Sector News

  1. Methadone Injection in a Canadian Context


    • According to the Substance Abuse and Mental Health Services Administration (2012), 669,000 people used heroin in the previous year in the United States. As well, the number of heroin users increased every year for five years in a row.

    • Although methadone is an effective treatment for patients with opioid use disorder and chronic pain, fatalities have continued to rise due to illicit methadone use.

    • The authors aimed to look at the factors associated with methadone injection in an urban Canadian setting where access to methadone prescribed through primary care physicians is common.


    The authors used two prospective cohorts of individuals who use drugs in Vancouver (Vancouver Injection Drug Users Study (VIDUS), and AIDS Care Cohort).


    • Approximately 7% of participants injected methadone over the study period. The authors found this behaviour to be associated with socioeconomic vulnerability and other addictions.

    • Methadone injection was not associated with enrolment in a methadone program. Interestingly, the findings of this study contrast with other studies, which propose that enrolment in a methadone maintenance program is associated with injection of methadone. Due to this, the authors suggest that these individuals may represent a sub-population of PWID “for whom evidence-based addiction treatment services remain out of reach.”

    • The rates of diversion (transfer of legally prescribed drugs from the patient to another person for illicit use) show a need to implement tools that enhance the flexibility of program rules for patients at low risk of diversion. , while at the same time ensuring that patients at risk of selling their medication ingest their medication at the time it is provided.

    • However, the authors also note that PWID may be purchasing and using street methadone as a means to reduce their heroin consumption and self-treat opioid withdrawal symptoms.


    The injection of methadone is associated with several other high-risk behaviors. Due to this, access to methadone programs should be optimized while also making efforts to limit diversion of methadone to the street.

    Tucker, D., Milloy, M.J., Hayashi, K., Nguyen, P., Kerr, T., and Wood, K. (2015). Factors Associated with Illicit Methadone Injecting in a Canadian Setting. The American Journal on Addictions. 24:532-537.

  2. Perceived Risk of Opioid Overdose


    Globally, opioid use is on the rise. Opioid dependence is estimated as the largest contributor to the global burden of disease from drug dependence. In the United Stated, over 25 million people began using nonmedical opioids between 2002 and 2011. During this time, the drug-poisoning mortality rate more than doubled.


    The authors surveyed 172 opioid users in San Francisco to assess predictors of risk perception for opioid overdose.


    • Older individuals and those who injected more frequently were less likely to see themselves at a high risk for opioid overdose. However, the literature indicates that those who are older are actually more likely to die from overdose.
    • Those who injected more frequently were less likely to perceive themselves as high risk for overdose.
    • Interestingly, although concurrent use of opioids and alcohol was associated with a high-perceived risk of overdose, concurrent use of opioids and benzodiazepines or cocaine was not. Yet previous research shows that concurrent use of these substances is linked to opioid overdose.
    • Participants who experienced a past overdose, used heroin and mixed opioids and alcohol more frequently were more likely to see themselves as high risk for overdose. This finding is consistent with the literature, which shows previous overdose to be the strongest predictor of overdose and overdose death.
    • HCV positive participants were more likely perceive themselves at high risk for overdose. However this association was not found amongst HIV positive participants, despite the risks. This suggests a gap in risk perception amongst this particular population.


    There are gaps in awareness between real overdose risk factors and perceived overdose risk amongst opioid users. The authors highlight the need for educational interventions.

    Rowena, C., Santos, G.M., Behar, E., and Coffin P.O. (2016). Correlates of overdose risk perception among illicit opioid users. Drug and Alcohol Dependence. 159: 234-239.

  3. Deindustrialization and Overdose Risk


    “In 2013, more Americans died from overdoses than car crashes” – Hilary Clinton in 2015 on the growing need to address the epidemic of drug overdose.

    • Opiate- and opioid-type drugs have been associated with a rising proportion of overdose deaths – from over 38% in 2004 to just under 52% in 2013 in the United States.
    • The initial rise in mortality was due to an in crease in prescription opioid (PO) abuse, but more recent data shows that heroin use has risen in popularity partly due to the attempts to control prescription drug misuse.
    • In 2008, heroin represented approximately 30% of overdose deaths. By 2014, heroin accounted for 61%, making it the most prevalent substance associated with overdose deaths.
    • Recent research has considered how the shifting dynamics of the U.S. illicit drug market have heightened overdose risk in places newly supplied with cheaper, more potent Colombian heroin.

