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Naloxone and the Inner City Youth Experience (NICYE): a community-based participatory research study… Mitchell, Keren; Durante, S. E; Pellatt, Katrina; Richardson, Chris G; Mathias, Steve; Buxton, Jane A Jun 7, 2017

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RESEARCH Open AccessNaloxone and the Inner City YouthExperience (NICYE): a community-basedparticipatory research study examiningyoung people’s perceptions of the BC takehome naloxone programKeren Mitchell1,2*, S. Elise Durante1, Katrina Pellatt1, Chris G. Richardson3, Steve Mathias1 and Jane A. Buxton3,4AbstractBackground: Take home naloxone (THN) programs reduce mortality by training bystanders to respond to opioidoverdoses. Clinical observation by the health care team at the Inner City Youth (ICY) program indicated that youngadults appeared to enthusiastically participate in the THN program and developed improved relationships with staffafter THN training. However, we found a dearth of literature exploring the experiences of young adults with THNprograms. This study set out to address this gap and identify suggestions from the young adults for programimprovement. The primary research question was “How do street-involved young people experience the THNProgram in Vancouver, BC?”Methods: The study was undertaken at the ICY Program. Two peer researchers with lived experience of THN wererecruited from ICY and were involved in all phases of the study. The peer researchers and a graduate studentfacilitated two focus groups and five individual interviews with ICY program participants using a semi-structuredinterview guide. Audio recordings were transcribed verbatim. The cut-up-and-put-in-folders approach was used toidentify emerging themes.Results: The themes that emerged were perceptions of risk, altruism, strengthening relationship with staff, accessto training, empowerment, and confidence in ability to respond, and suggestions for youth-friendly training. Thesethemes were then situated within the framework of the health belief model to provide additional context.Participants viewed themselves as vulnerable to overdose and spoke of the importance of expanding access toTHN training. Following training, participants reported an increase in internal locus of control, an improved sense ofsafety among the community of people who use drugs, improved self-esteem, and strengthened relationships withICY staff. Overall, participants found THN training engaging, which appeared to enhance participation in other ICYprogramming.Conclusions: Young people perceived THN training as a positive experience that improved relationships with staff.Participant recommendations for quality improvement were implemented within the provincial program.Keywords: Naloxone, Narcan, Youth, Young adult, Take home naloxone, Harm reduction, Opioids, Participatoryresearch, Mental health* Correspondence: kmitchell@providencehealth.bc.ca1Inner City Youth Program, 1260 Granville Street, Vancouver, BC V6Z 1M4,Canada2School of Nursing, University of British Columbia, Vancouver, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Mitchell et al. Harm Reduction Journal  (2017) 14:34 DOI 10.1186/s12954-017-0160-3BackgroundProvidence Health Care’s Inner City Youth (ICY) Pro-gram is a mental health and addiction team which sup-port young people aged 16 to 24 years at the time ofintake who are homeless or precariously housed inVancouver, British Columbia (BC). To qualify for the In-tensive Case Management (ICM) stream, young peoplepresent with moderate to severe mental illness and/orsubstance use disorders (as defined by the AmericanPsychiatric Association Diagnostic and Statistical Man-ual of Mental Disorders (5th ed.) For many, opioids aretheir drug of choice. Young people in the ICM streamare eligible for a range of services, including psychiatriccare, primary care, psychosocial rehabilitation, and sup-portive housing.Opioids are a class of drugs that relieve pain and arecentral nervous system (CNS) depressants. Heroin, fen-tanyl, methadone, and hydromorphone are among themore commonly used opioids among ICY clients. In partdue to opioid’s action as a CNS depressant, (which slowsand even stops breathing) there is a relatively highprevalence of witnessing or experiencing overdoseamong people who use intravenous, non-prescriptionopioids [1, 2]. Specific to ICY, many ICY clients are in-volved in behaviors that increase their risk of overdose,such as injecting drugs, mixing other substances withopioids, and using after periods of abstinence. Naloxoneis a pure opioid antagonist that when administered dur-ing an opioid