Background
Canada continues to face an unprecedented public health crisis of fatal and non-fatal overdose, with approximately 21 deaths per day in 2021 largely driven by the increasing contamination and toxicity of the unregulated drug supply [
1]. To respond to the complexity of this crisis, the Canadian Drugs and Substances Strategy (CDSS) indicates that no single sector or intervention is adequate, but rather comprehensive and collaborative approaches are required (e.g., prevention, treatment, harm reduction, enforcement) [
2]. In the Canadian province of Ontario, overdose response strategies have been implemented that reflect the comprehensive approach of the CDSS. Additionally, public health units received provincial funding to support the development and implementation of local overdose response plans [
3]. Local opioid or overdose response plans are an emerging public health model that involves the coordinated efforts of multiple community stakeholders to implement actions to prevent and address overdose and related harms (e.g., naloxone distribution, access to treatment, supervised consumption services). These plans vary based on the different contexts in which they are applied [
4‐
7]. Across North America, local plans refer to initiatives responding to either opioids or overdose. Throughout this paper, we refer to them as overdose response plans to recognise that drug overdose is the main outcome of interest and that multiple substances are often present when an opioid-related death occurs [
1].
As communities set out to develop and implement local overdose response plans, there is a need to understand how best to build capacity for successful implementation. The World Health Organization (WHO) defines capacity building as the “development of knowledge, skills, commitment, structures, systems and leadership to enable effective health promotion” [
8]. Capacity building has been recognised as a fundamental component of the sustainable development and implementation of evidence-based public health practices [
9‐
11]. Within various areas of public health, the application of capacity building strategies and techniques has demonstrated success in a range of outcomes including knowledge enhancement, skills, and improvements in practices or polices [
12,
13]. In the context of overdose prevention and response, several US state/ Canadian provincial agencies have launched centralised structures to build capacity and advance local overdose response efforts by offering funding, training, technical assistance, and other supports [
14‐
22]. Examples of these centralized supports include the Overdose Emergency Response Centre and the Community Crisis Innovation Fund in British Columbia. In the Australian context, the Alcohol and Drug Foundation supports Local Drug Action Teams by providing research, resources, and expertise for Community Action Plans on alcohol and other drugs [
23]. Preliminary analyses have shown some positive outcomes for community overdose response plans that have received centralised supports including increases in local implementation of evidence-based strategies [
15] and decreases in opioid-related deaths [
24]. However, the evidence base for centralised supports for community overdose response plans is limited. There is a need to further understand where gaps exist and what supports are needed for the successful planning and implementation of overdose response plans, particularly within the context of Ontario.
For this reason, we sought to engage key stakeholders to understand the local context and capacity building needs. This step will inform the development and delivery of strategies to build capacity for the planning and implementation of community overdose response plans in Ontario. To become familiar with community overdose response plans, we first conducted a scoping review [
25]. Later, we conducted a separate search to identify a complete set of available Ontario plans. Building on this work, we conducted a situational assessment to develop understanding of community overdose response plans. Our guiding research question was: What priority actions should our project pursue to support the work of community overdose response plans in Ontario? The aims of our situational assessment was to understand: (1) current planning and implementation practices and needs; and (2) priority supports for community overdose response plans in Ontario. Subsequently, we hosted a co-design workshop to delve further into the detailed components, prioritisation, implementation, and evaluation of supports which will be reported elsewhere.
Results
In total, 66 participants took part in key informant interviews (n = 10), focus groups (n = 25), or surveys (n = 31). There were two key informant interviews with local coordination roles with potential for overlap in focus group or survey participation. While there was no overlap of participation in key informant interviews and focus groups, local coordinators who participated in key informant interviews or focus groups may have taken part in responding to the survey as the intended purpose was to have one survey completed per community overdose response plan. Overlapping focus group and survey participants are likely given the representation of similar roles in recruitment. Further, 13 people participated in both the focus group and the verification webinar.
