The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

Early detection and prediction of non-fatal drug-related incidents and fatal overdose outbreaks using the Farrington algorithm

AIMS

The aim of this study was to assess the validity of undertaking time-series analyses on both fatal and non-fatal drug overdose outcomes for the surveillance of emerging drug threats, and to determine the validity of analyzing non-fatal indicators to support the early detection of fatal overdose outbreaks.

DESIGN, SETTING AND PARTICIPANTS

Time-series analyses using county-level data containing fatal overdoses and non-fatal overdose counts were collected at monthly intervals between 2015 and 2021 in California and Florida, USA. To analyze these data, we used the Farrington algorithm (FA), a method used to detect aberrations in time-series data such that an abnormal increase in counts relative to previous observations would result in an alert. The FA's performance was compared with a bench-mark approach, using the standard deviation as an aberration detection threshold. We evaluated whether monthly alerts in non-fatal overdose can aid in identifying fatal drug overdose outbreaks, defined as a statistically significant increase in the 6-month overdose death rate. We also conducted analyses across regions, i.e. clusters of counties.

MEASUREMENTS

Measurements were taken during emergency department and emergency medical service visits.

FINDINGS

Both methods yielded a similar proportion of alerts across scenarios for non-fatal overdoses, while the bench-mark method yielded more alerts for fatal overdoses. For both methods, the correlations between surveillance evaluations were relatively poor in the detection of aberrations (typically < 35%) but were high between evaluations yielding no alerts (typically > 75%). For ongoing fatal overdose outbreaks, a strategy based on the detection of alerts at the county level from either method yielded a sensitivity of 66% for both California and Florida. At the regional level, the equivalent analyses had sensitivities of 81% for California and 77% for Florida.

CONCLUSION

Aberration detection methods can support the early detection of fatal drug overdose outbreaks, particularly when methodologies are applied in combination rather than individual methods separately.

Rethink Recovery: A Qualitative Approach to Exploring Messaging for Medication-Assisted Recovery (MAR)

Similar to national trends, in Illinois, fatal opioid overdoses have risen. Black men (35+) outrank all other racial subgroups for the highest rate of fatal opioid overdoses in the state. To address this, Prevention First and the Illinois Department of Human Services developed a public health education campaign to support increasing enrollment in recovery services, with a focus on Black men (35+). Self-reported Black participants with opioid use disorder (OUD) made up the analytic sample. Study goals were to understand lived experiences of the campaign audience; investigate knowledge, attitudes, and beliefs regarding OUD and treatment; explore perceived barriers and facilitators to treatment; and evaluate messaging that showcased medication-assisted recovery (MAR) as a viable tool for treatment and recovery. Interviews were recorded and transcribed for thematic analysis. Participants shared long and cyclical journeys of use and recovery. Participants had low levels of knowledge of available treatment options and struggled to imagine themselves in recovery because of the fear of cravings and withdrawal. Messaging that was realistic about the cyclical nature of recovery, showed the varying options for MAR, and addressed cravings and withdrawals were well received. These findings illustrate the importance of understanding an audience and involving them in campaign development to create messaging that promotes behavior change and sustained health. Through the Decision Blocks strategic framework, we discovered information gaps, barriers to treatment, and practical solutions to increase access to treatment for Black men with OUD that has been limited due to inequities caused by structural racism.

An initial randomized controlled trial of a Combined Medication and Behavioral Activation Treatment (CoMBAT) for people with opioid use disorder

INTRODUCTION

Opioid use disorder is a chronic, relapsing disease and a major source of morbidity and mortality in the U.S. Medications for opioid use disorder (MOUD) have been shown to reduce opioid use; however, MOUD maintenance is often suboptimal. Depression is a well-documented risk factor for MOUD treatment disengagement; thus, behavioral interventions to address depression and support ongoing MOUD use in community settings are warranted.

METHODS

We evaluated the feasibility, acceptability, and preliminary efficacy of the CoMBAT (Combined Medication and Behavioral Activation Treatment) intervention via a pilot randomized controlled trial. We hypothesized that the CoMBAT intervention, which uses behavioral activation, motivational interviewing, and problem-solving techniques, would be feasible and acceptable to participants and decrease depression, increase goal-directed activity, improve MOUD care engagement, and reduce opioid use among adults with depressive symptoms who had a missed dose or clinical MOUD visit in the past 30 days. We enrolled 32 participants prescribed methadone or buprenorphine in the community; each received 2 health navigation and substance use counseling sessions (HN_SUC) before being randomized into (a) the 8-session CoMBAT intervention + HN_SUC + treatment as usual or (b) HN_SUC + treatment as usual only. The primary outcomes were intervention feasibility and acceptability. Preliminary efficacy measures included self-reported past-30-day MOUD doses and clinical visits, depressive symptoms, behavioral activation; and opioid-positive urinalysis; each assessed at baseline and 3- and 6-month follow-up visits.

RESULTS

The intervention was feasible (88 % of intervention sessions completed; 100 % retention at 6 months) and acceptable (86 % of intervention participants were satisfied/very satisfied with the intervention at 3-months; and intervention participants had a high level of alliance with their counselor at the mid-point: mean = 5.7 out of 7 [SD = 1.3] and end of their treatment: mean = 5.5 out of 7 [SD = 1.1]. At 6-months, intervention participants reported fewer missed MOUD doses and visits, less depressive symptoms, greater behavioral activation scores, and a lower percentage of opioid-positive toxicology screens relative to the control condition.

CONCLUSION

Findings provide evidence of intervention feasibility and acceptability and demonstrate initial efficacy for ongoing MOUD care engagement, depressive symptom reduction, increased behavioral activity, and reduced opioid use. Future intervention testing in a fully-powered efficacy trial is warranted.

Misclassification of opioid-involvement in drug-related overdose deaths in the United States: A scoping review

PURPOSE

Most drug-related deaths in the United States (US) in 2022 involved opioids. However, methodological challenges in overdose surveillance may contribute to underestimation of opioid involvement in the overdose crisis. This scoping review aimed to synthesize existing literature to examine the breadth and contributing sources of misclassification of opioid-related overdose deaths.

METHODS

In October 2022, we searched PubMed, Web of Science, and Scopus for studies on overdose surveillance, death certificates, and medicolegal death investigation (MDI) systems in the US published in 2013-2022. Two reviewers independently screened abstracts, reviewed full-texts, and performed data extraction of study characteristics.

RESULTS

We identified 17 studies examining misclassification in drug-related deaths. Across studies, opioid involvement in drug-related deaths was underestimated nationally by 20-35 %. Unspecified drug-related deaths differed by geographic areas and MDI systems and decreased over time. States/counties with coroner MDI systems were more likely to report unspecified overdose deaths than those with medical examiners. Integrating toxicology testing, death scene investigations, and other data with death certificates identified additional opioid-related overdose deaths, particularly those involving heroin.

CONCLUSIONS

Findings highlight the need for additional resources for surveillance efforts, training for coroners, and data integration to improve reporting of opioid involvement in overdose deaths to inform interventions.

Temporal stability and volatility in population-level high-risk illicit polysubstance use by gender and marital status in the United States, 2002-2019

Population-level patterns in determinants of risky polysubstance use receive little attention despite rising mortality. We use secondary data from the National Survey on Drug Use and Health, 2002-2019 (N = 706,891), and weighted logistic regression to test trends and associations between gender and marital status on the probability of high-risk polysubstance use (i.e., illicit use of pharmacologically-distinct overdose-associated drugs). Our results show that at the population-level about 0.7% of adults engaged in high-risk illicit polysubstance use in the past month. Our regression analyses reveal that polysubstance use was lowest among married women (pˆ = 0.27%) and highest among never married and previously married men (pˆ = 1.06%). When we predicted polysubstance use from 2002 to 2019, the estimates were remarkably stable for women and married adults, with no statistically significant differences for women across the span and few for married adults. Yet, polysubstance use among men had statistically significant variation (ranging from pˆ = 0.55 to pˆ = 0.96%), and the gender gap was larger and more consistently significant as illicit drugs became prominent later in the study period. This pattern suggests that use among men is shaped by drug contexts and availability. Our findings also highlight the important roles of family structure in shaping high-risk drug use. Rising polysubstance use mortality may not stem from rising rates of use or large changes in patterns among high-risk groups, but may be related to the growing share of non-married adults, especially men, who are high-risk relative to married adults and women.

