Substance use disorders among African, Caribbean and Black (ACB) people in Canada: a scoping review protocol.

INTRODUCTION: Previous research demonstrated that substance use continues to be one of the most complex and prevalent problems among African, Caribbean and Black (ACB) people. A number of studies were conducted to characterise substance use patterns in this population. To our knowledge, this is the first known review in Canada characterising substance use disorders on ACB people.This scoping review seeks to answer the following research questions: What characterises substance use disorders among ACB people in Canada? What are the different types and prevalence of substance use among ACB people in Canada? Do ACB people in Canada use more than one substance? What factors are associated with substance use among ACB people in Canada? What are the health and social impacts of substance use in ACB people in Canada? METHODS AND ANALYSES: This study will use the methodological framework for scoping reviews developed by Arksey and O'Malley. We will search electronic bibliographic databases including Ovid MEDLINE, PsycINFO and CINAHL. We will limit our search to English articles published between 2000and2019. In addition, we will conduct a grey literature search. Two investigators will independently screen citations and full-text articles. Our findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for scoping reviews guidelines. We will provide a descriptive summary of the studies and summarise the findings with respect to the outcomes and report any gaps that might require further investigation. ETHICS AND DISSEMINATION: Our proposed study does not involve human participants; therefore, research ethics approval is not required. This study will provide evidence that will inform the development of strategies for appropriate interventions, as well as policy and further research. The results will be disseminated through publications in open access peer-reviewed journals, presentations at scientific meetings and to the lay public. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Our search strategy is very comprehensive, as it was developed with a team that has extensive experience with literature search and was reviewed in consultation with a medical research librarian.

Our review uses a rigorous scoping review methodology and includes all types of study designs such as cohort, cross-sectional, systematic reviews, text and opinion.

Our source of literature is expansive, as it includes three databases that cover our research questions as well as grey literature.

This study is limited only to Canadian context and the findings will only be relevant to Canada.

Another limitation of our study is the inclusion of literature published only in the English language.

Background

According to the 2016 Canadian census, 1 198 545 people self-identified as Black, representing 3.5% of Canada’s total population and 16% of the total visible minority population. About 37% of the Black population in Canada lives in Toronto.1 In Western countries, racialised minorities are more likely to face structural and social stressors that lead to health disparities and exacerbate poor health status.2 3African, Caribbean and Black (ACB) people, especially those who are immigrants and refugees, experience a myriad of challenges and problems such as language barriers, exclusive immigration policies, unemployment, poverty, lack of access to healthcare, discrimination and racism.4 Research confirms that social inequities, systemic racial discrimination, sexism, poverty and marginalisation contribute to the compromised mental health among racialised people.5 Evidence also indicates that some marginalised ACB people turn to substance use as a coping strategy to overcome cumulative hardship and stressful life conditions.6 Depending on different factors such as the type of drugs used, doses, frequency and pre-existing health conditions, drug use can have various short-term and long-term health and social effects such as heart attack, crime, stroke, healthcare spending, drug dependence, change in blood pressure, violence, HIV/AIDS, hepatitis C virus, mental health issues, overdose and ultimately death.7 8

Like other Canadians, ACB people have a reported history of substance use. Data derived from multiple cycles (2005–2011) of the Canadian Community Health Survey—Mental Health in Ontario showed that 40% of Caribbean and 18% of African adults reported lifetime cannabis usage; also, 23% of Caribbean and 9% of African adults have reported using cannabis in the past year.9 The prevalence of problematic use of cannabis (that can lead to harm, abuse or dependence, moderate/high score of 8 or more) on the Alcohol, Smoking and Substance Involvement Screening Tool-Cannabis Involvement Score was 8% for Caribbean and 4% for African adults.9 In a community-based study of party drug use among ethno-racially diverse gay and bisexual men (Asian, Caribbean, Latino, Aboriginal, mixed and others) in Toronto, participants reported regular use of ecstasy, cannabis, ketamine and cocaine.10 In the same study, 43% of participants were polydrug users and almost all participants reported engaging in sex while they were on drugs.10 For women, data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study reported various types of drug users. Among participants who self-identified as ACB, 5% used tobacco, 41% drank alcohol, 5% were ‘socially acceptable’ poly-substance users, 4% were illicit poly-substance users and 3% were illicit poly-substance users of all types.11

