Endocarditis among people who inject drugs: What do prevention and treatment look like?

Endocarditis is a serious heart infection that is on the rise among people who inject drugs in Canada. This article will explore what we know about endocarditis among people who inject drugs, discuss how challenges associated with treatment are causing harms, and provide an overview of strategies and approaches that service providers and agencies can take to reduce harms and improve supports for people who inject drugs.

What is endocarditis and what is happening among people who inject drugs in Canada?

Endocarditis is a life-threatening infection of the inner lining of the heart and its valves.¹ Symptoms of endocarditis can be different for different people. They may appear suddenly or develop over time. Potential symptoms include chest pain; nausea; shortness of breath; fever; cough; fatigue; swelling of the abdomen, legs, or feet; and a fluttering or a murmuring sound in the heart.^1,2 Previously, endocarditis was primarily seen among older people or people with a compromised immune system.³ However, it is now increasingly common among people who inject drugs, who are generally younger.³

Evidence indicates that rates of endocarditis among people who inject drugs have increased sharply in Canada in recent years. In New Brunswick, cases of endocarditis associated with injecting drugs increased from 2.28 cases per 100,000 in 2014 to 4 cases per 100,000 in 2017. ⁴ In Manitoba, rates of endocarditis among people who inject drugs increased from 0.11 per 100,000 in 2004 to 2.87 per 100,000 in 2018.⁵ Among people with an opioid use disorder in Ontario, there was an 167% increase in cases of endocarditis between 2013 and 2019.⁶

Medical treatments for endocarditis are effective, and people who use drugs often have better short-term outcomes following treatment than people who do not use drugs.⁷ However, their survival rates in the immediate year or two after medical treatment are poor because of endocarditis re-infection or complications and drug poisoning.^2,8 This means that even though a person’s infection has been treated, underlying factors that increase their risk of infection and drug poisoning death remain unaddressed. Improving supports provided during and following endocarditis treatment may help to improve longer term outcomes for people who use drugs.

What causes endocarditis among people who inject drugs?

Among people who inject drugs, endocarditis is often caused by bacteria called Staphylococcus aureus,³ which are commonly found on the skin and in the mucous membranes of the throat, mouth and nose. These bacteria can cause endocarditis when they enter the bloodstream and travel to the heart. When drugs are prepared for injection, bacteria in the drug solution may be injected into the bloodstream. During the injection process, bacteria from the skin on the person’s fingers or at the injection site can be injected into the bloodstream. Bacteria can also spread from existing skin and soft tissue infections and cause endocarditis.⁹

Other aspects of injecting drugs can damage tissues and promote bacterial growth and spread. This includes damage to blood vessels caused by particles contained in some drugs (e.g., solid bits of undissolved drug or fillers)¹⁰ and certain injecting practices (e.g., injecting under the skin or into muscles, missing the vein, leaving the tourniquet on when injecting), which can lead to damage at the injection site.^11,12

How can endocarditis be prevented?

Certain practices can help people who inject drugs to reduce the risk of endocarditis and are important to include in safer injecting education. Practices that can prevent bacteria from entering the body when injecting include:

• Washing hands with soap and water or hand sanitizer before handling drugs or harm reduction supplies^10,13
• Cleaning the skin at the injection site with an alcohol swab and letting the skin dry^10,12
• Using all new, sterile supplies for every injection (e.g., new needle and syringe, cooker, filter and sterile water)¹⁴
• Using heat to cook the drug solution until it bubbles (if it is appropriate for the drug)^15,16
• Not using saliva to prepare drugs and not licking the needle before injecting¹⁰
• Covering the injection site with a clean tissue or post-injection dry swab after injecting¹³

Practices that can reduce tissue damage when injecting include:

• Filtering the drugs before injecting¹³
• Avoiding injecting under the skin or into muscles^11,12
• If using a tourniquet to help find a vein, releasing it before injecting^11,13
• Avoiding injecting long-acting pills (e.g., controlled-release hydromorphone, Kadian), as they may contain fillers that can damage tissue and promote bacterial growth¹⁷

However, a person’s ability to implement individual-level practices that can help prevent endocarditis is influenced by multiple social factors, including the unregulated drug supply, access to safe spaces (e.g., housing), healthcare policies and practices, and access to harm reduction supplies.¹⁸