Opioid-induced respiratory depression: clinical aspects and pathophysiology of the respiratory network effects

Important insights and consensus remain lacking for risk prediction of opioid-induced respiratory depression (OIRD), reversal of respiratory depression (RD), the pathophysiology of OIRD, and which sites make the most significant contribution to its induction. The ventilatory response to inhaled carbon dioxide is the most sensitive biomarker of OIRD. To accurately predict respiratory depression (RD), a multivariant RD prospective trial using continuous capnography and oximetry examining five independent variables, age ≥60, sex, opioid naivety, sleep disorders, and chronic heart failure (PRODIGY trial), were undertaken. Intermittent oximetry alone substantially underestimates the incidence of RD. Naloxone, with an elimination half-life of ∼33 min (cf. morphine 2-3 h; fentanyl and congeners only 5-15 min), has limitations for the rescue of patients with severe OIRD. Buprenorphine is potentially valuable in patients being treated long term since its high µ-receptor (MOR) affinity makes it difficult for an opioid of lower affinity (e.g., fentanyl) to displace it from the receptor. In the last decade, synthetic opioids, for example, fentanyl, its potent analogs such as carfentanil, and the benzimidazole derivative nitazene "superagonists" have contributed to the exponential growth in opioid deaths due to RD. The MOR, encoded by gene Oprm1, is widely expressed in the central and peripheral nervous systems, including centers that modulate breathing. Opioids bind to the receptors, but consensus is lacking on which site(s) makes the most significant contribution to the induction of OIRD. Both the preBötzinger complex (preBötC), the inspiratory rhythm generator, and the Kölliker-Fuse nucleus (KFN), the respiratory modulator, contribute to RD, but receptor binding is not restricted to a single site. Breathing is composed of three phases, inspiration, postinspiration, and active expiration, each generated by distinct rhythm-generating networks: the preBötC, the postinspiratory complex (PiCo), and the lateral parafacial nucleus (pFL), respectively. Somatostatin-expressing mouse cells involved in breathing regulation are not involved in opioid-induced RD.

An interrupted time series analysis of fentanyl, naloxone, and opioid-involved deaths in five counties in Eastern Missouri

INTRODUCTION

Rates of opioid overdose deaths (OOD) have increased since the introduction of illicitly manufactured fentanyl in the U.S. drug supply. Though community-based naloxone distribution efforts have been found to effectively reduce OOD, no studies to date have examined their effects during the fentanyl era, nor in the epicenter of a state's overdose crisis. Thus, the current study assessed the impacts of both fentanyl and of subsequent grant-funded community-based naloxone distribution on OOD across Missouri's St. Louis region.

METHODS

Medical examiner data includes individuals who died within one of the five study counties (St. Louis City, St. Louis County, and Franklin, Jefferson, St. Charles counties [combined as "Collar Counties"]) between 2011 and 2022 due to an opioid overdose (N = 6,799). Naloxone distribution date and location data came from Missouri's university-based naloxone distribution team. We conducted a controlled interrupted time series using an autoregressive model via proc ARIMA to examine changes over time in the rate of OOD associated with the introduction of fentanyl (defined to be present in 25% of opioid overdose deaths; June 2015) and the start of naloxone distribution for each location (August 2017, October 2017, and January 2018, respectively).

RESULTS

The introduction of fentanyl into the drug supply of St. Louis City was associated with an increased rate of OOD over time (p < .001). Naloxone distribution in the City was associated with an immediate decrease in OOD (p < .001) followed by a slowed increase in OOD (p < .001). These findings were not replicated in St. Louis County nor the Collar Counties.

CONCLUSIONS

The effects of fentanyl and naloxone on OOD varied by region in Eastern Missouri. Specifically, fentanyl and naloxone effects were only found in a high-need urban area with existing harm reduction and street outreach programs, but not in surrounding suburban or rural areas. State-level naloxone distribution decision-makers should prioritize funding harm reduction services in both urban and non-urban settings to help increase targeted naloxone distribution to those actively using drugs. Additionally, interventions tailored for people who engage in solitary drug use - such as safe consumption spaces and overdose detection technologies - should receive increased investment and implementation, particularly in rural areas where harm reduction infrastructure is more scarce.

A deep learning analysis for dual healthcare system users and risk of opioid use disorder

The opioid crisis has disproportionately affected U.S. veterans, leading the Veterans Health Administration to implement opioid prescribing guidelines. Veterans who receive care from both VA and non-VA providers-known as dual-system users-have an increased risk of Opioid Use Disorder (OUD). The interaction between dual-system use and demographic and clinical factors, however, has not been previously explored. We conducted a retrospective study of 856,299 patient instances from the Washington DC and Baltimore VA Medical Centers (2012-2019), using a deep neural network (DNN) and explainable Artificial Intelligence to examine the impact of dual-system use on OUD and how demographic and clinical factors interact with it. Of the cohort, 146,688(17%) had OUD, determined through Natural Language Processing of clinical notes and ICD-9/10 diagnoses. The DNN model, with a 78% area under the curve, confirmed that dual-system use is a risk factor for OUD, along with prior opioid use or other substance use. Interestingly, a history of other drug use interacted negatively with dual-system use regarding OUD risk. In contrast, older age was associated with a lower risk of OUD but interacted positively with dual-system use. These findings suggest that within the dual-system users, patients with certain risk profiles warrant special attention.

Association between prescribed stimulant medications and overdose among individuals receiving opioid agonist therapy: A retrospective cohort study from British Columbia, Canada

AIMS

We measured the association between prescribed stimulant medications and overdose among individuals receiving opioid agonist therapy (OAT) for opioid use disorder.

DESIGN

Retrospective cohort study using the British Columbia Provincial Overdose Cohort, a linked administrative database.

SETTING

We used data from British Columbia, Canada, from January 2015 through February 2020.

PARTICIPANTS

In total, 9395 individuals contributed 18 273 person-years of follow-up while dispensed OAT.

MEASUREMENTS

We examined the association between stimulant prescription (primary exposure) and fatal or non-fatal overdose (primary outcome, allowing for recurrent events) after adjusting for potential confounders including sociodemographic characteristics and substance use patterns. As a secondary analysis, we evaluated type of OAT (full agonists involving methadone or slow-release oral morphine versus partial agonist involving buprenorphine/naloxone alone) as a potential effect modifier.

FINDINGS

There were 1746 overdose events; 37 (2.1%) were fatal. Overall, there was no increased risk of overdose among individuals dispensed a stimulant medication while on OAT [adjusted Cox regression hazard ratio (AHR) = 1.13, 95% confidence interval (95% CI) = 0.86-1.49, P = 0.39]. When analyzed by type of OAT medication, for individuals on buprenorphine, dispensation of a stimulant medication was associated with a reduced risk of overdose (AHR = 0.47, 95% CI = 0.23-0.96, P = 0.037) while, for individuals on full agonist OAT, dispensation of a stimulant medication was associated with an increased risk of overdose (AHR = 1.51, 95% CI = 1.09-2.07, P = 0.012).

CONCLUSIONS

There does not appear to be an overall increased risk of overdose for individuals co-prescribed a stimulant medication with opioid agonist therapy (OAT). There appears to be a reduced risk of overdose for individuals dispensed buprenorphine with a stimulant medication compared with those dispensed buprenorphine alone, and an increased risk of overdose for individuals dispensed full agonist OAT (methadone or slow-release oral morphine) with a stimulant medication compared with those dispensed full agonist OAT alone.

Harm Reduction Strategies for People Who Use Drugs

This JAMA Insights explores harm reduction strategies for people who use drugs and the clinicians who treat them to help reduce the risk of unintentional drug overdose and infection.

Identification of Behavioral, Clinical, and Psychological Antecedents of Acute Stimulant Poisoning: Development and Implementation of a Mixed Methods Psychological Autopsy Study

Background

Despite increasing fatal stimulant poisoning in the United States, little is understood about the mechanism of death. The psychological autopsy (PA) has long been used to distinguish the manner of death in equivocal cases, including opioid overdose, but has not been used to explicitly explore stimulant mortality.

Objective

We aimed to develop and implement a large PA study to identify antecedents of fatal stimulant poisoning, seeking to maximize data gathering and ethical interactions during the collateral interviews.