We conducted 10 key informant interviews with representatives involved in centralised support for community overdose response or harm reduction (provincial-level in Canada; state-level in the US) (
n = 5), evaluators of community coalitions/drug strategies (
n = 2), coordinators of community overdose response plans (
n = 2), and partner organisations on plans (
n = 1). Of the 10 key informants, four were from the United States. Focus groups (
n = 25) and survey respondents (
n = 31) were coordinators of community overdose response plans in Ontario including public health unit or municipal drug strategy representatives. Twenty-five participants took part in the verification webinar, however, several participants indicated that others were with them on the call. Table
1 provides details of participants’ roles in community overdose response plans We did not collect socio-demographic information during interviews, focus groups, or surveys.
Table 1
Participant Roles in Community Overdose Response Plans
Ontario-based coordinators (e.g., public health professionals, municipal drug strategy coordinators) | 58 |
Provincial/state-level representatives supporting community overdose response plans | 5 |
Evaluation support | 2 |
Representatives from partner organisations | 1 |
Below, we present results from the interview and focus groups, survey, and verification webinar. First, we describe how the need to address substance use-related stigma (e.g., social, structural) and equity issues as highlighted in both the qualitative and quantitative data. These results are foundational to understanding the themes identified in the qualitative results. For the interview and focus group results, we describe the current implementation practices of community overdose plans and priority areas for supports for capacity building. Four overarching themes for needs and supports emerged related to community overdose response planning: 1) data and information; 2) evidence and practice; 3) implementation/ operational factors; and 4) partnerships, collaboration, and engagement. We discuss the needs identified within each theme. Next, we describe the related capacity building supports for community overdose response planning and implementation across the four themes.
Stigma and equity
Data from interviews, focus groups, and surveys indicate that stigma and equity are critical for the consideration of all needs and supports related to community overdose response plans. Addressing stigma and equity was described both in the planning process as well as specific strategies and actions included in community overdose response plans. For example, in terms of stigma, participants spoke to the need for specific strategies addressing structural stigma within the healthcare and social service system as well as social stigma towards people who use drugs that influences community support for harm reduction strategies. Meanwhile, within each theme, issues related to equity often centered on the equitable engagement of communities—people with living and lived expertise of substance use and Indigenous and racialised communities—throughout planning process and implementation of community overdose response plans to make sure services better met their needs. Specific gaps were also identified in knowledge and understanding of tailored services, and equity-oriented overdose response actions. For example, some non-Indigenous participants mentioned that more needs to be done to address the colonial lens through which planning and implementation of community overdose response plans take place. Equity-oriented actions aim to address the effects of structural inequities [
39‐
41] on people who use drugs. This includes addressing the effects of intersecting factors that exacerbate racism, discrimination, and stigma experienced by people who use drugs, their access and experiences of services, and the availability of services that meet their social and cultural needs. Culturally safe and trauma-informed approaches are thus aspects of an equity-oriented community overdose response plan [
40,
41].
Interview and focus groups results
Current implementation activities
The current implementation and structure of community overdose response plans varied, and reflect activities aligned with common implementation frameworks and guides [
42‐
44]. Most participants mentioned a dedicated coordination role that was key to ensuring consistent work and messaging on plan activities. This role consisted of tasks related to project management, facilitation, and relationship-building with a variety of partners. Other participants spoke of steering committees, advisory boards, or the use of specific leads, workgroups, or sub-committees to organize different plan activities. These organized structures were seen by many to ensure coordination, collaboration, priority-setting, and accountability with the partners. Generally, it was noted that public health infrastructures and personnel were involved as leads or in supportive roles for the ongoing operation of plans.
Table
2 provides a summary of the four themes for needs and supports: 1) data and information; 2) evidence and practice; 3) implementation/ operational factors; and 4) partnerships, collaboration, and engagement. We provide an overall description of each theme, priority areas, and exemplar quotes from participants to illustrate interpretations.