Substance use is associated with increased risk of developing other mental disorders, utilisation of emergency rooms and can have severe impact not only on individuals, but also on those closest to them, and society in general. Population-based data from the Ontario HIV Treatment Network reported recreation drug use (RDU) (16%) and co-occurring RDU and depression (34%) among heterosexual individuals. Among specific ethnic groups (African, Caribbean, Asian or Latino), 14% reported RDU and 12% reported co-occurring RDU and depression.12 Moreover, RDU-only or co-occurring depression and RDU were associated with increased incidence of emergency department (ED) visits.12 Previous observational study showed that opioid poisonings led to 16 hospitalisations per day in Canada.13 In the same study, it was found that substance use also increased ED visits. Over the last 5 years, heroin or synthetic opioid poisonings increased the number of ED visits by 10-fold in Alberta, whereas in Ontario, ED visits increased fourfold and doubled due to heroin and synthetic opioid poisonings, respectively.13 A study investigating substance use and intimate partner violence (IPV) showed that cocaine use was associated with IPV among Black men who have sex with men.14 Moreover, a significant association between illegal drug use and criminal behaviour exists.15 In several studies, it was demonstrated that alcohol can significantly increase the risk of sexual assault.16 A cross-sectional study investigating predictors of sexual assault found that the number of sexual assaults committed by African American and Caucasian men were associated with alcohol problems.17 Also, the relationship between driver blood alcohol concentration (BAC) and involvement in motor crash is well documented. Previous studies have reported that higher BACs significantly increase the likelihood of drivers to be involved in crashes.18 Substance use is associated with increased risky sexual behaviour and the risk of HIV acquisition. Evidence from a Canadian study showed that ACB women reported having sex under alcohol, substance use and drug influence; 2% had shared drug use equipment and 27% had ever mixed sex with drugs or alcohol and 44% of ACB men reported that they had engaged in sex while using drugs or alcohol.19

ACB in Canada experience different challenges that increase their vulnerability to use substances, however, the literature is rather sparse on this population. An initial search of the topic in PubMed, the JBI database of systematic reviews and implementation reports and PROSPERO did not identify previous reviews or any review currently underway. There is a need to characterise substance use disorders among this population. The proposed scoping review aims to explore the available research evidence regarding common substance use disorders by ACB people in Canada as well as their health and social impacts.

Methods and analysis

Patient and public involvement

Patients are not involved in the design of this scoping review study.

Scoping review

We will conduct a search of all research designs and types of publications, as well as grey literature and reports. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines, including search strategy, selection criteria, data extraction and data analysis.20 Furthermore, the review will be conducted using the methodological framework for scoping reviews proposed by Arksey and O’Malley.21 The framework recommends the following six steps: (1) Identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results and (6) consultation. The review will be reported according to PRISMA for Scoping Reviews (PRISMA-ScR) guidelines and a checklist will be completed.22 Our scoping review was initiated on 1 December 2018 and is to be completed by 30 August 2019.

What characterises substance use disorders among ACB people in Canada?

What are the different types and prevalence of substance use among ACB people in Canada?

Do ACB people in Canada use more than one substance?

What are the factors associated with substance use among ACB people in Canada?

What are the health and social impacts of substance use among ACB people in Canada?

Step 1: Identifying the research question

The following research questions of the scoping review were identified

The following population, intervention, comparison, outcome was formulated:

Population: Canadian ACB people.

Intervention: Study examines substance use.

Comparison: Other ethnic groups if provided.

Outcomes:

Types of substance use disorders.

Prevalence of substance use disorders and poly drugs use.

Health impact of substance use.

Social impact of substance use.

Factors associated with substance use.

Step 2: Identifying relevant studies

In order to address the objectives of the review, an internet-based search of published and grey literature will be conducted using electronic databases and Google. Also, we will search the website of key organisations, such as Health Canada, Statistics Canada and the Canadian Centre on Substance Use and Addiction. For each individual database, our search strategy will combine Medical Subject Headings and ‘free-text’ terms in conjunction with the Boolean operators ‘and’ and ‘or’. We will conduct searches in relevant electronic databases: Ovid MEDLINE, PsycINFO and CINHAL.

Our search will be limited to English language publications. Only studies published between 2000 and 2019 will be included in this review. Our search strategy is described in tables 1–3. Also, we will check reference lists of included studies to identify any additional relevant articles that were not captured by our search strategy.

Step 3: Study selection

We will use Endnote 9 (Clarivate Analytics), a citation management software programme, to manage references and remove duplicates. To facilitate study screening and selection, all citations obtained using the search strategy will be imported into Rayyan, a web and mobile application for systematic reviews.23 Study selection will proceed according to the stages described below.