overdose will reverse the effects of CNSdepression.Take home naloxone (THN) programs involve provid-ing naloxone and teaching people how to prevent,recognize, and respond to an opioid overdose, includingseeking professional help, rescue breathing, and how tocorrectly administer naloxone [3]. Most overdoses occurin the presence of other people, including peers, familymembers, and others [4]. Literature shows that peoplewho use opioids and their support people can be effect-ively trained to identify and respond to an overdose withTHN [5]. Knowledge and comfort with overdose identi-fication and response improves after THN training [6].The risk involved in administering naloxone is minimal[7]. There are THN programs in Canada, the USA, Eur-ope, Asia, and Australia [4, 8].ICY staff noticed that young adults appeared eager toparticipate in the THN program, and staff-client rela-tionships seemed to be enriched after participating inthe THN training. To date, studies on THN programshave predominantly focused on people with longer-termopioid use, and there is a lack of literature on the impactof THN training on young adults. This study set out toaddress this knowledge gap by investigating the experi-ence of THN training among young adults at ICY whohad a history opioid use. The authors also explored howparticipating in the THN program affected engagementin other aspects of mental health and addictions pro-gramming and collected suggestions on how to improvethe THN program.The BC Centre of Disease Control (BCCDC) imple-mented the BC THN program in August 2012. TheBCCDC develops the training materials and providesregistered sites with free THN kits and training suppliesfor people who are personally at risk of overdose. Sitescomplete training and kit distribution records, and assistclients in filling out naloxone administration forms aftera person has responded to an overdose event. The sitessend all records to the BCCDC to collate. The programwas found to be “easy to implement and empowering forclients” [9]. The ICY program became a THN trainingsite on October 1, 2013. As of January 2017, 94 youthand 195 support people had been trained in THN byICY, and there were 55 THN kits reported to be used byICY participants to respond to overdose.A public health emergency was declared in BritishColumbia (BC) on April 14, 2016 by the ProvincialHealth Officer, due to a substantial increase in opioidoverdose-related injury and death across the province[10]. Recent reports from the BC Coroners Service iden-tify 366 illicit drug overdose fatalities in BC in 2014, 514in 2015, and more than 900 deaths in 2016 [11]. Inaddition, the proportion of overdose deaths known to belinked to fentanyl has increased from 4% in 2012 to 62%in 2016 [12]. As a result, a federal policy change oc-curred to improve access to naloxone. When this studybegan, naloxone was available by prescription only, andpeople at personal risk of overdose could be prescribed akit only after completing THN training. Health Canadaremoved naloxone from the Schedule 1 prescriptiondrug list in March 2016 [13]; naloxone is now availableover the counter in pharmacies in BC. The BC THNprogram makes kits available at 492 sites at no cost topeople who use opioids, and kits are now available tofamily and friends. In 2016 alone, more than 22,000 kitswere dispensed and 4200 kits were reported used to re-verse an overdose [14].THN programs effectively train people to respond toan overdose by using naloxone. Young adult participantsarticulated the need for easy access to THN, and thisfinding has been consistent across current press cover-age on this topic [15]. This study aimed to address a gapin the literature and provide insights about how youngadults perceive and interpret the effect that THN pro-grams have upon them and their behaviors, and to ex-plore how providing THN programming may influencetheir relationship with their health-care team. Thesefindings will inform changes in THN and other pro-grams at ICY to increase engagement and improveoutcomes.Mitchell et al. Harm Reduction Journal  (2017) 14:34 Page 2 of 8MethodsPrinciples of community-based participatory research(CBPR) informed the study design. CBPR supports theinclusion of the community members who are from thegroup that is being researched. Two peer researchers,with lived experience of THN, were recruited fromyoung adults attending ICY. The peer researchers re-ceived training on research methods alongside the co-investigators. The “ladder of participation” is a modelthat measures peer involvement in CBPR from non-participatory and tokenized levels on the lower rungs, toactive and equal