Firstly, the unregulated drug supply can increase the risk of endocarditis because the quality of the drugs might be poor: the drugs might contain unknown substances, they may be contaminated by bacteria or they might not dissolve properly.¹⁸ The unregulated supply also influences the drugs that people have access to, which can increase risk of endocarditis. For example, the arrival of fentanyl in the unregulated supply has been associated with increased risk of infections such as endocarditis.⁶ This is because fentanyl has a shorter duration of action, which leads to more frequent injections,¹⁹ which can in turn increase the opportunities for bacteria to get into the body and cause an infection.¹²

Secondly, injecting in unsafe spaces (e.g., unhygienic, poorly lit, public) can increase the risk of endocarditis as these environments can lead to unsafe drug preparation and injection techniques.¹⁸ Injecting in unsafe spaces can occur because people lack safe housing or are attempting to avoid police when using outside.¹⁸

Thirdly, healthcare policies and practices that discriminate against and stigmatize people who use drugs can lead people to avoid healthcare for skin and soft tissue infections or to leave medical treatment early.¹⁸ Avoiding healthcare increases the chance for bacteria to spread from local skin and soft tissue infections, increasing the risk for endocarditis.⁹ Leaving medical treatment early increases the risk that infections can spread or worsen.²⁰

Finally, inadequate access to harm reduction supplies can cause people to reuse supplies or use non-sterile equipment,¹⁸ which can lead to endocarditis.

Gender may also play a role in increasing risk of endocarditis. Women who inject drugs have been found to be at increased risk of endocarditis.^12,14 This may be due to a combination of social (e.g., challenges navigating safer injecting within intimate relationships because of power imbalances) and individual (e.g., challenges finding a vein because of their smaller size) factors.

Social factors are themselves shaped by structural forces such as criminalization, stigma, poverty and racism.¹⁸ Research indicates that addressing these factors is crucial to reducing the risk of endocarditis and other bacterial infections among people who inject drugs.¹⁸

Treatment for endocarditis

Endocarditis can be cured and evidence shows that treatment is effective for people who use drugs.^2,7 Treatment for endocarditis requires antibiotics. Approximately half of cases can also involve surgery to repair or replace damaged heart valves.² Treatment can be provided through inpatient hospital care, through outpatient care (if surgery is not required) or through a combination of these approaches. Antibiotic treatment is commonly given intravenously (IV) for up to six to eight weeks.² IV antibiotics are typically delivered through a peripherally inserted central catheter (PICC line), which is a long tube threaded through veins in the arm to the larger veins near the heart. PICC lines can remain in place for the duration of endocarditis treatment.

While treatment can occur through outpatient care, people who inject drugs are sometimes denied this option and are expected to remain in hospital for the duration of their IV antibiotic treatment.² Care providers may be concerned that people will inject drugs using the PICC line used for IV antibiotic treatment^2,21 and that people who inject drugs will not be able to properly disinfect the PICC line outside of hospital.²² These assumptions are stigmatizing and problematic,²² because evidence indicates that people who inject drugs can complete outpatient IV antibiotic treatment just as safely as people who do not inject drugs.^2,20 Furthermore, research suggests that alternative treatments (e.g., oral antibiotics and combined IV and oral antibiotics) are effective.^2,20 These medications can support people to receive treatment as outpatients. They can also improve outcomes in the case of early discharge from hospital.²³

Engaging in hospital-based care or remaining in hospital during treatment can be challenging for people who use drugs because of stigmatizing and discriminatory policies and practices in hospitals.^24,25 Hospital policies and practices are often rooted in an expectation of abstinence.²⁶ This means that supports around substance use and harm reduction (e.g., harm reduction supplies, supervised consumption, consultations with addiction medicine specialists) are often neglected or non-existent. For example, while opioid agonist treatment (OAT) is the standard of care for people with opioid use disorder,^27,28 access within hospitals is inconsistent.^26,29,30

