Bridging the gap in harm reduction using Mobile Overdose Response Services (MORS) in the context of the COVID-19 pandemic: A qualitative study.

The COVID-19 pandemic introduced a myriad of challenges for accessing healthcare services, especially for people who use substances (PWUS). Numerous supervised consumption sites (SCS) across Canada faced shutdowns and reduced operating capacity in order to comply with public health measures, which has exacerbated the mortality rates associated with opioid toxicity. In an effort to reduce the harms associated with these dual public health crises, Mobile Overdose Response Services (MORS) were introduced to allow PWUS to consume substances under virtual supervision. Here, we examine the role of MORS in the context of the pandemic. A total of 59 semi-structured interviews were conducted with relevant interest groups, including PWUS, health care providers, harm reduction workers, and operational experts. Major themes and subthemes were identi�ed using inductive thematic analysis informed by grounded theory. Overall, participants felt that the COVID-19 pandemic shifted the public focus away from harm reduction and neglected the needs of PWUS. MORS were regarded as a useful tool to mitigate the closure/reduced capacity of physical SCS, prevent the transmission of COVID-19, and help alleviate the prevailing sense of isolation during public health crises. MORS were seen as a useful and much-necessary adjunct service to address the unmet needs of physical SCS during the pandemic and beyond.


INTRODUCTION
In the last decade, North America has seen an unprecedented rise in fatal drug overdoses primarily involving unregulated synthetic opioids (e.g., fentanyl, carfentanil) and adulterants (e.g., benzodiazepines, xylazine) 1,2 .One evidence-based harm reduction strategy aimed at curbing such mortality rates is supervised consumption sites (SCS), also known as safe injection sites or overdose prevention sites.SCS are safe and regulated spaces where people can consume drugs under the physical supervision of trained staff 1 .They may also provide clients with safe drug supplies, education on safer substance use, access to social services, and more 1 .To date, there have been no fatal overdoses in any of the 38 SCS operating in Canada 2 .
Public health measures in response to the COVID-19 pandemic restricted access to SCS due to various factors, including reductions in operating hours/capacity, sta ng, and outright closure, driving many who previously had access to SCS to use substances in high-risk environments 1,3 .For instance, decreased visits to physical SCS in Vancouver during the pandemic have been positively associated with greater illicit fentanyl use 4 .Moreover, isolation measures and gathering restrictions ran contrary to public health messaging before the pandemic in which people who use substances (PWUS) were directed to "never use alone", heightening the already disproportionate mortality rate seen within this population 2 .
Even with resumed operations of SCS post-pandemic, many provinces across Canada contend with the highest mortality rates seen since the opioid crisis.Though these restrictions are now removed, SCS continue to face limitations that deter PWUS from utilizing the services, including limited hours of operation, fear of altercations with the police/law enforcement, and lack of transportation, necessitating the continued development of novel approaches to harm reduction 5,6 .Indeed, the majority of fatal overdoses occur in private residences 7 .In light of this, more comprehensive overdose prevention tools are needed, especially in rural and remote areas where SCS are challenging to access or do not exist at all 2,8 .
During the pandemic, "spotting" gained popularity as grassroots, alternative harm reduction method that enabled PWUS to consume substances under the virtual supervision of others (e.g., phone calls) 5 .One of the advantages of spotting is that it offers autonomy in overdose response planning since PWUS often rely on friends or their loved ones to monitor them during use (for instance, such a plan may not need to involve emergency services) 5 .Previous literature has examined the bene ts and limitations of informal spotting among PWUS; however, we are unaware of studies that have qualitatively examined formalized virtual interventions in the context of isolation, the pandemic, and public health measures.Mobile Overdose Response Services (MORS) are novel technologies to prevent overdoses, especially for those who use substances alone.Several MORS are currently available in Canada 9 , including a national overdose prevention hotline (the National Overdose Response Service, NORS) and BRAVE.Within the United States, a hotline service known as Never Use Alone (NUA) provides similar services.These lines often connect clients to an operator that dispatches emergency medical services or a community-based response to the overdose site if the individual becomes unresponsive.British Columbia and Alberta have both implemented automatic countdown-based mobile applications such as Connect by LifeGuard and the Digital Overdose Response Service (DORS), respectively, which initiate an emergency response if the individual is unable to shut off or renew the application timer.The e cacy of these interventions is yet to be determined, but a summary of other services has been recently highlighted in a systematic review 10 .