involvement with researchers on thehigher rungs. The research team strove to work as equalpartners with youth researchers to ensure that peer in-volvement was on the higher rungs of the ladder. There-fore, shared decision-making was employed in all areasof the study, including design, interviewing subjects, datainterpretation, and information dissemination. Peer par-ticipation in research increases relevance, and assists inmore culturally appropriate data collection, analysis, anddissemination [16]. We used a phenomenological ap-proach to bring the experiences and interpretations ofthe situation (opioid overdose and THN) from the indi-viduals’ or actors’ (young adults) own perspectives [17].Ethical approval was obtained from the Behavioral Re-search Ethics Board at the University of BritishColumbia.Participants and samplingAt the time of the study development in December2014, 103 individuals were enrolled in the Intensive CaseManagement stream of ICY; 34 (33%) of these wereidentified by their case manager as using opioids and 27(79%) of these met DSM-5 criteria for moderate to se-vere opioid use disorder [18]. Diagnoses of substanceuse disorders were made by an ICY physician or by anurse practitioner.Recruitment occurred through posters, word ofmouth, and announcements in ICY group sessions. Pur-posive sampling methods ensured participants werefrom the Intensive Case Management stream and meteligibility criteria of age 19–25 years, self-identified ashaving used opioids, had received THN training by anICY team member, and included youth who identified asmale and female. ICY follows youth who are 24 years oldat the time of intake; however, young people may still beenrolled in the program at age 25 while planning transi-tion to an adult service. Youth under 19 years were ex-cluded from this study due to ethical concerns.Members of the research team who work as clinicians atICY were not directly involved in participant recruit-ment or data collection. It was explicit that participationwas voluntary and would not affect a participant’s accessto clinical services. Interested young adults contacted anon-clinical team member to enroll and were providedwith written informed consent prior to their participa-tion. Participants completed a brief demographic ques-tionnaire regarding age, gender, and recent substancesused.Data collectionData were collected through focus groups and individualinterviews conducted by peer researchers and a Mastersof Public Health (MPH) student in July and August2015. Interviews and focus groups took place in ICY of-fices and at the Granville Youth Health Centre, whereparticipation was confidential and participants were fa-miliar with the surroundings. Peer and staff researchersdeveloped a semi-structured interview questionnaire.Participants were advised that mental health supportwas available if needed during or after the interview orfocus group. Participants received a small honorarium of$20 CDN to compensate for their time and for sharingtheir experience and snacks were provided. (focus groupand individual interview questionnaires are included asAdditional files 1 and 2).Data analysisFocus groups and interviews were audio recorded andtranscribed verbatim. All identifying information wereremoved; researchers in a clinical role with ICY cli-ents were not permitted to know the identity of par-ticipants. Team members read transcripts andanalyzed data manually as a group. The team adaptedthe “cut-up-and-put-in-folders approach” by which“meaning units” were identified and cut out withsource information to provide context. [19] The teammembers took turns to read each quote aloud andthe team discussed and coded each quote. The teamidentified emerging themes and placed the cut-outtext in the corresponding “theme” envelope. As the it-erative process continued, the team revisited thethemes and decisions to reorganize (divide, combine,or rename) themes were determined by consensus.The process continued until team members came toagreement of the key themes, quotes, and meaning ofdata. This approach was selected rather than usingqualitative data analysis software so that the researchteam could discuss each transcript in detail, whichwas possible given the relatively small data set. Thisresulted in a nuanced understanding of participant re-sponses. Additionally, the use of analysis software iscomplex, and may have limited the ability of teammembers to participate equally. A peer researcher wasinvolved at all times during data analysis to increaserelevance, which is aligned with the CBPR approach.Mitchell et al. Harm Reduction Journal  (2017) 14:34 Page 3 of 8ResultsIn total, 11 