Building capacity to reduce overdose among formerly incarcerated people in British Columbia

BC is facing dual public health emergencies of COVID-19 and a public health emergency of overdose, first declared in 2016. New interventions have been introduced to reduce overdose in BC, including efforts to decriminalize drug possession and the introduction of pharmaceutical alternatives to the toxic drug supply, known as “Risk Mitigation Guidance” (RMG) prescribing. RMG allows physicians to prescribe pharmaceutical medications (e.g. opioids, stimulants) to people at risk of overdose. While provincial evaluations of pharmaceutical alternatives are ongoing, little is known about the impact of these interventions on people who have been incarcerated, who face a disproportionate burden of overdose risk and mortality in BC, particularly in the weeks immediately following release from correctional institutions.

We aim to address this knowledge gap by convening a Peer Advisory Group of people with lived and living experience of substance use and incarceration. The group will advise on how data sources created in response to the 2016 public health emergency (BC-ODC) can be used to investigate interventions to reduce overdose, with attention to the unique and context-specific overdose risks faced by people who have been incarcerated.


Team members: Ana Becerra (BC Centre for Disease Control); Helen Brown (UBC); Jane Buxton (BC Centre for Disease Control); Ruth Elwood Martin (UBC); Kurt Lock (BC Centre for Disease Control); Tonia Nicholls (UBC); Erin Wilson (University of Northern British Columbia); Chloe Xavier (BC Centre for Disease Control); Sofia Bartlett (BC Centre for Disease Control); Cameron Geddes (UBC); Heather Palis (BC Centre for Disease Control); Marnie Scow (UBC); Chas Coutlee (Indian Residential School Survivors Society); Nicholas Crier (UBC’s Transformative Health and Justice Cluster); Jade Hoffman (Prince George Urban Aboriginal Justice Society); Patrick Keating (UBC’s Transformative Health and Justice Cluster ); Jenny McDougall (BC Centre for Disease Control); Rick Meier (Coalition of Substance Users of the North); Elder Roberta Price (UBC’s Transformative Health and Justice Cluster); Glenn Young (Unlocking the Gates Services Society); Pam Young (Unlocking the Gates Services Society); Andrew Ivsins (Ministry of Mental Health and Addictions); Carrie McCully (BC Corrections); Angus Monaghan (BC Mental Health and Substance Use Services); Justine Patterson (BC Mental Health and Substance Use Services); Kathryn Proudfoot (BC Mental Health and Substance Use Services); Vijay Seethpathy (BC Mental Health and Substance Use Services)

Evaluating the impact of pharmaceutical interventions to reduce overdose among people with criminal justice system involvement in British Columbia

People with criminal justice system involvement (i.e. who have been to prison for a criminal offence) are more likely to use drugs like heroin and methamphetamine compared to the general population. People who use drugs also are at higher risk of negative outcomes like overdose and more rapid or frequent return to prison. Efforts to address overdose, both in prisons and in the community, have been focused on providing treatment for people who use opioids (e.g. heroin, fentanyl). This alone may not be sufficient to reduce overdose risk, particularly among people who use other substances (e.g. cocaine, alcohol) in addition to opioids. In March 2020, in the context of COVID-19, the British Columbia (BC) Ministry of Health provided new Risk Mitigation Guidance (RMG) for doctors, permitting them to prescribe opioids, stimulants, benzodiazepines, and alcohol withdrawal management medications to people at risk of overdose. In this study, I will evaluate whether the RMG has reduced overdose and return to prison among people with criminal justice system involvement in BC. This study will highlight gaps in substance use services in BC, and will inform evidence-based services that can help to reduce overdose in prison and community.

Identifying leverage points for strengthening coordinated intersectoral action for health promotion in British Columbia

This Health System Impact Fellowship is co-funded by CIHR, MSFHR, and BC Centre for Disease Control (health system partner), to help build BC’s health policy research capacity for the integration of policy research into decision-making.

