Introduction

Overdose deaths and non-fatal overdoses, largely attributed to the presence of fentanyl, have increased significantly in recent years across Canada and the United States.1,2 In Canada, nearly 4000 people died of an opioid-related death in 2017. The death rate was 10 per 100,000 population, which represents a 34% increase compared with 2016.3,4 Western Canada has been particularly impacted by opioid-related deaths.4 Following several years of escalating rates of fatal illicit drug-related overdoses, the Provincial Health Officer of British Columbia (BC) declared the situation to be a public health emergency in April 2016.5 By end of 2017, the BC coroner confirmed approximately 1450 overdose deaths.6 As of April 2018, the rate of overdose deaths in BC rose to 32 deaths per 100,000 individuals (an average of about four deaths per day).6 In Ontario and the Western provinces, the number of overdose deaths due to fentanyl is increasing relative to other opioids.7-10 Prescription drug misuse combined with the entry of fentanyl into the illegal drug market are driving what is quickly becoming a national public health crisis.3

Overdose deaths are not confined to one group or segment of the population but are distributed across a social gradient. However, lower income populations, including those who are homeless or at risk of homelessness, continue to carry a disproportionate burden of harms and deaths.10-12 The proportionate burden and impact of overdose deaths also vary by age, ethnicity, sex and gender. Opioid-related deaths are higher among youth and adults younger than 40 years than among older adults.8-10 For the general population of both BC and Ontario, there is a higher rate of overdose death among males than among females.6,13 Among First Nations communities in BC, however, mortality related to opioid overdose is three times higher than the general population, with almost equal numbers of males and females.14 In a street-based sample of people 19 years of age and older, researchers found higher rates of non-fatal overdose among younger people and those who identified as LGBTQ (lesbian, gay, bisexual, transsexual, queer).15 These trends are in alignment with established social gradients whereby the proportionate burden of poor health and harms increases as wealth and power decrease.

Although these inequities in opioid-related deaths are beginning to be reported, there is a lack of comprehensive health system equity-oriented responses that address the contexts of harm as part of overdose prevention. In addition to reducing the risks of overdose across the socio-economic gradient, specific approaches that attend to age, sex, ethnicity and gender are needed. For Indigenous people, a decolonizing approach to substance use and harm reduction seeks to shift the historical and current practices of deficit-based framing. Indigenous-specific priorities, practices and beliefs are integrated as part of a strengths-based approach that centres Indigenous approaches to wellness.16 Ideally, targeted approaches should be delivered as enhanced services within a universal framework (known as proportionate universalism) to promote equity and reduce the harms of stigma or overdose.17,18

Responding to the contexts of substance use-related harms

Research consistently shows that people who use illegal substances often experience intense stigma when they attempt to access health care.19-21 Stigma is deeply embedded in health and social systems as a result of current policies that criminalize drug use and neo-liberal beliefs that people who use substances are to blame for their own problems.22 Feelings of being unsafe in healthcare settings due to fear or experiences of judgments and stereotyping can lead people to delay and avoid seeking the care they require. As a result of stigma, people who use drugs often distrust healthcare providers and fear being shamed and humiliated when accessing care.23,24

Substance use-related stigma is compounded when coupled with socio-economic disadvantages, racism, sexism, heteronormativity and/or diagnoses of HIV/AIDS or hepatitis C virus-conditions that are themselves marginalizing.25 It is the multiplicity of these factors that has exponential impacts of further stigmatization and marginalization.26,27 The compounding impact of these social locations on stigma extends beyond the individual; it affects the very design, development and delivery of services and policies meant to respond to the overdose emergency.22 It is important to recognize and attend to systemic forms of stereotyping and discrimination (e.g. racism, sexism, hetero-sexism, ableism) on the development of health services for people who use substances and specifically for the development and delivery of overdose responses.28

To be both acceptable and accessible, evidence and experience indicate that health and social services for people who use drugs and live in high-risk environments must be culturally safe,29,30 trauma-informed31,32 and guided by harm-reduction principles.33,34 These three specific approaches have been identified as important and relevant to health equity-oriented (HEO) care.35,36 These concepts and related principles illustrate the broader structural conditions in which people are harmed by substance use, while also emphasizing the need to mitigate racism, stigma and criminalization.