young adults participated in 2 small focusgroups of 2 and 4 participants, and 5 individual interviews.Focus groups were small because not all enrolled partici-pants arrived for the scheduled sessions. Young peoplewho missed the focus groups were offered the option ofan individual interview. Seven participants identified asmale, four as female, and none identified as transgender;nine participants reported using opioids in the precedingweek. Opioids reported used included heroin, hydromor-phone, morphine, and methadone. Eight participants alsoidentified using methamphetamine in the preceding week.Other substances participants reported having used in theprevious week included cannabis (n = 5), cocaine (n = 2),alcohol (n = 1), and benzodiazepines (n = 1).The major themes that emerged were perceptions ofrisk, motivations for participating in training, altruism,strengthening relationships, and the importance of ac-cessible naloxone, empowerment, and suggestions foryouth-friendly improvements to THN education and ser-vice delivery.We considered the major themes identified in the con-text of various health behavior models and theories; thehealth belief model was determined to be the most ap-propriate framework to illuminate the findings. Thehealth belief model focuses on the individual’s attitudesand beliefs; it originally had four constructs: perceivedsusceptibility, perceived severity, perceived benefits, andperceived barriers. Two additional concepts have beenadded cues to action (strategies to activate “readiness”)and self-efficacy (confidence in one’s ability to take ac-tion) [20]. Empowerment can be considered a conse-quence of achieving self-efficacy and gaining masteryover one’s own life [21].Table 1 shows how the identified themes aligned withthe core components of the health belief model. Manyof the comments identified by participants as quality im-provement were suggestions to reduce barriers and im-prove self-efficacy.1. Perceived threat:Perceptions of riskYoung adult’s understanding of overdose riskdeveloped over time, and was influenced by closeencounters with overdose. Participants said thatpersonally experiencing or witnessing anoverdose made them acutely aware of theirvulnerability, which was a source of concern asthey recognized themselves at personal risk ofoverdose.“– it really kind of wakes you up and makes yourealize that it’s real life and you’re kind of playing withfire sometimes.” Participant 3“Yeah, it’s just – you can never really prepare yourself.It’s, I mean, you think going into it that you’reinvincible and that you’re going to be able to noticewhen you’re going to start slipping into an overdoseand that things are going to be okay for you, butyou’re the same as everyone else. You can fall victimto the same casualty.” Participant 82. Perceived benefits:AltruismThroughout the interviews and focus groups,participants spoke a sense of altruism towardstheir peers, family, and community as reasons tocarry naloxone and receive training in overdoseresponse. Participants identified the ability tosave other lives as a powerful motivator toparticipate in the training. They felt they had aresponsibility to take care of other people whouse substances, and they perceived thisresponsibility in a positive way.“You can save a person’s life by using this stuffbecause I had first-hand experience and I know thatthe stuff works.” Participant 2“Because a family member close to me died from anoverdose. And I kind of think of it as, like, in honor ofher, you know.” Participant 9THN training appeared to increase the sense ofsafety for the participants. They felt more aware ofwhat to do in the event of an overdose, and theybelieved that naloxone would be effective.“I felt like I could actually do something to stop theiroverdose.” Participant 5Table 1 Alignment of the identified themes with the healthbelief modelHealth belief model Themes identified1. Perceived threat(perceived susceptibilityand perceived severity)Perceptions of risk2. Perceived benefits Motivation for participatingin training: altruismImproved relationshipswith staff3. Perceived barriers Access to training4. Cues to action (strategiesto activate “readiness”)Training and awareness5. Self-efficacy (confidencein one’s ability to take action)Empowerment and improvedself-esteem;confidence in ability to respond:Youth relevant video‘Dummy’ for trainingOffer repeat training/refreshersMitchell et al. Harm Reduction Journal  (2017) 14:34 Page 4 of 8Relationships with staffParticipants linked the training in overdoseprevention to being genuinely cared for, valued, andrespected by staff. They reported feeling that theywere treated with compassion and not judged,which contrasted with their expectations toexperience negative reactions linked to their druguse.