsanctioned OPS Sanctioned SCS

December 2016

PROVINCE OF BRITISH COLUMBIA Ministerial Order No. M 488 ORDER OF THE MINISTER OF HEALTH Emergency Health Services Act

I, Terry Lake, Minister of Health, as per my authority under section 5.2 of the Emergency Health Services Act and section 7.1 of the Health Authorities Act, order British Columbia Emergency Health Services and the regional health boards to provide, on the advice of the provincial health officer, during the public health emergency declared under the Public Health Act on April 14, 2016, overdose prevention services for the purpose of monitoring persons who are at risk of overdose, and providing rapid intervention as and when necessary, as ancillary health services, in any place there is a need for these services, as determined by the level of overdose related morbidity and mortality.

OPS definition – in British Columbia

OPSs are a health service providing supervised injection and immediate overdose response. An OPS provides a space for people to inject their previously-

• btained illegal substances with sterile equipment in a setting

where staff can observe and intervene to prevent overdoses. Not an alternative to Health Canada sanctioned SCS. Rather, a temporary measure to save lives without breaching the Controlled Drugs and Substances Act while waiting for Health Canada approval of supervised consumption services.

Our research

• Informed by Consolidated Framework for Implementation

Research (CFIR)

• Multiple case study design
• 3 sites in Victoria BC
• 27 semi-structured interviews

–12 service users –15 staff & implementers

• Cross case analysis

Implementation Findings

• Rapid implementation
• Government directed and community defined
• Integrated within multiple settings
• Diverse models & staffing
• Peers central to model

Rapid Implementation

• Over 20 sites within a few days to

a few months in all health authorities in BC.

• First year: 550,000 visits, 2,500

non-fatal overdoses, and no

• verdose deaths.
• In Victoria, BC there was no local
• pposition and no substantial

consultations.

• In a federal and international

context of protracted SIS implementation.

Rapid Implementation

“I think these services can be set up quite easily, I mean we basically had ours set up in less than a month … it doesn’t have to be complicated, it is actually quite basic.” (Harm reduction worker).

Government directed

• Legal (within professional regulations)
• Paid staff
• Funded as ancillary health service
• However – minimal regulations and policies

Update …

A Services Guide rather than regulations and approvals.

Community defined

Diverse to the unique settings Flexible implementation Feedback & modifications

Impacts

• Zero deaths
• From safer supplies to safer spaces
• Reduced risk environment – providing space, time, safety,

cleanliness

• Overdose responses changed – from naloxone to oxygen
• Destigmatizing personal drug use
• Enhanced trust and relationships

Wallace, B., Barber, K., & Pauly, B. (2018). Sheltering risks: Implementation of harm reduction in homeless shelters during an

• verdose emergency. International Journal of Drug Policy, 53, 83-89.

doi: 10.1016/j.drugpo.2017.12.011

Trauma response – Preventing rather than responding to overdose “I think a big thing that I didn’t anticipate about the overdose prevention sites is catching the

• verdose before its happening, you can totally

do that. Like, I thought it would just be like people dropping, dropping, dropping … So you can like get them up, get them breathing, sternum rub, give them water, and you actually prevent the overdose.”

Pauly, B., Wallace, B., & Barber, K. (2017). Turning a blind eye: implementation of harm reduction in a transitional programme setting. Drugs: Education, Prevention, and Policy, 25(1), 21-30. doi: https://doi.org/10.1080/09687637.2017.1337081

Providing space for trust and relationships

“... we don’t often don’t find someone down anymore, it’s usually people coming to us so I think just having the OPU and the staff and the acceptance of like we want to support you has kind of created that.” “If you talk to the folks in the OPU they’ll talk about people like to go in there, even non-users because it’s a space that’s quiet and you can talk, and whereas most of our avail - you don’t get that one on one or that, that time, so that has kind of changed some of the relationships …”