Cultural safety extends beyond cultural sensitivity and competence to focus attention on power imbalances, institutional discrimination and the inequitable positioning of certain groups within these dynamics.29,30 What is deemed to be culturally safe is determined by those receiving care, while the healthcare provider is required to reflect on his or her position of power and privilege and dominant norms within the healthcare system.22,37

Trauma- and violence-informed care recognizes the impact of trauma and the important role of healthcare providers in creating an environment in which people are not further traumatized through their encounters with the health system.31 Adverse childhood experiences are common among those who use substances, as is trauma due to sexualized and physical violence.32 Many people who use substances, particularly those who also experience structural disadvantages, have negative and even traumatic past experiences with health care, policing and social services, and anxiety is a common experience that contributes to avoiding or delaying accessing care.38,39 Thus, trauma- and violence-informed care do not treat trauma but are a way of recognizing and understanding the structural conditions that produce trauma and working to mitigate these conditions in health care.

Harm reduction is premised on the need to treat people who use drugs in a more respectful, inclusive and compassionate manner.33,40,41 Harm reduction meets people where they are "at" with the goal of keeping people safe regardless of substance use. Harm reduction focuses on preventing the harms of ongoing use and, in the case of illegal drug use, provides an alternative to criminalization. Evidence-based harm reduction interventions to prevent overdoses include naloxone distribution and supervised consumption sites.42,43 These interventions are informed by harm reduction's pragmatic philosophy and set of principles and practices that can be integrated into a range of programs as part of a strategy to reduce the stigma of drug use.34

While practitioners often have opportunities to learn about the principles of cultural safety, trauma-informed care and harm reduction, there is a lack of knowledge about how to integrate and incorporate these approaches into policy, programs and practice.37 Further, there is a lack of knowledge about how to implement comprehensive HEO approaches as a strategy to facilitate access to services and to prevent the harms of stigma or overdose when people use illicit or street drugs, or prescription opioids for other than their intended purpose.

A preliminary search for existing scoping and systematic reviews was conducted on April 19, 2018, in the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, PROSPERO, CINAHL and Ovid MEDLINE. No reviews addressing the overall purpose of this scoping review were identified.

The opioid overdose crisis is an example of a "wicked problem" that needs complex, integrated responses.27 Ultimately, the literature identified will be used to develop a comprehensive HEO framework that integrates the concepts of harm reduction, cultural safety and trauma- and violence-informed care, all of which have been shown to be integral to addressing the harms of stigma or overdose related to opioid drug use.

Inclusion criteria

Participants

This review will consider studies that include people who use illicit opioids or street drugs or use prescription opioids for other than their intended purpose. This review focuses on the drug-related harms of stigma or overdose, so papers that present the perspectives of service users, service providers or policymakers will be included. Participant characteristics will be described to help identify gaps in the research literature. Papers focusing on cannabis or marijuana use will be excluded.

Concept

An HEO approach involves recognizing and addressing health inequities that are understood as unfair, systematic and socially produced injustices rooted in social arrangements that disadvantage some population groups more than others in terms of health outcomes and opportunities.44 Related terms include a social justice or decolonizing perspective, critical theory or intersectionality (where attention is paid to intersecting forms of inequities related to gender, race or social class). These and other HEO approach-related terms, including cultural safety, trauma- and violence-informed care and harm reduction, are described in the background section of this protocol and have been used to inform our search strategy. For the purpose of this scoping review, an HEO approach is a response that addresses health inequities in the context of the drug-related harms of stigma or overdose.