“I think it, like, really [inaudible] reinforced and, like,people [ICY staff] are genuinely caring about us. And-you guys are a bunch of junkies, you don’t fuckingneed to, like-were actually, like, really gave a shit andwere, like, considerate and polite.” Participant 6“I like that they’re [ICY staff] aware that not all drugusers are, like, scum or anything. They treat us well.And they’re preparing us for like possible death and Ilike that it’s, like, harm reduction in general.”Participant 7“Well, we’re not looked down upon just because weuse. And, like, stigma is not changing the relationshipbetween a user and a non-user.” Participant 9Participants spoke about recognizing that ICY staffwanted to speak with them candidly about theirsubstance use and harm reduction. Young adultsexpressed that the THN program provided themwith a valuable skill, and improved theirrelationships with ICY staff. After THN training,they felt they could speak openly about issues thatthey previously were not comfortable discussing.Young people recognized that ICY staff weregenuinely concerned and wanted them to be safe,which improved trust and helped them feel lessself-conscious discussing substance use.“They [ICY staff]– like, I guess they knew I was at apoint where I was doing some pretty dangerousthings. So they wanted – didn’t want to see anythingbad happen to me, so they really pushed for me to dothe Naloxone training.” Participant 4“Like, it almost feels like a weight has been lifted orkind of like - I don’t know how to describe it, butwhen a layer has been, like, taken or, like, there’s aninvisible wall that was broken. And we can now talkabout something a bit more casually, even though it’sserious.” Participant 9Empowerment and improved self-esteem were re-ported by participants as perceived benefits of theprogram, but were also identified as improvingconfidence in one’s ability to take action and aretherefore addressed in “self-efficacy” section.3. and 4.Perceived barriers and cues to action:Access and awareness of trainingParticipants repeatedly spoke about the need tohave increased access to naloxone and THNtraining. They suggested that ICY offers traininguniversally to all clients, and that THN kits beavailable in public places. An example of this is thesuggestion to keep naloxone in ‘hotels.’ (In thiscontext ‘hotel’ refers to single room occupancies(SRO), which are low income housing units withshared bathrooms and cooking areas. SRO hotelsare often low-barrier and first-stage housing forpeople who have been homeless.)“They should actually have, like, a fire extinguisher, acase, in every hotel [SRO] that people use drugs withNaloxone.” Participant 8“…the training should be a part of ICY. It should bemandatory for people who live in a hotel. You have achoice not to do it, but I totally recommend takingthe training because I was totally oblivious to Narcan.I didn’t know what it was. I thought it was just astimulant.” Participant 25. Self-efficacy:Empowerment and improved self-esteemParticipants were aware of the risk, but feltpowerless to respond to overdose prior to thetraining. THN training increased their sense ofagency.“Well, because you, like, before when you don’thave naloxone training, you don’t have a naloxonekit, when an overdose comes around and what canyou really – you can, like [inaudible] said, you cangive a person CRP (sic) and pray and hope for thebest. Whereas with naloxone you’re kind of giventhe power to try to do something about it.”Participant 8Participants who had used naloxone previouslytalked about a sense of accomplishment andincreased self-esteem. They felt empowered to beskilled in this intervention, and they recognized thatthis skill was valued and respected by peers,workers, family members, and other people in thecommunity.“So the ambulance came and they basically took over.They said ‘Great job. You could have saved his life,you did awesome. We’re going to take it from here.”Participant 3Mitchell et al. Harm Reduction Journal  (2017) 14:34 Page 5 of 8“It was very satisfying. Very, like, accomplishing. I wasglad I had helped someone.” Participant 1Confidence in ability to respondMixed feelings were expressed by young adultparticipants about their comfort and confidence intheir capability to respond to overdose followingtraining. While some young people expressedconfidence in their ability to respond to overdose,others stated that they felt somewhatunderprepared. Interestingly, one of the participantswho described feeling underprepared also reportedhaving successfully reversed an overdose followingthe training.