Gaps in hospital policy and practice can result in multiple barriers to care for people who use drugs, including inadequate pain and withdrawal management, experiences of stigma and discrimination, and surveillance by healthcare workers.^24,25 These barriers can cause people to hide their drug use, use alone or reuse supplies, which increases their risk of getting new infections and their risk of drug poisoning death.^24,25,31 It can also cause people to leave hospital early, disrupting their medical care, in order to address unmanaged pain or withdrawal.²⁴ Harms can be further compounded when people leave hospital because reduced tolerance can place people at increased risk of drug poisoning death.³²

Improving endocarditis care for people who use drugs

Improving endocarditis care in hospitals is essential to ensuring the best possible outcomes for people who use drugs. Improving supports for people who use drugs in the hospital environment can include developing policies and practices that take a harm reduction approach to substance use^26,33 and implementing multidisciplinary care teams that include addiction medicine specialists.^2,20

Hospitals need to address abstinence-oriented policies and practices.^26,33 Taking a harm reduction approach to substance use can help to improve the support that people who use drugs receive when seeking care from hospitals.^26,34 Hospitals can consider a range of harm reduction policies and practices such as education about substance use and harm reduction for healthcare workers and hospital staff,²⁶ distribution of harm reduction supplies,³⁵ implementation of in-hospital supervised consumption sites^36,37 and procedures around PICC line use.³⁸

Multidisciplinary care teams, which include a range of specialists and the patient, can also improve endocarditis care for people who use drugs and ensure that people’s needs are met.²⁰ Within multidisciplinary care teams, addiction medicine specialists can help educate other healthcare providers about substance use, address pain or withdrawal symptoms and increase access to OAT and other supports for people who are interested.^20,29 Access to a multidisciplinary team may also improve linkages to services and supports (e.g., harm reduction supplies, OAT, safe supply) in the community after treatment is complete or if a person leaves hospital early. These linkages can ensure continuity of care and help to reduce reinfections, drug poisoning deaths and other harms.^29,39

Implications for service providers

Addressing the rising number of cases of endocarditis among people who inject drugs involves supporting people to implement safer injecting practices every time they use.

To support endocarditis prevention, service providers can:

• Provide education about safer injecting practices that help to reduce the risk of endocarditis. People who inject drugs should be provided with education about how to prepare their drugs and inject as safely as possible. This includes: the importance of cleaning the preparation surface, hands and the injection site; using sterile equipment when injecting drugs; using a new needle for every injection; using a filter; using heat to cook the drugs (if it is appropriate for the drug); releasing the tourniquet before injecting; and covering the injection site afterwards.
• Distribute a full range of safer injecting supplies and advocate for increased availability, coverage and reliable access in a variety of locations.
• Educate clients that switching to smoking or snorting can reduce the risk of endocarditis^40,41 and distribute a full range of supplies for safer smoking and snorting.
• Support people who use drugs to continue distributing new harm reduction supplies to one another and educating each other about safer substance use practices.¹⁸
• Recognize the range of factors that can prevent people from using safer injecting practices and provide supports or referrals to address these factors (e.g., OAT, safe supply, housing, income supports).
• Develop programs that provide low-barrier medical care for injection-related infections or wounds, which may help prevent bacteria from these infections spreading and causing endocarditis.⁹
• Advocate for or provide access to supervised consumption sites and overdose prevention sites in your community, including expanding access to sites that provide access to supervised inhalation. These interventions can support safer substance use practices by providing access to supplies for safer injecting, a safe and hygienic space to inject in and education about safer practices.^42,43 Providing access to supervised inhalation may also support people to safely switch to smoking.⁴⁴
• Advocate for improved access to OAT, injectable OAT (iOAT) and safe supply, as these can reduce people’s reliance on the unregulated drug supply, reduce injection frequency and promote safer substance use practices.^39,45–48
• Advocate for the inclusion of high-dose, injectable opioids on provincial drug formularies. These drugs would provide additional options for iOAT and safe supply programs that allow people to avoid injecting tablets.⁴⁹

Service providers can also support individuals to navigate endocarditis treatment and care by listening to service users and advocating for their needs to be prioritized in care plans. This can include supporting people to advocate for their needs around substance use (e.g., accessing harm reduction supplies, accessing pain and withdrawal management, challenging stigmatizing practices), general comfort and well-being (e.g., medication doses and timing, meal timing) and planning for discharge and linkage to care after leaving the hospital.⁵⁰