    Study Setting

    • Small cities across the Monongahela River Valley have lost ‘‘90 percent of everything’’ – residents, jobs, and businesses – over the past three decades
    • According to the Allegheny County Medical Examiner (ACME), fatal overdoses nearly tripled from 2000 to 2014, from 109 to 307.
    • Case-level mortality data from Allegheny County shows an obvious spatial association between deadly overdose and poverty, with the highest fatality rates clustered in the region’s deindustrialized communities and Pittsburgh’s inner-city neighbourhoods.

    Risk environments =‘‘spaces – whether social or physical – in which a variety of factors interact to increase the chances of harm occurring’’ (Rhodes, 2009).


    In a survey, participants described their own most recent overdose event and/or the last overdose they had personally witnessed. They were also asked to speculate upon the roots of the local overdose epidemic, while suggesting possible remedies.


    • Participants viewed overdose and addiction as part of life in a poor city.
    • Participants lacked access to prevention education and free naloxone (for treating overdoses) from the county needle exchange program due to transportation barriers.
    • Several participants sold heroin in order to support their own drug use and many feared the criminal consequences of a buyer having a fatal overdose.


    The authors suggest that the road into drug use is shaped by a deindustrialized context. Lack of opportunity, social support, and hope are met by the expanding illicit drug market, which offers both employment and recreation. Due to this, policy makers should be aware of the underlying factors and future overdose interventions should take into account that drug-related risks are complex and multifaceted when designing accessible programs for low/no-income individuals.

    McLean, K. (2015). ‘‘There’s nothing here’’: Deindustrialization as risk environment for overdose. International Journal of Drug Policy. Vol. 29. Pp. 19-26.

    Rhodes, T. (2009). Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy. 20: 193–201.

  4. Exploring the Connection between Heroin and Steroid Use


    Steroids, properly called Anabolic–androgenic steroids (AAS), are commonly used drugs in some populations of young men. Several studies have found an association between illicit drugs, such as heroin and other opiates, with steroid use.  There are various possible explanations for the connection between steroid use and illicit drug use:

    • a) Both may be associated with criminality and deprivation;
    • b) Heroin might depress certain hormones resulting in a decrease in testosterone, which may predispose a person to replacement through AAS (steroids);
    • c) Both may share similar pleasure-seeking neuropathways, which could be the reason for findings showing a high prevalence of opiate users in a group of steroid users with characteristics of dependence compared to a group of steroid users who did not show characteristics of dependence; and
    • d) An association between heroin and steroid (AAS) use may be due to social and cultural contexts.


    In an urban area in the North East of England, the authors used several focus groups (total of 30 participants) to look at the socio-cultural links to steroid use (AAS) and the link between steroid use and heroin.


    • Participants, including those who were heroin users, viewed heroin use with a great deal of stigma.

    Hiding weight loss

    • Due to the association of heroin with weight loss, participants associated heroin recovery with weight gain. They commented that recovery involved stopping heroin, going to the gym, eating more and becoming bigger in size and more muscular. One participant commented that he used steroids partly to make his family believe that he was recovering from heroin.

    Intimidation purposes

    • Several participants felt that in order to function well in their social environment (e.g. drug dealer or other roles) they needed steroids for intimidation purposes. The increased strength and increased physical size, helped heroin users to function well within their social context. Participants commented that they used steroids for both intimidation purposes and for progression to being a more effective drug-dealer.
    • Participants who had been in prison said that limited opportunities to do other things and boredom contributed to their focus on increasing their size and strength.

    Other studies also, have found that steroids were used for reasons such as “to feel brave” and as an attempt to hide the effects of heroin.


    There are important socio-cultural reasons for the association between heroin and AAS use, which include the need to function through intimidation, and to hide the stigma associated with heroin use. It is important to note that most steroid users do not use heroin and most heroin users do not use steroids. Further research could focus on determining which heroin users are at risk of using steroids and of those who use them, investigating who is at the greatest risk for developing dependence on steroids.

