Medicine, Faculty of
Non UBC
Population and Public Health (SPPH), School of
DSpace
Substance Abuse Treatment, Prevention, and Policy. 2021 Mar 20;16(1):26
The Author(s)
Macleod, Emilie R
Tajbakhsh, Iren
Hamilton-Wright, Sarah
Laliberte, Nancy
Wiese, Jessica L
Matheson, Flora I
Background: Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone access landscape, there is a need for up-to-date research on Canadian women’s experiences with opioids. Studies on Canadian take-home naloxone programs are promising, but research beyond these programs is limited. Our study is the first to focus on women’s experiences and perspectives on the opioid crisis in Ontario, Canada’s most populous province, since the opioid crisis began in 2010. Objective: Our objective was to address research knowledge gaps involving Canadian women with criminal justice involvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioid overdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts, especially involving naloxone, are meeting their needs. Methods: We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women with experience of opioid use. They were recruited through the study’s community partner in Toronto. Participants provided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadian government’s responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysis was conducted to determine major themes within the data. Results: Thematic analysis identified seven major concerns despite significant differences in participant life and opioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counter in 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to 2016. The portability, dosage form, and effects of naloxone are important considerations for women who use opioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadian government’s response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needs and views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma, addiction management, and housing. Conclusions: Participants experienced with naloxone use found it to be useful in preventing fatal overdose, however many of their needs with regards to physical, mental, and social health, housing, harm reduction, and access to opioid treatment remained unmet.
RESEARCH Open Access“They’re not doing enough.”: women’sexperiences with opioids and naloxone inTorontoEmilie R. Macleod1, Iren Tajbakhsh2, Sarah Hamilton-Wright1, Nancy Laliberte3, Jessica L. Wiese1 andFlora I. Matheson1,4*AbstractBackground: Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone accesslandscape, there is a need for up-to-date research on Canadian women’s experiences with opioids. Studies onCanadian take-home naloxone programs are promising, but research beyond these programs is limited. Our studyis the first to focus on women’s experiences and perspectives on the opioid crisis in Ontario, Canada’s mostpopulous province, since the opioid crisis began in 2010.Objective: Our objective was to address research knowledge gaps involving Canadian women with criminal justiceinvolvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioidoverdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts,especially involving naloxone, are meeting their needs.Methods: We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women withexperience of opioid use. They were recruited through the study’s community partner in Toronto. Participantsprovided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadiangovernment’s responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysiswas conducted to determine major themes within the data.Results: Thematic analysis identified seven major concerns despite significant differences in participant life andopioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counterin 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to2016. The portability, dosage form, and effects of naloxone are important considerations for women who useopioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadiangovernment’s response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needsand views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma,addiction management, and housing.(Continued on next page)© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.* Correspondence: Flora.Matheson@unityhealth.to1MAP Centre for Urban Health Solutions, St. Michael’s Hospital, 30 BondStreet, Toronto, ON M5B1W8, Canada4Dalla Lana School of Public Health, University of Toronto, 55 College StRoom 500, Toronto, ON M5T 3M7, CanadaFull list of author information is available at the end of the articleMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 https://doi.org/10.1186/s13011-021-00360-3(Continued from previous page)Conclusions: Participants experienced with naloxone use found it to be useful in preventing fatal overdose,however many of their needs with regards to physical, mental, and social health, housing, harm reduction, andaccess to opioid treatment remained unmet.Keywords: Qualitative, Naloxone, Opioids, Women, Overdose, Criminal justiceBackgroundOpioid overdose deaths have increased dramaticallyacross North America over the past decade, stemmingfrom a combination of over-prescribing of addictive opi-oid painkillers and fentanyl contamination in the illicitopioid supply [1–4]. Canada reported 8.8 opioid over-dose deaths per 100,000 in 2016, increasing to 12.3 per100,000 in 2018 [4]. In total, in Canada, from January2016 to March 2019, an estimated 12,800 people havedied of opioid overdose [4]. The epidemic continues toclaim lives despite no official federal declaration of pub-lic health emergency [5], with Canadian policymakers re-sistant to institutionalized, large-scale harm reductioninterventions [6]. The lack of opioid research focused onwomen has only recently begun to receive broader rec-ognition [7], and this lack is especially felt in Canada.A few recent studies on Canadian women’s opioid usehave emerged from Vancouver [8–12], but Vancouverrepresents a unique risk environment where drug use isconcentrated in an area of single-occupancy residenceswith high poverty [13]. Research from Vancouver doesnot necessarily reflect the environment elsewhere inCanada, as Canada’s health system is organized by prov-ince. There remain substantial gaps in research involvingCanadian women who use opioids outside of BritishColumbia. For instance, the opioid overdose crisis hasstrongly affected Toronto, Canada’s largest city, with 308people dying of overdose in 2017 alone [14]. In Augustof 2017, activists established an unsanctioned but highlyneeded overdose prevention site in a local park, when noofficial sites had yet been approved, and Toronto subse-quently became the first major city in Eastern Canada toestablish an overdose prevention site [15, 16]. Torontorepresents an interesting and evolving harm reductionenvironment where the study of women who use opioidsis sorely absent. In Ontario, a thesis compared sex differ-ences in opioid use based on systematic reviews, datafrom the Genetics of Opioid Addiction (GENOA) study,and qualitative accounts from 492 men and women whouse opioids [17]. Results showed female participantswere more likely to be unemployed, to report morephysical and psychological difficulties than men and tobe exposed to opioid use through a prescriber; howeverthis thesis was written prior to Canada’s spike in opioidoverdose deaths, and this information may have changedsince. One other study compared women’s and men’sopioid-related deaths in 2017, finding overdose deathsruled as suicides in Ontario made up 9% of men’s, com-pared to 19% of women’s deaths [18]. Women who diedof overdoses were also more likely to have taken benzo-diazepines, antihistamines, and antidepressants com-pared to men [18], which may connect with their mentalhealth burden [17]. Toronto has seen opioid overdosedeath counts hold steady since 2016 [14]; this contrastof steady deaths with the lack of up-to-date women’sopioid use research in Ontario is of great concern.Internationally, research into women’s opioid use hasalso received only limited attention and is