Improving endocarditis treatment is complex as there are often challenges with hospital policies and practices. Service providers can also work with hospitals to address barriers to care for people who use drugs:

• Collaborate with hospitals to support the engagement of people who use drugs in the development of hospital policies about substance use and harm reduction.²⁶
• Provide or facilitate access to education about substance use and harm reduction for healthcare workers, hospital staff and hospital administrators.
• Link people who use drugs to services that can help them to safely complete outpatient IV antibiotic treatment, such as stable housing and OAT.⁵¹
• Support hospitals to distribute harm reduction supplies and sharps disposal boxes in their facilities. Supplies should be available without judgment and without changes to an individual’s care plan. These interventions can support people to reduce harms related to substance use while they are in hospital.
• Work with hospitals to implement hospital-based supervised consumption and overdose prevention sites. These interventions can support people to stay in hospital, promote conversations about substance use, improve person-centred care and reduce harms.^36,37
• Work with hospitals to improve linkages between services provided in hospital and in the community (e.g., OAT, safe supply).

Related resources

• Steps to Safer Injecting
• Overdose Prevention Site at St. Paul’s Hospital
• Canadian IDU Endocarditis Working Group
• Guidance Document on the Management of Substance Use in Acute Care
• Safer Tablet Injection: A Resource for Clinicians Providing Care to Patients Who May Inject Oral Formulations