Table 2
Themes (by alphabetical order), Priority Needs and Related Supports, and Exemplar Quotes
THEME | DATA AND INFORMATION |
Description | Access, use, and communicate data and information. We use the term “data” to mean the collection and presentation of numbers and unit values. By information, we mean the analysis and presentation of data, including evaluation |
Priority needs | · Collecting and sharing data · Accessing different sources of local data · Analysing and interpreting data · Using data and information to make decisions and measure the success of plans · Communicating data and information (e.g., alerts, emerging trends) |
Related supports | · Provincial coordination and technical assistance in data collection, analysis/interpretation, surveillance, approaches to early warning systems, and communicating data and information |
Exemplar quotes | “So we want to track things, we want to show that what we're doing is making a difference and have our indicators but when we ask our partners for data it's like it's not a priority to them and they don't know where to get it.” (KI6) “We still don’t have access to local emergency medical services (EMS) data, even though we’ve been working on a data sharing agreement with them for about a year and a half now.” (FG1) “So, of course, the Ministry and ODPRN and PHO have increased sort of data availability, opioid-related data access and different types of data that have supported us in identifying priority populations or areas for action. However, sometimes it's difficult to really prioritize, especially for a community like us that experiences quite a high burden in many areas of morbidity and mortality for opioids. So prioritizing, you know, which information requires the most urgent action and then bringing it into the community coalition. How to kind of show the right community partners and get their support in actually addressing them, who needs to be engaged in certain priorities.” (FG1) |
THEME | EVIDENCE AND PRACTICE |
Description | Access, use, and communicate evidence and best practice. We use the term evidence to refer to information that is gathered for research purposes, contextualized, and used to support a practice, intervention, etc [ 45]. |
Priority needs | · Developing knowledge of topics related to overdose response · Accessing research evidence and best practice · Using evidence to inform decision-making and practice · Communicating evidence |
Related supports | · Offering training supports · Facilitating access to evidence, common frameworks, e-learning modules, and other tools through a centralised repository · Facilitating consultations and connections to individuals and groups involved in research and practice |
Exemplar quotes | “..So much is being pumped out [laughs] as far as, you know, what publications, lessons learned, you know, all of the above. What we normally find out is it does not always trickle down to the community where it needs to.” (KI2) “…which interventions were most effective and which ones might be considered favorable by funding organisations; so yeah we ended up on the internet looking at different things and trying to compare evidence but it was really hard to rank different interventions in terms of their evidence base. So I think this would really help with the evidence base” (KI3) “That information is kind of more easily accessible and available rather than having to do it—you know each Public Health Unit or each Drug Strategy Coordinator – on their own. Definitely there’s benefits to ensuring that there’s – you know there’s somewhere we can turn to – like a trusted source for quality information on effective interventions.” (FG1) |
THEME | IMPLEMENTATION/OPERATIONAL FACTORS |
Description | Address the factors that affect the implementation of plans |
Priority needs | · Planning strategically · Using consistent approaches to guide development, implementation, and evaluation of plans · Adapting to changing community context · Addressing barriers |
Related supports | · Facilitating access to standardised tools, templates, and guides · Facilitating consultation, mentorship, and peer support to other community overdose response plans |
Exemplar quotes | “…people have tended to jump to oh, we’ve been doing this and it’s working so we’re getting money and we’re going to keep doing this, you know, without taking a step back and looking at the data and looking at where we need to build capacity before they … you know, so I think the strategic planning process is really important.”(KI7) “…a lot of the organizations are overtaxed to it’s very difficult if you’re trying to bring a group of people together to have them have the time and resources available for this work, I know people are asked to sit on committees all over the place.”(KI3) “We’re finding since the development of plan and the implementation of a couple of related working groups is that there’s been a pretty significant shift in focus for the drug strategies based on some other also very pressing issues substance use-related largely around crystal meth.” (FG3) |
THEME | PARTNERSHIPS, COLLABORATION, AND ENGAGEMENT |
Description | Engage, work together, and build trusting partnerships with diverse groups |
Priority needs | · Partnerships → identifying partners, building partnerships, navigating, and maintaining partnerships · Collaboration → doing collective and coordinated work · Engagement → ongoing engagement with new sectors, meaningful engagement of people who use drugs, Indigenous communities, and other communities experiencing oppression |
Related supports | · Facilitating access to tools for partnership planning and community engagement and resources for developing common visions, goals, and language with community partners · Providing opportunities to connect with diverse groups through online platforms (e.g., online meetings, workshops) |
Exemplar quotes | “I think sometimes as the longevity, whether the drug strategy or the coordinator for the local action plan has been around for some time and it's the ability to maintain relationships. And on the flip side it's once you actually get inroads with some of your community partners and have developed strong relationships, one of the challenges is if they leave” (FG2) “These are groups that historically don’t work with each other. And I think there was a lot of misunderstanding as to what the specific roles of each of the individuals were and really what programming was going on in the public safety world and the public health world and how that can be overlapped.” (KI4) “I think the biggest need is to try and make sure that decisions that are ultimately affecting people who use drugs and not being made without their voice at the table or in the decision-making process.” (KI5) |