Challenges

• Does not meet scale of need
• Questionable reach to some populations
• Policies that limit service limit effectiveness
• No primary care
• Operating in contexts of scarcity of services
• Staff supports
• In context of prohibition and criminalization

Shifting Restrictive Policies

• Assisted injections
• Sharing/splitting of drugs
• Jugging
• Inhalation

Limitations

• Effective yet insufficient
• Contexts of:

–Scarcity –Criminalization –Toxic drug supply

• Sites of intense labour

and trauma

Limitations

It’s a really a small part of the larger puzzle, and, so, it really does feel like a crisis response to a crisis situation and not a comprehensive response to a really big problem which, is ultimately drug policy, both federally and globally. [Harm Reduction Staff]

Possible lessons learned

• National and international example of an alternative to

sanctioning processes for SCSs.

• Alternative to sanctioning demands that limit responsiveness,

adaptation and innovation.

• Centering PWUD in service design, implementation and

delivery

• Innovative and inclusionary practices were possible within

state-sanctioned OPSs

• Rules discounting drug-user culture limit access and

effectiveness

Conclusions

• End restrictive policies and expand services.
• OPS as integrated services within harm reduction,

housing, and health and social services.

• Explore the expansion of needle distribution services

to include safer spaces to use.

• Prioritize experiential and peer staffing and peer-
• perated sites with suitable, equitable salary and

supports.

OPS expansion

Drug checking within an overdose crisis

Bruce Wallace & Bernie Pauly May 2019

Drug checking definition

• Drug checking is a harm reduction approach which allows

people to identify the contents of a substance and receive drug information from a peer and/or harm reduction worker.

• A history in nightlife and festival settings, and now increasingly

explored as a potential response to the illicit overdose crisis which occurs throughout all communities.

Drug checking in the overdose crisis

“Given the alarming influx of high potency and adulterated drugs in the market in British Columbia in recent years, and the corresponding increase in overdose deaths, real-time, consumer-derived, street level generated data regarding trends in the illegal drug supply may be instrumental in appropriately allocating federal, provincial, and regional harm- reduction resources, and in providing potentially life-saving information to people who use illegal drugs” [4] (Pg:26).

Questions & cautions A recent BMC article on drug checking as a response to opioid

• verdose ends with the caution:

“[I]mplementation in the absence of rigorous evaluation could result in the wasting of precious resources, and more importantly, more lost lives to fatal overdose” (2018:2).

Victoria drug checking project

A three year project to pilot and evaluate drug checking in community settings to assess the limitations and benefits of the instruments as a response to the current

• verdose emergency and will

assess how the services could potentially be scaled-up as harm reduction responses.

Marquis reagent Chemical-based, formaldehyde + sulfuric acid Colour indicates class of compound

http://testkitplus.com/wp-content/uploads/mdma-test-kit.jpg http://www.careshop.co.uk/7844-thickbox_default/fentanyl-test-strip-1x50.jpg

Strip tests Antibody based

Chemical tests Drug-checking technologies:

Drug-checking technologies:

https://www.atago.net/ https://www.agilent.com/ http://www.nanalysis.com/ http://www.perkinelmer.com/

Instrumental tests

Immunoassay Test Strips

Fentanyl Testing Strips, produced by BTNX

Infrared (IR) Absorption Spectroscopy

4500a FTIR produced by Agilent

Gas Chromatography-Mass Spectrometry (GC-MS) Torion T-9 Portable GC-MS produced by Perkin Elmer

Raman Spectroscopy

Resolve Handheld Raman produced by Cobalt (now Agilent) with Surface Enhanced Raman Scattering (SERS)

Drug Checking in Context

• The contexts of the current illicit drug overdose

emergency.

• Politicized harm reduction and drug checking.
• Evaluation framework - harm reduction, health equity and

social justice principles.

• Drug checking vs. safe supply – false binary.