The focus of the scoping review is on mapping HEO approaches including strategies, action plans, programs, interventions, frameworks, lenses and guides that inform responses for people who use substances. A conceptual framework or model can also provide guidance for action, so it has been included in our definition of an approach. For the purposes of this review, a framework is defined as a particular set of ideas or beliefs that form a conceptual structure to guide or support responses to or the study of health and social problems.

Context

The overall context for this review is the recent Canadian and global opioid overdose crisis. A global context was selected for this review to identify creative ideas that have been used in other countries as potential strategies for preventing the harms of stigma or overdose when people use illicit or street drugs, or use prescription opioids for other than their intended purpose.

Studies published since January 1, 2000, will be included, as the context for the opioid overdose crisis has changed markedly since this time with the introduction of more powerful opioids into the street or illicit drug market. The year 2000 was also selected as this date marks the time when work on cultural safety and harm reduction become prominent in the literature, followed later by increasing references to trauma- and violence-informed care.38,39,45-48

Types of studies

This review will consider quantitative, qualitative and mixed-methods study designs. In addition, peer-reviewed health policy or discourse analysis papers, quality improvement and program evaluation sources and literature reviews that meet the inclusion criteria will be included.

Text and opinion papers will also be considered for inclusion in this scoping review if they report on an HEO framework and meet the review objectives. These framework papers can be documents from organizations, agencies or governments and will be located through searching the gray literature.

Studies published in English will be included. Unfortunately, time and resource constraints preclude the inclusion of papers and other resources written in languages other than English that require translation. Papers retrieved that are written in other languages will be considered for inclusion if a detailed English abstract is provided.

Methods

The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews as outlined in the Joanna Briggs Institute Reviewer's Manual.49 The title of this scoping review has been registered with JBI.

This research team has well-established and long-standing relationships with many community groups who work with people who use substances or are street-involved. Representatives of these community groups have been providing ongoing guidance for the development of this scoping review and will be involved in knowledge translation activities. This review is also guided by community-based participatory research and integrated knowledge translation principles and practices.50-53

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL has been undertaken (April 19, 2018) followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. This informed the development of a search strategy, which will be tailored for each information source.

Initial search terms used include opioids and substance-use related terms, along with stigma or overdose. Terms related to the HEO approach include health equity, social justice, decolonizing, indigenous ways of knowing, critical theory, intersectionality, cultural safety, harm reduction and trauma- and violence-informed care.

Due to the complexity of this review, two research librarians have provided guidance for the development of the literature search strategy, which involves a slightly different strategy for the peer reviewed and gray literature. A full search strategy for CINAHL is detailed in Appendix I. The reference lists of all included studies will also be screened for potential papers.

Information sources

The databases/sources to be searched will include CINAHL, MEDLINE, JBI Database of Systematic Reviews and Implementation Reports, Academic Search, PsycINFO, Social Work Abstracts, Sociological Abstracts, Embase and the Canadian Health Research Collection. The trial registers to be searched will include Cochrane Database of Systematic Reviews and PROSPERO.

The search for unpublished literature will include ProQuest Dissertations and Theses; GreyLit; OpenGrey; government websites in Canada, the United States of America, Europe, Australia and New Zealand; non-governmental and think-tank websites such as the Bill & Melinda Gates Foundation, World Health Organization, United Nations, the Canadian Centre on Substance Use and Addiction; and search engines such as DuckDuckGo and Google. For literature related to Indigenous peoples, the search will also include the Aboriginal Health Abstract Database, First Nations Periodical Index and the National Indigenous Studies Portal.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X7 bibliographic software and citation management system (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. The full text of selected papers will be retrieved and assessed in detail against the inclusion criteria. Studies that could potentially meet the inclusion criteria will be reviewed and their details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). Full-text papers that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review report. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.54 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers using a modification of the standardized JBI data extraction tool that was developed for this scoping review (Appendix II). The data extracted will include specific details about the population, concept, context, study aims, methods and key findings or recommendations relevant to the review objectives.

The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objectives of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objectives and question. A draft charting table is provided in Appendix III.