focused over-whelmingly on the effects of opioid use on pregnantwomen, pregnancy outcomes, and neonatal wellbeing[19–39]. While this research is valuable to support thecare of pregnant women who use opioids, it excludeswomen who are not pregnant or cannot get pregnant,and focuses mainly on the physical health of women andthe babies they are carrying, not their life experiencesand perspectives. International qualitative studies on thestigma against women who use opioids [40, 41],women’s opioid use with intimate partners [42, 43], theintersection of opioid use and sex work [44, 45], womenwho use opioids in a shelter context [46], and otherhealth outcomes for women who use opioids [47], can atbest hint at the experiences of Canadian women whouse opioids, but are no substitute for direct research.Many additional interconnected environmental factorscan render women more vulnerable to opioid overdoseand death [13], such as criminal justice involvement,opioid criminalization, housing instability, social isola-tion, and Indigenous status. Mortality is high amongmen and women leaving prison and overdose is a lead-ing cause of these deaths [48–50]. A recent systematicreview and meta-analysis found a pooled prevalence esti-mate of drug use disorders of 51% among incarceratedwomen, compared with 1.9% of women in the generalUS population [51]. One reason suspected for the in-crease in deaths after release from prison is a reductionin physiologic tolerance after a period of abstinence [52,53]. Women who have criminal justice involvement anduse opioids struggle additionally with the ongoingcriminalization of opioids; recent research amongpeople incarcerated in the United States showed harshercriminalization of opioid-related activities further stig-matized the behavior of people who use opioids, withoutMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 2 of 15improving their safety [54]. The Ontario government hasdelayed the opening of additional safe injection sites [55,56], despite evidence that they can prevent overdosedeaths and connect people who use opioids to other ser-vices [57]. These barriers stand in major contrast toPortugal, where drug decriminalization in response to arise in overdose deaths in the 1990s resulted in halvedannual opioid overdose deaths, a reduction in opioid useinitiation, and a 94% increase in uptake of opioid treat-ment [58, 59]. A better understanding of how these bar-riers affect Canadian women who have criminal justiceinvolvement and use opioids can help to inform waysto address the high mortality in this group.People who use opioids in Canada have also criticizedpolicymakers for their reluctance to address structuralcauses of the opioid crisis related to poverty and housing[9, 10, 60]. The issue of stable and affordable housinghas been raised as a driver of opioid use in the UnitedStates [46, 61], and when people who use opioids arealso socially isolated or live alone, the risk of overdosespikes [62, 63]. Most overdose deaths in Toronto haveoccurred in private dwellings, and slightly more thanhalf while the person is alone [14]. A lack of social net-work, shame, withdrawal symptoms, and financial cir-cumstances can all push people to use opioids alone,even when the dangers of doing so are well-understood[64]. A recent intervention to introduce naloxone train-ing into single-room occupancy hotels in Vancouverhelped engage tenants who used opioids and felt iso-lated, but poor building conditions, stigma from buildingmanagers, and criminalization of opioid use acted asbarriers to implementation [62]. Another Vancouverhousing-based overdose prevention intervention was notaccessible to female tenants as they did not feel safeusing it [9, 10]. Finally, police discrimination against In-digenous people in Canada [65] further complicates con-nections between opioid criminalization, criminal justiceinvolvement, and other overdose risk factors. When acommunity-developed opioid treatment program in anorthwestern Ontario First Nations community took thefocus off policing, addiction-related medical evacuationswere reduced and community participation improved,demonstrating a link between policing of Indigenouspeople, opioid use, and overdose [66]. There is a highrisk of death and a strong need for access to naloxone toprevent untimely deaths among these vulnerable groups.Research with women experiencing some or all of thesefactors is urgently needed to prevent additional deaths.Naloxone, sometimes known as Narcan®, is an opioidoverdose antidote available in both injectable and nasalforms which, in blocking the brain’s opioid receptors,can reverse potentially fatal overdose effects such as re-spiratory inhibition. Naloxone availability in Ontario andin Canada more broadly has evolved significantly inrecent years, between the creation and expansion oftake-home naloxone programs in major cities, and fed-eral adjustments to dispensing requirements allowing ac-cess to the medication without a prescription as of June2016 [67, 68]. However, regional variabilities in naloxoneuptake by pharmacies and local populations [69, 70],along with American research indicating naloxoneawareness, use, or carrying of a kit is not always com-mensurate with increased availability [71], point to aneed to understand whether or how women in Ontarioare learning about, accessing, and using naloxone. Thisis especially necessary in light of the 2017 TorontoOverdose Action Plan stressing the city’s need for ex-panded naloxone access [72], as well as international re-search, mostly involving men, pointing to issues ordifficulties people may have surrounding its usage, suchas strained peer relationships, precipitated opioid with-drawal, and a lack of overdose aftercare [73–76]. Nalox-one is a safe drug, but any unacknowledged gapsin naloxone access, knowledge, and use in Canada mayaffect overdose outcomes. Given naloxone’s lifesavingimportance, research is needed to understand whetheror how women who use opioids are able to navigatethese barriers in Ontario’s current context, and wheredifferent or tailored approaches may be needed.Women have received almost no focus in Canadianopioid research, especially outside of British Columbia,and even fewer studies explore experiences of opioid useamong women with criminal justice involvement andother intersecting socioeconomic vulnerabilities. Whileearlier studies begin to shed light on issues facing thesegroups, they fail to achieve a greater depth of under-standing of the specific needs, experiences, and ongoingbarriers to care facing Canadian women who use opi-oids, hence the need for qualitative research in this area.The aim of this study is to begin to address these gapsin knowledge among women in Ontario who use opioidsand have criminal justice involvement. The study willalso simultaneously begin to address a research gap onnaloxone knowledge and use among women experien-cing criminal justice involvement and who are particu-larly vulnerable to opioid use and overdose deaths fromopioids. In so doing, we hope to inform health profes-sionals, policymakers, social workers, and counselorsabout the potentially unique or unaddressed challengesfacing women with criminal justice involvement who useopioids and naloxone in an urban Canadianenvironment.MethodsSettingThis study was conducted in Toronto, Ontario, a citystrongly affected by the opioid overdose crisis. Interviewswere conducted from January to April 2018, providing aMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 3 of 15snapshot of a unique point in time in Toronto’s initialscale-up of overdose prevention efforts.ApproachThis study was designed using a community-based par-ticipatory research (CBPR) approach to connect withwomen with criminal justice involvement who had directexperience using opioids [77, 78]. CBPR links academicresearchers with local community partners to assesspublic health disparities, the findings of which can beused to assist in relevant and sustainable communityhealth improvement efforts. CBPR prioritizes the needsof the community being researched by providing a plat-form to those most