Health policies and programs are increasingly being driven by people from the community to more effectively address their needs. While a large body of evidence supports peer engagement in the context of policy and program development for various populations, little is known about this form of engagement among people who use drugs (PWUD). Therefore, a narrative literature review was undertaken to provide an overview of this topic. Searches of PubMed and Academic Search Premier databases covering 1995–2010 were conducted to identify articles assessing peer engagement in policy and program development. In total, 19 articles were included for review. Our findings indicate that PWUD face many challenges that restrict their ability to engage with public health professionals and policy makers, including the high levels of stigma and discrimination that persist among this population. Although the literature shows that many international organizations are recommending the involvement of PWUD in policy and program development, our findings revealed a lack of published data on the implementation of these efforts. Gaps in the current evidence highlight the need for additional research to explore and document the engagement of PWUD in the areas of policy and program development. Further, efforts to minimize stigmatizing barriers associated with illicit drug use are urgently needed to improve the engagement of PWUD in decision making processes.

To better understand risk factors associated with leaving the hospital against medical advice among PWUD, future research should consider the effect of individual, social, and structural characteristics on leaving the hospital against medical advice among PWUD. The development and evaluation of novel methods to address interventions to reduce the rate of leaving the hospital prematurely is necessary.

Background While persons with addiction are often hospitalized, hospitals typically employ abstinence-based policies specific to illicit drug use. Although illicit drug use is known to occur within hospitals, this problem has not been well characterized. Therefore, we sought to investigate the prevalence of and factors associated with having ever used drugs in hospital among people who use drugs (PWUD) in Vancouver, Canada. Methods Data were derived from prospective cohort studies of PWUD between December 2012 and May 2013. Multivariable logistic regression was used to identify demographic and behavioural factors associated with having ever used illicit drugs in hospital. Results Among 1028 participants who had experienced ≥ 1 hospitalization, 43.9% reported having ever used drugs while hospitalized. In multivariable analyses, factors positively associated with having ever used drugs in hospital included: daily cocaine injection and daily crack non-injection (both p < 0.05). Factors negatively associated with the outcome included: older age and male gender (both p < 0.05). The most common reasons for drug use in hospital were “wanting to use” and “being in withdrawal”. Drugs were most commonly used in patient washrooms. Conclusions Our findings demonstrate that an abstinence-based approach to drug use in hospitals may be ineffective at prohibiting drug consumption. High-risk drug use behaviours arising from ongoing drug use may pose risks for further harm and illness. Efforts to minimize the harms associated with using drugs in hospital are urgently needed.

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BackgroundLeaving hospital against medical advice (AMA) is common among people who use illicit drugs (PWUD) and is associated with severe health-related harms and costs. However, little is known about the prevalence of and factors associated with leaving AMA among PWUD.MethodsData were collected through two Canadian prospective cohort studies involving PWUD between September 2005 and July 2011 and linked to a hospital admission/discharge database. Bivariable and multivariable generalized estimating equations were used to examine factors associated with leaving hospital AMA among PWUD who were hospitalized.ResultsAmong 488 participants who experienced at least one hospitalization, 212 (43.4%) left the hospital AMA at least once during the study period. In multivariable analyses, factors positively and significantly associated with leaving hospital AMA included: unstable employment (AOR = 1.92; 95% confidence interval [CI]: 1.22–3.03); recent incarceration (AOR = 1.63; 95%CI: 1.07–2.49); ≥ daily heroin injection (AOR = 1.49; 95%CI: 1.05–2.11); and younger age per year younger (adjusted odds ratio [AOR] = 1.04; 95%CI: 1.02–1.06).ConclusionsWe found a substantial proportion of PWUD in this setting left hospital AMA and that various markers of risk and vulnerability were associated with this phenomenon. Our findings highlight the need to address substance abuse issues early following hospital admission. These findings further suggest a need to develop novel interventions to minimize PWUD leaving hospital prematurely.

Background & Aims: Despite the high burden of hepatitis C virus (HCV) infection among people who inject drugs (PWID), uptake of interferon-based therapies has been extremely low. Increasing availability of direct-acting antiviral (DAA)-based therapies offers the possibility of rapid treatment expansion with the goal of controlling the HCV epidemic. We evaluated DAA-based treatment uptake among HCVpositive PWID in Vancouver after introduction of DAAs in the government drug formulary. Methods: Using data from three cohorts of PWID in Vancouver, Canada, we investigated factors associated with DAA-therapies uptake among participants with HCV Results: Of the 915 HCV-positive PWID, 611 (66.8%) were recent PWID and 369 (40.3%) had HIV coinfection. During the study period, 146 (16.0%) initiated DAA-therapies, a rate of 6.0 per 100 person-year, with higher initiation rates among non-recent PWID and an increasing trend over time. In multivariable analysis, HIV coinfection (Adjusted Odds Ratio [AOR] = 2.29, 95% Confidence Interval [CI]: 1.55-3.40), white race (AOR = 1.56, 95% CI: 1.05-2.35), and engagement in HCV care (AOR = 1.94, 95%CI: 1.31-2.90) were positively associated with DAA-therapies uptake, while high-risk drinking (AOR = 0.47, 95% CI: 0.23-0.88) and daily crack use were negatively associated (AOR = 0.41, 95% CI: 0.17-0.85). Among recent PWID, engagement in opioid agonist therapy emerged as an independent correlate of DAA uptake. Conclusions:Despite increases in HCV treatment uptake among PWID after the introduction of DAAs in our setting, disparities in access remain. Social-structural and behavioural barriers to HCV care should be addressed for the success of any HCV elimination strategy.