These services can potentially remove key barriers and extend the reach of harm-reduction resources 6 .
With increasing reliance on telemedicine and virtual modes of interaction, it is imperative to understand the value of these formal spotting technologies (MORS) among PWUS in the context of isolation or pandemic measures.The aim of this study was to qualitatively explore the role of MORS during COVID-19 to better inform the provision of these virtual technologies going forward in future public health emergencies.

METHODS
This exploratory qualitative study was designed to examine the perspectives of various key interest groups on how MORS could support PWUS during the COVID-19 pandemic or similar public health emergencies.This Canada-wide study was open to individuals who were 18 years of age or older, able to communicate effectively in English, able to provide informed consent, and with access to a mobile device.Participants were all familiar with MORS and were recruited through a combination of snowballing and convenience sampling using pre-existing networks.Verbal informed consent was obtained with assurances that all information provided would remain con dential and anonymous.Supplementary mental health and addiction support were offered in case participants became distressed during the interviews (no participants accessed these supports).
The interviews were conducted between November 2021 and April 2022 by evaluators from a third-party research organization specializing in qualitative research.The evaluators and interview participants had no previously established relationship with each other and were the only individuals present during the call.The telephone interviews ranged from 20 to 60 minutes, and all participants were provided with a brief verbal overview of various MORS and spotting prior to the interview to ensure a baseline understanding of the services.Honorariums were provided to people with lived experience in the amount of $50.00.Other key informant groups were not provided an honorarium.TapeACall was used to record the interviews, and a third-party transcription service was used to transcribe the data.
The interview guide was created in collaboration with MORS operators, individuals with lived and living experience of substance use, and the research team.It was mostly informed by questions from various government and health o cials on how best to support PWUS during the pandemic.Inductive thematic analysis informed by grounded theory was utilized to identify major themes and subthemes that re ect the perceptions of participants regarding MORS and their relevance during the COVID-19 pandemic 11,12 .Member checking was conducted by sharing a paper format of the key themes with the participants to ensure that the data accurately re ected the perspectives of relevant parties.Two evaluators (SJ and LA, both with master's level training in qualitative methods) used Dedoose software to code the transcripts.
Both evaluators collectively inspected the rst three transcripts to ensure alignment between various identi ed themes.Thereafter, they coded the transcripts independently using a jointly created codebook, with each evaluator coding approximately half of the transcripts.Throughout the process, each evaluator reviewed the transcripts coded by their counterpart through Dedoose and communicated to ensure the coding was in line with the identi ed themes.Coding discrepancies were discussed between the two evaluators and the principal investigator (MG) to ensure consensus if disagreement remained.Once initial coding was complete, the two evaluators reviewed a representative sample of coded quotations for each theme with a consulting project manager (KM, with master's level training in qualitative methods).
Interviews were conducted until thematic saturation across all participants was reached based on the consensus of the two evaluators, a consulting project manager (KM), and the principal investigator (MG).
The work was supported through funds from a Health Canada grant whose mandate was to look at the effects of the pandemic on harm reduction resources.We used the Consolidated Criteria for Reporting Qualitative Research

RESULTS
The 59 semi-structured interviews included 25 individuals with lived or living experience of substance use, 10 health care providers, 12 harm reduction workers and MORS operators, and 12 members of the public.The following key themes pertaining to the use of MORS during COVID-19 were identi ed: shift in public health priorities, transmission of COVID-19, closures and reduced capacity of SCS, quarantine and self-isolation practices, as well as an opportunity to bridge the gap in mental health services for PWUS (Figure 1).Theme 1: The COVID-19 pandemic brought unforeseen changes to public health priorities, potentially neglecting the needs of PWUS.