Health promotion (HP) enables people to increase control over health and reduce health inequities through action on the determinants of health. HP actions include developing personal skills, creating supportive environments, strengthening community action, building healthy public policy, and reorienting health services to improve population health and wellness.The COVID-19 pandemic has emphasized the need for more coordinated, integrated and intersectoral HP action. The focus and value-add of the project is the development of co-created (with research, policy, and practice stakeholders) recommendations for enhanced HP and the innovative application of a complex systems approach to support this work. Using physical activity as a starting point, this project will to map (inventory) HP initiatives targeting physical activity at the provincial, regional, and local levels and identify areas to enhance coordination and integration to build healthier communities. The anticipated impacts and value of achieving this goal include:

  • Shared leadership, governance, and accountability for HP.
  • Increased collaborative capacity to align HP.
  • Enhanced focus among stakeholders on reducing health equities.
  • Shared resources (human, financial, infrastructure) to implement HP.
  • Improved information (knowledge exchange, research and evaluation, monitoring and surveillance).
  • Shared learning and understanding among stakeholders of new approaches to HP identified through the lens of a complex systems paradigm.

There are three objectives:

  1. Describe and map existing physical activity HP initiatives and systems in BC.
  2. Assess systems to identify facilitating and hindering factors and key feedback mechanisms that influence implementation, coordination and integration.
  3. Strengthen systems through identification of priority leverage points and recommendations for more synergistic implementation of coordinated intersectoral HP in BC.

Source: CIHR Funding Decisions Database

Novel metabolomics approach for the diagnosis of infectious diseases

Tests to determine whether an individual has a disease or not are often expensive and performed on complex instruments in laboratories. As such, there is currently an important unmet need for tests to diagnose infectious diseases with highly accurate, inexpensive and simple methods that could be performed nearer to the patient.

We have developed a method that can identify the metabolites (small molecules) that change in response to infection. As a proof-of-concept, we demonstrated its successful use for the highly accurate detection of respiratory viruses directly from swabs taken from the nasopharynx (upper part of the throat behind the nose).

We now aim to expand this method to a new testing instrument at the BC Centre for Disease Control and assess its test performance for the detection of other infectious diseases like human papillomavirus (HPV) and tuberculosis (TB). Identification of a limited set of metabolites for each condition will enable the adaptation of the method to a simpler, near-patient diagnostic test. Such a test has the potential to reduce the time it takes to obtain an accurate diagnosis and improve clinical outcomes at a population level.

Population-based Study of Coronavirus Antibody Cross-Reactivity to Inform SARS-CoV-2 Seroprevalence Surveys, Severity Profiles, and Vaccine Strategies

Most people have had one or more colds due to seasonal coronaviruses (CoV) with the number of prior infections increasing with age. SARS-CoV-2 entered the human population in late 2019, causing the COVID-19 pandemic. Before that no one had immunity yet older males are at higher risk of severe COVID-19 illness. One explanation is that prior antibodies to seasonal CoVs may enhance SARS-CoV-2 risk through a process called antibody dependent enhancement. To assess that hypothesis we first need to know if seasonal CoV antibodies interact with SARS-CoV-2, how common those antibodies are, and if older men have more of them. We will develop a pan-CoV assay to compare prevalence of all human CoVs by age and sex. Findings will inform SARS-CoV-2 sero-surveys, severity profiles and vaccine strategies.

Measuring the Impact of Physical Distancing Measures and Creating Paths for Monitoring during the Relaxation Phase of the COVID-19 Pandemic

As of April 30, 2020, Coronavirus disease 2019 (COVID-19) has caused over 3.2 million cases and 230,000 deaths, globally. The SARS-COV-2 virus causes COVID-19 and is spread by close contact. To reduce its spread, physical distancing measures have been implemented in British Columbia (BC). These measures will be relaxed once transmission is low, but this could increase transmission.

This project will establish a system to measure physical distancing behaviours in BC with:

  1. ongoing surveys to monitor local contact patterns; and
  2. analysis of mobility data from multiple sources, such as TransLink, traffic data, and mobility indices from Google, Citymapper and Apple. This system will inform education and communication needs and policy decisions related to physical distancing measures in BC.

Towards TB elimination in Canada: Optimizing tuberculosis screening and prevention

The World Health Organization (WHO) aims to eliminate TB by 2050, but Canada is not on target to meet that goal. To reach our national TB elimination targets, we must reduce TB rates by 10% per year but we are only reducing TB rates by 2% per year. My research program is aimed at developing evidence to improve TB screening, prevention and treatment policies in order to accelerate TB elimination in British Columbia (BC) and Canada.  

In my primary research project, my team is using provincial health databases to describe TB epidemiology in the foreign-born population of Canada. Our goal is to develop a TB risk score and to create evidence that informs cost-effective TB screening policy. My team is also using TB genome sequencing data to understand TB transmission networks and to find areas for public health intervention. Lastly, we are developing evidence to improve treatment outcomes for people affected by TB.   