References

1. Mayo Clinic. Endocarditis [Internet]. Mayo Clinic. 2022 [cited 2022 Oct 4]. Available from : https://www.mayoclinic.org/diseases-conditions/endocarditis/symptoms-causes/syc-20352576
2. Vervoort D, An KR, Elbatarny M et al. Dealing with the epidemic of endocarditis in people who inject drugs. Canadian Journal of Cardiology. 2022;38(9):1406-17.
3. Schranz A, Barocas JA. Infective endocarditis in persons who use drugs: epidemiology, current management, and emerging treatments. Infectious Disease Clinics of North America. 2020;34(3):479-93.
4. Mosseler K, Materniak S, Brothers TD et al. Epidemiology, microbiology, and clinical outcomes among patients with intravenous drug use-associated infective endocarditis in New Brunswick. CJC Open. 2020 Sep 1;2(5):379-85.
5. Maguire DJ, Arora RC, Hiebert BM et al. The epidemiology of endocarditis in Manitoba: a retrospective study. CJC Open. 2021 Dec 1;3(12):1471-81.
6. Gomes T, Kitchen SA, Tailor L et al. Trends in hospitalizations for serious infections among people with opioid use disorder in Ontario, Canada. Journal of Addiction Medicine. 2022;16(4):433-39.
7. Yucel E, Bearnot B, Paras ML et al. Diagnosis and management of infective endocarditis in people who inject drugs. Journal of the American College of Cardiology. 2022 May 24;79(20):2037-57.
8. Straw S, Baig MW, Gillott R et al. Long-term outcomes are poor in intravenous drug users following infective endocarditis, even after surgery. Clinical Infectious Diseases. 2020 Aug 1;71(3):564-71.
9. Schneider KE, White RH, Rouhani S, et al. Self and professional treatment of skin and soft tissue infections among women who inject drugs: implications for wound care provision to prevent endocarditis. Drug and Alcohol Dependence Reports. 2022 Jun;3:100057.
10. Olubamwo O, Onyeka IN, Aregbesola A et al. Association between route of illicit drug administration and hospitalizations for infective endocarditis. SAGE Open Medicine. 2017 Dec;5:205031211774098.
11. Hope VD, Parry JV, Ncube F et al. Not in the vein: “missed hits”, subcutaneous and intramuscular injections and associated harms among people who inject psychoactive drugs in Bristol, United Kingdom. International Journal of Drug Policy. 2016 Feb 1;28:83-90.
12. Larney S, Peacock A, Mathers BM et al. A systematic review of injecting-related injury and disease among people who inject drugs. Drug and Alcohol Dependence. 2017;171:39-49.
13. Miskovic M, Zurba N, Beaumont D et al. Connecting: a guide to using harm reduction supplies as engagement tools. Kingston (ON): Ontario Harm Reduction Distribution Program, Kingston Community Health Centres; 2020.
14. Shah M, Wong R, Ball L et al. Risk factors of infective endocarditis in persons who inject drugs. Harm Reduction Journal. 2020 Jun 5;17(1):35.
15. Kasper KJ, Manoharan I, Hallam B et al. A controlled-release oral opioid supports S. aureus survival in injection drug preparation equipment and may increase bacteremia and endocarditis risk. PLoS ONE. 2019;14(9):1-12.
16. British Columbia Centre on Substance Use. Safer tablet injection: a resource for clinicians providing care to patients who may inject oral formulations. Vancouver: British Columbia Centre on Substance Use; 2020 Sep [cited 2023 Jan 8]. Available from: https://www.bccsu.ca/wp-content/uploads/2020/09/Resource-Safer-Tablet-Injection.pdf 
17. Silverman M, Slater J, Jandoc R et al. Hydromorphone and the risk of infective endocarditis among people who inject drugs: a population-based, retrospective cohort study. The Lancet Infectious Diseases. 2020;20(4):487-97.
18. Brothers T, Bonn M, Lewer D et al. Social and structural determinants of injection drug use-associated bacterial and fungal infections: a qualitative systematic review and thematic synthesis. medRxiv preprint [Internet]. 2022. Available from: https://doi.org/10.1101/2022.10.02.22280620
19. Lambdin BH, Bluthenthal RN, Zibbell JE et al. Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs. International Journal of Drug Policy. 2019 Dec 1;74:299-304.
20. Attwood LO, McKechnie M, Vujovic O et al. Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient‐centred multidisciplinary care. Medical Journal of Australia. 2022;217(2):102-9.
21. Brooks HL, Salvalaggio G, Pauly B et al. “I have such a hard time hitting myself, I thought it’d be easier”: perspectives of hospitalized patients on injecting drugs into vascular access devices. Harm Reduction Journal. 2022 Dec;19(1):54.
22. Guta A, Perri M, Strike C et al. “With a PICC line, you never miss”: the role of peripherally inserted central catheters in hospital care for people living with HIV/HCV who use drugs. International Journal of Drug Policy. 2021 Oct 1;96:103438.
23. Marks LR, Liang SY, Muthulingam D et al. Evaluation of partial oral antibiotic treatment for persons who inject drugs and are hospitalized with invasive infections. Clinical Infectious Diseases. 2020 Nov 15;71(10):E650-6.
24. McNeil R, Small W, Wood E et al. Hospitals as a “risk environment”: an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Social Science and Medicine. 2014;105:59-66.
25. Strike C, Robinson S, Guta A et al. Illicit drug use while admitted to hospital: patient and health care provider perspectives. PLoS ONE. 2020;15(3):e0229713.
26. Lennox R, Martin L, Brimner C et al. Hospital policy as a harm reduction intervention for people who use drugs. International Journal of Drug Policy. 2021 Nov 1;97:103324.