familiar with the issue, involvingcommunity workers in study design, and presenting re-sults back to the community.Eligibility criteria and recruitmentParticipants were recruited through a local communityorganization that supports women with a history ofcriminal justice involvement. Potential participants wereinformed of the study during their routine in-personvisits with counselors over a 4-month period (January toApril 2018), and through an informational pamphletprovided to counselors. Interested clients could volun-teer to participate in an in-person interview with a re-search team member (ERM) if they met the inclusioncriteria of identifying as a woman, aged 18 years or older,and with self-reported previous or current opioid useexperience.Data collection methodsQualitative face-to-face interviews were conducted with10 women at the community organization’s primary lo-cation. Interviews ranged from 30 to 60 min, dependingon the level of detail each participant was comfortableproviding. The interviewer had no prior relationshipwith any participants, and participants were notified ofthe interviewer’s student status and the study goals dur-ing the informed consent process.Participants provided verbal consent to maintain theiranonymity, and interviews were audio-recorded andtranscribed verbatim. Counselors were available on-siteto support participants if needed. Participants received$20 gift cards and transit fare for their time and reflec-tions. Transcripts and results were not returned to par-ticipants for feedback, as personal contact informationwas not gathered by the researcher, again to maintainanonymity. All participants completed the interview andthere were no early withdrawals from the study. Thisstudy was approved by the Research Ethics Board at StMichael’s Hospital.Interview guide designThe interview guide (see Additional File 1: Qualitativeinterview guide) contained four sections: socio-demographic characteristics, opioid experiences, nalox-one experiences, and perspectives on the opioid crisis.The organization’s staff provided input into the structureand content of the interview guide, and they approvedthe guide before it was used in the interviews. The inter-view guide was pilot tested.AnalysisStudy transcripts were evaluated by thematic analysis[79, 80] using an inductive approach [81]. Participantanswers were compared by organizing answers to eachquestion in Excel spreadsheets to see where commonal-ities in experience emerged. Some answers were furthercompared based on how recently participants had usedan opioid, category of opioids used (licit or illicit),and whether the participant had experienced an opioidoverdose; these comparisons were not intended to makeany quantitative statements on the data but to betterunderstand specific factors relating to usage, such asparticipant awareness of naloxone.Memos were written by the primary analyst (ERM)throughout the analysis process to track emerging in-sights. Common responses amid individual questionswere grouped according to recurring sub-themes duringresearch team meetings involving all co-authors. An in-ductive approach was used to connect responses acrossthe interviews and incorporate related sub-themes tocreate the major overarching themes presented herein.Due to small sample size, numbers smaller than 6 arenot reported in the results to maintain participant confi-dentiality. This study was conducted as part of a 4th yearundergraduate independent study. The sample size wasselected to ensure that the project could be completedwithin the course requirements. It is possible that satur-ation was not achieved. The authors completed a checklist of criteria for reporting qualitative research (SeeAdditional File 2: COnsolidated criteria for REportingQualitative research checklist).ResultsParticipant characteristicsParticipants ranged in age from 27 to 60, with an aver-age age of 42. A majority were White, with a minority ofparticipants identifying as Indigenous. The study fea-tured both cisgender and transgender participants. Allparticipants were low-income and several had less thanhigh school education. Most participants had fixed ad-dresses, but some did not. Each participant had been liv-ing with at least one mental or physical illness and mostparticipants had multiple chronic conditions, includingpost-traumatic stress disorder and/or chronic pain.Macleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 4 of 15Nearly all participants were taking at least one non-opioid medication, with some concurrently taking five ormore medications.The most commonly used opioid reported by partici-pants was heroin, followed by Percocet, Oxycontin, andmorphine. Participants also mentioned other opioids in-cluding Tylenol 3, codeine, fentanyl, methadone, hydro-morphone, or unspecified pills. The majority ofparticipants used more than one type of opioid withmany having used three or more in their lifetime. Partic-ipants reported that cocaine and crack were the mostcommon substances combined with opioids, followed byalcohol. The most frequently cited reasons for combin-ing opioids with other substances was to experience newsensations, to come down from a high, manage pain, ornumb negative emotions. Nearly all participants knew atleast one person who had experienced an opioidoverdose.Naloxone knowledge and experience in relation to opioiduse patterns and pathwaysEach participant described a unique initiation into opi-oid use, with many experiencing more than one ex-tended phase of opioid use over the course of their lives.Some participants experienced an initial period of pre-scription opioid use for illness or injury, followed by aphase of injecting heroin. For instance, one participantwas prescribed Percocet in her mid-20s, ceased use, thenbegan injecting heroin in her late 20s with a partner.Other participants used heroin and opioids recreation-ally and later were prescribed these drugs to addresshealth conditions; one participant had smoked heroinwhile younger, then was prescribed opioids in middleage for degenerative disc disease. Participants who expe-rienced only one phase of opioid use were initiatedthrough prescriptions, pressure from romantic partners,or using with friends.Participant awareness of and possession of naloxoneappeared to relate to how recently they had used an opi-oid and the type used. Many participants were using opi-oids at the time of study or during the preceding year,and most participants with recent opioid use were awareof naloxone. Only one participant who had recently usedopioids reported not ever having a naloxone kit; this par-ticipant had taken a low-dose prescription opioid anddid not display a pattern of recent illicit use. All otherparticipants engaged in current or recent opioid use, andaware of naloxone or in possession of it, had been usingopioids illicitly, primarily heroin. Most participants en-gaged in illicit opioid in more recent years had receiveda naloxone dose, some from take-home naloxone kits,others from emergency medical personnel for both sus-pected and actual opioid overdose. Many wereknowledgeable of both injectable and nasal forms ofnaloxone and had used naloxone on another person atleast once.Conversely, participants not engaged in recent illicitopioid use at the time of interview, who in some caseshad not used opioids in several years, either did notknow about naloxone prior to study recruitment, or hadonly heard of it in passing, such as on the news, withoutpursuing additional training or knowledge. No one inthis group had administered naloxone to another person,and when asked, many were not interested in acquiringa kit. One participant who had not used opioids in morethan a year at the time of interview had previously beenprescribed Narcan® but had not used it.Participants engaged in illicit opioid use since 2016 de-scribed obtaining multiple naloxone kits and informationfrom a variety of sources: primarily friends, partners,community or public health services, methadone clinics,and pharmacies. Some participants turned to the newsor online research for additional information on nalox-one. No