Examining how contextual factors and health equity considerations shape the implementation of an internet-based testing service for sexually transmitted and blood-borne infections

This study will examine how organizations are able to roll-out and improve GetCheckedOnline (GCO), an internet-based testing service for sexually and blood transmitted infections currently available in British Columbia.

Using the research approach of institutional ethnography, this study aims:

  1. to learn what it takes to implement and expand GCO in fair and sustainable ways, and
  2. to speak to healthcare and community stakeholders in British Columbia to understand the contextual obstacles and opportunities that have shaped the implementation of GCO.

This study's findings will help to inform how GCO can be improved to expand the service to new locations in British Columbia and potentially to the healthcare system in Toronto, Ontario. More generally, this project will offer insights into how sexual health services are implemented and how to promote the equitable growth of digital health interventions.

Utilizing a syndemic approach for population level prevention, care and treatment cascades of hepatitis C virus and related epidemics

Different distributions of social conditions, vulnerabilities, (e.g. drug use, mental illness) or other infections (HIV, HBV, TB), contribute to differences among populations affected by hepatitis C virus (HCV) infection. The different distribution of these comorbidities drives differences in cascades of care (diagnosis, initiation of treatment, cure and retention in care). 

This study aims to improve HCV treatment and prevention by applying concepts of syndemic theory (how co-occuring conditions interact) to improve the integration and delivery of health services among populations affected by HCV infection, such as people born 1945-65 ("Baby Boomers") and people who inject drugs (PWID). Using the British Columbia Hepatitis Testers Cohort (BC-HTC), which includes all individuals tested for HCV, HIV, HBV, sexually transmitted infections or TB since 1990, linked with administrative and healthcare data, the study will extend the HCV cascade of care to include prevention and care related to underlying syndemic factors (e.g. drug use, mental illness and other co-infections). 

Identifying and investigating gaps in HCV care cascades, and syndemic factors associated with these gaps, will help identify avenues for shared and integrated interventions to improve prevention and care for HCV, and underlying substance use.

At-home cervical cancer screening & strategies to enhance engagement with the care pathway for under-screened populations

Co-leads:

  • Gina Ogilvie
    UBC
  • Marette Lee
    BC Cancer

Executive sponsor:

  • Dirk van Niekerk
    BC Cancer

Cervical cancer is caused by persistent infection with human papillomavirus (HPV). It can be prevented with early detection through regular screening. Irregular or non-attendance to screening is one of the key barriers to further reducing cervical cancer rates in BC. HPV DNA testing is an evidence-based, highly sensitive, and effective way to screen for cervical cancer, where women can collect the sample for testing at home (HPV self-collection).

This project will look to HPV DNA testing as the best way to implement at-home cervical cancer screening for under-screened populations in BC.

Two implementation approaches will be used:

  1. CervixCheck, an online service for at-home cervical cancer screening for women who do not regularly attend screening, piloted in selected family medical clinics in Surrey, BC and in northern BC in partnership with Métis Nation BC.
  2. At-home screening piloted in First Nations community health centres in partnership with Carrier Sekani Family Services in rural northern BC.

By offering women an alternative to clinician collected samples for screening, this work can address many of the personal, geographic, historical and system-level barriers women face. However, as with other screening programs, HPV screening identifies women most at risk for progressing to cervical cancer, and is not a diagnostic tool in itself. Therefore, it is necessary to examine implementation and evaluate engagement in the full pathway of screening, diagnosis, treatment, and follow-up.

Through an implementation science approach, this project aims to:

  1. Determine strategies to optimally engage under-screened women through the full pathway of screening, diagnosis, treatment and follow-up, primarily with colposcopy.
  2. Assess the needs, gaps, and facilitators at the user, clinical, and health system levels to inform adaptability for other settings and contexts in the province.

Quantitative and qualitative methods will be applied, using the Quality Implementation Framework to inform evaluation design.

The outcomes for this project will be adoption, penetration, fidelity, and safety. Planning and development is already underway for the pilot implementation of CervixCheck. A critical aspect of this approach will be to assemble a team of stakeholders at the community level in pilot sites including patient advocates and physician and nursing leads, as well as at the health system level at the BC Cancer Cervical Cancer Screening Program and the BC Colposcopy Program.