Methods

We ascertained death records from the California Electronic Death Reporting System (CA-EDRS) and the San Francisco Office of the County Medical Examiner (OCME) from June 2022 through December 2023. We selected deaths determined to be due to acute poisoning from cocaine or methamphetamine, which occurred 3-12 months prior and were not attributed to suicide or homicide. We identified 31 stimulant-fentanyl and 70 stimulant-no-opioid decedents. We sought 2 informants for each decedent, who were able to describe the decedent across their life course. Informants were at least 18 years of age, communicated with the decedent within the year before death, and were aware that the decedent had been using substances during that year. Upon completion of at least one informant interview conducted by staff with bachelor's or master's degrees, we collected OCME, medical record, and substance use disorder treatment data for the decedent. Planned analyses include least absolute shrinkage and selection operator regressions of quantitative data and thematic analyses of qualitative data.

Results

We identified and interviewed at least one informant (N=141) for each decedent (N=101). Based on feedback during recruitment, we adapted language to improve rapport, including changing the term "accidental death" to "premature death," offering condolences, and providing content warnings. As expected, family members were able to provide more data about the decedent's childhood and adolescence, and nonfamily informants provided more data regarding events proximal to death. We found that the interviews were stressful for both the interviewee and interviewer, especially when participants thought the study was intrusive or experienced significant grief during the interviews.

Conclusions

In developing and implementing PA research on fatal stimulant poisoning, we noted the importance of recruitment language regarding cause of death and condolences with collateral informants. Compassion and respect were critical to facilitate the interview process and maintain an ethical framework. We discuss several barriers to success and lessons learned while conducting PA interviews, as well as recommendations for future PA studies.

Combinations of substances contributing to death among overdose decedents in Maryland (2020-2021)

BACKGROUND

In 2020, Maryland had the fourth-highest opioid overdose mortality rate in the USA. We describe substances identified in postmortem toxicology screening and designated as cause of death (COD) for overdose decedents in Maryland, including specific combinations of substances designated as COD.

METHODS

We performed a retrospective analysis of N=5442 adult overdose decedents (ie, manner of death unintentional or undetermined) in Maryland between January 2020 and December 2021. Overdose mortality data from the State Unintentional Drug Overdose Reporting System. Substances were categorised into five major categories: opioids, alcohol, psychostimulants, sedative-hypnotics and psychotropic drugs. Opioids were further divided into prescription opioids (eg, oxycodone, methadone, tramadol) and illicit opioids (eg, illicitly manufactured fentanyl (IMF), heroin).

RESULTS

Opioids were present in 93% of cases and designated as COD for 92%. IMF was the predominant opioid designated as COD (82% of cases), whereas heroin was COD in only 3%. Psychostimulants, predominantly cocaine, were present in 48% of cases and designated as COD in 41%. Opioids alone were COD in 39% of cases, opioids and psychostimulants in combination were COD for 27%, followed by opioids and alcohol (9%), opioids, alcohol and psychostimulants (6%), and opioids and sedative-hypnotics (4%).

CONCLUSIONS

IMF is, by far, the leading cause of overdose in Maryland. For more than one-quarter of decedents, opioids and psychostimulants in combination were COD. Specific drug combinations have implications for public health surveillance and harm reduction efforts to keep people who use drugs safer from a volatile drug market and potential fatal overdose.

Invited commentary: motivating better methods-and better data collection-for measuring the prevalence of drug misuse

The United States continues to suffer a drug overdose crisis that has resulted in over 100 000 deaths annually since 2021. Despite decades of attention, estimates of the prevalence of drug use at the spatiotemporal resolutions necessary for resource allocation and intervention evaluation are lacking. Current approaches for measuring the prevalence of drug use, such as population surveys, capture-recapture, and multiplier methods, have significant limitations. In a recent article, Santaella-Tenorio et al (Am J Epidemiol. 2024;193(7):959-967) used a novel joint bayesian spatiotemporal modeling approach to estimate the county-level prevalence of opioid misuse in New York State from 2007 to 2018 and identify significant intrastate variation. By leveraging 5 data sources and simultaneously modeling different opioid-related outcomes-such as numbers of deaths, emergency department visits, and treatment visits-they obtained policy-relevant insights into the prevalence of opioid misuse and opioid-related outcomes at high spatiotemporal resolutions. The study provides future researchers with a sophisticated modeling approach that will allow them to incorporate multiple data sources in a rigorous statistical framework. The limitations of the study reflect the constraints of the broader field and underscore the importance of enhancing current surveillance with better, newer, and more timely data that are both standardized and easily accessible to inform public health policies and interventions. This article is part of a Special Collection on Mental Health.

The Rise of Fentanyl: Molecular Aspects and Forensic Investigations

Fentanyl is a synthetic opioid widely used for its potent analgesic effects in chronic pain management and intraoperative anesthesia. However, its high potency, low cost, and accessibility have also made it a significant drug of abuse, contributing to the global opioid epidemic. This review aims to provide an in-depth analysis of fentanyl's medical applications, pharmacokinetics, metabolism, and pharmacogenetics while examining its adverse effects and forensic implications. Special attention is given to its misuse, polydrug interactions, and the challenges in determining the cause of death in fentanyl-related fatalities. Fentanyl misuse has escalated dramatically, driven by its substitution for heroin and its availability through online platforms, including the dark web. Polydrug use, where fentanyl is combined with substances like xylazine, alcohol, benzodiazepines, or cocaine, exacerbates its toxicity and increases the risk of fatal outcomes. Fentanyl undergoes rapid distribution, metabolism by CYP3A4 into inactive metabolites, and renal excretion. Genetic polymorphisms in CYP3A4, OPRM1, and ABCB1 significantly influence individual responses to fentanyl, affecting its efficacy and potential for toxicity. Fentanyl's side effects include respiratory depression, cardiac arrhythmias, gastrointestinal dysfunction, and neurocognitive impairments. Chronic misuse disrupts brain function, contributes to mental health disorders, and poses risks for younger and older populations alike. Fentanyl-related deaths require comprehensive forensic investigations, including judicial inspections, autopsies, and toxicological analyses. Additionally, the co-administration of xylazine presents distinct challenges for the scientific community. Histological and immunohistochemical studies are essential for understanding organ-specific damage, while pharmacogenetic testing can identify individual susceptibilities. The growing prevalence of fentanyl abuse highlights the need for robust forensic protocols, advanced research into its pharmacogenetic variability, and strategies to mitigate its misuse. International collaboration, public education, and harm reduction measures are critical for addressing the fentanyl crisis effectively.

"They Don't Give You No Note If It's Got Fentanyl": Using Cognitive Interviews to Understand Self-report and Urine Drug Screen Discrepancies

Background

Fentanyl, a highly potent synthetic opioid, is now involved in the majority of drug overdose deaths in the United States. Discrepancies between substance use self-reports and urine drug screens (UDS) are common, especially when users are unaware of fentanyl adulteration.

Objectives

The objective of this study was to examine the cognitive processes underlying discrepancies between self-reported fentanyl use and UDS results, specifically focusing on participants unaware of their fentanyl exposure.

Design

This was a cross-sectional qualitative study.

Methods

This study conducted cognitive interviews with 10 participants from a larger clinical trial who tested positive for fentanyl in a UDS but reported no fentanyl use. The interviews explored participants' understanding of survey questions about fentanyl use and their interpretation of UDS results. Responses were analyzed to identify themes related to self-report discrepancies.

Results

Participants often underreported fentanyl use, not due to social desirability bias, but because they interpreted survey questions as asking about known, rather than suspected, fentanyl use. Many acknowledged their drugs were likely adulterated but only reported use when they were certain of fentanyl's presence.

Conclusion

The findings suggest that refining survey questions to capture both intentional and unintentional fentanyl exposure could improve the accuracy of self-reported data. These adjustments are critical to improve the accuracy of data collected to inform surveillance strategies, effective public health policies, and clinical interventions.

Naloxone administration and survival in overdoses involving opioids and stimulants: An analysis of law enforcement data from 63 Pennsylvania counties

BACKGROUND

In consideration of rising opioid-stimulant deaths in the United States, this study explored rates of naloxone administration and survival in suspected opioid overdoses with, versus without, stimulants co-involved.

METHODS

The study analyzed 26,635 suspected opioid-involved overdoses recorded by law enforcement/first-responders in the Pennsylvania Overdose Information Network in 63 Pennsylvania counties, January 2018-July 2024. All measures, including suspected drug involvement, were based on first-responder assessment/report. Relative frequencies and chi-square tests were first used to compare suspected opioid overdoses with, versus without, stimulants (cocaine or methamphetamine) co-involved. Next, mediation analyses tested naloxone administration as a mediator in the association between stimulant co-involvement (in opioid overdoses) and survival.