Participants believed that the onset of the COVID-19 pandemic brought a sudden halt to the already scarce harm reduction initiatives.They felt that the public health focus did not take into account the needs of vulnerable populations which brought negative outcomes particularly amongst PWUS, harm reduction advocates, and front-line addiction workers.
"I think COVID had kind of caused this issue to take a backseat.Where I feel like three years ago we were really starting to get into it.And it was really starting to kind of like go towards the right direction.And then suddenly it's like oh pandemic, let's focus on that.Where this problem isn't going away.Mental health is at its all-time worst.Substance abuse is at its all-time worst.People's necessity to escape the world around them is probably at an all-time high."(Member of the Public) The repercussions of the pandemic also worsened the health quality and wellness of PWUS.Several respondents emphasized how it contributed to the distribution of a more toxic supply of substances, creating "a new element of danger" (Community Harm Reduction Worker).
Theme 2: MORS can effectively serve as an adjunctive harm reduction service to compensate for the reduced operating capacity and closures of SCS.
The utility of MORS may have gained signi cant momentum during the pandemic by providing a virtual spotting service and removing the need to locate a physical site.Many expressed frustrations towards the reduced operations and capacity of SCS to prioritize social distancing measures.This ultimately resulted in individuals waiting longer in line than usual to consume substances, or even using alone.PWUS also felt apprehensive about contracting the virus, which convinced many to use substances alone in their home or private residence.Both PWUS and MORS operators felt that the use of MORS was preferable to using substances alone.
"The Safe Consumption site I was going to, they did cut back the amount of number of people -of people you can go in there to use…So, I ended up going there and waiting for three hours -two, three hours -to get in to use.And most of the time, I'd just end up being like, "F** it," and going to use on the street or going home…I de nitely used to go in person way more to use before COVID, because they had more availability for people to go in there, so." (PWUS) "With COVID-19 […] a lot of people are sitting in their own homes, a lot of people are not accessing supervised consumption service for various reasons […] there was a reduction in capacity […] a lot of booths were shut down, every other booth was open, which led to long lineups.A lot of people were worried about going into these sites, because they were afraid of being exposed to COVID […] So many of them were using alone at home, or not interacting or engaging with other individuals, which they should be doing in order to keep themselves alive."(MORS Operator) "With all the restrictions that come along with COVID […] like at our site we're only allowed 10 people in at a time and so if it's minus 50 you don't want to have to wait outside in the cold to consume or waiting to consume while other people inside are consuming, you know?[…] COVID has made people very paranoid, in some ways, to be around other people and whatnot.So at least this way, yeah, you're in the comfort of your own home, you know the whole cleanliness aspect of it, the whole sanitized, you know what's happening in your house and who's in your house.So, I de nitely think that COVID would contribute to people wanting to just be able to do it virtually."(Community Harm Reduction Worker) While pandemic-related public health measures (e.g., gathering restrictions) were deemed necessary to curb the transmission of COVID-19, this posed additional risks for PWUS who were more likely to consume substances alone.It was felt that MORS could be used to minimize the risk of overdose associated with solitary use."People didn't want to go out and so it would be, in their mind perhaps, safer to use the app or make the phone call instead of having to go out of their homes and go to an actual site, or use with their buddies.You know that maybe they didn't want to use it with their buddies because of the fear of COVID."(PWUS) "I think they're [MORS] super important.I think they're lifesaving.I think especially with COVID that they are more important, now more than ever, especially with people, you know, consuming drugs now at home, rather than out, because there are restrictions."(Member of the Public) Theme 4: MORS were seen as a novel way to mitigate the sense of isolation experienced by PWUS during the pandemic.
During the interview, participants noted the complex interplay between isolation, mental health, and substance use.There were suggestions that MORS could help rekindle social relationships and mitigate the sense of isolation with services such as NORS and BRAVE, which are facilitated by operators with lived experience of substance use as opposed to the automatic countdown services like LifeGuard and DORS.Participants noted that the hotline-based services encouraged a sense of connection within the community by providing "follow-up support, [with] someone who was non-judgemental […] it's just nice to hear someone's voice when you're worried if you're going to live or die" (PWUS).