participants reported initially learning about na-loxone at a pharmacy. The decision to seek outnaloxone training was often a product of the initialawareness of naloxone they had gained from peers:“I lived in a house where a lot of people were usingIV drugs. A lot of people came there to use IVdrugs, so- and nobody was being careful. So, I tookit upon myself that I always had- I was the one tocall [public health service] to get clean kits, fits,everything.” (Participant 6)Despite a lack of knowledge of naloxone, a few partici-pants with earlier-life heroin use who were later pre-scribed opioids for medical reasons consciously limitedtheir prescription use. These participants tapered offtheir prescriptions or avoided taking them unless abso-lutely necessary, citing a fear of becoming addicted, thedesire to pursue Indigenous spiritual and mindfulness-based pain management practices, and side effects asreasons for their self-imposed restrictions. These partici-pants had not experienced accidental opioid overdoses(though one had intentionally overdosed in the past, andone had intentionally overdosed on a non-opioid) anddid not express interest in acquiring naloxone kits.Participants who had described recent heroin use, re-gardless of whether they had been prescribed opioids inthe past, had experienced accidental overdoses prior tothe interview. Although naloxone did appear to bereaching these participants, who were in need of it, theever-present danger of overdose loomed:“I went to the pharmacy to fill my medication andthe day before I had- I ran into a guy overdosing onthe street, and a week before that a girl overdosedMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 5 of 15on the TTC and I- at which point I didn’t have anyof the- naloxone or anything and I just realized that,whether I want to see an epidemic or not, it is hap-pening in my cities … so … I just picked one up.”(Participant 5)Participants engaged in more recent (post-2016) illicitopioid use were the most experienced with naloxone,and tended to seek out naloxone knowledge as a meansof mitigating their overdose risks, with some relying ontheir informal social networks to access and learn aboutnaloxone. Participants who had used illicit opioids in thepast and then were later prescribed opioids for medicalreasons were not very aware of nor interested in nalox-one kits, even if they had overdosed in the past, but con-sciously limited their use of medication in other ways.These differences in naloxone usage and knowledgeacross specific opioid initiation and use pathways wereconsistently apparent in the data.Naloxone’s dosage form, effects, and ease of useInjectable naloxone kits were available in Ontario priorto Narcan®, the nasal spray form. These kits, the size of alarge wallet, contain two ampoules of naloxone, two sy-ringes, gloves, alcohol swabs, and instructions. Nearly allparticipants were supportive of naloxone use, but whenasked what they found positive or negative about thekits, one participant said their bulkiness is an impedi-ment to women carrying them:“ … if they don’t fit in our purse … chances are it’sgonna be sitting at home, somewhere in a safe spotbut not where you need to have it … like a regularepi pen like keep it in your tampon container inyour makeup bag or in your purse and, it’d be a lotmore effective.” (Participant 5).Multiple participants drew comparisons between na-loxone and epi-pens as a fast-acting, portable emergencymedicine. When asked, participants experienced withnaloxone use were inclined to prefer the nasal sprayform over injectable forms due to ease of set-up, as wellas fear of needles or discomfort surrounding needle size.One participant described severe naloxone-inducedwithdrawal after an overdose, after which she used add-itional opioids to manage her symptoms. These with-drawal effects greatly distressed her, and she expressed aneed for greater support for people immediately post-overdose:“ … it brings you out of your overdose, but at thesame time, you get extremely sick, you know? Likeit takes out every, every opiate in your body andyou’re basically in withdrawal and then like what if-what if that was the last of your money or yourdope and now you’re gonna have to go find some-thing else and- and you’re so sick that you don’teven want to do anything, you know? And nobodyhelps. So it’s- that’s the only part I fuckin’ hateabout those kits.” (Participant 3)Another study participant, who supported the aboveparticipant through her overdose, independently sharedher belief that health officials and authorities lackawareness of naloxone’s effects and how to best managethem:“I believe doctors, police officers, jail people, theyare not knowledgeable enough about how this drug[naloxone] affects people and what happens to themwhen they go through withdrawal.” (Participant 2)Some participants identified the dosage form of nalox-one, as well as its effects, as points of anxiety, discom-fort, or even distress. The portability of kits was alsoidentified as a concern by one participant. Despite this,most participants expressed a positive view of naloxone.Gendered violence, alienation, stigma, and the role ofsocial supportWhen asked if they had experienced gender-based dis-crimination when accessing health, naloxone, or harmreduction services, most participants answered no; how-ever, one participant highlighted difficulties resultingfrom a lack of services focused on women:“ … when I got in trouble, and got arrested, the onlyplace in the world that could help me was here …And, it was like there’s not enough places out therefor women. And, prior to me, I was screaming outfor help.” (Participant 4)Even though most participants answered that they didnot experience discrimination in harm reduction con-texts, they did report conflicted self-perceptions overtheir opioid use, strained family relationships, social iso-lation, and instances of violence against women who useopioids. Participant responses painted a sense of collect-ive alienation with regard to their roles as women andtheir place in society:“… I guess I feel that women are supposed to havetheir shit more together or we’re expected to be ofmore moral and more, higher standards than- doyou know what I mean? … Yeah, the motherly fig-ure, right? Like what the hell’s a mom doing shoot-ing up or asking for naloxone, you know?”(Participant 1)Macleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 6 of 15This experience of stigma was reflected in other par-ticipants’ stories of fractured relationships in associationwith their opioid use:“I had a high paying job. I drove a really nice car. Iowned a home. I was a single parent to my daugh-ters. And one by one, I lost, absolutely everything.”(Participant 2)“My daughter, my wife. I’d pick on them, the co-caine would pick on them, the Oxys- or the opiateswould pick on them. And, when I’d be around themI’d be miserable.” (Participant 4)Another participant, who identified as transgender, felther estrangement from her family was due to a combin-ation of disclosing her drug use, and her transition totrans status at an older age:“Yeah it was- it caused a lot of problems and dis-trust and just owning up- you know what I mean? ...afterwards you know my family tried to disown meand, doesn’t want anything to do with me nowpretty much ... and especially now I think that I’veturned trans because I lived [age] as a heterosexualmale and I just started transitioning like 2 years agoso.” (Participant 7)However, these negative self-images and experienceswere not uniform across the study participants; one par-ticipant described her catharsis when her mother was ul-timately supportive of her recovery:“I don’t know how it came out. We were talking,then it went from talking, to yelling, to me scream-ing and crying “I’m a fuckin’ IV drug user!” and mymom’s like “I’m not understanding!” and, I’m like “ISHOOT NEEDLES IN MY ARM!!” and she waslike- then you know, then she broke down with meand then she became my biggest supporter.” (Par-ticipant 1).Participants felt their social lives were deeply affectedby their opioid