RESULTS

Naloxone was reportedly administered in 72.2 % of the suspected opioid-no-cocaine overdoses, compared to 55.1 % of the opioid-cocaine-involved overdoses, and 72.1 % of the opioid-no-methamphetamine overdoses vs. 52.4 % of the opioid-methamphetamine-involved overdoses. With respect to survival rates, 18.0 % of the suspected opioid-no-cocaine overdoses ended in death, compared to 41.3 % of the opioid-cocaine overdoses; 18.1 % of the opioid-no-methamphetamine overdoses ended in death, versus 42.9 % of the opioid-methamphetamine overdoses. In mediation analyses (adjusted for demographics, county, year, and other drug co-involvement), naloxone administration mediated 38.7 % (95 % Confidence Interval [CI], 31.3-46.0 %) of the association between suspected cocaine co-involvement and survival and 39.2 % (95 % CI, 31.3-47.1 %) of the association between suspected methamphetamine co-involvement and survival.

CONCLUSIONS

Among suspected opioid overdoses recorded in the Pennsylvania Overdose Information Network, stimulant co-involvement was associated with lower naloxone administration and higher fatality, with naloxone partially mediating the association between stimulant co-involvement and death.

Characteristics of Overdose Deaths Related to Illicitly Manufactured Fentanyl - Arizona, July 2019 - June 2020

Using the Arizona State Unintentional Drug Overdose Reporting System (AZ-SUDORS), the study aims to identify the social and drug characteristics of illicitly manufactured fentanyl (IMF)-related overdose deaths. The data include drug overdose deaths from July 1, 2019 to June 30, 2020. Decedents were categorized into four groups by types of opioids detected: (1) IMF-positive; (2) heroin-positive (negative for IMF); (3) pharmaceutical opioid-positive (negative for heroin or IMF); (4) nonopioid. Bivariate statistics were used to compare differences between IMF and other groups. Among 2,029 decedents, 77.8% tested positive for opioids. The IMF group included 57.9%, the heroin group included 9.5%, the pharmaceutical opioid group 10.5%, and the nonopioid group 22.2%. The IMF group was younger (mean age 35.0), more likely to be from a large urban area (78.2%), and with a greater proportion of ethnic/racial minorities (48.6%), compared to the other three groups. The IMF group was less likely to test positive for methamphetamine (24.9%), compared to heroin (63.7%) or pharmaceutical opioid groups (34.0%), but more likely to test positive for cannabis (31.3%), compared to the other three groups. Our data show disproportionate IMF impacts on younger persons and ethnic minorities. Interventions need to be tailored to account for distinct psychosocial profiles associated with IMF use.

Addressing the Intersections of Chronic Pain and OUD: Integrative Management of Chronic Pain and OUD for Whole Recovery (IMPOWR) Research Network

The appearance of both chronic pain (CP) and opioid use disorder (OUD)/opioid misuse is common, can bidirectionally affect treatment outcomes, and can be challenging to treat. The successful treatment of these conditions can be further complicated by co-occurring hazardous alcohol use, general anxiety disorder, and/or major depressive disorder, and calls for the need to attend to the whole health of the patient. Health systems providing care for these individuals are often fragmented, and suffer from limited resources, expertise, and communication. The National Institute on Drug Abuse, with support from the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative, funded the Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) network in 2021 to address the needs of this complex population. With continuous collaboration with community partners, the network supports 11 unique clinical trials and a Coordination and Dissemination Center which are described in this commentary. This article introduces the scientific rationale and structure of the network and highlights the themes connecting the trials together to collectively create data-driven and actionable solutions for individuals with co-occurring CP and OUD/opioid misuse.

Prevalence of stimulant use and the role of opioid agonist treatment among people who inject drugs in France: Results from the COSINUS cohort study

INTRODUCTION

The co-use of stimulants and opioids, including opioid agonist treatment (OAT), is very prevalent worldwide. A large body of data exists on the association between stimulant use and its health complications, and on OAT effectiveness among people with opioid use disorder. However, few data exist on stimulant-opioid co-use among people receiving OAT. Using data from the COSINUS cohort study, we investigated the association between the type of OAT and problematic stimulant use among persons who inject drugs (PWID).

METHODS

COSINUS is a 12-month French cohort study of 665 PWID. Data were collected in face-to-face interviews at enrolment, at 6 and 12 months. We defined problematic stimulant use as daily use of and/or injecting stimulants. We used Bayesian model averaging (BMA) to identify factors associated with problematic stimulant use.

RESULTS

At baseline, 76% (n = 505) of the participants reported problematic stimulant use. The optimal model from the BMA estimation showed that, after adjusting on social precarity and daily injection, participants on prescribed morphine sulfate as an OAT (compared with methadone) and those who use daily unprescribed buprenorphine were less likely to report problematic stimulant use.

DISCUSSION AND CONCLUSIONS

Our work highlights the high prevalence of problematic stimulant use among PWID in France but also the potential association between the type of OAT taken and stimulant use, by suggesting a protective effect of morphine sulfate on stimulant use. Since it has a higher intrinsic activity than other opioids, PWID on this OAT may be less interested in stimulants. Our findings warrant further investigation in clinical studies.

Opioid agonist treatment outcomes among individuals with a history of nonfatal overdose: Findings from a pragmatic, pan-Canadian, randomized control trial

BACKGROUND AND OBJECTIVES

History of nonfatal overdose (NFO) is common among people who use opioids, but little is known about opioid agonist treatment (OAT) outcomes for this high-risk subpopulation. The objective of this study was to investigate the relative effectiveness of buprenorphine/naloxone and methadone on retention and suppression of opioid use among individuals with opioid use disorder (OUD) and history of NFO.

METHODS

Secondary analysis of a pan-Canadian pragmatic trial comparing flexible take-home buprenorphine/naloxone and supervised methadone for people with OUD and history of NFO. Logistic regression was used to examine the impact of OAT on retention in the assigned or in any OAT at 24 weeks and analysis of covariance was used to examine the mean difference in opioid use between treatment arms.

RESULTS

Of the 272 randomized participants, 155 (57%) reported at least one NFO at baseline. Retention rates in the assigned treatment were 17.7% in the buprenorphine/naloxone group and 18.4% in the methadone group (adjusted odds ratio [AOR] = 0.54, 95% CI: 0.17-1.54). Rates of retention in any OAT were 28% and 20% in the buprenorphine/naloxone and methadone arms, respectively (AOR = 1.55, 95% CI: 0.65-3.78). There was an 11.9% adjusted mean difference in opioid-free urine drug tests, favoring the buprenorphine/naloxone arm (95% CI: 3.5-20.3; p = .0057).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Among adults with OUD and a history of overdose, overall retention rates were low but improved when retention in any treatment was considered. These findings highlight the importance of flexibility and patient-centered care to improve retention and other treatment outcomes in this population.

A multilevel analysis of changing telehealth availability in opioid use disorder treatment settings: Conditional effects of rurality, the number and types of medication for opioid use disorder available, and time, US, 2016-2023

PURPOSE

The opioid overdose crisis requires strengthening treatment systems with innovative technologies. How people use telehealth for opioid use disorder (OUD) is evolving and differs in rural versus urban areas, as telehealth is emerging as a local resource and complementary option to in-person treatment. We assessed changing trends in telehealth and medication for OUD (MOUD) and pinpoint locations of low telehealth and MOUD access.

METHODS

We used national data from the Mental health and Addiction Treatment Tracking Repository (2016-2023) to identify specialty outpatient SUD treatment facilities in the United States (N = 83,988). We modeled the availability of telehealth using multilevel multivariable logistic regression, adjusting for covariates. We included a 3-way interaction to test for conditional effects of rurality, the number of MOUD medication types dispensed, and year. We included two random effects to account for clustering within counties and states.

FINDINGS

We identified 495 facilities that offered both telehealth and all three MOUD medication types (methadone, buprenorphine, naltrexone) in 2023, clustered in the eastern United States. We identified a statistically significant 3-way interaction (p < 0.0001), indicating that telehealth in facilities that did not offer MOUD shifted from more telehealth in rural facilities in earlier years to more telehealth in urban facilities in later years.

CONCLUSIONS

Treatment facilities that offer both telehealth and all three MOUD medication types may improve access for hard-to-reach populations. We stress the importance of continued health system strengthening and technological resources in vulnerable rural communities, while acknowledging a changing landscape of increased OUD incidence and MOUD demand in urban communities.

