Ryan McNeil

Background: Amidst a sustained drug poisoning crisis, there is growing recognition in Canada of the need to expand injectable opioid agonist treatment (iOAT). iOAT is an intensive treatment that involves the daily self-administration of hydromorphone or diacetylmorphine under healthcare provider supervision, typically accompanied by other health and social services. While this treatment has demonstrated effectiveness in reducing drug use-related risks, high threshold characteristics may also create barriers to engagement. This study examined patients’ experiences of barriers and facilitators to iOAT with attention to how social and structural factors (e.g., housing vulnerability, poverty) shape program engagement. Methods: This study draws on qualitative interviews and fieldwork observations with people accessing four iOAT programs in Vancouver’s Downtown Eastside neighbourhood from May 2018 to November 2019. Data included baseline and follow-up interviews and approximately 50 h of observational fieldwork. Analysis leveraged a structural vulnerability lens to examine how social and structural factors shape people’s engagement with iOAT. Results: Participants highlighted how improved access to health and social services, compassionate and relational care, and flexible and individualized approaches to treatment delivery that addresses and accounts for the structural vulnerabilities facilitated engagement in treatment. However, dosing supervision, operational capacity and medication formulation were experienced as barriers to treatment. These barriers were magnified by structural vulnerabilities such as housing instability and mobility challenges. Conclusions: Study findings highlight how people navigate the barriers and facilitators to iOAT engagement in light of the structural vulnerabilities they experience. Adaptations to and ongoing support for iOAT programs may help to facilitate engagement and should focus on equity-oriented and patient- centered treatment models that includes the integration of social supports, support for relational care and treatment planning that supports patient autonomy.

Background: People living with HIV (PLHIV) who use drugs face overlapping social-structural inequities that contribute to suboptimal adherence to antiretroviral therapy (ART). Recent research suggests that long-acting antiretroviral therapy (LA-ART) can offer an important alternative to daily oral ART by mitigating adherence barriers, but this work has largely excluded PLHIV who use drugs. We, therefore, explored the acceptability of injectable and transdermal LA-ART among PLHIV who use drugs in Canada, which has no-cost universal access to oral ART. Greater understanding of PLHIV who use drugs’ perspectives on LA-ART will be essential to fully leverage treatment advances and maximize its individual- and population-level benefits. Methods: From February 2019 to February 2020, we conducted in-depth interviews with 33 PLHIV who use drugs in Vancouver, Canada with suboptimal ART adherence (i.e., ≦ 50%). Participants were recruited for interviews through a prospective cohort study. Interviews were audio-recorded, transcribed, and analyzed using inductive and deductive approaches. Results: Our analysis identified key factors shaping LA-ART acceptability. First, LA-ART enthusiasm was highest among participants who were less satisfied with oral ART regimens due to pill burden or adverse side effects for oral ART and participants who struggled with daily adherence due substance use and social-structural factors (e.g., homelessness, incarceration). Moreover, participants who had physicians they trusted identified their physicians as credible sources of information on LA-ART, and indicated a desire for informed and shared decision-making regarding treatment changes. Finally, participants emphasized that there is no one-size-fits-all treatment approach for PLHIV who use drugs and highlighted the importance of access to a full range of available treatment options, including LA-ART. Conclusions: There is potential for high LA-ART uptake among PLHIV who use drugs, particularly those who experience adherence barriers due to their substance use and structural vulnerability. While our findings are limited by the specific population and setting, they nevertheless underscore the need for efforts to ensure universal and equitable access to LA-ART.

Palliative care is undergoing shifts to identify and respond to social and structural inequities. Caregiving in a palliative context is steeped in assumptions that those who provide care are biologically or legally (biolegal) related, well‐resourced, and able to balance the many demands of work and life with caregiving. As families in the Western world change, people are increasingly looking outside their biolegal families for care. This is common among people experiencing homelessness, but little is known about how this translates at the end of life. To address this knowledge gap, we undertook an ethnographic study informed by critical perspectives, integrating social justice and health equity approaches. Over a period of 27 months, approximately 300 h of observation and 44 interviews were conducted with service providers, clients, and caregivers in three Canadian cities. We found that caregiving in contexts of inequity challenges dominant understandings of palliative caregiving. Rather than a biolegal family, people with life‐limiting conditions were found to be accessing care from a constellation of formal and informal caregivers (e.g., friends, neighbors, and spouses). For this analysis, we focus on exploring the experiences of unrelated, informal caregivers, with thematic findings illustrating three main aspects: (1) Relationships and roles in informal caregiving, (2) identifying and perceiving informal caregivers, and (3) biolegal privileging and exclusion of unrelated caregivers. For palliative care to improve the quality of life of people who face inequities and their caregivers, there is a need to better identify, engage, and support all of those who participate in care at the end of life regardless of whether they are biologically or legally related.

Introduction: In Canada, the COVID‐19 pandemic collided with an ongoing overdose crisis driven by a toxic unregulated drug supply. Public health guidance intended to limit transmission of COVID‐19 (e.g., social distancing) directly contradicted guidance responding to the ongoing overdose crisis (e.g., never use drugs alone), exacerbating harms among people reliant on the toxic unregulated drug supply. While existing literature characterises many harms associated with consuming unregulated drugs during COVID‐19, less is known about the specific impacts on women. We explored the perspectives of women who use unregulated drugs and experienced socio‐economic marginalisation on how the COVID‐19 environment shaped their overdose risk in British Columbia, Canada.Methods: We conducted semi‐structured interviews remotely with 45 participants between May 2020 and September 2021, and analysed the data thematically using a social violence framework.Results: Participants identified contamination of the unregulated drug supply, particularly with benzodiazepines, as a significant driver of overdose and gendered violence among women who use drugs. ‘Social distancing’ guidelines (e.g., guest restrictions in supportive housing, reduced capacity in harm reduction services) compounded these risks and resulted in more women using drugs alone, reducing opportunities for timely overdose intervention. In response, participants practiced individualised acts of caregiving (e.g., establishing informal networks that regularly check on each other) to mitigate the risks of overdose and gendered violence for themselves and their community.Discussion and Conclusions: These intersecting health crises perpetuated individualised approaches to addressing the risks of overdose and gendered violence, rather than addressing underlying social and structural drivers of these risks.