Housing, homelessness, and care trajectories among young people who use drugs in Vancouver

The proposed study will employ longitudinal qualitative and ethnographic methods to examine how urban young people who use drugs (YPWUD) navigate experiences of housing and homelessness across time. Cities like Vancouver are creating more comprehensive and integrated systems of services for YPWUD, including programs that aim to simultaneously address their housing and care needs (e.g. supportive housing with on-site access to harm reduction, opioid agonist therapies). Innovative social science research is needed to describe how particular supportive and temporary modular housing models can both ameliorate and exacerbate health and social harms among YPWUD, including overdose. The proposed anthropological and community-based participatory action research study will generate new knowledge to support the development, adaptation and scale up of targeted housing and substance use care interventions for YPWUD. Working together with a Youth Advisory Council comprised of YPWUD and youth co-researchers, study findings will be disseminated via youth-driven outputs aimed at a broad public; presentations and community reports for youth, their providers and key decision makers; and press releases, media interviews, and social media engagement.

Investigating women’s socio-structural risk environment of overdose

British Columbia, Canada, continues to grapple with an overdose epidemic. Substantial gaps remain in the implementation and scale up of overdose prevention strategies, including attention to gender equity. Little has been said regarding how marginalized women (trans inclusive) are impacted by the crisis, or how they might be differently navigating overdose risk environments or access to life-saving health services.

The ultimate goal is to generate new evidence to reduce overdose-related harms among women who use drugs and increase the responsiveness of existing and emerging overdose interventions to gender inequities. The objectives of this research program are to:

  1. Identify how women’s overdose risk is shaped by evolving individual, social, structural, and environmental factors;
  2. Investigate factors that create barriers to (or that facilitate) women’s engagement with existing, novel and emerging overdose prevention interventions; and
  3. Document perspectives, experiences, and impact of women who use drugs working in overdose-related interventions to inform how best to optimize their engagement in ongoing and future initiatives.

Investigating the impact of evolving cannabis access and use on high-risk drug use behaviours and addiction treatment

Cannabis remains the most widely produced, trafficked and consumed illicit drug worldwide, and at this time Canada and many other countries are implementing alternative regulatory approaches to cannabis. While research on cannabis has traditionally focused on the harms of cannabis use, an emerging body of evidence suggests that cannabis use can also alter high-risk drug practices, such as reducing cocaine use, opioid use and associated overdose. Much of this work suggests that cannabis is often used as a substitute for harder drugs of abuse which may have important implications for health policy responses to the current opioid epidemic in British Columbia.

However, this evidence has been primarily cross-sectional and ecological in nature, and lacking are rigorous longitudinal studies unpacking the precise impacts of cannabis use and evolving cannabis policy on the development of high-risk drug use behaviours. Further, the impacts of cannabis use on HIV and addiction treatment outcomes remains unclear. In light of the recent legalization of non-medical cannabis, identifying the impacts of cannabis on high-risk substance use and drug treatment outcomes will be important for informing clinical and public health practice, as well as policy.

Prevalence, patterns, and harms associated with the co-injection of illicit opioids and crystal methamphetamine

Crystal methamphetamine use is associated with a wide array of physical and social harms. In spite of this, its prevalence is rising in many parts of North America. Several small studies have suggested increasing rates of co-injection of methamphetamine and opioids, though no research has focused on the specific harms associated with this trend. In Vancouver, preliminary reports have noted a similar pattern, in a context where fentanyl has become the most widely used form of illicit opioid.

In this study we propose to use a prospective cohort of people who inject drugs to ask how trends in the co-injection of methamphetamine and opioids are changing over time, and to explore the health consequences associated with this pattern of substance use as it relates to overdose risk and response to treatment.

Answering these questions will provide insight into important changes in the evolving epidemiology of substance use, and will provide information on potential implications. An appreciation of these changing patterns is not only crucial in developing evidence-based harm reduction and treatment strategies, but also in understanding how to devote treatment resources appropriately in the fight to reduce opioid-related deaths.

Improving substance use care for gay, lesbian and bisexual youth in British Columbia

Gay, lesbian, and bisexual youth (GLBY) are at increased risk of experiencing substance use disorders (SUD) in comparison to their heterosexual counterparts. The aim of Dr. Ferlatte’s research is to identify the factors associated with SUD experienced by GLBY to inform interventions.

This will include:

  1. Examining individual, social and structural factors that influence SUD among GLBY through photovoice methods.
  2. Identifying challenges experienced by GLBY in accessing SUD-related care by gathering experiences through an online survey.
  3. Identifying how a coordinated set of interventions and policies could best be adapted to address SUD among GLBY through two world cafés, where GLBY and other stakeholders (e.g., intervention decision makers) will be invited to identify solutions to this issue.

The findings of this research will be shared through presentations, articles, and photovoice exhibitions to inform policy and programming decision-making that improves SUD care for GLBY.

Optimizing care for opioid use disorder in British Columbia

British Columbia is facing an unprecedented and escalating opioid crisis, underscoring the urgent need for innovative science-driven solutions. There is critical implementation gap of evidence-based care for opioid use disorder (OUD), this research will seek to narrow this gap.

First, Dr. Socias will seek to advance the implementation of evidence-base treatments for OUD, by leading a series of ongoing and planned clinical trials evaluating innovative and promising models of care (e.g., take-home strategies) and alternate treatment options (e.g., slow-release oral morphine).

