Introduction Rising overdose deaths are a devastating problem across the United States and Canada. Despite the availability of observed consumption sites in British Columbia (BC), data suggest people who use drugs (PWUD) alone in private residences are most at risk of overdose death. These individuals may not use consumption sites due to fear of stigmatization, lack of privacy, or personal preference. It is this population that would benefit from overdose monitoring alternatives. Methods This 2018 study employed two sources of data. (1) A provincial harm reduction distribution site client survey administered at 27 sites across BC asked about cell phone possession and functionality. (2) Structured interviews with PWUD in Vancouver gathered perspectives regarding monitoring devices and alerting systems. Results The client survey was administered to 486 individuals. Among 443 respondents, 48% ( n = 212) owned a cellphone and 68% ( n = 115) of individuals with a cellphone with access to internet ( n = 168) would use an application to mitigate opioid-related overdose deaths. Thirty qualitative interviews were performed; thematic analysis of the responses identified three major themes – safety, public versus private drug use, and technological monitoring and function. The relevance of technological devices was affected by the inconsistent availability of cellphones, concerns about anonymity, as well as personal comfort while using drugs. Conclusions Technological applications may not be suitable for clients with transient lifestyles, no permanent home, and lack of consistent access to a mobile device. Thorough needs assessments, considerations of lifestyle limitations, and understanding perceptions around cellphone and overdose monitoring can increase the potential that devices will be used. Highlights • 45% ( n = 219) of client survey respondents owned a cellphone • Out of cellphone owners, 59% ( n = 102) of client survey respondents had access to internet • Of 168 with internet access, 68% willing to use any applications for overdose response • Applications not suitable for transient lifestyles, no permanent home, and lack of consistent access to cellphone

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Background North American communities are severely impacted by the overdose crisis, particularly in British Columbia (BC), which has the highest toxic drug overdose death rate in Canada. Most fatal overdoses in BC occurred among individuals using alone and in private residences. This study aimed to assess prevalence and reasons for using drugs alone among people accessing harm reduction services in BC. Methods We recruited harm reduction supply distribution site clients from 22 communities across BC. Descriptive statistics and multivariable logistic regression were used to describe factors associated with using alone. Thematic analysis of free-text responses providing reasons for using alone were grouped with survey data and additional themes identified. Results Overall, 75.8% (n = 314) of the study sample (N = 414) reported using drugs alone within the last week. Those that reported using alone did not differ from those that did not by gender, age, urbanicity, or preferred drug use method. Among those that used alone, 73.2% (n = 230) used opioids, 76.8% (n = 241) used crystal meth, 41.4% (n = 130) used crack/cocaine, and 44.6% (n = 140) used alcohol in the past week. Polysubstance use involving stimulants, opioids, and/or benzodiazepines was reported by 68.5% (n = 215) of those that used alone. Additionally, 22.9% (n = 72) of those that used alone had experienced an opioid and/or stimulant overdose in the past 6 months. In a multivariable logistic regression model, having no regular housing and past week crack/cocaine use were associated with using alone (adjusted odds ratio (AOR): 2.27; 95% CI 1.20–4.27 and AOR: 2.10; 95% CI 1.15–3.82, respectively). The most common reason reported for using alone was convenience and comfort of using alone (44.3%). Additional reasons included: stigma/hiding drug use (14.0%); having no one around (11.7%); safety (9.6%); and not wanting to share drugs with others (8.6%). Conclusions Using drugs alone, particularly for convenience and comfort, is ubiquitous among people accessing harm reduction services. Overdose prevention measures that go beyond individual behaviour changes, including providing a safer supply of drugs and eliminating stigma, are paramount to mitigate harms. These interventions are especially necessary as emergence of coronavirus disease may further exacerbate unpredictability of illicit drug content and overdose risk.

Introduction Increased use of crystal methamphetamine (“crystal meth”) has been observed across North America and international jurisdictions, including a notable increase in the presence of methamphetamines in illicit drug toxicity deaths in British Columbia (BC), Canada. We used data from a cross-sectional survey and urine toxicology screening to report the prevalence, correlates, and validity of self-reported crystal meth use among clients of harm reduction sites in BC. Materials and methods Survey data were collected from 1,107 participants across 25 communities in BC, through the 2018 and 2019 Harm Reduction Client Survey. We described reported substance use and used a multivariate logistic regression model to characterize crystal meth use. Urine samples provided by a subset of participants were used to derive validity of self-reported three-day crystal meth use compared to urine toxicology screening. Results Excluding tobacco, crystal meth was the most frequently reported substance used in the past three days in 2018 and 2019 (59.7% and 71.7%, respectively). Smoking was the dominant route of administration for crystal meth, crack, heroin, and fentanyl. Multivariate analysis determined significantly higher odds of crystal meth use among those who used opioids (Adjusted Odds Ratio [AOR] = 3.13), cannabis (AOR = 2.10), and alcohol (1.41), and among those who were not regularly housed (AOR = 2.08) and unemployed (AOR = 1.75). Age ≥50 was inversely associated with crystal meth use (AOR = 0.63). Sensitivity of self-reported crystal meth use was 86%, specificity was 86%, positive predictive value was 96%, and negative predictive value was 65%. Conclusions Crystal meth was the most commonly used substance among clients of harm reduction sites in BC in 2018 and 2019, and was frequently used concurrently with opioids. Comparison to urine samples demonstrated high validity of self-reported crystal meth use. Understanding evolving patterns of substance use will be imperative in tailoring harm reduction and substance use services for individuals that use crystal meth.

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