usage. Some participants avoided disclos-ing their opioid use to others but felt as though theywould inevitably be found out. Others described how so-cial pressures from opioid-using friends or intimate part-ners either initiated or perpetuated their opioid use.Multiple participants described a shift in opioid use overtime; from using opioids with others, such as at parties,towards using opioids in smaller groups or alone. Someparticipants explained this shift as a result of a lack oftrust in people who use drugs, a desire to keep drugs forthemselves, or a sense they would be judged for howmuch they were using, sometimes to a point where theyavoided connections with other people who use opioids.Participants described two instances where perceivedstigma against women who use opioids was so severe asto result in violence. One involved an incident on publictransport:“ … there was this girl, front of the bus, clearly shewas not drunk, she was OD’ing you know what Imean? Like, all the signs were there. The bus driverkicked her. Then he kicked her again. Then he said“Hey- hey you, you damn drunk! You’ve got to getup off my bus.” I said “She’s not drunk. You need tophone 911.” He’s like “How do you know?” I waslike “Cause I’m a junkie you asshole”.” (Participant1).Another participant recounted a violent altercationwith emergency and hospital personnel after her partnerhad suffered a non-opioid overdose while opioids werestill in her system. Medical staff administered naloxone,and her partner went into opioid withdrawal:“As soon as they [medical staff] Narcan’d her, w-well- whatever you call it- all the drugs came out ofher system so as soon as she went through-through- with this- what do you call that, with-withdrawal. Yeah, so she wanted to leave, rightaway, to go and get high. And they wouldn’t let hergo, and so she started like- flipping out and. They[personnel unclear] tied her down, they beat her …she had bruises on her face, everything.” (Participant3).Participants and those around them experienced socialalienation, and often rejection from past support net-works. Participants also described dangerous situationsthey or other women had experienced while using opi-oids. Despite these conditions, participants did not feeldiscriminated against while accessing harm reductionservices, and some participants expressed that theybenefited greatly from the continued support of theirfamilies.Government response to the crisisWhen asked about the municipal, provincial, and federalgovernments’ responses to the opioid crisis, one partici-pant stated it was “kind of disgusting.” (Participant 2).Most participants felt that the response at every level ofgovernment was too slow, and reflected negative publicsentiment surrounding opioid use. When asked whetherthe overdose crisis should be declared a provincial publichealth emergency, nearly all participants thought so,with multiple participants additionally stating theyMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 7 of 15wanted a nationwide, not just provincial, emergency dec-laration. They felt that a lack of desire by politicians tohelp, rather than an inability to help, was making the cri-sis worse:“We live in Canada. We have access to free health-care. And yet there’s people that are suffering. Evenfor rehab, you know? W-we have to wait and go onwaiting lists, and we have to cut through all this redtape. It’s bullshit. Absolute bullshit. Somebodywants help, they want help that day.” (Participant 2).“If they were so concerned, why didn’t they do it awhile ago? Right? Why did people have to die? Anda public outcry, for things to change around?” (Par-ticipant 8).“They’re not down you know working with people,face-to-face, interacting and seeing how manypeople are being affected … they’re very detached.”(Participant 10).Participants were nervous that not enough was beingdone about fentanyl in the drug supply. They felt that alack of adequate opioid addiction treatment services wasresulting in unanswered pleas for help and even deathsof people they knew:“They’re not doing enough at all, they’re not doingenough. My- I had a girlfriend … her nephewpassed away waiting for a bed to get in treatment.”(Participant 1)One participant, who tried methadone treatment, returnedto heroin as she felt the dose was too low. She experiencedsevere withdrawal symptoms and felt she had no support:“They start you off at a really low dose, and becauseI was using such high doses of heroin that I wouldstill feel sick like I would still be like vomiting, mylegs would still ache.” (Participant 3)Participants described how they felt economic issues,when unaddressed by different levels of government,could perpetuate opioid use and keep people at risk ofoverdose. One topic that came up spontaneously frommultiple participants were concerns over housing avail-ability and pricing in the Greater Toronto Area. Nearlyall participants were in precarious housing situationswith limited incomes, giving them a very personalinsight on this issue:“I think the number one problem with the opioidcrisis is that, a lot of it affects homeless people and… they can get better rehab but we put them backon the streets with the same problems in the samesituations, they’re gonna go to what’s known tothem and that’s the drugs.” (Participant 5)“These people don’t necessarily wanna live on thestreet, but there’s nowhere else to go, for them.With disability you only get so much money, andyou can’t afford a house or an apartment, becausethe prices in Toronto’re skyrocketing … you can’tget a- a basement apartment under 800. One-bedroom. A bachelor’s! Like it’s ridiculous. How doyou live? Where do you live? … I was shocked tohear yesterday, since the beginning of December, 70people died on the streets so far … I just think thelower class is getting’ rubbed into the ground now.”(Participant 4)Participant responses were not entirely negative; somepraised the Moss Park initiative, an overdose preventionsite established by activists and peers, in the months be-fore officially sanctioned sites began opening in Toronto.Participants also expressed gratitude for government ap-proval of safe injection sites, which began to open whileinterviews were taking place:“I think it’s amazing that they have safe sites. WhereI come from that’s not an option. Like I said, druguse is very behind closed doors … I think Toronto’staking a good approach to having safe sites. Notonly do people use there, they feel safe there.” (Par-ticipant 1)When asked about the government’s response to theopioid crisis, participants’ responses prioritized ongoing,unaddressed structural causes of the epidemic (e.g., thehousing crisis, perceived stigma, and a dearth of opioidmanagement services) and the lack of motivation by gov-ernment officials to address the issue in a reasonabletime frame or listen to those who are suffering most.Preferred emergency personnel for overdose responseParticipants were asked how they felt about fire services,police services, and paramedics carrying naloxone. Mostfelt all responders should carry naloxone, and some evenwent so far as to say they should be readily available inother public spaces as well.“Everyone! Everyone should be carrying them, youknow what I mean?! They should be in restaurants”(Participant 1)“All of them should have it. One hundred. I thinkthat a lot of cops on bikes should have them too ...Macleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 8 of 15in the summer in Toronto they’re the first one onresponses in the streets ...” (Participant 5)Other participants were unsure about police officerscarrying naloxone, believing what they consider thepunishment-oriented ethos of law enforcement to be atodds with helping people whose drug use iscriminalized.