Second, leveraging vast data from two long-standing cohort studies of over 3,000 people who use drugs, she will apply innovative quality metrics (i.e., cascade of care framework) to evaluate the impacts of addiction health system implementation efforts in BC over time. Identifying individual-, social- and structural-level facilitators and barriers to uptake and effectiveness of novel interventions, as well as to how these new addiction programs may impact health care access and outcomes of OUD care and related comorbidities (e.g., HIV, hepatitis C) will be key to informing efforts to improve the delivery of addiction care in BC.

Improving substance use treatment trajectories for men who have sex with men

British Columbia is currently in the process of developing and implementing new evidence-based policies and clinical reforms to address problematic substance use, including new: (i) pharmacotherapy approaches (e.g., replacement therapies); (ii) clinical practice guidelines; and (iii) integrated service delivery models of care. While men who have sex with men (MSM) represent a key group with historically high levels of substance use disorder and subsequent social and health-related sequelae (e.g., increased rates of HIV and sexually transmitted and blood-borne infections), there remains a gap in our knowledge about how best to design and implement services for today's generations of various sub-groups of MSM who use drugs (e.g., MSM who are: young; Indigenous; economically deprived).

Dr. Knight's five-year population health research program will adapt health policy and service delivery practices to improve substance use treatment trajectories for key groups of MSM who use drugs and are at risk for severe health and/or social consequences (i.e., the criteria for substance use disorder, as defined under DSM-V criteria). The aim will be to identify the most efficacious and scalable combinations of strategies to adapt interventions that respond to MSM's individual needs and broader social and structural conditions. This approach to implementation science offers a way to go beyond describing the problem and to focus on building an evidence base for implementing and adapting context-sensitive and population-specific solutions into routine policy and practice.

With collaborators representing the BC Ministry of Health, Vancouver Coastal Health, BC Centre for Disease Control and YouthCO HIV/Hep C Society and the BC Centre for Excellence in HIV/AIDS, as well as through the engagement of the BC Centre on Substance Use's Community Advisory Board, Dr. Knight's findings will be used to inform the development of policies (including clinical and provincial guidelines) to effectively scale up and integrate services that have the capacity to improve substance use treatment trajectories for MSM. Contributions to new knowledge will include the identification of the individual, social and structural factors shaping MSM's ability to reduce problematic drug use and prevent severe health and social outcomes (e.g., HIV and/or Hep C). Study outputs will also be assessed at an annual Stakeholder Workshop in which recommendations will be developed and refined for clinical and provincial guidelines.

Innovative addiction research program: Addressing polysubstance use

British Columbia (BC) faces a mental health and addiction crisis with an estimated cost of $100 million annually. In April 2016, a public health emergency was declared due to an alarming increase in opioid-related overdose deaths in recent years.

People who use illicit drugs (PWUD) bear a great burden of preventable morbidity and mortality from drug overdoses as well as other comorbidities including mental disorders and infectious diseases. While opioid agonist therapies (OAT) have proven effective in reducing heroin use, concomitant use of opioids and stimulant drugs (e.g., heroin and cocaine) is common among PWUD. Furthermore, recent research has suggested that many PWUD also suffer from untreated chronic pain, which may be driving prescription opioid (PO) misuse among this population. However, little is known about patterns of concomitant use of illicit opioids, POs and stimulants, and how OAT and other health services may serve to mitigate potential harms associated with such polydrug use. Currently, no approved pharmacotherapies exist for stimulant use disorder, necessitating urgent research effort in this area.

Dr. Hayashi's research will inform policies, programs and clinical practice to reduce harms associated with polydrug use. The primary research objectives are:

  • To investigate and address the impact of PO misuse, untreated chronic pain and concomitant opioid and stimulant use on patterns of drug-related harm.
  • Evaluate "naturally occurring" interventions and policy changes (i.e., new opioid addiction-related services and Vancouver Coastal Health's Downtown Eastside Second Generation Strategy) that are relevant to polydrug users.
  • Evaluate the efficacy of a novel pharmacotherapy to treat polydrug users. 

The research will employ vast longitudinal behavioural and biological data collected since 1996 via three ongoing prospective cohort studies of over 3000 PWUD in Vancouver. The findings are expected to inform care development and overdose prevention efforts for a high needs population in BC. One objective will involve implementing a clinical trial to evaluate whether an amphetamine-based medication reduces powder/crack cocaine use among 130 patients on OAT, who have both opioid and cocaine use disorders. If the study medication proves effective, Dr. Hayashi's research will potentially contribute to the identification of the first proven medication for cocaine addiction.

Opioid addiction research program to improve prescribing practices and reduce overdose

Canada is amid an opioid crisis, with six or seven deaths a day due to opioid overdose. Prescription opioid misuse can also transition to illicit opiate and intravenous drug use, substantially increasing the risk for overdose and blood-borne infections. Rates of overdose death due to counterfeit fentanyl have also risen and represent a growing crisis in most regions in Canada, with British Columbia (BC) being particularly hard hit. Half of the 800 anticipated overdose deaths for 2016 in BC are expected to involve fentanyl.

Dr. Fairbairn's research will:

  • Address the effectiveness of a randomized controlled trial to evaluate a designated opioid prescriber intervention using BC's centralized prescription network to reduce inappropriate opioid dispensation and overdose risk.
  • Inform overdose prevention strategies by characterizing the inter-relationships between medication prescribing patterns and patterns of illicit drug use.
  • Evaluate the longitudinal impacts of new overdose prevention initiatives and addiction treatment guidelines on overdose outcomes.

This research directly responds to BC's recent declaration of a public health emergency, Health Canada's urgent call to develop strategies to tackle the overdose epidemic, and the global challenge of prescription opioid abuse by generating evidence for safer prescribing practices and informing and broadening the evidence base for the treatment of opioid addiction.