    Cornforda, C.S., Keanb, J., and Nash, A. (2014). Anabolic–androgenic steroids and heroin use: A qualitative study exploring the connection. Journal of International Drug Policy. Vol. 25, Issue, 5. Pp. 928-930.

  5. Injecting Risk Behaviours after Hepatitis C Virus Treatment in Australia


    Hepatitis C virus (HCV) infection prevalence is high among people who inject drugs (PWID) and is a major cause of morbidity and mortality among this population. Due to concerns that HCV treatment may increase injecting risk behaviours among people who inject drugs (PWID) the authors compared recent (past month) injecting risk behaviours between PWID who received and did not receive HCV treatment.


    • Of the 124 Australian participants with a history of injection drug use, 69% were male with 68% treated for HCV infection.
    • HCV treatment was not associated with an increase in recent injection drug use (adjusted odds ratio (aOR) 1.06, 95% CI 0.93, 1.21). This is consistent with previous study findings.
    • HCV treatment was not associated with recent used needle and syringe borrowing (aOR 0.99, 95% CI 0.89, 1.08).
    • Treatment was associated with a decrease in recent ancillary injecting equipment sharing (aOR 0.85, 95% CI 0.74, 0.99). This is important given that sharing of equipment contributes to HCV transmission.
    • Although a small sample, the 24 participants who remained in follow-up (24 weeks) showed a significant decrease in injecting equipment sharing during follow-up. This is at least interesting to note because the side effects of interferon-based therapy mimic opioid withdrawal, which is a concern for some physicians (they worry that treatment might lead to relapse or an increase in drug use).


    Hepatitis C virus assessment and treatment for people who inject drugs should be enhanced due to its effectiveness as it does not lead to increases in injection risk behaviours and has already been shown to be safe and effective for PWID populations.

    Alavi, M.,  Spelman, T.,  & Matthews, G.V. (2015). Injecting risk behaviours following treatment for hepatitis C virus infection among people who inject drugs: The Australian Trial in Acute Hepatitis C. International Journal of Drug Policy. Vol. 26. Issue 10, pp. 976-983.

  6. Cost-effectiveness of Harm Reduction Strategies


    Health care providers and governments across the globe are faced with an urgent task to improve health outcomes for PWID, specifically reducing increasing rates of HIV and HCV transmission.


    The authors assess needle exchange programs (NSPs), opioid substitution therapy (ORT), and antiretroviral therapy (ART) in isolation and then in combination.


    Effectiveness and Cost-effectiveness of needle syringe programs (NSPs)

    • NSPs are generally the least expensive at $23 -$71 (US) per person each year. This variation is cost depends on region of the world and the delivery system (e.g. pharmacies, mobile outreach).

    Effectiveness and Cost effectiveness of opioid substitution therapy (OST)

    • OST is a structural intervention with other societal benefits. Although it is more expensive than NSP, the largest benefits relate to a reduction in the number and severity of relapses due to opiate use, as well as, lower rates of criminal activity and incarceration for drug related crimes. OSTs are particularly more cost effective when these factors are included in economic analyses.

    Effectiveness and Cost effectiveness of antiretroviral therapy ART

    • Several studies have shown that ART is cost-effective for both keeping people alive and for the prevention benefits it offers.
    • A Russian study found that ART would cost approximately $1501 (US) per QALY gained when targeted to PWID. This is considered good value for money.
    • ART costs are expected to decline by 2020

    Effectiveness and Cost effectiveness of combination strategies

    • Comprehensive strategies appear to be a better approach because generally no single harm reduction strategy is sufficient.
    • Research shows that needle syringe programs (NSPs), opioid substitution programs, and antiretroviral therapy (ART) together have shown to be effective to reduce drug dependency, reduce injection equipment sharing, improve quality of life, and avoid HIV infections.
    • Overall, the unit cost of harm reduction interventions is low, but it can vary based on type of provider, delivery model, and region.


    Harm reduction interventions are good value for the money invested and improve health outcomes for PWID, as well as, the broader population. Currently, coverage of harm reduction programs is too low across almost all global regions. Although scaling up is costly, it is worthwhile not only for the societal benefits, but also for the significant returns on investment for governments.