Direct analysis in real time mass spectrometry (DART-MS/MS) for rapid urine opioid detection in a clinical setting

BACKGROUND AND AIMS

Current laboratory methods for opioid detection involve an initial screening with immunoassays which offers efficient but non-specific results and a subsequent liquid chromatography-tandem mass spectrometry (LC-MS/MS) confirmation which offers accurate results but requires extensive sample preparation and turnaround time. Direct Analysis in Real Time (DART) tandem mass spectrometry is evaluated as an alternative approach for accurate opioid detection with efficient sample preparation and turnaround time.

MATERIALS AND METHODS

DART-MS/MS was optimized by testing the method with varying temperatures, operation modes, extraction methods, hydrolysis times, and vortex times. The method was evaluated for 12 opioids by testing the analytical measurement range, percent carryover, precision studies, stability, and method-to-method comparison with LC-MS/MS.

RESULTS

DART-MS/MS shows high sensitivity and specificity for the detection of 6-acetylmorphine, codeine, hydromorphone, oxymorphone, hydrocodone, naloxone, buprenorphine, norfentanyl, and fentanyl in urine samples. However, its performance was suboptimal for norbuprenorphine, morphine and oxycodone.

CONCLUSION

In this proof-of-concept study, DART-MS/MS is evaluated for its rapid quantitative definitive testing of opioids drugs in urine. Further research is needed to expand its application to other areas of drug testing.

Prevalence and Characteristics of Alcohol Use in Substance-Involved Deaths in St. Louis, Missouri, From 2011 to 2022

OBJECTIVE

Alcohol contributes to a large number of deaths annually, in terms of both deaths fully attributed to alcohol (e.g., alcohol poisoning) and deaths where alcohol is a contributing cause (e.g., motor vehicle accidents). Nationally, alcohol-involved deaths are increasing. This study examines alcohol's role in substance-involved deaths and factors that are associated with alcohol involvement in the St. Louis, Missouri region.

METHOD

The present study examined 7,641 substance-involved deaths that occurred in the St. Louis, Missouri region. Data were provided by city and county medical examiner offices and comprised all substance-involved deaths between 2011 and 2022. We examined the prevalence of alcohol stratified by manner of death, sex, and race. We conducted logistic regression predicting odds of alcohol involvement based on demographic factors, presence of medical conditions, involvement of other substances, and year of death.

RESULTS

Overall, 26.29% (2,009/7,671) of substance-involved deaths involved alcohol, and annual alcohol-involved deaths increased by 54.33% from 2011 to 2022. Most substance-involved deaths were overdose deaths (82.54%; 6,307/7,641). Alcohol-involved overdose deaths increased by 60.76% from 2011 to 2022. Prevalence of alcohol was higher for overdose deaths involving opioids and benzodiazepines (18%-24%) than for other drug classes (7%-16%). Odds of alcohol involvement in overdose deaths increased with age (odds ratio = 1.02, 95% CI [1.01, 1.02]) and were higher for males (odds ratio = 1.67, 95% CI [1.43, 1.96]).

CONCLUSIONS

The St. Louis metropolitan area saw increases in alcohol-involved fatalities for all manner of deaths, particularly overdose deaths and deaths among Black men. To improve prevention strategies for alcohol fatalities, further research is needed to investigate the role of alcohol in polysubstance overdose deaths.

Characterizing and responding to stimulant overdoses: Findings from a mixed methods study of people who use cocaine and other stimulants in New England

PURPOSE

To explore people who use stimulants' (PWUS) stimulant overdose experiences and identify factors associated with calling 911 for personal and witnessed stimulant overdoses.

METHODS

From 2022-2023, 222 people in Massachusetts and Rhode Island with past-30-day illicit stimulant use were surveyed. Adjusted multivariable logistic regression models examined the association between sociodemographics, substance use, and stimulant overdose history and whether 911 was called for participants' last personally experienced and witnessed stimulant overdoses.

RESULTS

Overall, 42.2 % of PWUS witnessed- and 34.5 % personally overdosed on stimulants. Nearly half (48.7 %) of participants who overdosed used crack cocaine prior, 35.5 % reported extremely severe symptoms (e.g., heart attack, stroke, seizure, loss of consciousness), and 34.2 % said 911 was called at their last overdose. Among those who last witnessed a stimulant overdose, 41.5 % reported crack cocaine involvement, and 47.9 % said 911 was called (20.0 % personally called). Higher educational attainment and experiencing extremely severe symptoms were positively associated with 911 being called at participants' last stimulant overdose, whereas the number of overdoses witnessed and crack cocaine use by the person overdosing were negatively associated with 911 being called at participants' last witnessed stimulant overdose (all p-values<.05).

CONCLUSION

Stimulant overdoses were common. Most participants reported moderate-to-severe symptoms, yet 911 was called in less than half of personal or witnessed stimulant overdoses. Emergency help-seeking also varied by symptom severity, stimulant type, and the sociodemographics of the person overdosing. Research is needed to understand barriers to formal help-seeking and the practices PWUS engage in to prevent fatal stimulant overdoses.

The public health risks of counterfeit pills

Synthetic illicit drugs, such as nitazenes and fentanyls, are becoming commonplace in countries around the world, including in Europe, Australia, and Latin America, which raises concern for overdose crises like those seen in North America. An important dimension of the risk represented by synthetic drugs is the fact that they are increasingly packaged in counterfeit pill form. These pills-often indistinguishable from authentic pharmaceuticals-have substantially widened the scope of populations susceptible to synthetic drug overdose in North America (eg, among adolescents experimenting with pills or tourists from the USA seeking psychoactive medications from pharmacies in Mexico). The non-medical use of diverted prescription medications is relatively more common, and less stigmatised, than the use of powder drugs. Many consumers of counterfeit pills are unaware that they contain synthetic illicit drugs, believe them to be authentic pharmaceuticals, and would be unlikely to consume those drugs knowingly or if in powder form. Given these issues, we recommend the expansion of educational and awareness campaigns, pill testing programmes to help consumers shift demand to safer products, increased monitoring in routine clinical scenarios and overdose death toxicology, and expanding medically managed safer alternatives to counterfeit pill use.

Patent Review of Novel Biologics Targeting Opioid Use Disorder (2018-2024)

Drug overdose deaths in 2023 in the United States exceeded 107,000, with 80,000 of these deaths attributed to opioids alone. The emergence of synthetic opioids such as fentanyl and its analogues have worsened the opioid overdose epidemic. A novel approach to treat opioid overdose and opioid use disorder (OUD) has been the introduction of biologics, which include monoclonal antibodies that bind to circulating opioids, preventing them from reaching the central nervous system, or peptides that have antinociceptive effects but lack the abuse liability of synthetic opioids. A challenge in the treatment of opioid overdose has been renarcotization, where an overdose patient revived with naloxone can re-enter an overdose state from residual opioid in the body. Biologics such as vaccines and monoclonal antibodies are excellent strategies that have been demonstrated to prevent renarcotization. In this review, we retrieved and discussed patents filed in the past six (6) years that focus on novel biologics reported as treatments for opioid overdose and OUD. We also provide a perspective on the use of biologics as therapeutics for OUD and opioid overdose.

Self-Harm as a Contributor to the Opioid Epidemic: Data From the Toxicology Investigators Consortium Registry

OBJECTIVES

Although considerable focus has been placed on understanding the causes of opioid drug overdoses, the intentions for such overdoses are not well characterized. We investigated the motivations behind nonfatal opioid exposures resulting in serious adverse health outcomes.

METHODS

We analyzed prospectively collected data on nonfatal opioid overdoses in the multicenter Toxicology Investigators Consortium (ToxIC) Core Registry between 2014 and 2021. Included patients were age ≥11 years with serious toxicity after use of pharmaceutical and/or nonpharmaceutical opioids for whom the reasons for opioid exposure were determined. Pharmaceutical opioids were defined as United States Food and Drug Administration-approved medications. All other opioids were classified as nonpharmaceuticals.

RESULTS

The 5250 cases meeting the criteria were 56.6% male with a median age of 36 years (IQR, 26-50). There were 2960 (56.4%) opioid misuse cases and 1456 (27.7%) self-harm attempts. Within the self-harm group, 1242 (85.3%) were suicidal, and 1187 (95.6%) of these used pharmaceutical opioids in their suicide attempt. Only 94 (4.2%) patients using nonpharmaceutical opioids did so in a suicide attempt. Pharmaceutical opioid suicide attempts as a percent of all registry cases peaked between 2015 and 2017 and fell dramatically thereafter (P = 0.005). For comparison, benzodiazepine overdoses similarly decreased (P = 0.003), whereas non-opioid analgesic or antidepressant overdoses increased.