More information

website: https://substance.uvic.ca team email: substance@uvic.ca

@UVIC_CISUR

Comprehensive Equity Oriented Responses

Bernie Pauly RN, Ph.D Bruce Wallace, RSW, Ph.D UVIC Schools of Nursing and Social Work Canadian Institute for Substance Use Research (CISUR)

Time Period: April 2016 (when emergency declared) to

Dec 31st 2017 (21month) in BC # Overdose Deaths: 2,177 overdose deaths

Death events averted all interventions:

Estimated 3,030 (2,900 – 3,240).

By Intervention:

Take Home Naloxone: 1,580 deaths (1 480 – 1 740) Overdose Prevention Services: 230 (160 – 350) 13 months OAT: 590 (510 – 720) Reference: Irvine et al., 2019, Addiction

How Effective are the responses?

Is there a Social Gradient in Overdose Epidemics?

Unsafe Drug Supply Changes in Opioid Prescribing Insufficient Treatment Systems Insufficient SDOH, Colonization, Increasing Criminalization, Stigma and Discrimination

Pauly, 2018

Photo credit: Public Health Watch

Overdose Deaths and Harms

Contexts of harm

(Historical-Social- Economic- Political)

• Poverty
• Homelessness
• Colonization: Racism
• Gender Norms: Sexism
• Heteronormativity
• Criminalization
• Age restrictions_Ageism
• Trauma and

Intergenerational trauma

Harms Overdose HIV/HCV, Addiction

Brown & Pauly, 2017

Medicalized Responses

Health Equity Responses

Social Harms Injury, Violence Stigma Social Exclusion

Toward an Equity Oriented Framework to Inform Responses to Opioid Overdoses: A Scoping Review

What is an Equity Oriented Response to Overdose? Health System Functions

Health Promotion Health Protection Prevention Surveillance Treatment

Shifting Values: People Not Pathologies

SEE People STOP Pathologizing People as Capable Moralizing Knowledgeable Medicalizing Deserving Undeserving Strong Victimizing

Social Networks

Organizations by and for People who use Drugs, Peer to Peer Networks

• f PWUDs, Families, &

Communities Specific attention to Women, LGBTQ, racialized groups

Harm Reduction

Art by” Xan Beauchamp

Drug User Activism: Overdose Prevention Sites

August, 2016: Pop Up Site in Surrey October, 2016 Overdose Tent Established by Volunteers December, 2016 Establised by a Ministerial Order under Emergency Services and HA Act Novel, Nimble, Responsive (Wallace, Pagan & Pauly, under review)

File Photo: Georgia Straight and Canadian Press

❑Peer Engagement in Research, Policy, Education

✓Peer Involvement in visioning, development

• f policies

✓Peer informed design and implementation of services ✓Peer Educator Roles ✓Peer Research Roles

❑Peer 2 Peer Interventions

✓Peer Counsellors (shared experience) ✓Peer Navigation and Accompaniment ✓Peer 2 Peer Education ✓Peer Outreach

Enhancing Peer Engagement (www.bccdc.ca)

\

Use People-first language Use language that reflects the m edical nature of substance use disorders

Lan guage m at t ers…

4 guid elin es t o usin g n on -st igm at izin g lan guage

1

vs.

2

vs.

vs.

3

Use language that promotes recovery

vs.

4

Avoid slang and idioms

VISIT t ow ard t h eh eart .com FOR M ORE IN FORM ATION

Organizational Recommendations: Peers

Recipient of Services: Client Tokenism: Informing, Advisory, Consultation

Organization Initiated: Lone Peer Reps Peer Workers Peer Led and Initiated: Building a Peer Workforce/ Organization Partnership Shared Power and Decision Making

Arnstein, 1969 Hart, 1992;1997 Strength and Resilience

76

For Programs and Services

➢Increase Reach, Effectiveness and Relevance of initiatives due to community connections ➢Peer workers preferred by clients for support, greater safety ➢More able to connect and communicate due to shared life experiences

For Peer Workers:

➢ feelings of dignity, pride, accomplishment, confidence, ➢ sense of purpose, empowerment ➢ Build morale, skills andemployment record

Benefits of Peer Work

Background Peer engagement (PE) in BC

• PE has been increasingly recognized

as a ‘best practice’ in BC

• Largely due to advocacy of peer-

based orgs like VANDU, Solid Outreach etc.