    Wilson, D.P., Donald, B., Shattock, A.J., Wilson, D., and Fraser-Hunt, N. (2015). The cost-effectiveness of harm reduction. International Journal of Drug Policy. Vol. 26, pp. S5-S11.

  7. How does a Positive or Negative Hepatitis C Virus Test Impact Behavior?


    • Worldwide, Hepatitis C virus (HCV) prevalence among injection drug users is estimated between 50% and 90%.
    • HCV testing and counselling can be used as an opportunity to influence behaviour and transmission of HCV at the time of test notification. For example, a study conducted in Montreal showed a decrease in syringe sharing after participants were made aware of both positive and negative HCV test results in an addition to a reduction of alcohol use. However the results were limited due to a small sample size.


    • The authors used data from the International Collaboration of Incident HIV and HCV Infection in Injecting Cohorts (InC3 Study), which is a multicohort study of pooled data from prospective studies of people who inject drugs (PWID) in Canada, USA, The Netherlands, and Australia. Participants were recruited and followed between 1985 and 2011. The sample included 829 people who inject drugs.


    • Notification of a HCV test result showed a reduction in recent injection drug use and recent syringe sharing for both those who received a positive and negative HCV test result (5% and 3% reduction, respectively). There were no significant differences between the two groups.
    • Recent Australian and Canadian data show some sustained behavioural changes associated with the notification process.
    • The proportion of participants using alcohol increased among those who received a positive HCV test
    • Younger (under 25 years) PWID populations who received a positive HCV test significantly increased alcohol consumption in comparison to the HCV-negative group.


    Timely notification of HCV test results is a key opportunity for risk behavior reduction counseling. In addition, there is need to expand post-test counseling services and monitoring in order to address post-diagnosis alcohol use.

    Spelman, T., Morris, M.D., and Zang, G. (2015). A longitudinal study of hepatitis C virus testing and infection status notification on behavior change in people who inject drugs. J Epidemiol Community Health. 69(8): 745–752.

  8. Exploring Health Services Access to Non-active Injectors


    It is important for former injectors to maintain connections with syringe exchange programs (SEPs) in order to access general social and health services that will help them to maintain sobriety. This study looked at walking distance to needle exchange programs for both current and former people who inject drugs (PWID).


    The study surveyed 137 people who inject drugs who presented for services at syringe exchange program (SEP) mobile distribution sites in Washington DC.


    • Active and non-active injectors do not have equal access to syringe exchange program (SEP) services.
    • Those who are not actively injecting may have less motivation to travel to access services compared to when they were actively injecting and seeking sterile equipment.
    • Non-active injectors may also be seeking healthcare services elsewhere.
    • Challenges to enhancing access to SEP services include policies that restrict where needle exchange programs can legally operate (e.g. certain proximity to schools). Future work should explore enhancing access in areas of greatest need.


    Providing comprehensive services for former/non-active substance users, a vulnerable population, is important for addressing their complex medical and social health care needs such as addiction treatment and support and housing.

    Allen, S., Ruiz, M., and O’Rourk, A. (2015).How far will they go?: assessing the travel distance of current and former drug users to access harm reduction services. Harm Reduction Journal. Vol. 12. Issue 3.

  9. Challenges faced by Peer Helpers


    • The role of peer helpers came out of a need to address the limitations of the traditional “provider-client model.”
    • Mediators or Peer Helpers act as both secondary distribution agents and advocates. They have become a valuable component of the most successful strategies aimed at injection drug using communities as they bring the reality of the lives of marginalized populations into strategic discussions.
    • This study aimed to explore the difficult situations peer helpers may find themselves in when they attempt to implement harm reduction practices and balance potential serious health problems and even death against anticipated backlash from users, medical staff, and the community.


    A series of focus group sessions were conducted with peer helpers over a two-year time frame in Cape Breton, Canada.