“Obviously the other ones have like some form oftraining in health care or, you know- emergencyand (sigh). They’re more like concerned about, youknow” “Are you okay?” you know are you- like, let’ssave the person whereas law enforcement’s like,“Let’s put you in jail!” (Participant 10)One Indigenous participant reported repeated negativeexperiences with police that made her suspicious of theirability to deliver appropriate help to people sufferingfrom overdose, and, additionally, believed paramedicsoveruse naloxone:“Personally I don’t give- don’t think cops give afuck...I’ve dealt with them before, they don’t give afuck. I’ve been dealing with them since I was 12 ….I just think they would let somebody die whereas, Idunno the ambulance... my partner had somethinghappen to her and it had nothing to do with any-thing to do with drugs or anything and they Nar-can’d her...They are not properly trained...I thinkthey overuse it.” (Participant 3)While some participants were accepting of the possi-bility of having naloxone administered by police, otherswere opposed, especially if they felt their overdose wouldbe punished or treated with indifference.Views on opioid criminalization and legalizationParticipants were asked their views on the legalization ofillicit opioids, and expressed a wide range of opinions,but each framed their responses in terms of which op-tion they felt would best protect others from overdose.For some, this meant supporting current restrictions onhighly potent opioids like heroin, even if they had usedthem themselves. Some viewed the prospect of legalizingall opioids to be a safety measure that would reducestigma and ensure patients know precisely which drugsthey are using:“I think drugs should be legal all the way around. Ithink, or- have it regulated. Like there’s a Europeancountry where people go shoot up pharmaceuticalgrade heroin and they’ve done tests that, you knowthe dr- the crime has gone down in that area and Ithink they should do the same thing here becausewe’re in an epidemic right now, it’s bad.” (Partici-pant 6)“I think the system does criminalize it and it-it’s nothelping, it’s, like, like that whole punishment, likeaspect of things makes you want to do it more,makes you feel worse about yourself, and makes youfeel like “Well there is no hope so why would I stopanyway?” … There should be more help when itcomes to people who have, addiction I mean like atthe end of the day, whether it’s a street drug or apharmaceutical. Most of- all- everyone in our popu-lation use some form of something” (Participant 10)Other participants were torn on the best approach tolegalization; they acknowledged concerns related to opi-oid misuse, while also stressing their importance in painmanagement:“I’m torn because I really believe in thedecriminalization and legalization of pot. I don’t thinkopioids should be legalized for anybody. However, Ifeel like it’s really being a blurred line … I feel likesometimes it’s harder for people who actually needthat to help with their pain.” (Participant 5)“It- it shouldn’t be given out like candy. It should belabeled to cancer patients and only cancer patients,people that are dying ... people that are in massivemassive pain.” (Participant 4)Each participant framed their views on opioid legalizationin terms of what they felt would be the safest option forpeople who use opioids, but these priorities were expressedin many different ways, depending on the individual. Overall,very few participants outright opposed the legalization ofillicit opioids, but not all were in support, either.Unique needs, preferences, and coping methods foropioid useEach participant had a unique approach to processing,managing, or in some cases ceasing their opioid use. Aparticipant, who identified as Indigenous and two-spirit,felt her opioid use had been in conflict with her beliefs,and eventually ceased taking her prescription:“… I’m really spiritual, I follow my ceremonies and stuff.So it- I don’t feel- I would be a hypocrite [if I continuedto take opioids], you know?” (Participant 8)One participant expressed a positive view of her opioiduse in the face of multiple chronic illnesses, explaininghow opioids helped her to live a more normal life:Macleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 9 of 15“Oh! I could run, I could jump, I could do what Iwanted to do!” (Participant 4)Some participants felt completely overwhelmed by theimpacts their opioid usage had had on their lives:“It sucks it’s like a full time job it’s like you alwayshave to have your next dose ready or this or thatand you have to deal with being sick and. It’s con-suming.” (Participant 5)An older participant acknowledged the negative im-pact her opioid use had on her life, but explained howshe had come to accept the way her experiences hadshaped her life:“… it’s like a waste of my life kind of thing youknow but without that experience I wouldn’t be theperson I am now. You know what I mean?” (Partici-pant 7)Participants did not represent a monolith, and eachhad unique experiences and needs when it came to liv-ing with their opioid usage.DiscussionThis study is the first in Canada outside of BritishColumbia, and one of a limited number internationally,to specifically examine the experiences and policy per-spectives of women who use opioids in the context ofthe current opioid overdose epidemic. This study alsoaddresses a gap in knowledge within Canadian naloxoneresearch. The research, conducted with people who useopioids directly, is in line with the priorities laid out inthe Toronto Overdose Action Plan [72] and other Can-adian opioid research indicating the perspectives ofpeople who use opioids requires additional attention [6,60], and wider calls for additional opioid research involv-ing women [7]. In examining both individual circum-stances, experiences, and viewpoints, we garnered agreater understanding of the risk environments faced bywomen who use opioids, and where current approachesmay be insufficient [13]. Such research also has implica-tions for governments and organizations considering theimplementation of naloxone kit programs and otherharm reduction services, to ensure these services meetthe needs of women.Nearly all participants found the Canadian federal andprovincial governments’ responses inadequate in ad-dressing structural influences on present-day opioid use,such as lack of affordable housing, widespread socialstigma, and a lack of other opioid services. This inactionhas been repeatedly criticized in the literature [6, 60]and our findings reiterate perceptions of governmentneglect and ongoing suffering. Previous limited researchon women’s opioid use in Ontario indicates a high men-tal health burden [17] and a higher instance of deathfrom intentional overdose [18], in addition to previousresearch indicating high mortality from overdose amongpeople with criminal justice involvement [48–51]; pairedwith our findings, we can begin to understand what isdriving these vulnerabilities, especially among partici-pants who engaged in opioid use at the time of study. Alack of rapid or broadly-focused interventions left partic-ipants in this study feeling ignored and undervalued.The issue of stable housing raised in opioid studies inthe US and British Columbia [9, 10, 46, 61] was reflectedin our study population. Participants felt the local riskenvironment in Toronto [13], involving rising rents andhomelessness, and low incomes or disability payments,would hamper overdose prevention or opioid treatmentefforts. As well, many of our participants struggled withsocial alienation, and described a shift over time to usingopioids alone, which is a significant known risk factorfor opioid overdose [62, 63], particularly in Toronto,where most overdose deaths have occurred when peoplewere by themselves in their own homes [14]. Participantreasons for using alone developed in complex ways andmirrored findings of other research on solo opioid use,where a lack of trust in peers, or shame over drug use orthe amount of drug used, drove them to avoid using opi-oids with others [64]. Participants praised naloxone andthe existence of overdose prevention sites, including theunsanctioned Moss Park overdose prevention site, as ef-fective harm reduction interventions. In research pub-lished since this study was conducted, support for thisunsanctioned site has only been reified by people whouse drugs in Toronto [15]. However, both the life cir-cumstances and views of