Table
2. Themes (by alphabetical order), Priority Needs and Related Supports, and Exemplar Quotes.
One of the needs and supports we identified is related to local data and information. Of particular concern, was the routine collection and sharing of local data with partners to understand the scope of the problem, needs, and gaps in their community. For example, participants described barriers to the development of data sharing agreements across sectors to gain comprehensive understanding of overdose to inform program development and support evaluation activities with limited resources. Similarly, understanding what local sources of data were available and how to access them was another identified need that posed challenges to understanding overdoses and the impacts of interventions aimed at preventing and addressing overdoses.
Additionally, participants discussed a lack of having appropriate skills and resources to analyse, interpret, and apply data. These areas were viewed as foundational components of strategic planning, early warning, surveillance, and assessing progress and outcomes of plans. A few participants reported on the lack of standardised data indicators and approach to the prioritisation of diverse data that made decision-making for urgent action difficult. Once data was analysed and understood, participants identified the need to better communicate the relevant information to diverse stakeholder using effective, appropriate, and accessible techniques. Discussions on equity and stigma within data and information focused on the need to include and centre the knowledge and experiences of community members and community-based agencies at the forefront of overdose response.
Theme 2: Evidence and practice
A second theme was the gap in knowledge and use of research evidence to inform strategies included in community overdose response plans. In general, the need to learn about different frameworks and approaches to addressing substance use-related harms, including those that focus on the structural determinants of health (e.g., housing, drug policies, and stigma) was described. An identified barrier to the development of individual knowledge was the limited access to research evidence on effective interventions that reaches the community level where it is needed to inform actions. Further, when access to evidence was available, participants spoke to uncertainty and unfamiliarity with identifying the effectiveness of various solutions within different sectors addressing overdose-related harms.
Next, several participants stated the need to develop understanding of the evidence base related to overdose prevention and response strategies to inform decision-making throughout the development and implementation of community overdose response plans. When evidence was accessible, participants described challenges in understanding which overdose prevention and response strategies have worked well and in which contexts and populations to adapt and tailor strategies (e.g., urban vs. rural contexts). Further, it was noted that the community overdose response context was constantly shifting, and there was uncertainty with incorporating approaches with newer and less clear evidence of effectiveness. Some also pointed out issues related to equity, specifically how knowledge of culturally safe approaches for community overdose was lacking to inform appropriate intervention design and implementation for Indigenous communities. Lastly, participants described the need for support on how to effectively communicate the evidence base of interventions to decision-makers and the public. This included understanding ways to present the evidence into actionable items and use effective channels for different audiences (e.g., websites, social media).
Theme 3: Implementation and operational factors
Another theme related to specific factors linked to the implementation and operation of community overdose response plans. First, most participants expressed challenges with implementing strategic planning processes related to clarifying scope and work, and organizing and communicating the goals and actions of community overdose response plans (e.g., description of resources, activities, and expected outcomes). Other participants reported on the need to address the coordination of services among different partners within overdose response plans through the use of consistent approaches and standardized provincial tools to guide the strategic planning process. Secondly, for many participants, challenges were identified with the community context in which overdose response plans were situated in, specifically the need to adapt the activities within the plan to the changing community structures, needs, and trends. (e.g., increased methamphetamine use).Many highlighted the gap in integrating an equity lens in programs and services, such as addressing regional inequities and meeting the needs of Indigenous and racialized communities. Participants also emphasized the need to communicate and share plans with stakeholders as a means of increasing trust and engagement. Dependent on the sociopolitical community context, needs around strategizing to communicate plans with stakeholders were also articulated. Finally, many participants identified the need for supports to address implementation barriers, including limited resources (e.g., financial, human) and time, substance use stigma and community buy-in, and infrastructure.