    Findings/Key Themes

    Officially sanctioned peer helper practices

    • Overall, few moral dilemmas arose with the official distribution part of the peer helper role unless there was a shortage of supply.
    • Peer helpers viewed education of new users as a very important part of their harm reduction role. They felt that the hidden nature of injecting left them responsible for “how to” training.
    • Contrary to public discourse, peer helpers attempt to dissuade individuals from taking that first hit. However, they were exposed to threats from others such as neighbours and child protection workers because of how their role is perceived by the general public.
    • Peer helpers can be credited with the high rates of safe needle disposal. They play a key role in developing and reinforcing return practices.

    Unofficial peer helper practices

    • Given that peer helpers are viewed as authorities on safe injection within their community, one of the first ways they can be drawn into an unofficial role is through requests for assistance.
    • The imminent threat of death from overdose is on the top of the minds of peer helpers, not the threat of blood-borne pathogens.
    • Peer helpers are the ones who typically step in to deal with overdose and will usually make the call to emergency services despite repercussions from health professionals and police as well as the users themselves. As a result, peer helpers find themselves caught in the middle of competing courses of action – do they call the police or not?
    • Due to users’ hesitation to seek medical treatment, peer helpers find themselves treating wounds and abscesses. Some helpers find themselves saving and sharing antibiotics (even though they know it’s problematic) to help those who refuse to seek medical attention.
    • Many peer helpers also take on the role of counselor
    • Peer helpers lived experience enables them to empathize with those struggling with addiction – “they almost never give up on people.” They let people who were homeless come to their homes for food, a shower and a night’s sleep.


    Peer helpers find themselves in difficult situations with user populations often because people who inject drugs feel undeserving of services and discriminated against when they do seek services. This adversely impacts users, and particularly the peer helpers seeking to assist them. In an effort to keep users alive, peer helpers engage in practices that extend far beyond their roles of disseminating sterile syringes and safe injection materials.

    Dechman, M.K. (2015). Peer helpers’ struggles to care for “others” who inject drugs. International Journal of Drug Policy. Vol. 26. Pp. 492-500.

  10. Risky Income Activities of Vancouver’s Street- Youth


    Due to unemployment and poverty, street-involved youth may turn to risky activities such as sex work, salvaging/recycling, squeegeeing car windows for donations, panhandling, drug dealing, theft and other criminal activities to generate income. The authors used a prospective cohort design (2005 – 2012) to study risky employment of street-involved youth in Vancouver.

    Street-involved: recently homeless or having used services designated for street-youth in the last year.


    • Of the 1008 participants during the 6-year study, 735 (73%) reported engaging in risky income generation activities at their baseline study visit, and 826 (82%) participants reported engaging in risky income generation activities at some point during the study period.
    • Those with intense addition such as binge drug use, injection drug use, and drug overdose were more likely to engage in risky income generating activities. Since this finding is substantiated in previous research, reducing the intensity of substance use may be an opportunity to reduce risky income generation.
    • A sub-analysis of 825 participants found that 63% mentioned “dealing drugs” as an income generation activity.
    • Approximately 53% (n=440) said they would be willing to give up a source of risky income if they were not using drugs. The need for income to fund drug ongoing drug use is a key factor perpetuating risky income generating activities.
    • Youth who recently attended addiction treatment were significantly more willing to give up their risky income generating activities if they did not use drugs.
    • Still, a large proportion, 47%, said they would persist with their risky income sources regardless of substance use. Based on this, we know that substance use is not the only factor pushing youth to engage in risky income generation.
    • The role of age in influencing substance use and income generation trajectories should also be explored as the authors found older age to be associated with willingness to give up risky income sources.
    • Income assistance programs in the current study setting have high barriers to access and do not provide adequate financial support to meet basic survival need.
    • Overall, there is limited availability and access to economically sufficient legal income sources in the participant’s environment. This highlights the need to explore ways to reduce the economic vulnerability of youth.


    The high prevalence of risky income generating activities among street involved youth, particularly those who use drugs, highlights the need for policy-makers to address deficiencies in accesses to timely addiction treatment for youth. However, the large percentage of youth who still intended to participate in risky income generation activities suggests a need to evaluate structural interventions to target the economic vulnerability of youth.

    Cheng, T., Kerr, T., Small, W., Nguyen, P., Wood, E., and DeBeck, K. (2016). High prevalence of risky income generation among street-involved youth in a Canadian setting. International Drug Policy People. Vol. 28, pp. 91-97.