• Support for peer engagement and

workplace standards remain an issue

78

• Criminal Record Checks
• Drug Testing
• Reinforce notions of abstinence
• Need for Low Barrier Employment Options

Labor Market Discrimination

79

• Lack of Knowledge or awareness of role and value of peers
• Vague and unclear role expectations and responsibilities (note

peers will always go above and beyond!!!!!)

• Lack of knowledge of peers life circumstances and supports.
• Workplace Stigma and discrimination by non peer staff
• Volunteerism, low wages (exploitation)
• Precarious work, Job Insecurity (daily, temporary, lack of

stability, multiple jobs)

• Work stress, trauma and loss
• Lack of understanding of peer diversity of lived experience

(e.g. sex trade, Indigenous, HIV, type of drug use, housing and homelessness experiences, gender, age). Experiential knowledge should relate to their job.

Organizational Issues (Greer et al, 2019)

PEEP (Peer Engagement and Empowerment Project (2015-2017) (www.bccdc.ca)

PEER ENGAGEMENT PRINCIPLES AND BEST PRACTICES

VERSION 2

PAYING PEERS IN COMMUNITY BASED WORK

81

Peer Payment Standards For Short Term Engagements (www.bccdc.ca)

• 1. Be Upfront about

Payment (amount, timing)

• 2. Provide Options
• 3. Pay Cash
• 4. Pay other costs

(transportation, meals)

• 5. Discuss implications for

social assistance/welfare

PEER PAYMENT STANDARDS

February 2018 V1

82

POLICY: Employees and peers may not come to work showing signs of inebriation. All staff— including outreach workers—are expected to perform their professional duties in a coherent, competent, and respectful manner. POLICY: Management may not conduct witch hunts or drug testing to determine drug use by employees.

Past Versus Current Use

Who are the First Responders?

Definitions

• Compassion fatigue: profound emotional and physical erosion

when unable to refuel and regenerate “cost of caring” for others in emotional pain

• Vicarious trauma: beliefs in the world shift in helping

professionals when they work with individuals who have experienced trauma and they are repeatedly exposed to traumatic material

• Burnout: physical and emotional exhaustion that workers

experience when they have low job satisfaction and feel powerless and overwhelmed at work

• Moral distress: when you know the right thing to do but can’t

do it because of system constraints

Peer2Peer Project aims

• Identify peer support

interventions for people who are working in BC OD response environments, determined as needed by Peers themselves

• Health Canada Funded
• Co-led by Pauly, Buxton,

SOLID and RainCity

Project setting

• SOLID Outreach: Victoria, BC

–Provide overdose prevention services across settings

• RainCity: Vancouver, BC

–Housing-first organization that provides housing and social supports

P2P Project Methods

Step 1: Identify what matters most to peers Step 2: Develop a model Step 3: What do peers think? Evaluate the model Step 4: Improve/expand the model Step 5: Implement the model

Mixed-methods, multiple phase participatory community-action research design

Developing a peer wellness model

• What constitutes peer support in overdose

work?