“Yeah, well, I guess right after I first got it, I’ve neveractually done it before so—you know, watching it on avideo and getting a little piece of paper saying I cando it and having the little kit on me and actually beingable to do it or two different things. Yeah, the firsttime I did it I was a bit scared. But, yeah, there wassomeone there try—you know, calming me down and,you know, making sure I was, like, okay. And I was onthe phone with the paramedics or whatever.”Participant 1Participants provided concrete suggestions for waysto improve the training and make it more youth-friendly, such as updating the training video, usingtraining dummies, and making refresher trainingavailable. Young adults felt these changes wouldmake the THN training more practical and wouldincrease their confidence in their ability to resusci-tate someone from an overdose.“They could have, like, you know, brought in adummy or something and shown … what positions toput the person’s body or what to do to help thembreathe or whatever.” Participant 1“It might be good to do a refresher every now andthen.” Participant 3“The video was a bit dated.” Participant 8DiscussionWorking within a framework of harm reduction, our pri-mary research question was prompted by clinical obser-vations that young adults appeared to positively engagewith THN training. The community-based participatoryresearch (CBPR) design intended to promote maximalinvolvement of service users, a pillar of harm reduction[22], in all aspects of research, quality improvement, andknowledge dissemination. CBPR promotes engagementamong street-involved young people [16] and supportsuser-driven quality improvement in vulnerable popula-tions [23]. The health belief model organized andgrounded our interpretations of how THN training af-fects individual’s attitudes and beliefs.Themes that emerged from the ICY study includedperception of risk, motivation to take the training,empowerment, strengthening relationships with staff,access and importance of THN, and youth-friendlyimprovements. THN training increased a sense ofsafety at a time when the risk of overdose was high.Receiving THN training also fosters a sense ofagency and increased self-esteem, with a newly ac-quired skill recognized by peers. This also seems tohave influenced the client-clinician relationship, asyoung adults not only felt recognized by their clini-cians but also were more willing to engage. Giventhe challenges of working with a young street-involved population, THN can serve as an importantengagement tool.Study participants had several recommendations, inboth policy and practice, for quality improvement.One specific benefit of using a CBPR design is theease and speed with which participant recommenda-tions can effect change and be quickly put into prac-tice [24]. Specific recommendations from the youngadult participants included improving the trainingvideo, using simulation dummies and offering repeat/refresher training. Some of these changes have beenimplemented both locally and provincially. For in-stance, the recommendation to increase access toTHN training led ICY to establish daily trainings ledby peers. Participants recommended providing andadvertising THN refresher courses, making THN opt-out rather than opt-in for ICY clients, and continuingto encourage participation in THN for youth, youngadults, and support people. In response, ICY nowroutinely offers refresher courses when a young per-son requests a replacement kit, expresses interest inrepeating the training, or describes risky behaviorsamongst themselves or their peer group. At the pro-vincial level, a new youth-specific video has been de-veloped with input from the young adult peerresearchers and participants [25].Another important aspect of CBPR is the sharing ofresearch findings in an accessible manner back to thecommunity. A graphic booklet using direct quotesfrom this study illustrated by ICY participants wascreated and disseminated amongst youth, youngadults, families, and service providers. Postcards usingthe same illustrations and quotes from the bookletand including information on how to recognize andrespond to an overdose on the reverse side have alsobeen developed and distributed [26].Mitchell et al. Harm Reduction Journal  (2017) 14:34 Page 6 of 8Limitations of this study include a small sample sizeand exclusion of youth under the age of 19. However,participants included males and females and reportedvaried duration of opioid use and a variety of other sub-stances used. The dual roles of some research teammembers as researchers and staff