Background. Leaving the hospital against medical advice is an increasing problem in acute care settings and is associated with an array of negative health consequences that may lead to readmission for a worsened health outcome or mortality. Leaving the hospital against medical advice is particularly common among people who use illicit drugs (PWUD) and has been linked to a number of complex issues; however, few studies have focused specifically on this population beyond identifying them as being at an increased risk of leaving the hospital prematurely. Furthermore, programs and interventions for reducing the rate of leaving the hospital against medical advice among PWUD in acute care settings have not been well studied. Objectives. We systematically assessed the literature examining hospital discharge against medical advice from acute care among this population and identified potential methods to minimize the occurrence of this phenomenon. Search methods. We searched 5 electronic databases (from database inception to August 2014) and article reference lists for articles investigating hospital discharge from acute care against medical advice among PWUD. Search terms consistent across databases included “patient discharge,” “hospital discharge,” “against medical advice,” “drug user,” “substance-related disorders,” and “intravenous substance abuse.” Selection criteria. Studies were eligible for inclusion if they were published in a peer-reviewed journal as an original research article in English. We excluded gray literature, case reports, case series, reviews, and editorials. We retained original studies that reported illicit drug use as a predictor of leaving the hospital against medical advice and studies of discharge against medical advice that included PWUD as a population of interest, and we assessed significance through appropriate statistical tests. We excluded studies that reported patients leaving the hospital against medical advice from psychiatric hospitals, drug treatment centers and emergency departments, and studies that discussed misuse of alcohol but not illicit drugs. Data collection and analysis. We created an electronic database that included study abstracts and relevant information matching the keywords and search criteria. We reviewed potentially eligible articles independently by scanning the titles, abstracts, and full texts of articles after removing duplicates. We identified studies for which eligibility was unclear and decided which studies to include after thoroughly reviewing and discussing them. Results. Of the 1649 studies that matched the search criteria, 17 met our inclusion criteria. Thirteen studies identified substance misuse as a significant predictor of leaving the hospital against medical advice. Three studies assessed the prevalence and predictors of leaving the hospital against medical advice among people who inject drugs and found that this phenomenon was commonly reported (prevalence range = 25%–30%). Factors positively associated with leaving the hospital against medical advice included recent injection drug use, Aboriginal ancestry, leaving on weekends and welfare check day. In-hospital methadone use, social support, older age, and admission to a community-based model of care were negatively associated with the outcome. Conclusions. To better understand risk factors associated with leaving the hospital against medical advice among PWUD, future research should consider the effect of individual, social, and structural characteristics on leaving the hospital against medical advice among PWUD. The development and evaluation of novel methods to address interventions to reduce the rate of leaving the hospital prematurely is necessary.

Introduction and AimsDrug checking is a harm reduction intervention increasingly used in the context of the opioid overdose epidemic. The aim of the study was to determine the limit of detection for fentanyl of two point‐of‐care drug checking technologies.Design and MethodsSamples tested at point‐of‐care using Bruker Fourier transform infrared (FTIR) spectroscopy and BTNX fentanyl immunoassay strips were sent for confirmatory laboratory analysis using quantitative nuclear magnetic resonance (qNMR) spectroscopy. Concentrations by weight were determined and compared to results obtained with point‐of‐care methods.ResultsIn total, 283 samples were sent for qNMR analysis; among these, 173 (61.1%) tested positive for fentanyl. As determined by qNMR, fentanyl concentration by weight ranged from 1% to 91%. Among these 173 samples, fentanyl was not detected in 30 (17.3%) samples by FTIR and in 4 (2.3%) samples by test strip. Samples containing fentanyl that went undetected by FTIR had concentrations ≤10%. The four samples containing fentanyl that went undetected by test strip had concentrations ≤5% (i.e. 1%, 3%, 4%, 5%).Discussion and ConclusionsFentanyl immunoassay strips were able to consistently detect the presence of fentanyl in samples at lower concentrations than FTIR spectroscopy. Given that FTIR spectroscopy is able to quantify content, mixture and concentrations on an array of compounds beyond just fentanyl but requires concentrations generally greater than 10%, these findings provide evidence for use of FTIR spectroscopy and immunoassay strips in combination to compensate for the limitations of each technology alone.