Theme 4: Partnerships, collaboration, and engagement
The last theme pertained to the partnerships, collaboration, and engagement of community within overdose response plans. According to participants, sectors responding to overdose and related harms often operated in silos and had limited pre-existing structures and experience working together. This presented difficulties navigating local overdose-related activities and identifying and establishing trusting partnerships with key sectors (e.g., healthcare, pharmacy, law enforcement). Some described the competition for resources, lack of communication, unwillingness, and the different disciplines of sectors as contributing factors to the barriers to building partnerships. Further to this were concerns around how to work collaboratively with partners outside of a mandate. Several participants expressed that effort was needed to develop an awareness and understanding of the terminology used by each sector to establish a shared framing, build consensus, prioritise, and coordinate intervention strategies with multiple partners.
Participants also commented on the need for greater equitable engagement and outreach to diverse stakeholders for representation in community overdose response plans. In particular, the meaningful engagement of people with living and lived expertise of substance use was seen as lacking. Despite favorable views of engagement with people with living and lived expertise of substance use, capacity, resources, and stigma were commonly highlighted as barriers in doing so. Others mentioned the need to build capacity to engage and partner with Indigenous and racialised communities and organisations to develop specific recommendations that appropriately meet their needs.
Supports to address needs across themes
Often, suggested supports were relevant and applicable to addressing the four different themes. For example, a common support emphasized by participants was the access to standardized tools and templates, planning and implementation frameworks (e.g., guide the design, delivery, and evaluation of substance use practices), and educational and other resources (e.g., for developing a common vision, goal, and language with community partners) through centralised repository for coordinators and partners of community overdose response plans. In particular, participants suggested standardised tools and templates for: partnership planning and community engagement; decision-making and prioritisation; action planning and environmental scans; and monitoring and reporting plan outcomes.
Other support strategies included consultations, connections, and online platforms (e.g., online meetings, workshops) to facilitate access to and use of evidence as well as collaboration and engagement with diverse groups responding to overdose-related harms. Mentorship and peer support from other community overdose response plans was also suggested to help address barriers and adapt tools and strategies to local contexts. To develop knowledge, training supports and e-learning modules were noted in the areas of harm reduction, trauma-informed approaches, knowledge translation, evaluation, stigma, cultural safety, community engagement and development, and evidence-informed practices. Lastly, provincial coordination and technical assistance were suggested for data collection, analysis, surveillance, early warning systems, and identifying and implementing strategies to communicate local data and information (e.g., alerts, emerging trends).
Survey results
A total of 31 respondents completed the survey, with 26 of 34 public health units in Ontario represented. Table
3 summarises the characteristics of survey respondents.
Table 3
Characteristics of Survey Respondents
Organization |
Public Health Unit | 16 (51.6) |
Combined Public Health Unit/Municipal Drug Strategy | 10 (32.3) |
Municipal Drug Strategy | 3 (9.7) |
Other | 2 (6.5) |
Region of Ontario |
South Central | 9 (29.0) |
South West | 9 (29.0) |
North | 7 (22.6) |
South East | 6 (19.4) |
When asked to rank the top five pre-determined areas related to overdose response plans for capacity building supports, the findings were ordered accordingly: evidence use and application, program implementation, community engagement, knowledge and skill development, and partnership and collaboration, (See Table
4). Respondents were also asked to describe any other areas for support to their overdose response plans. Open-ended responses to this question were grouped into five categories reflecting similar themes: 1) provincial coordination and alignment with sectors to address overdose and determinants of health issues; 2) data and surveillance including early warning, alert communication, and real-time provincial data collection systems involving all community partners; 3) professional development opportunities for staff involved in local overdose-related work; 4) equity considerations to plan for and meet the access needs of diverse communities including Indigenous peoples; and 5) policy and funding supports for overall implementation of community overdose response plans as well as to scale up key harm reduction and treatment services.