clinicians in this studypresented an ethical challenge of recruiting eligibleyoung people while protecting their identity from re-searchers involved in their clinical care.Trustworthiness of the findings is enhanced by includ-ing experiential peers in the research and analysis pro-cesses. The peer researchers confirmed interpretation ofthe themes and helped to create relevant and acceptableknowledge disseminations tools. This study suggests thatmental health and addiction programs that provide over-dose response training empower street-involved youngadults to care for their health and their communities.Programs that communicate respect and capacity helpyoung people understand that they are valued, even ifthey continue to engage in risky behaviors. This ap-proach to engagement could improve other health andharm reduction programs for this population.ConclusionsPrevious findings of THN programs have shown that itis an effective harm reduction intervention. The findingsfrom this qualitative study support additional benefits ofTHN programs in a street-involved young adult popula-tion as findings suggest improved safety, altruism, andempowerment, and improved self-esteem because oftraining. Other benefits include increased young adultengagement with health care staff that provide THN,and with other aspects of health care programming. TheCBPR process also generated participant recommenda-tions, which have been incorporated into the provincialand local THN initiatives.Additional filesAdditional file 1: Focus Group Questionnaire. (DOC 34 kb)Additional file 2: Individual Interview Questionnaire. (DOC 28 kb)Abbreviations$ CDN: Canadian dollars; BC: British Columbia; BCCDC: British ColumbiaCentre for Disease Control; CBPR: Community-based participatory research;CNS: Central nervous system; DSM-5: Diagnostic and statistical manual, fifthedition; ICY: Inner City youth program; MPH: Masters of public health;SRO: Single room occupancy; THN: Take home naloxoneAcknowledgementsThe authors wish to thank Mike Fawkes and Zakary Zawaduk for their tirelesswork training, interviewing, and interpreting data. Thank you as well toChantell Dunlop, Aggie Black, and Wilma Chang for supporting the researchproject and thanks to the enthusiastic support of BCCDC, ICY staff, and ICYparticipants for the courageous lives they lead every day.FundingThis study was funded by the Providence Health Care Practice-based ResearchChallenge and the BC Centre for Disease Control.Availability of data and materialsOriginal transcripts will not be shared.Authors’ contributionsKM, ED, and JAB conceived and designed the study. KP was involved inconducting interviews and focus groups. ED, KM, KP, and JAB performed thequalitative analysis. KM drafted the manuscript. ED, KP, CR, SM, and JABprovided critical input into the manuscript. All authors read and approvedthe final version.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicableEthics approval and consent to participateEthical approval was obtained from the Behavioral Research Ethics Board atthe University of British Columbia. Participants completed a written consentform prior to participation.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Inner City Youth Program, 1260 Granville Street, Vancouver, BC V6Z 1M4,Canada. 2School of Nursing, University of British Columbia, Vancouver,Canada. 3School of Population and Public Health, University of BritishColumbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada. 4BC Centre forDisease Control, 655 West 12th Ave, Vancouver, BC V5Z 4R4, Canada.Received: 23 March 2017 Accepted: 24 May 2017References1. Martins SS, Sampson L, Cerda M, Galea S. 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Principles of harm reduction. 2016. Availablefrom: http://harmreduction.org/about-us/principles-of-harm-reduction/.Accessed 27 Aug 2016.23. Graham T, Rose D, Murray J, Ashworth M, Tylee A. User-generated qualitystandards for youth mental health in primary care: a participatory researchdesign using mixed methods. BMJ Qual Saf. 2014;23(10):857–66.24. The role of community-based participatory research. Creating partnershipsimproving health. Rockville: Agency for Healthcare Research and Quality;2003. Accessed 27 Aug 2016.25. Naloxone Wakes you up Video 2016. Available from: http://towardtheheart.com/assets/naloxone/wakes-you-up_200.pdf. Accessed 19 May 2017.26. Naloxone wakes you up Postcards 2016. Available from: https://towardtheheart.com/naloxone/. Accessed 19 May 2017.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Mitchell et al. Harm Reduction Journal  (2017) 14:34 Page 8 of 8


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