Stage 1

A customised form reflecting the inclusion criteria in box 1 will be pilot tested by two reviewers. Specifically, a screening form will be developed and will be applied by two reviewers independently to a sample of 5% abstracts to ensure consistency of use and clarity of the instrument. A Cohen’s kappa statistic24 will be estimated to measure inter-rater reliability, and screening will begin when >60% agreement is achieved.

Eligibility checklist

Inclusion criteria

Population: Canadian ACB male and female.

Intervention: Study examines substance use.

Comparison: Other ethnic groups if provided.

Outcomes: at least one of the following:

Types of substance use disorders.

Prevalence of substance use or poly drugs use.

Factors associated with substance use.

Health impact of substance use.

Social impact of substance use.

Exclusion criteria

Article describes normal prescription drug use.

Stage 2: Assessment of studies for inclusion

Inclusion criteria

To be included in this study a reference should meet the following criteria:

Population: Canadian ACB people.

Intervention: Study examines substance use.

Comparison: Other ethnic groups if provided.

Outcomes—Study examines at least one of the following:

Types of substance use disorders.

Prevalence of substance use disorders and poly drugs use.

Health impact of substance use.

Social impact of substance use.

Factors associated with substance use.

All titles and abstracts identified from the electronic database search will be reviewed independently by two reviewers. Differences in opinion will be resolved by consensus. Discussion with a third author will take place in situations where consensus cannot be reached. In cases where abstracts are not provided, are unclear, or there is any other reason for uncertainty, the full article will be obtained before making a decision regarding eligibility for inclusion. The full text of all potentially relevant articles will be obtained and will be reviewed using the inclusion criteria defined above.

Exclusion criteria

Articles that describe normal prescription drug use.

Step 4: Charting the data

Eligible studies will be extracted using a pre-designed data extraction form. The data extraction form will be pilot tested with a sample of five studies to ensure clarity and consistency. We will extract basic study information like first author, title, purpose, year of publication and province. In addition, we will extract information about the population, method, age, type of substance use, poly drug use, impact of drug use, findings and limitations of the study (box 2).

Study author

Title

Year

Province

Purpose

Design

Method

Sample size

Population gender (M/F)

Comparator if applicable

Age (youth: 16–25 year; adult >25 year)

Outcomes

Type of substance use disorders (stimulant, depressant, hallucinogen, opioids, inhalants, cannabis, alcohol, tobacco).

Prevalence of substance use and poly drugs use.

Associated factors of substance use.

Social impact.

Health impact.

Main findings

Limitations

Conclusion

Step 5: Collating, summarising and reporting the results

Rather than provide a quantitative synthesis of literature, as is typically the use of systematic reviews, this scoping review aims to summarise a wide range of findings regarding substance use disorders among ACB people in Canada.25 Therefore, we will provide a descriptive summary of the gathered articles including peer-reviewed articles, text, opinion or systematic reviews. The descriptive summary will contain the characteristics of included studies, such as the overall number of studies, types of study design, years of publication, characteristics of the study populations and provinces where studies were conducted. In addition, we will summarise the study findings with respect to the outcomes and report any gaps that might require further investigation. Our synthesis will inform whether ACB people in Canada experience disorders related to alcohol, tobacco, stimulants, depressants, hallucinogens, opioids or cannabis. Also, our synthesis will inform whether ACB people in Canada use more than one drug at a time and, the health and social impacts of substance use.

Step 6: Consultation

Neither patients nor public will be involved.

Ethics and dissemination

Our proposed study does not involve human participation. As a scoping review, this study will use only published literature. Therefore, research ethics approval is not required. Results will be disseminated through publications in open access peer-reviewed scientific journals, presentations at scientific meetings and presentations to the lay public through the media where appropriate. The results from this review will be used to plan future systematic reviews.

Discussion and conclusion

The proposed scoping review will have the potential to inform research, programmes and services that could be used to improve the health and well-being of ACB people in Canada. Specifically, this review will inform policy-makers, healthcare providers, clinicians and researchers on substance use among Canadian ACB people.

