High Use of Canada’s Overdose Response Hotline by Women

Certain demographic groups, especially urban women, show higher usage of Canada’s National Overdose Response Service (NORS) than others, new research revealed.

The results can be used to target public health messaging toward those who get the most benefit from the service and interventions to those who are at the highest risk of using drugs alone, the authors suggested.

“The study shows us that we should try to determine what facilitators and barriers there are for individuals to use the service, and perhaps why [some] do not use the service as frequently as others,” S. Monty Ghosh, MD, an addiction specialist at the University of Alberta in Edmonton, told Medscape Medical News.

The study was published on February 18 in the Canadian Journal of Public Health.

A Few Surprises

“Given the large rise in drug poisoning events in the pandemic, the NORS was created to support individuals who use substances alone,” said Ghosh. NORS is a multimodal harm-reduction service available across Canada that provides virtual supervised consumption services through text and a hotline.

“We noticed unique trends in service utilization that differed from typical supervised consumption services…and we felt it was prudent to understand the extent of these differences and if there was any pattern to this,” Ghosh explained.

The findings brought a few surprises, he said. “Given the lack of harm-reduction resources in rural communities, we were surprised that the rate of use by rural users was much less than that of individuals living in larger municipalities.”

The team was also surprised that those who were helped through an adverse event while on the helpline were less likely to return. “We would have assumed that if they had a successful overdose reversal, which they all did, it would prompt them to use the service more, but it was not necessarily true,” Ghosh said. That could be because they had to seek medical support, including opioid agonist treatment, after the event.

Fewer Calls by Men

Formalized virtual spotting services such as the NORS have gained popularity as a harm-reduction intervention, showing early effectiveness in reducing overdose mortality, the authors noted. Virtual spotting is when individuals reach out to contacts to supervise them during a substance-use session. The individuals ensure that emergency services are dispatched should the contacts become unresponsive.

The researchers examined characteristics of people who recurrently use the service, focusing only on phone call log data from inception (December 15, 2020) through August 31, 2023, because the texting capability is relatively new. Demographics including age, gender, province, community size, substance used, routes of administration, and adverse events were imputed into a marginal means and rates model to determine the predictors of recurrent service use.

A total of 7340 unique calls were included in the analysis. About half (51%) of callers were female, 15.8% were male, 18.1% were gender diverse, and 14.9% did not report their gender.

Less than 1% of callers were individuals younger than 18 years. About 49% were aged between 18 and 30 years, 7.6% were aged between 31 and 40 years, 34.1% were aged between 41 and 50 years, 7.1% were aged 51 years or older, and 2% did not report their age.

Men’s rate ratios (RRs) for recurrent calls were significantly lower than women’s (RR, 0.08). “Much of this may be due to concerns around safety around supervised consumption services and viewing physical supervised consumption services as gender-based spaces that often cater more to men,” Ghosh said.

RRs were lower for respondents aged 31-40 years than for those aged 18-30 years.

RRs for callers from British Columbia (RR, 0.28) and the Atlantic provinces (RR, 0.09) were significantly lower than those (RRs) for callers from Ontario. Similarly, as Ghosh noted, rural callers demonstrated lower recurrent service use (RR, 0.08) than urban callers.

Overall, 93 calls were classified as overdose events. Of those with the respondent type recorded, 72 required emergency medical services (EMS) dispatch and naloxone administration, 15 involved notifying trusted community members to respond, and four required dispatches of both EMS and community responders. Most of the events (66) occurred in Ontario.

The authors pinpointed the following key implications for public interventions, practice, and policy:

• Public health interventions should target men, rural populations, and the 31- to 40-year age group, as these groups are less likely to engage with overdose response services.
• Rural communities need outreach to raise awareness and reduce the stigma around virtual harm-reduction services.
• Tailored substance-specific messaging, particularly for nonopioid users, and improved data collection for marginalized groups can enhance public health strategies in harm-reduction efforts.

‘Being Watched’ an Issue

Timothy K. Brennan, MD, MPH, chief of clinical services at the Addiction Institute of Mount Sinai and program director of the fellowship in addiction medicine at the Icahn School of Medicine at Mount Sinai, both in New York City, commented on the study for Medscape Medical News.

“I do not think these data should be used to extrapolate public health message targeting,” he said. “People who use a virtual spotting service are a small minority of the population who use opioids, and public health officials should be careful to draw any conclusions about the population at large that uses drugs.

“I’m not sure if the findings would be similar in the United States,” he noted. “Canadian and American cultures are similar, of course, but they do not entirely overlap. Likewise, there are different perceptions of privacy in Canada vs the United States. Being ‘watched’ by a virtual spotting service may not be palatable to some folks.”

As wearables gain more traction, he said, “it will be interesting to see additional data regarding their efficacy in preventing lethal opioid overdoses.” Meanwhile, he added, “virtual spotting services are one tool in the wide array that is available to people who use drugs and people who care for people who use drugs. They are not a substitute for medication treatment for opioid use disorder.”

Health Canada’s Substance Use and Addictions Program and the Canadian Institutes of Health Research supported this work. Ghosh cofounded NORS and belongs to the Canadian Society of Addiction Medicine and had no personal financial conflicts of interest to disclose. Brennan had no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.