CONCLUSIONS

A majority of serious opioid overdoses were sequelae of opioid misuse, but over a quarter were intentional self-harm attempts, primarily involving pharmaceutical opioids. Decreased prescribing of opioids and benzodiazepines after 2016-2017 may have resulted in decreased pharmaceutical opioid and benzodiazepine misuse and self-harm attempts. Similar trends were not seen for nonpharmaceutical opioids.

Association between buprenorphine dose and outcomes among pregnant persons with opioid use disorder

BACKGROUND

Opioid use disorder contributes to maternal morbidity and mortality in the United States. Little is known about how the patterns of buprenorphine dose and duration throughout pregnancy may affect neonatal and postpartum outcomes.

OBJECTIVE

To determine the associations between trajectories of buprenorphine utilization and dose during pregnancy on maternal and neonatal health outcomes.

STUDY DESIGN

Retrospective cohort study among 2925 pregnant persons with opioid use disorder, followed from the estimated start date of pregnancy through 90 days after delivery. We used administrative healthcare data from Medicaid-enrolled individuals to assess buprenorphine dose and use and maternal (postpartum buprenorphine continuation and overdose) and neonatal (low birthweight, neonatal abstinence syndrome (NAS)) outcomes. Group-based trajectory modelling was used to identify trajectories of buprenorphine dose and use during pregnancy. Weighted multivariable logistic regression assessed the association between buprenorphine trajectories and outcomes.

RESULTS

We identified 8 trajectories of buprenorphine utilization and dose during pregnancy. Regression analyses found that high doses of buprenorphine and a longer duration of buprenorphine use during pregnancy was associated with higher odds of postpartum buprenorphine continuation and reduced rates of overdose. Higher doses and longer duration of buprenorphine treatment were not associated with an increase in NAS or term low birth weight, relative to moderate or low doses or shorter treatment duration.

CONCLUSION

A longer duration and higher dose of buprenorphine treatment during pregnancy were associated with improved odds of postpartum buprenorphine continuation and were not associated with adverse neonatal outcomes.

"I Been Taking Adderall Mixing it With Lean, Hope I Don't Wake Up Out My Sleep": Harnessing Twitter to Understand Nonmedical Prescription Stimulant Use among Black Women and Men Subscribers

Black women and men outpace other races for stimulant-involved overdose mortality despite lower lifetime use. Growth in mortality from prescription stimulant medications is increasing in tandem with prescribing patterns for these medications. We used Twitter to explore nonmedical prescription stimulant use (NMPSU) among Black women and men using emotion and sentiment analysis, and topic modeling. We applied the NRC Lexicon and VADER dictionary, and LDA topic modeling to examine feelings and themes in conversations about NMPSU by gender. We paid attention to the ability of natural language processing techniques to detect differences in emotion and sentiment among Black Twitter subscribers given increased mortality from stimulants. We found that, although emotion and sentiment outcomes match the directionality of emotions and sentiment observed (i.e., Black Twitter subscribers use more positive language in tweets), this belies limitations of NRC and VADER dictionaries to distinguish feelings for Black people. Even still, LDA topic models showcased the relevance of hip-hop, dependence on NMPSU, and recreational use as consequential to Black Twitter subscribers' discussions. However, gender shaped the relevance of these topics for each group. Greater attention needs to be paid to how Black women and men use social media to discuss important topics like drug use. Natural language processing methods and social media research should include larger proportions of Black, Hispanic/Latinx, and American Indian populations in development of emotion and sentiment lexicons, otherwise outcomes regarding NMPSU will not be generalizable to populations writ large due to cultural differences in communication about drug use online.

[Opioid prescriptions for insured individuals without cancer in Germany: data from the BARMER]

BACKGROUND

The importance of opioids in the treatment of non-cancer pain is under debate. No current data are available from Germany on the prevalence of opioid treatment for non-cancer pain.

AIM OF THE STUDY

Data on the prevalence of short- and long-term opioid prescriptions for patients without cancer, prescribed agents, co-medication, specialty of prescribing physicians, demographic and clinical characteristics of patients.

MATERIALS AND METHODS

Retrospective analysis of billing data of adult BARMER-insured persons without evidence of cancer (N = 6,771,075) in 2021 and for patients initiating opioid therapy in 2019 (n = 142,598).

RESULTS

In total, 5.7% of the insured persons without a cancer diagnosis received at least one prescription for an opioid in 2021, while 1.9% received long-term therapy. Tilidine and tramadol were the most frequently prescribed opioids in short- and long-term therapy. Women received opioids more frequently than men. The frequency of prescriptions significantly increased with age. In 2021, 22.5% of insured persons with long-term opioid therapy received a co-medication with pregabalin and/or gabapentin, 37.5% with an antidepressant and 58.1% with metamizole and/or NSAIDs. A total of 59.5% of first prescriptions were issued by general practitioners. In the first year of therapy, an average of 2.1 practices were involved in prescribing analgetics for people on long-term opioid therapy and 13 different chronic diseases were documented.

DISCUSSION

Opioid therapy for non-cancer-related pain is predominantly carried out by general practitioners in older and multi-morbid patients. The indication for or against opioid therapy requires shared decision-making with patients and, if necessary, their relatives, as well as a review of possible drug interactions.

Perspectives on Diversion of Medications From Safer Opioid Supply Programs

Importance

Safer supply programs were implemented in Canada to provide pharmaceutical-grade alternatives to the toxic unregulated drug supply. While research shows clinical benefits and reduced overdose mortality among safer supply patients, medication diversion remains a concern.

Objective

To examine provider (prescribing clinicians and allied health professionals) and patient perspectives on diversion of opioids prescribed in safer supply programs.

Design, Setting, and Participants

In 2021, qualitative interviews and sociodemographic questionnaires were conducted with patients and providers across 4 safer supply programs in Ontario, Canada. Interviews with 21 providers (physicians, nurse practitioners, and allied health professionals) and 52 patients examined experiences implementing safer supply or receiving care. Initial data analysis was conducted from December 2021 to March 2022, and the subanalysis focused on diversion was conducted from December 2023 to March 2024.

Exposures

Participation in safer supply program as a patient or provider.

Main Outcomes and Measures

Data about diversion were coded, extracted, and thematically analyzed.

Results

Of 52 patient participants, 29 (55.8%) were men and 23 (44.2%) were women; 1 was Black (1.9%), 9 (17.3%) were Indigenous, 1 was Latino (1.9%), and 41 (78.8%) were White; and the mean (SD) age was 46.5 (9.6) years. Of 21 provider participants, 6 (28.6%) were men, 13 (61.9%) were women, and 2 (9.5%) were nonbinary; and the mean (SD) age was 37.6 (7.6) years. Participants characterized diversion as a spectrum ranging from no diversion, to occasional medication sharing and loss, to selling all prescribed doses of safer supply (considered rare and easy to detect). Most patients reported they consumed all or most of their prescribed medications and rarely shared or sold their doses. However, providers and patient participants shared that people might share, trade, and/or sell some of their medications with other opioid-using people for multiple reasons. Most prominent reasons for diversion were (1) compassionate sharing with intimate partners and friends to manage withdrawal and overdose risk; (2) selling or trading medications to address their own unmet substance use needs (eg, high opioid tolerance); and (3) medication loss due to poverty, homelessness, and associated vulnerabilities to theft and coercion. Programs used nonpunitive urine drug screening practices and patient self-report to monitor medication use. When diversion was identified, providers described using nonjudgmental conversations to understand patients' needs and develop mitigation strategies that addressed underlying reasons for diversion, including changing doses and medications prescribed to better match patients' needs, enrolling eligible intimate partners, and developing safety plans to mitigate vulnerabilities to theft and coercion.

Conclusions and Relevance

Diversion encompasses a wide spectrum of practices (selling, sharing, and loss of medications), and occurs for complex reasons that surveillance and punitive measures are unlikely to mitigate. Diversion may be best addressed by expanding medication options to better match patients' diverse substance use needs and high tolerance, alongside wraparound social supports.

Addressing Racial and Ethnic Inequities in Opioid Overdose Mortality: Strategies for Equitable Interventions and Structural Change

PURPOSE OF REVIEW

This review synthetizes findings reflecting the increasing racial and ethnic inequities in opioid overdose mortality and emphasizes the necessity for tailored interventions as well as other policy-level and structural strategies to stem this trend.