Table 1

Database search strategy

Ovid MEDLINE search
	Key term	#Hits
1	exp ALCOHOLS/or Binge drink*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	621 613
2	(illicit adj2 drug*).tw.	9827
3	Marijuana.mp. or exp Cannabis/	22 250
4	(Inhalant adj2 nitrite).tw.	40
5	Street Drugs/	10 253
6	poppers.tw.	338
7	exp COCAINE/or exp CRACK COCAINE/	24 487
8	(Amphetamines or N-Methyl-3,4- methylenedioxyamphetamineor 3,4- Methylenedioxyamphetamine or Ecstasy or MDMA or MDA).tw.	56 092
9	(Psychedelic* or Psychotropic Drugs).tw.	6855
10	exp HEROIN/	5376
11	Opiate*.tw.	23 681
12	exp OPIUM/	1961
13	exp BENZODIAZEPINES/	63 290
14	Demerol.tw. or exp Meperidine/	5791
15	(Cigarette* or tabacco).tw.	63 819
16	(Psychedelic adj2 drug*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	218
17	(Hallucinogenic adj2 Drug*).mp. or hallucinogens.tw. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	1630
18	Vicodin.tw.	56
19	exp CODEINE/	6561
20	exp FENTANYL/	15 005
21	Sedative*.tw.	17 745
22	Valium.tw. or exp Diazepam/	17 699
23	Xanax.tw. or Alprazolam/	1754
24	Ritalin.tw. or exp Methylphenidate/	6870
25	Adderall.tw.	158
26	(Erectile adj2 dysfunction adj2 drug).tw.	57
27	Viagra.tw. or Sildenafil Citrate/	5335
28	Cialis.tw. or Tadalafil/	1317
29	(Levitra or Vardenafil Dihydrochloride).tw.	101
30	Crystal.tw.	189 761
31	(GHB or Gamma-hydroxybutyrate).tw.	2544
32	canada/	85 054
33	(Canada or Canad*).tw.	112 521
34	(alberta or british columbia or nova scotia or prince edward island or newfoundland or labrador or nunavut or northwest territories or Yukon or Quebec or Saskatchewan or manitoba or Ontario or new brunswick).ti,ab.	60 865
35	Caribbean.mp. or exp Caribbean Region/	35 105
36	(Black* or Caribbean or African or Immigrant* or immigra* or migration or migrant*).tw.	493 685
37	(Black adj2 canadian*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	32
38	Ethnic Groups/or foreign-born.mp.	59 963
39	(new adj2 Canadian).tw.	197
40	(asylum or new comer or refugees or minorit*).tw.	66 945
41	racial*.mp.	36 734
42	substance-related disorders/or alcohol-related disorders/or amphetamine-related disorders/or cocaine-related disorders/or drug overdose/or heroin dependence/or inhalant abuse/or marijuana abuse/or opioid-related disorders/or phencyclidine abuse/or psychoses, substance-induced/or substance abuse, intravenous/or substance abuse, oral/or substance withdrawal syndrome/or “tobacco use disorder”/or opioid dependence.mp.	172 286
43	Alcoholic Intoxication/	12 144
44	exp OPIUM DEPENDENCE/	12
45	exp HEROIN DEPENDENCE/	8793
46	substance addiction.tw.	250
47	(drug adj2 addiction).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	7594
48	(drug adj2 abuse).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	17 792
49	exp Inhalant Abuse/	187
50	exp Cocaine Smoking/	6
51	exp Cocaine-Related Disorders/	7724
52	substance addiction.tw.	250
53	drug addiction.mp.	7334
54	exp Prescription Drug Misuse/	11 373
55	“substance use disorders”.mp.	7809
56	1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31	1109 799
57	32 or 33 or 34	185 044
58	35 or 36 or 37 or 38 or 39 or 40 or 41	622 158
59	42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55	196 134
60	56 and 57 and 58	182
61	57 and 58 and 59	132
62	60 or 61	261
63	limit 62 to English language	258
64	limit 63 to (English language and yr=“2000–2019”)	212

Table 2

Web-based search strategy: Google search engine

No.	Search term	# of Hits
1	Substance abuse or substance use or or name of substance, eg, alcohol, cannabis, poppers	TBD
2	Blacks or Caribbean or African	TBD
3	Canada	TBD
4	#1 and #2 and #3 First five-pages of the web-based search will be reviewed Limitation: English. 2000-present.	TBD

TBD, to be decided.

Table 3

Health Canada, Statistic Canada and the Canadian Centre on substance use and addiction search strategy

No.	Search term	# of hits
1	Substance abuse or substance use or name of substance, eg, alcohol, cannabis, poppers, etc. And African or Caribbean or Blacks	TBD
2	Limitation: English 2000-present	TBD

TBD, to be decided.