Theme 5: The pandemic shifted the way virtual supports in harm reduction were viewed and accepted.
Many participants stated that the pandemic escalated the overall awareness and acceptability of MORS by normalizing the use of technologies and online services, especially regarding healthcare delivery.
"Through COVID it's kind of enlightened everybody that everything doesn't have to be in person.Virtual is now somewhat normal for people.So, whereas even three years ago the thought might have seemed a little bit silly, or like there wouldn't be uptake on it, but now I think everybody is more in tune with virtual services of different sorts."(Member of the Public) Conversely, some participants believed that the pandemic did not necessarily ramp up interest among PWUS in using MORS.One participant cited, "A lot of vulnerable people, although they are aware of COVID-19, they don't necessarily let it affect their lives" (Healthcare Provider).Thus, interviewees felt that COVID-19 would not necessarily be a strong determinant in whether or not PWUS would opt for MORS, especially for those in a state of drug-seeking."I think COVID has de nitely thrown in you know that physical divide.Where you're probably doing a lot more on your own.And I think a lot more people due to the fact that you know we are in COVID.There are a lot more Zoom activities.A lot more of our world is now virtually based.So, I would say that would probably cause a lot of people to be more comfortable than they used to be with virtual services."(Member of the Public) "I don't think that that [COVID] would be a factor [to use MORS] when you're in a state that you're drugseeking.I think COVID is the last concern that you have."(Healthcare Provider) "I think it doesn't matter what's going on in the world, if I need the services and I don't want to die it doesn't matter if it's COVID or not."(PWUS) Theme 6: MORS continue to contend with concerns surrounding privacy and con dentiality.
Despite the ability of some MORS to offer peer connection during periods of isolation, some individuals preferred to use automated app versions to protect their privacy and identity.When asked if they would be open to using MORS during the pandemic, some already had other reliable systems in place to support them, including access to a spotter or physically supervised consumption site in order to mitigate the risk of overdose while using alone."I don't think so.[…] I got my pastor and I talk to him and I'm kind of a pretty private guy and I don't like everybody knowing what I do."(PWUS)

DISCUSSION
To our knowledge, this is the rst study to examine the perceptions of various key interest groups across Canada towards MORS during the COVID-19 pandemic.Figure 1 illustrates some of the challenges faced by PWUS during this time, when the federal government and local jurisdictions implemented rigorous public health measures that included social distancing, travel restrictions, and closure of non-essential businesses and services 13 .SCS across Canada were also subjected to these guidelines, often shutting down or reducing capacity in order to accommodate physical distancing and other measures 1,14,15 , resulting in a sharp spike in overdose deaths that spanned the breadth of demographics 16 .Populations facing homelessness and substance use disorders (SUD) were particularly affected 17,18 , as they faced isolation and loss of community support that drove many to use substances alone 15 .Participants in the current study described how the pandemic shifted public health focus away from the drug poisoning crisis, leaving many to feel abandoned without access to equitable health and harm reduction services.Moreover, pressure to create more easily transported substances and reduce costs led to a less reliable drug supply lled with a greater number of adulterants 13,14 .The potency of substances increased in variability in ller content, altering drug tolerance and heightening the risk of fatal overdose 13 .Some interviewees expressed concerns about contracting the virus while waiting in line or consuming substances indoors or con ned spaces where others were present.The fears expressed by participants surrounding COVID-19 contraction are warranted, as these groups are more susceptible to adverse health outcomes due to substance use-related immunosuppression and concomitant lung diseases 13,19 .Opioidinduced respiratory depression can also heighten the severity of hypoxemia associated with COVID-19 pneumonia 19 .As MORS allows autonomy and freedom to use substances in a private residence, the authors believe (and participants felt) that they are a useful adjunct service that can minimize risks to the physiological health and safety of PWUS, especially those with chronic conditions.