RECENT FINDINGS

Factors contributing to inequities in overdose mortality include changes in drug supply, persistent social-structural vulnerabilities stemming from structural racism, and inequities in access to medication for opioid use disorder and harm reduction services. Key strategies to address these inequities include the cultural adaptation of evidence-based interventions within an equity-based framework, integrating social determinants of health into addiction treatment, centering anti-racism praxis in addiction research, diversifying the addiction workforce, and integrating structural competency as a tool to restructure education and inform practice. Structural racism must be recognized as a key driver of inequities in substance use outcomes, and this understanding must be integrated into existing models of substance use disorder prevention, treatment, and research.

Associations Among Sleep, Pain, and Medications for Opioid Use Disorder: a Scoping Review

Purpose of Review

We present current evidence on the associations among sleep, pain, and medications for opioid use disorder (MOUD) among individuals with opioid use disorder (OUD).

Recent Findings

We searched MEDLINE, Embase, PsycInfo, Web of Science, and Cochrane Library from inception until September 2023 for original research studies examining sleep, pain, and MOUD. We identified 19 manuscripts (14 were cross-sectional studies, four were prospective cohort studies, and one was a randomized controlled trial). Measures of sleep and pain varied. Sleep disturbance and pain were highly prevalent and associated. However, the associations between MOUD treatment characteristics (e.g., initiation, type, dose, and prior MOUD) and a) sleep and b) pain were mixed or unclear. Limited sample sizes and covariates such as opioid use disorder severity sometimes complicated the examination or interpretation of these associations. Few studies examined possible mediators underlying these associations.

Summary

While sleep and pain were consistently associated, it is unclear whether sleep and pain are associated with MOUD treatment characteristics or other covariates such as opioid use disorder severity. Future research on the associations among sleep, pain, and MOUD among individuals with OUD should consider a) comparing different MOUD treatments including formulations and dose schedules, b) qualitative and mixed methods studies to assess patient and provider preferences for the treatment of sleep and pain in OUD treatment settings, c) longitudinal studies that employ reliable and valid measures with sufficiently powered sample sizes to examine mediation and moderation, and d) testing whether interventions addressing pain or sleep among patients receiving MOUD improve pain, sleep, and MOUD outcomes.

A review of implementation research funded by the National Institute on Drug Abuse, 2007-2023: Progress and opportunities

BACKGROUND

The ongoing and evolving overdose epidemic highlights the need to translate research results into routine clinical practice to address urgent service delivery needs. Implementation science is a relatively new discipline intended to develop systematic, replicable, scalable strategies to accelerate this translation. This article presents a comprehensive review of implementation research funded by the National Institute on Drug Abuse (NIDA).

METHODS

The study identified all NIDA-funded research grants awarded in fiscal years 2007 through 2023 in treatment services or prevention research (n = 1111) and screened them to find those with a pre-specified implementation science component (n = 248). Using the text of the grant application, two reviewers independently coded the key characteristics of each study.

RESULTS

The characteristics of these grants, and trends over time, are described, and priority gap areas are identified. NIDA's implementation research grants have demonstrated increasing rigor in design and measurement.

CONCLUSIONS

Growth in the portfolio has been driven in part by NIDA's investments in research-practice partnerships in the criminal-legal system, and by recent efforts to address the overdose epidemic.

A place-based spatial analysis of racial inequities in overdose in St. Louis County Missouri, United States

OBJECTIVE

The objective of this study was to identify place features associated with increased risk of drug-involved fatalities and generate a composite score measuring risk based on the combined effects of features of the built environment.

METHODS

We conducted a geospatial analysis of overdose data from 2022 to 2023 provided by the St. Louis County Medical Examiner's Office to test whether drug-involved deaths were more likely to occur near 54 different place features using Risk Terrain Modeling (RTM). RTM was used to identify features of the built environment that create settings of heightened overdose risk. Risk was estimated using Relative Risk Values (RRVs) and a composite score measuring Relative Risk Scores (RRS) across the county was produced for drugs, opioids, and stimulants, as well as by Black and White decedents.

RESULTS

In the model including all drugs, deaths were more likely to occur in close proximity to hotels/motels (RRV=39.65, SE=0.34, t-value=10.81 p<.001), foreclosures (RRV=4.42, SE=0.12, t-value = 12.80, p<.001), police departments (RRV=3.13, SE=0.24, t-score=4.86, p<.001), and restaurants (RRV=2.33, SE=0.12, t-value=7.16, p<.001). For Black decedents, deaths were more likely to occur near foreclosures (RRV=9.01, SE=0.18, t-value =11.92, p<.001), and places of worship (RRV= 2.51, SE=0.18, t-value = 11.92, p<.001). For White decedents, deaths were more likely to occur in close proximity to hotels/motels (RRV=38.97, SE=0.39, t-value=9.30, p<.001) foreclosures (RRV=2.57, SE=0.16, t-value =5.84, p<.001), restaurants (RRV=2.52, SE=0.17, t-value=5.33, p<.001) and, auto painting/repair shops (RRV=0.04, SE=0.18, t-value =3.39, p<.001).

CONCLUSION

These findings suggest that places of worship, the hospitality industry, and housing authorities may be physical features of the environment that reflect social conditions that are conducive to overdose. The scaling up of harm reduction strategies could be enhanced by targeting places where features are co-located.

The preponderance of opioid overdoses among middle-aged individuals in the US: Analysis of 911 dispatch data - Q1 2018 to Q3 2023

BACKGROUND

Opioid overdoses have increased at a concerning rate in recent years. Middle-aged individuals have been reported as an age group of high concern for opioid overdoses. The purpose of this study was to assess trends in opioid overdose 911 dispatches between Q1 2018 and Q3 2023 among different age groups. It was hypothesized that the steepest increase in dispatches would be among middle-aged individuals.

METHODS

We assessed age-related trends in opioid-related 911 dispatches using emergency medical service (EMS) data collected by biosptial, io. Data encompassed all 50 states and were broken into yearly quarters between Q1 2018 and Q3 2023. Age groups included younger- (10 to 29), middle- (30 to 49), and older-aged (50 to 69) individuals. Joinpoint regression was utilized to examine these trends.

RESULTS

There were a total of 1,420,298 opioid-related 911 dispatches reported. Most were reported among middle-aged individuals, accounting for 48.9 % (n = 682,132) of all dispatches. Significant increases in dispatches were identified overall between Q1 2018 and Q2 2021 (β = 0.096, SE = 0.006, P ≤ 0.001). The steepest increase was identified among middle-aged individuals between Q1 2018 and Q2 2021 (β = 0.104, SE = 0.007, P ≤ 0.001). There was a significant decrease in dispatches among younger-aged individuals between Q2 2021 and Q3 2023 (β = -0.024, SE = 0.011, P = .036).

CONCLUSION

Middle-aged individuals experienced significant increases in opioid-related 911 dispatches between Q1 2018 and Q2 2021, and had the steepest increase compared to the other age groups. Conversely, younger-aged individuals have experienced a recent decrease in dispatches. These findings support previous indications that middle-aged individuals are at significant risk for opioid overdose. Additional research is necessary to identify geographic and demographic factors that may affect these trends.

Illicitly Manufactured Fentanyl: Anesthesia's Role in the Perioperative Setting

In wave 4 of the opioid crisis, which is dominated by illicitly manufactured fentanyl (IMF) and stimulant use, anesthesia personnel could play an important role in the perioperative care of these persons. Knowledge of the extent and lethality of opioid use in the current wave of the opioid crisis could raise awareness of the problem among anesthesia personnel. In the absence of research to guide development of best practice recommendations, knowledge of the historical trends in opioid use, the epidemiology of IMF use, and pragmatic clinically-oriented approaches for identifying persons using IMF could provide a general framework for future research.

Engaging healthcare teams to increase access to medications for opioid use disorder

OBJECTIVE

To assess the effectiveness of evidence-based quality improvement (EBQI) as an implementation strategy to expand the use of medications for opioid use disorder (MOUD) within nonspecialty settings.

DATA SOURCES AND STUDY SETTING

We studied eight facilities in one Veteran Health Administration (VHA) region from October 2015 to September 2022 using administrative data.

STUDY DESIGN

Initially a pilot, we sequentially engaged seven of eight facilities from April 2018 to September 2022 using EBQI, consisting of multilevel stakeholder engagement, technical support, practice facilitation, and data feedback. We established facility-level interdisciplinary quality improvement (QI) teams and a regional-level cross-facility collaborative. We used a nonrandomized stepped wedge design with repeated cross sections to accommodate the phased implementation. Using aggregate facility-level data from October 2015 to September 2022, we analyzed changes in patients receiving MOUD using hierarchical multiple logistic regression.