our participants indicate,alongside relevant literature, the need for a dramaticallyscaled-up government response at the provincial andfederal level. Concerns around safety were also reflectedin descriptions of stigma and violence witnessed by someparticipants on public transit or in health care settings,indicating a potential need for greater supports forworkers in public service environments that are morelikely to encounter people experiencing an opioid over-dose in a public setting. This could include providingworkers with additional tools and education on overdoseresponse and non-violent intervention methods, as wellas implementing prevention efforts that lower the likeli-hood of overdose in the first place.While multiple provinces have established take-homenaloxone kit programs through pharmacies and commu-nity health services, with positive results on a programlevel, high numbers of opioid overdose deaths have per-sisted in Canada [67, 68]. Variabilities in naloxone accessand knowledge have the potential to impact itsMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 10 of 15effectiveness [69, 70]. Only 56% of participants in a re-cent large survey of formerly incarcerated men andwomen in addiction treatment in Michigan correctlyidentified naloxone as an opioid overdose antidote [71].These variabilities by region, demographics, and throughthe naloxone use cascade, all highlight a need for furtherresearch into specific groups who use opioids, to deter-mine how they acquire naloxone knowledge or perceivenaloxone use.In the mid-2010s opioid overdose deaths and fentanylpoisonings increased significantly and naloxone becameavailable over-the-counter [82]. The differences we ob-served in naloxone experiences for women who usedillicit drugs more recently could have been generated byeither increased naloxone access or from the increase inoverdoses and overdose risk (e.g., uptake in naloxoneeducation and acquisition among participants). Whilewe cannot say definitively that the scheduling changeallowing for over-the-counter naloxone access was theimpetus for increased awareness and/or use of naloxonethis is an important area of inquiry for future research.Naloxone research in the United States with majority-male samples, for instance, has shown current opioiduse, witnessing an overdose, and recent non-fatal experi-ence of overdose were associated with greater naloxoneknowledge and possession of a kit [83, 84]. The oppor-tunity for peer-led support in this study populationneeds to be highlighted, as women often learned aboutnaloxone through informal social networks, instead ofthrough health care providers. Though naloxone use waswidely supported by participants, they preferred smaller,portable, needle-free forms such as Narcan®, a naloxonenasal spray that became available in Ontario after thestudy was conducted. The findings also revealed whatwomen felt was an unmet need for appropriatenaloxone-induced withdrawal aftercare and reduction inwait times for opioid treatment services. Only a few re-cent studies with majority-male samples have examinednaloxone-induced opioid withdrawal, but the findingsare also consistent with those of our study [73–76]. Par-ticipants in these studies often felt unable to provide ap-propriate care for someone experiencing acute opioidwithdrawal symptoms. Naloxone’s lifesaving qualitiesshould not overshadow issues around precipitated opioidwithdrawal, both in public health interventions, policy-making, and in its use by medical or emergencypersonnel. One of our participants described using add-itional opioids after naloxone-induced withdrawal madeher sick and distressed, putting herself at risk for a re-peat overdose, but also demonstrating the limits ofOntario’s current approach to naloxone. To our know-ledge, Canadian interventions involving post-overdosesupport for acute withdrawal have yet to be studied.While some of our participants began carrying naloxoneout of a sense of responsibility to their community,others, usually those who had not engaged in recent opi-oid use, were much less familiar with naloxone and notinterested in carrying a kit. A qualitative study involvingsex workers in Vancouver stressed the emotional toll offrequently being expected to administer naloxone to cli-ents who use drugs [12], and along with our results, wecan see how widespread naloxone possession as a well-intentioned public health goal, in the absence of broaderoverdose prevention or aftercare interventions, shifts anundue burden of care onto individuals who may not al-ways be ready or able to provide assistance. Naloxonedoes not address the steps leading up to an overdose,and our study revealed difficulties women can haveusing this method of last resort despite their positiveviews of the antidote and its ease of access.Indigenous-identifying participants in our study wereall opposed to police services responding to an overdoseand administering naloxone, which is consistent with In-digenous experiences of police discrimination in Canada[65] and with the positive results of a community-developed opioid treatment intervention study in aNorthwestern Ontario Indigenous community thatavoided a police-based approach [66]. Non-Indigenousparticipants also expressed opposition to police adminis-tering naloxone. This skepticism is also apparent in thefindings of the Toronto Overdose Action Plan, where89% of survey participants felt it would be of large orvery large benefit for police not to attend overdose calls,and citing Vancouver as an example of a city that hasimplemented a policy in this vein [72]. Harsher punish-ments for people who use opioids in the form of stricterdrug-induced homicide laws and mass incarceration, inthe United States, have worsened the health and well-being of incarcerated people who use drugs [54], andthis view was mirrored in participants who opposed po-lice as emergency overdose responders. Fear of punish-ment by law enforcement can cause people who usedrugs to avoid calling 911 during a medical emergencysuch as an overdose [54, 72]; these fears largely relate tothe ongoing criminalization of drugs such as illicit opi-oids. Opioid criminalization is also reflected in the reluc-tance by the Ontario government to open additional safeconsumption sites [55, 56], despite other research indi-cating such sites lower overdose deaths [57]. Our partici-pants expressed a wide variety of views on the questionof opioid legalization, with some in full support ofdecriminalization as seen in other countries, such asPortugal [58, 59]. Other participants were completelyopposed to the legalization of high-potency opioids suchas heroin even if they currently or previously used itthemselves, as they felt it would enable or endangerpeople who use opioids further to have easier access.Multiple participants were unsure which stance to take.Macleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 11 of 15All participants framed their preferences, in terms ofwhat would provide the safest environment for peoplewho use opioids, as opposed to what they personallywanted, showing concern for their community. Somespoke openly in support of safe consumption sites, eventhough they were not asked specifically about them be-cause none had yet been approved and opened in To-ronto at the time of the study. Based on the participants'responses, a similar community-based approach to theaccessible opioid substitution treatment described inKanate et al. [66] may benefit Indigenous women whouse opioids in Toronto.Delivery of opioid-related services to women will needto consider the unique needs of women, especially thosewho experience criminal justice involvement [85]. In apaper about women in correctional settings the au-thors described five guiding principles that are gender-responsive and designed to support women with crim-inal justice involvement [85]. These include a recogni-tion that gender differences affect pathways toincarceration; that safety, respect and dignity are criticalcomponents of policy, programs, and services designedto support and enhance connections to children, signifi-cant