• Developed model first
• Rooted in social determinants of health
• Model accounts for

1) material determinants 2) non-material determinants

Step 1: Identify what matters most to peers Step 2: Develop a model Step 3: What do peers think? Evaluate the model. Step 4: Improve/expand the model Step 5: Implement the model

Creative Art and Music Therapy Work Place Supports

Assistance with Equitable Living Conditions (e.g. Housing income and other resources)

Peer to Peer Counselling

Valuing Work: Equitable Pay and Working Conditions

Peer workers & worker solidarity = Essential Goal: Health and wellbeing

Skill development and Training

P2P: Peer Wellness Model

Foundation:

Focus Groups with Peers

– Refine the model – Develop interventions to best implement the model – Baseline interviews (without model)

Step 1: Identify what matters most to peers Step 2: Develop a model Step 3: What do peers think? Evaluate the model. Step 4: Improve/expand the model Step 5: Implement the model

P2P Initiative

Skill-Building Recognition

• f Peer Work

Organization al Support

P2P Findings

Job Title, Job Description, Living Wage, Clarity re Breaks, Sick Time, Fair and Equitable Pay, Housing Coach Ability to Refer to Resources Peer Debriefing/Support Mental Health First Aid and CPR Conflict Resolution Communication Skills Self Defence Meet and Greet with

• ther professionals

Day in the Life, Awards,

Next steps

• Expand, improve & implement the model
• Interviews @ midpoint and endpoint
• Peer Support Manual for Overdose Prevention

Step 1: Identify what matters most to peers Step 2: Develop a model Step 3: What do peers think? Evaluate the model. Step 4: Improve/expand the model Step 5: Implement the model

Creating Cultural Shifts: Organizational Recommendations

• Harm Reduction Policies
• Education re harms and impacts of stigma
• Knowledge of benefits and effectiveness of harm

reduction interventions

• Structural Competency: Recognize role of racism/stigma
• Cultural Safety Training at all levels in the organization
• Involve peers in education
• Training in socio ecological understanding of inequities
• Training informed by social justice frameworks

There is still a need for public policy changes……From current drug policy to healthy public policy

Healthy Public Policy….Harm Reduction

“The new strategy ‘restores harm reduction as a core pillar of Canada’s drug policy.’ That new strategy would also put drug policy back under the health ministry and away from Justice Department” (Dec 12, 2016)

Passed May, 2017 but Knowledge and Implementation varies

97

BC Provincial Health Officer (April, 2019)

”Immediate provincial action is warranted, and I recommend that the Province of BC urgently move to decriminalize people who possess controlled substances for personal use.”

Compassion Clubs - Cooperatives

• Similar to cannabis compassion clubs from

people living with HIV/AIDS movements.

• A cooperative approach with heroin restricted to

to members and legally obtained from a pharmaceutical manufacturer and securely stored – similar to heroin prescription programs.

• Could undermine the illegal market
• Could be initiated at little to no operating

cost to the public.

• Could be peer based – those with most

experience in securing heroin – operated by NGOs.

Canadian Association of People Who Use Drugs (CAPUD)

• Safe supply refers to a legal and regulated supply
• f drugs with mind/body altering properties that

traditionally have been accessible only through the illicit drug market.

• Substitution treatments, such as methadone and

suboxone, do not meet the criteria as safe supply because they do not contain the mind/body altering properties that people seek in recreational drugs.

• Safe supply is a drug policy category that ought

to fit alongside other “pillars” of drug policy such as treatment, harm reduction, education, and prevention.

100

• Peer Led Community Network
• Monitoring structural conditions that produce drug related

harms

• Refinement of Equity Oriented Indicator Framework

(public policy, community, social networks, organizational indicators)

• Focus on responses to substance use and level of

services.

• Community of Practice

BC Community Network of SU Observatories (Funded by Health Canada for Five Years)

• Complex problems requires multi-faceted responses and

multiple interventions

• Peer engagement is essential - but do it right!
• Government policy and directives set the stage
• Community led and developed interventions
• Shifting culture and values can occur over time
• Address reach and coverage (Implementation)
• Don’t wait for research but use research
• Disrupt, be bold, advocate

Conclusions

Thank you Emails: barclay@uvic.ca bpauly@uvic.ca Twitter: @BarclayWallace @BerniePauly