Evan Wood

Fentanyl toxicity is the leading cause of unnatural death in British Columbia (BC), Canada, driven in part by fentanyl’s potency and unpredictable, highly variable concentration in unregulated drug samples. This study aims to identify emerging trends and the possible relationship between fentanyl concentrations in community drug samples and the postmortem blood of drug-toxicity decedents. Data for this ecological study were derived from Vancouver, BC community drug-checking sites and the BC Coroners Service. We analyzed fentanyl concentrations of opioid drug-checking samples alongside postmortem blood fentanyl concentrations from unintentional drug-toxicity decedents in which fentanyl contributed. The study period was January 2018 through December 2022. Monthly median fentanyl concentrations of drug-checking samples were compared to postmortem blood concentrations using generalized additive models. The primary time-series model, adjusted for potential confounders, did not identify a statistically significant association between drug-checking and postmortem concentrations (edf = 3.58, χ2 = 8.48, P = 0.104); however, a sensitivity analysis excluding extreme values revealed a significant nonlinear association (edf = 3.91, χ2 = 11.71, P = 0.038). Fentanyl concentrations in both the unregulated drug supply and postmortem blood changed over time with the two being mutually associated: as median fentanyl concentrations in opioid drug-checking samples increased, postmortem blood fentanyl concentrations generally decreased. Further research into complexities of the drug supply, changing substance use patterns, and rates of fentanyl exposure among opioid-naïve individuals may explain this nonlinear trend and inform strategies to abate the ongoing crisis.

Smoking-related illness has historically been a major cause of death in persons with substance use disorders. Smoking cessation has the potential to support improved substance use disorder outcomes, as well as improved physical and mental health outcomes in persons receiving other substance use disorder treatment. However, tobacco abstinence-oriented policies within substance use disorder care settings may create barriers to clients who are uninterested in quitting smoking being able to access other potentially lifesaving substance use disorder treatment. In British Columbia, where the drug toxicity crisis has become the leading cause of unnatural death, reducing barriers to accessing substance use disorder treatment is a key public health priority. We present areflection on considerations from a withdrawal management settingof a smoking policy change within that facility and review the potential benefits and harms of permissive smoking policies within substance use disorder care environments. Benefits include the elimination of a barrier to accessing other substance use treatment, patient autonomy over participation in smoking cessation treatment and the potential for less covert smoking and associated risks. Risks include ongoing physical and mental health harms of smoking, potentially poorer other substance use treatment outcomes, risks of tobacco relapse to other clients and secondhand smoke exposure to staff and other clients. Further research will be needed to explore the impacts of this policy change and evaluate the potential role for other smoking cessation innovations, including expansion of nicotine replacement options such as provision of nicotine electronic cigarette devices.

Background: Insomnia is a common condition experienced by many individuals with excessive alcohol use and alcohol use disorder, and the serotonin antagonist and reuptake inhibitor trazodone has emerged as a mainstay of treatment for insomnia in this population. Main body: However, an underappreciated literature has demonstrated potential for an increase in alcohol use while persons with alcohol use disorder are taking trazodone for sleep challenges. Additionally, multiple trials have identified trazodone’s metabolite meta-Chlorophenylpiperazine as a pharmaceutical inducer of increased alcohol craving and use. Conclusion: Increased awareness in the potential of worsening drinking behaviour with trazodone accompanied by the preferential use of safer alternative treatment strategies can likely improve outcomes for patients with heavy drinking and alcohol use disorder.

Postpartum depression is a serious, but treatable condition experienced after childbirth. While most cases do not involve excess substance use, alcohol and other substance use have been strongly associated with this condition. While serotonergic antidepressants have been a mainstay of pharmacologic therapy for postpartum depression, studies of antidepressant use in postpartum depression have largely excluded those with substance use disorder, and meta-analyses suggest antidepressants offer limited benefit in those with depression and co-occurring substance use disorder. There is also under-appreciated literature demonstrating the potential for a medication-mediated increase in substance use in some individuals taking serotonergic antidepressants. These facts and an examination of guideline recommendations on the treatment for postpartum depression highlight the need for new research and practice improvements for patients with comorbid substance use disorder and postpartum depression.

Objective: In recent years, Canada’s unregulated drug supply has become permeated by novel adulterants (e.g., fentanyl analogues, benzodiazepines, xylazine). While fentanyl has been shown to be associated with overdose mortality and other non-fatal health outcomes, adverse events (AE) associated with these adulterants remain poorly described. This study seeks to identify whether common adulterants identified through drug checking services are associated with increased prevalence of specific adverse events reportedly experienced by people who use drugs. Methods: Drug checking samples were analyzed using Fourier-transform infrared spectroscopy and immunoassay strips at harm reduction sites in British Columbia. Self-reported AE (e.g., non-fatal overdose, prolonged sedation, seizures) were recorded from individuals who checked opioids post-consumption. Adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) of AE among common adulterants were calculated using generalized linear models with a Poisson distribution, controlled for presence of other adulterants, expected drug, geographic location, and month. Results: Between February 2022 and May 2024, 80,415 samples were analyzed at community sites. Among eligible samples, 36.1% were expected opioids, 42.2% of which were checked post-consumption. AE were noted among 10.7% of post-consumption opioid drug checks. After adjustment, the presence of benzodiazepines in opioid samples was associated with increased prevalence of any AE (aPR 1.97; 95% CI 1.70–2.27), as was the presence of xylazine (aPR 1.50; 95% CI 1.09–2.07). Considering specific AE, benzodiazepines were associated with increased prevalence of overdose (aPR 2.05; 95% CI 1.68–2.51) and prolonged sedation (aPR 3.35; 95% CI 2.54–4.43). Conclusion: Non-fatal AE associated with unregulated opioids have been largely undescribed. Our findings report specific AE associated with different adulterants in the unregulated opioid supply. With this information, tailored public health interventions and services focused on these adulterants can be developed.