others and the community; and that services shouldbe holistic, culturally relevant and enhance women’sability to be financially self-reliant. Racially diverse andgender and sexual minority women require special con-sideration given their overrepresentation in prisons [86].Wright et al. [43, 87] echo the need for services to beappropriately responsive to the specific needs of women(gender-responsive framework). This starts with anawareness of the distinctive experiences of women, in-cluding pathways to criminal activity and the ways theirlives are shaped by relationships.Our study was designed with the aim of addressing theknown gap in up-to-date qualitative research on womenwho use opioids and naloxone, particularly in Canada.However gaps do persist in research on Canadianwomen who are not White, rural women, women inCanadian cities outside of Toronto and Vancouver, andincarcerated women who use opioids.Participants overall showed great awareness of the im-pacts of the opioid overdose epidemic on their commu-nities and lives and coped with their opioid use inunique ways. While participants faced many commonstructural issues such as economic and housing precar-ity, opioid-specific issues such as social stigma, and over-dose risks, the decision to continue or stop takingopioids also varied based on their beliefs, their access toaddiction management services, and their personal cir-cumstances. In light of the legalization of cannabis underCanadian federal law, which has implications for howCanadians manage pain [88], it is important to considercomplex individual factors and comfort levels whendiscussing pain management practices, overdose preven-tion methods, and opioid use treatment or managementwith women who use opioids.LimitationsThis study has both strengths and limitations. While thesample size was small, this was a pilot study set in anurban environment and the first to explore women’s ex-periences of opioid use in the context of widespread na-loxone use during Canada’s opioid overdose epidemic.The women in the study were mostly older and White,and as such, the experiences of people of younger and ofethnically diverse populations are missing from thisstudy, however a portion of the sample was Indigenousand their specific experiences are captured. Regardless,the themes that emerged from this study may not reflectall women who experience criminal justice involvementand opioid use. The sample was entirely low-income,and so did not account for the opioid- or naloxone-related experiences of middle- or high-income people,however the researchers and participating communityorganization were particularly interested in understand-ing opioid and naloxone experiences among this popula-tion. These missing perspectives are still needed inresearch so long as there is an opioid overdose crisis af-fecting their health outcomes and personal wellbeing.The study was conducted from January to April of2018, and may not reflect changes or policy develop-ments that have occurred since. Cannabis legalization,the introduction of Narcan® nasal spray, and the expan-sion of safe injection sites are all changes that have oc-curred in Toronto and now affect women who useopioids there. Overdose prevention sites, appropriateemergency response measures, and opioidcriminalization remain contentious political issues, andopioid overdose deaths remain a regular occurrence.Despite its limitations, the snapshot provided by thisstudy continues to be relevant within Canada’s currentpublic health context.ConclusionIn conclusion, difficulties concerning opioid-relatedstigma from families and strangers, naloxone-related dis-comforts, economic barriers to health and housing stabil-ity, and complex individual life experiences, all affect thehealth and safety of women who use opioids. Future,Canadian opioid policy must account for women’s needsaround naloxone and beyond in order to prevent add-itional overdose deaths. This includes adequatelyinforming people who use opioids on all forms of nalox-one available to them, expanding access to timely mentalhealth, opioid- and overdose-related care, assisting withthe formation of new social support networks amongwomen who use opioids, providing housing to people inMacleod et al. Substance Abuse Treatment, Prevention, and Policy (2021) 16:26 Page 12 of 15economic precarity with complex health needs, keepingsafe injection sites open and opening additional sites,and educating not just the public but policymakers andhealth professionals on opioid-related stigma that maystereotype women who use opioids and deny them dedi-cated, individually-tailored support. Further, research onwomen in Canada who use opioids and naloxone, espe-cially ethnically diverse women, Indigenous women, andwomen in rural areas, is necessary. Current research, in-cluding this study, supports the rapid implementation ofthese recommendations.AbbreviationsGENOA: Genetics of Opioid Addiction study; CBPR: Community-basedParticipatory ResearchSupplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s13011-021-00360-3.Additional file 1: Qualitative interview guide.Additional file 2: COnsolidated criteria for REporting Qualitativeresearch checklist.AcknowledgementsThe authors are grateful to the participants for their willingness to share theirstories and to the Elizabeth Fry Society Toronto for their collaboration on thestudy. The study was supported by MAP Centre for Urban Health Solutions,St. Michael’s Hospital. It was also supported by the Human BiologyDepartment and Dalla Lana School of Public Health at the University ofToronto, Ontario.Description of the research team:The interviews were conducted by a research team member (ERM) who wasan upper-year undergraduate student at the time of the study. Her super-visor (FIM) at the time of the study is a Sociologist who specializes in pris-oner health. An Indigenous co-author (NL) participated specifically in theanalysis of data from Indigenous participants, offering insight and assistanceto understand cases where their responses diverged. Other research teammembers (JLW, SH-W) are specialists in Psychology and Geography,respectively.Authors’ contributionsERM and FIM contributed to the intellectual content of the paper, in theform of conception and design. ERM generated the first draft of themanuscript supported by FIM. All authors participated in critical revision ofthe manuscript for intellectual content. NL contributed to the analysis ofIndigenous qualitative data and to the Indigenous intellectual content. Allauthors had full access to all of the data in the study and take responsibilityfor the integrity of the data and accuracy of the data analysis. All authorshad authority over manuscript preparation and the decision to submit themanuscript for publication. All authors read and approved the finalmanuscript.FundingThis study was unfunded.Availability of data and materialsAll data generated or analysed during this study are included in thispublished article.DeclarationsEthics approval and consent to participateParticipants provided informed verbal consent. This study was approved bythe Research Ethics Board at St Michael’s Hospital.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1MAP Centre for Urban Health Solutions, St. Michael’s Hospital, 30 BondStreet, Toronto, ON M5B1W8, Canada. 2Elizabeth Fry Society Toronto, 215Wellesley Street East, Toronto, ON M4X 1G1, Canada. 3School of Populationand Public Health, University of British Columbia, 2206 East Mall, Vancouver,BC V6T 1Z3, Canada. 4Dalla Lana School of Public Health, University ofToronto, 55 College St Room 500, Toronto, ON M5T 3M7, Canada.Accepted: 4 March 2021References1. Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The burdenof opioid-related mortality in the United States. JAMA Netw Open. 2018;1(2):e180217. https://doi.org/10.1001/jamanetworkopen.2018.0217.2. Kenney SR, Anderson BJ, Conti MT, Bailey GL, Stein MD. 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“They’re not doing enough.”: women’s experiences with opioids and naloxone in Toronto
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