Our study highlighted the various ways in which MORS may support PWUS not only as a life-saving intervention but to alleviate the sense of isolation and worsened mental health in general.The hotlinebased services are particularly aimed at assisting individuals in accessing harm reduction when access was limited by closures or reductions in services.In contrast, automatic app-based services such as LifeGuard and DORS were seen as more limited in their capacity to create connections in reducing isolation.Nonetheless, the authors are aware that many automated app-based services do provide lists of resources that might prove useful.The ability of MORS to offer mental health services during a public health emergency is signi cant, given the toll of the pandemic on mental health and associated increases in substance use 13,20,21 .
Reliance on telemedicine grew substantially during the pandemic, with an estimated 24-42% of physician services in Canada being offered virtually at some point 22 .Addiction and SUD treatments were not exempt to this trend [23][24][25] .Although the technique of "spotting" is not new and predates the COVID-19 pandemic, MORS have been deemed a much-needed service to complement these physical sites in dealing with public health measures and increased prevalence of solitary substance use 5 .It is our belief that the pandemic may have accelerated the utilization and acceptability of MORS, and this is supported by the ndings of this study.
PWUS often hesitate to call an ambulance in the event of an overdose due to potential repercussions including arrest, eviction, loss of child custody, and more [26][27][28] .Concerns around privacy and con dentiality also serve as a deterrent in utilizing SCS 29 .It is no surprise that some PWUS preferred MORS due to the level of anonymity that they offer, and should be thoroughly considered in the future provision and improvement of these services.
The authors believe that the pandemic opened the door to more innovative strategies to help spur the scalability of other virtual harm reduction services.Even though Canada has lifted COVID-19 measures as of 2022 30 , it is worth noting that the unique bene ts of MORS might be applied to other circumstances in which physical and social isolation becomes necessary .With the recent outbreaks of Shigella 31 and other infectious diseases that require supportive isolation, MORS could serve as a useful tool in ensuring the safe use of substances while alone.
The general consensus among participants that MORS are a viable strategy to address the drug poisoning crisis while limiting the spread of COVID-19 is encouraging.That said, the authors believe that MORS should not be a replacement for other harm reduction methods that are more widely studied like the SCS, overdose prevention sites, outreach programs, and needle exchange programs.These programs have a long, proven track record for safety and effectiveness.Rather, MORS should be regarded as adjunct services that might be scaled as needed particularly during pandemics and other public health crises in order to minimize morbidity and mortality associated with substance use.MORS also may retain utility outside of public health emergencies amongst groups that do not or cannot access SCS.
Strength, Limitations, and Future Directions One strength of this study is the large sample size that engaged the perspectives of various key interest groups.However, the use of snowball sampling through existing networks may have introduced a selection bias.The study also required participants to have access to mobile devices or access to a phone and be familiar with MORS; thus, we captured the opinions of a speci c subset of PWUS in Canada.This study also did not address other virtual harm reduction technologies currently on the market including wearable devices, bathroom sensors, and overdose buttons.A future nationwide study with a large sample size (particularly PWUS) and the inclusion of more interest groups could enhance the usefulness and generalizability of these ndings.

CONCLUSION
The dual crisis of the COVID-19 pandemic and the opioid epidemic has been detrimental to PWUS and the harm reduction community at large.MORS may be useful in mitigating some of these concerns by reducing solitary use and possibly the spread of COVID-19 and other infectious diseases.Future research should consider how hotline-based services may reduce isolation for service users outside of a pandemic environment, particularly for those who may be hiding their substance use from their support systems.There remains a need to demonstrate the effectiveness of MORS quantitatively.

Declarations
(COREQ) checklist to report the results.The study complies with the Tri-Council Policy Statement for Ethical Conduct for Research Involving Humans (TCPS 2) and the Helsinki Declaration.It was approved by the University of Calgary Conjoint Health Research Ethics Board (REB21-1655).

Funding
Health Canada's Substance Use and Addictions Program (SUAP) Grant [Agreement Number 2122-HQ-000021] and the Canadian Institutes of Health Research (CIHR) Grant [Funding Reference Number (FRN)