Acknowledgments

The following individuals and groups have contributed to the conceptualization of the grant and to the refinement of protocol through teleconference discussions: Canadian Institute for Substance Use Research; the University of Victoria (UVic) Centre for Evidence-Informed Nursing and Healthcare (CEiNHC): a JBI Affiliated Group; Island Health (Wendy Young, Richard Crowe, Richard Stanwick, Penelope Cooper); Interior Health (Trevor Corneil, Silvina Mema); First Nations Health Authority (Janine Stevenson, Andrea Medley); British Columbia Ministry for Mental Health and Addictions (Gina McGowan); South Island Community Overdose Response Network (Katrina Jensen, Heather Hobbs); National Collaborating Centre on the Determinants of Health (Connie Clement, Teri Emrich); North Saskatchewan Alcohol Strategy (Harold Johnson, Joan Johnson, Carla Frohaug).

Funding

Canadian Institutes of Health Research (CIHR) Operating Grant: Opioid Crisis Knowledge Synthesis competition (December 2017). The funds obtained for the scoping review were from a targeted call for grant proposals. CIHR does not have any direct role in the review process but has organized a meeting for researchers to present their findings.

Appendix I: Preliminary search strategy for CINAHL

Search conducted July 12, 2018

Appendix II: Data extraction tool

Research report details

Authors (year):

Research purpose/question(s):

Type of research: [quantitative, qualitative, mixed methods, community-based research/participatory action research, literature review (type), health policy analysis, discourse analysis]

Population (describe the particular population focus, e.g. age group, sex/gender, socioeconomic status):

* Opioid use

* Illicit drug use

* Other form of substance use (describe)

Context:

* Country

* Cultural Context (Does this paper focus on a particular cultural subgroup, e.g. people in criminal justice system)

* Informed by an Indigenous perspective/ ways of knowing [No Yes]

* Geographic setting: (e.g. urban/suburban, inner city, rural, remote, northern)

Concept:

1. Does this research report describe an HEO approach to address the harms of stigma or overdose (e.g. health inequities, critical theory, social justice, intersectionality, or decolonizing)? (If so describe).

2. Which of the following approaches are addressed:

a. Harm reduction

b. Cultural safety/antiracism

c. Trauma/violence informed care

d. Other (describe)

3. Gaps in knowledge/recommendations for further research

4. Recommendations for policy or practice: (related to how to integrate, implement or evaluate HEO approaches).

5. Reviewer comments:

Framework paper details (gray literature)

Authors (year)

Type of paper: expert opinion, health policy document, program report, other (describe)

Aim or purpose of the framework paper:

Population (describe the particular population focus, e.g. age group, sex/gender, SE status):

* Opioid use

* Illicit drug use

* Other form of substance use (describe)

Context:

* Country

* Cultural context (does this paper focus on a particular cultural subgroup? e.g. people in criminal justice system)

* Informed by an Indigenous perspective/ ways of knowing [No Yes]

* Geographic setting: (e.g. urban/suburban, inner city, rural, remote, northern)

Concept:

1. What is the focus of this program or policy framework? Does this framework describe an HEO approach to address the harms of stigma or overdose (e.g. health inequities, critical theory, social justice, intersectionality, or decolonizing)? (If so describe).

* Does this text describe a framework as a strategy/intervention)? If yes, describe

* Does this text report on the implementation of a framework? If yes, describe

* How does this framework address the harms of substance use related stigma or overdose?

* Has this framework been evaluated? If so how?

2. Which of the following concepts are addressed: a) health equity; b), social justice, c) decolonizing, d) indigenous ways of knowing, e) critical theory, f) intersectionality, g) cultural safety, h) harm reduction, and g) trauma and violence informed care.

3. Recommendations/ lessons learned: (related to how to integrate, implement or evaluate HEO approaches).

Reviewer comments:

Appendix III: Presentation of the findings

Draft study details, characteristics and presentation of findings instrument¹

References