Table 4
Weighted Ranking of Top Five Areas for Capacity Building Supports
Evidence and practice | Evidence use and application | 27 | 1 | 84 | 1 |
Partnership, collaboration, and engagement | Community engagement | 21 | 2 | 61 | 3 |
Implementation and operational factors | Public awareness and education | 19 | 3 | - | - |
Implementation and operational factors | Program implementation | 18 | 4 | 64 | 2 |
Evidence and practice | Knowledge and skill development | 16 | 5 | 49 | 4 |
Data and information | Evaluation capacity | 15 | - | - | - |
Partnership, collaboration, and engagement | Partnership and collaboration | 15 | - | 47 | 5 |
Data and information | Data collection | 14 | - | - | - |
Data and information | Data analysis and interpretation | 10 | - | - | - |
Table
4. Weighted Ranking of Top Five Areas for Capacity Building Supports.
Verification webinar
When asked how closely each theme reflects the needs of municipal drug strategy coordinators and relevant public health staff, there was strong agreement with the four main themes and subthemes. Table
5 presents how closely our analysis reflects the needs of participants. The
partnership, engagement, and collaboration had the lowest agreement, with 50% of participants reported that there were a few items missing. One of the main items identified in the verification phase that was not elucidated previously was the need to improve accountability of partnerships with implementing the actions. In terms of other themes, data quality and fidelity, technology options to administer overdose alerts, and evidence related to the sustainability of community overdose response plans were suggested as other considerations to inform our interpretation.
Table 5
Verification of Preliminary Analysis
Data and information | Very well | 13 (81%) |
You have most things but a few are missing | 3 (19%) |
I’d agree with about half of this list | 0 |
I don’t think the slide is reflective at all | 0 |
Evidence and practice | Very well | 11 (92%) |
You have most things but a few are missing | 1 (8%) |
I’d agree with about half of this list | 0 |
I don’t think the slide is reflective at all | 0 |
Implementation/operational factors | Very well | 11 (85%) |
You have most things but a few are missing | 2 (15%) |
I’d agree with about half of this list | 0 |
I don’t think the slide is reflective at all | 0 |
Partnership, collaboration, and engagement | Very well | 9 (50%) |
You have most things but a few are missing | 9 (50%) |
I’d agree with about half of this list | 0 |
I don’t think the slide is reflective at all | 0 |
Table
5. Verification of Preliminary Analysis.
Discussion
To our knowledge, this is the first situational assessment of the needs and priorities of communities developing and implementing overdose response plans. The current practice and structure of community overdose response plans vary in Ontario, and in other communities in Canada and the US. For example, local plans in Canada often refer to the Four Pillar Drug Strategy approach (i.e., prevention, treatment, harm reduction, enforcement) [
2], many in the US align with the Project Lazarus hub and spoke model, with 10 areas of focus including coalition action and prescription medication diversion control [
24], We found four common themes of needs and related supports were identified across plans in Ontario. These themes related to evidence and practice; data and information; implementation/operational factors; and partnerships, engagement, and collaboration. Needs for supports related to access, use, and communication of data, information, evidence and best practices on overdose and response strategies were also expressed. Current strategic planning processes, service coordination, standardization, and broader contextual factors were reportedly affecting the implementation/operation of community overdose response plans. Participants had challenges engaging, building trusting partnerships, and working collaboratively with diverse sectors and organisations involved in community overdose response plans. A consistent need to address stigma and equity issues in community overdose response plan was illustrated throughout all four themes.
Our findings highlight similarities with and map well onto common components of capacity building frameworks [
9,
46] such as training, tools, and technical assistance [
47]. The four themes that were determined in our study also aligned with those from situational assessments on other public health practices in Ontario, specifically needs related to data, evidence, and collaboration [
29‐
31]. Such consistencies across other areas underscore the need for broader capacity building efforts to support public health actions in Ontario [
29‐
31].