27. Bruneau J, Ahamad K, Goyer MÈ et al. Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018;190:E247-57.
28. Allen D, Brouwer J, Dong K et al. Management of substance use in acute care [guidance document]. Edmonton (AB): CRISM Prairies; 2020. Available from: https://crismprairies.ca/management-of-substance-use-in-acute-care-settings-in-alberta-guidance-document/ 
29. Brothers T, Mosseler K, Kirkland S et al. Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use associated infective endocarditis. PLoS ONE. 2022;17(1):e0263156.
30. Tsybina P, Kassir S, Clark M et al. Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review. Harm Reduction Journal. 2021;18(1):44.
31. Tan C, Shojaei E, Wiener J et al. Risk of new bloodstream infections and mortality among people who inject drugs with infective endocarditis. JAMA Network Open. 2020;3(8):e2012974.
32. Keen C, Kinner SA, Young JT et al. Periods of altered risk for non-fatal drug overdose: a self-controlled case series. Lancet Public Health. 2021;6(4):e249-e259.
33. Brothers T, Fraser J, Webster D. Caring for people who inject drugs when they are admitted to hospital. CMAJ. 2021;193(12):423-4.
34. Perera R, Stephan L, Appa A et al. Meeting people where they are: implementing hospital-based substance use harm reduction. Harm Reduction Journal. 2022;19(1):14.
35. Miskovic M, Carusone SC, Guta A et al. Distribution of harm reduction kits in a specialty HIV hospital. American Journal of Public Health. 2018 Oct 1;108(10):1363-5.
36. Dong KA, Brouwer J, Johnston C et al. Supervised consumption services for acute care hospital patients. CMAJ. 2020;192(18):E476-9.
37. Kosteniuk B, Salvalaggio G, Mcneil R et al. “You don’t have to squirrel away in a staircase”: patient motivations for attending a novel supervised drug consumption service in acute care. International Journal of Drug Policy. 2021;96:103275.
38. Chase J, Nicholson M, Dogherty E et al. Self-injecting non-prescribed substances into vascular access devices: a case study of one health system’s ongoing journey from clinical concern to practice and policy response. Harm Reduction Journal. 2022 Nov 24;19(1):130.
39. Barocas JA, Morgan JR, Wang J et al. Outcomes associated with medications for opioid use disorder among persons hospitalized for infective endocarditis. Clinical Infectious Diseases. 2021 Feb 1;72(3):472-8.
40. Islam S, Piggott DA, Moriggia A et al. Reducing injection intensity is associated with decreased risk for invasive bacterial infection among high-frequency injection drug users. Harm Reduction Journal. 2019 Jun 17;16(1):38.
41. Leonard L, DeRubeis E, Pelude L et al. “I inject less as I have easier access to pipes”: onjecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed. International Journal of Drug Policy. 2008;19(3):255-64.
42. Potier C, Laprévote V, Dubois-Arber F et al. Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence. 2014;145:48-68.
43. Wood E, Tyndall MW, Montaner JSG et al. Summary of findings from the evaluation of a pilot medically supervised safer injection facility. CMAJ. 2006;175(11):1399-404.
44. Bourque S, Pijl EM, Mason E et al. Supervised inhalation is an important part of supervised consumption services. Canadian Journal of Public Health. 2019;110(2):210-5.
45. Gomes T, Kolla G, McCormack D et al. Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario. CMAJ. 2022 Sep 19;194(36):E1233-42.
46. Ivsins A, Boyd J, Mayer S et al. “It’s helped me a lot, just like to stay alive”: a qualitative analysis of outcomes of a novel hydromorphone tablet distribution program in Vancouver, Canada. Journal of Urban Health. 2020;98(1):59-69.
47. March JC, Oviedo-Joekes E, Perea-Milla E et al. Controlled trial of prescribed heroin in the treatment of opioid addiction. Journal of Substance Abuse Treatment. 2006;31(2):203-11.
48. Kolla G, Long C, Perri M et al. Safer Opioid Supply Program: preliminary report. London (ON): London InterCommunity Health Centre; 2022. Available from: https://lihc.on.ca/wp-content/uploads/2022/01/2021-SOS-Evaluation-Full.pdf
49. Addictions and Mental Health Ontario. Planning for the appropriate use of prescription diacetylmorphine in Ontario: project summary. Toronto: Addictions and Mental Health Ontario. [cited 2023 Jan 8]. Available from: https://amho.ca/wp-content/uploads/AMHO_RxDiacetylmorphine_Pres_Full_FIN.pdf
50. Cahill TM. Webinar: A harm reduction nursing perspective on the care of people who inject drugs with endocarditis [Internet]. Canadian IDU Endocarditis Working Group; 2022 [cited 2022 Oct 6]. https://www.youtube.com/watch?v=_v3lgVji7hM&ab_channel=CanadianIDUEndocarditisWorkingGroup
51. Price CN, Solomon DA, Johnson JA et al. Feasibility and safety of outpatient parenteral antimicrobial therapy in conjunction with addiction treatment for people who inject drugs. Journal of Infectious Diseases. 2020 Oct 1;222(Supplement_5):S494-8.

 

About the author(s)

Magnus Nowell is CATIE’s knowledge specialist in harm reduction. Magnus has previously worked in harm reduction research, community organizing and housing. He has a master’s degree in health promotion

Externally reviewed by: Tali Cahill & Colleen Tower

 

Production of this article has been made possible through a financial contribution from Health Canada's Substance Use and Addictions Program. The views expressed herein do not necessarily represent the views of Health Canada.