Furthermore, our findings are consistent with barriers to community overdose action [
25] and strategies used by centralised structures supporting them such as provision of standardised tools, training, strategic planning support, and assistance with data and evaluation [
20,
21,
48]. While the need to address and reduce structural and social stigma related to substance use [
49] was presented in some centralised structures, a key theme that was integrated throughout our findings and lacking in others was the need to address equity related to planning and implementing community overdose response plans. It is known that the impacts of substance use-related stigma are exacerbated when intersecting with multiple forms of discrimination including systemic racism, sexism, and other forms of oppression connected to marginalization [
50]. Our findings reinforce the growing evidence and support the need to address structural inequities in public health planning and practice in the context of substance use-related harms [
41,
50‐
52].
Implications for practice
Within the context of the continually evolving overdose crisis, limited resources, and constantly shifting challenges, it is critical to understand where to focus supports for the development and implementation of community overdose responses in order to maximise impact on overdose-related harms. Our study asked potential recipients of supports what needs to be addressed, how to best address these, and what should be prioritised (i.e., data and information; implementation/operational factors; and partnerships, engagement, and collaboration; Table
2). In describing the priority needs and related supports, our analysis offers insights into the key components for building capacity of community-based overdose response in Ontario.
While there is variation in the planning and implementation contexts of community overdose response plans, the common themes identified, including the standardisation of data indicators, tools, and frameworks, demonstrate the potential role of centralised supports that can be adapted to local practice contexts. Community overdose response plans further emphasized the need for formalized provincial structures for coordination and knowledge sharing. These results will inform the next phase of our project – gathering detailed requirements for the design of capacity building supports through a multi-stakeholder co-design workshop (e.g., designing shared templates for stakeholder meetings or resource-sharing website). In recognising that community overdose response plans take place within complex organizational, clinical, and community environments, one area for further investigation will be at which level central capacity building supports be provided for community overdose response plans (e.g., coordinator-level). Once key supports have been detailed and developed together with community partners, we will work closely with three community initiatives in Ontario to implement and evaluate the supports. Further research and evaluation will be needed to improve our understanding of how components of our supports have influenced processes at the community-level, and to look for any positive or negative unintended consequences.
Strengths and limitations
A key strength was the study design and the use of multiple methods and sources. As such, our analysis allowed for a nuanced understanding of the planning and implementation of community overdose response plans, and highlighted similarities and differences in the data generated by each method. We primarily sought the perspective of those involved in coordination of community overdose response plans, which helps make sure the needs of key stakeholders are reflected in the development of supports for plan development and implementation. The involvement of other stakeholders supporting or partnering on community overdose responses plans in various regions across Canada and the U.S. allowed for a wider range of perspectives. The use of verification techniques with data collection and analysis also strengthened the rigor of our study and findings.
The limitations of our study should also be noted. First, our study reflects the Ontario context. Community overdose response plans elsewhere may operate differently, and our results do not reflect the range of needs and areas for capacity building supports in other jurisdictions. Other limitations were the small number of interviews and the depth of the focus group discussion due to time constraints from the project timelines. Our study focused primarily on the needs of professionals coordinating community overdose response plans including drug strategy coordinators. As such, the experiences of people with living and lived expertise of substance use were not captured and may not align with the priorities of other stakeholders. However, people with living and lived expertise of substance use were involved in interpreting the preliminary findings and their involvement will be ongoing with the design of support strategies including the multi-stakeholder workshop.
Since these data were collected, the nature of the overdose crisis and the challenges experienced by those responding may have evolved from the data presented here. Although the number of overdose deaths was increasing preceding the coronavirus pandemic (COVID-19), recent data highlights worsening rates since the start of the pandemic [
53]. The increasing toxicity of the unregulated drug supply [
53], service disruptions to harm reduction programs from public health measures, and the deployment of public health workforce to the COVID-19 response have impacted the landscape for community overdose response plans including the emergence of new stakeholders and strategies. As overdose deaths have escalated in this context, there has been increased focus and action on approaches such as decriminalization of drug possession for personal use and provision of a predictable supply of drugs as an alternative to the toxic drug market. Accordingly, there is a need to continue building capacity for sharing local information and experiences on innovative approaches.
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