DATA COLLECTION/EXTRACTION METHODS

Eligible patients had an opioid use disorder (OUD) diagnosis from an outpatient or inpatient visit in the previous year. Receiving MOUD was defined as having been prescribed an opioid agonist or antagonist treatment or a visit to an opioid substitution clinic.

PRINCIPAL FINDINGS

The probability of patients with OUD receiving MOUD improved significantly over time for all eight facilities (average marginal effect [AME]: 0.0057, 95% CI: 0.0044, 0.0070) due to ongoing VHA initiatives, with the probability of receiving MOUD increasing by 0.577 percentage points, on average, each quarter, totaling 16 percentage points during the evaluation period. The seven facilities engaging in EBQI experienced, on average, an additional 5.25 percentage point increase in the probability of receiving MOUD (AME: 0.0525, 95%CI: 0.0280, 0.0769). EBQI duration was not associated with changes.

CONCLUSIONS

EBQI was effective for expanding access to MOUD in nonspecialty settings, resulting in increases in patients receiving MOUD exceeding those associated with temporal trends. Additional research is needed due to recent MOUD expansion legislation.

Differences in hepatitis C virus (HCV) testing and treatment by opioid, stimulant, and polysubstance use among people who use drugs in rural U.S. communities

BACKGROUND

People who use drugs (PWUD) in rural communities increasingly use stimulants, such as methamphetamine and cocaine, with opioids. We examined differences in hepatitis C virus (HCV) testing and treatment history among rural PWUD with opioids, stimulants, and other substance use combinations.

METHODS

PWUD were enrolled from ten rural U.S. communities from 2018 to 2020. Participants self-reporting a positive HCV result were asked about their HCV treatment history and drug use history. Drug use was categorized as opioids alone, stimulants alone, both, or other drug(s) within the past 30 days. Prevalence ratios (PR) were yielded using adjusted multivariable log-binomial regression with generalized linear mixed models.

RESULTS

Of the 2,705 PWUD, most reported both opioid and stimulant use (74%); while stimulant-only (12%), opioid-only (11%), and other drug use (2%) were less common. Most (76%) reported receiving HCV testing. Compared to other drug use, those who reported opioid use alone had a lower prevalence of HCV testing (aPR = 0.80; 95% CI: 0.63, 1.02). Among participants (n = 944) who self-reported an HCV diagnosis in their lifetime, 111 (12%) ever took anti-HCV medication; those who used both opioids and stimulants were less likely to have taken anti-HCV medication compared with other drug(s) (aPR = 0.41; 95% CI: 0.19, 0.91).

CONCLUSIONS

In this pre-COVID study of U.S. rural PWUD, those who reported opioid use alone had a lower prevalence of reported HCV testing. Those diagnosed with HCV and reported both opioid and stimulant use were less likely to report ever taking anti-HCV medication.

Chronic disease diagnoses and health service use among people who died of illicit drug toxicity in British Columbia, Canada

BACKGROUND

Illicit drug toxicity (i.e., overdose) is the leading cause of death in British Columbia (BC) for people aged 10-59. Stimulants are increasingly detected among drug toxicity deaths. As stimulant use and detection in deaths rises, it is important to understand how people who die of stimulant toxicity differ from people who die of opioid toxicity.

METHODS

BC Coroners Service records were retrieved for all people who died of unintentional illicit drug toxicity (accidental or undetermined) between January 1, 2015, and December 31, 2019, whose coroner investigation had concluded and who had an opioid and/or stimulant detected in post-mortem toxicology and identified by the coroner as relevant to the death (N = 3788). BC Chronic Disease Registry definitions were used to identify people with chronic disease. Multinomial regression models were used to examine the relationship between chronic disease diagnoses and drug toxicity death type.

RESULTS

Of the 3788 deaths, 11.1% (N = 422) had stimulants but not opioids deemed relevant to the cause of death (stimulant group), 26.8% (N = 1014) had opioids but not stimulants deemed relevant (opioid group), and 62.1% (N = 2352) had both opioids and stimulants deemed relevant (opioid/stimulant group). People with ischemic heart disease (1.80 (1.14-2.85)) and people with heart failure (2.29 (1.25-4.20)) had approximately twice the odds of being in the stimulant group as compared to the opioid group.

CONCLUSIONS

Findings suggest that people with heart disease who use illicit stimulants face an elevated risk of drug toxicity death. Future research should explore this association and should identify opportunities for targeted interventions to reduce drug toxicity deaths among people with medical comorbidities.

Ultrasensitive electrochemiluminescencent multivalent aptamer sensor based on energy and electron transfer dual quenching tactics

An efficient "on-off-on" electrochemiluminescence (ECL) aptasensor utilizing dual-mechanism quenching was constructed for detecting furanyl fentanyl (FuF). The first signal "on" state was achieved by novel dual-ligand zinc metal-organic frameworks (Zn-MOFs), which were synthesized by self-assembly reaction using zinc atom clusters as metal nodes, achieving strong and stable ECL emission. The "off" state was realized by the energy and electron quenching effect of copper-doped WO3. Specifically, in addition to the overlap of the UV-Vis spectrum, energy transfer existed between the acceptor and donor after doping copper. Therefore, copper created a "highway" for electron transfer between the donor and acceptor, which greatly improved the quenching efficiency. Simultaneously, employing multivalent aptamers as capture probes augmented the binding affinity and probability of association between aptamer and target through a synergistic multivalent effect. Consequently, the second "on" state was the ECL signal restored by introducing FuF. Benefiting from the combination of the multivalent aptamers strategy with the "on-off-on" design, the developed aptasensor showed excellent linearity (1.0 × 10-13 to 1.0 × 10-6 g/L) with a low limit of detection of 5.5 × 10-14 g/L (S/N = 3). Additionally, it demonstrates a relative standard deviation (RSD) of less than 5% and good recovery ranging from 97.6 to 102%. The proposed aptasensor presents considerable potential for rapid, sensitive, and accurate determination of FuF.

Naloxone Administration and Survival in Overdoses Involving Opioids and Stimulants: An Analysis of Law Enforcement Data from 63 Pennsylvania Counties

Background

In consideration of rising opioid-stimulant deaths in the United States, this study explored rates of naloxone administration and survival in suspected opioid overdoses with, versus without, stimulants co-involved.

Methods

The study analyzed 26,635 suspected opioid-involved overdoses recorded by law enforcement/first-responders in the Pennsylvania Overdose Information Network in 63 Pennsylvania counties, January 2018-July 2024. All measures, including suspected drug involvement, were based on first-responder assessment/report. Relative frequencies and chi-square tests were first used to compare suspected opioid overdoses with, versus without, stimulants (cocaine or methamphetamine) co-involved. Next, mediation analyses tested naloxone administration as a mediator in the association between stimulant co-involvement (in opioid overdoses) and survival.

Results

Naloxone was reportedly administered in 72.2% of the suspected opioid-no-cocaine overdoses, compared to 55.1% of the opioid-cocaine-involved overdoses, and 72.1% of the opioid-no-methamphetamine overdoses vs. 52.4% of the opioid-methamphetamine-involved overdoses. With respect to survival rates, 18.0% of the suspected opioid-no-cocaine overdoses ended in death, compared to 41.3% of the opioid-cocaine overdoses; 18.1% of the opioid-no-methamphetamine overdoses ended in death, versus 42.9% of the opioid-methamphetamine overdoses. In mediation analyses (adjusted for demographics, county, year, and other drug co-involvement), naloxone administration mediated 38.7% (95% Confidence Interval [CI], 31.3%-46.0%) of the association between suspected cocaine co-involvement and survival and 39.2% (95% CI, 31.3%-47.1%) of the association between suspected methamphetamine co-involvement and survival.

Conclusions

Among suspected opioid overdoses recorded in the Pennsylvania Overdose Information Network, stimulant co-involvement was associated with lower naloxone administration and higher fatality, with naloxone partially mediating the association between stimulant co-involvement and death.

COVID-19 public health restrictions and opioid overdoes: a summative content analysis of emergency medical services records in three Texas counties

BACKGROUND

With the broad recognition of increased U.S. opioid overdose (OOD) rates between 2020 and 2021, media, public health, and healthcare organizations have raised significant concerns over the emergence of a simultaneous COVID-19-opioid "twindemic." Research in this area has explored the possible relationships between negative externalities associated with the pandemic and/or COVID-19 public health interventions and increased risks for opioid use and overdose alongside diminished outcomes following OOD events.

METHODS

The study offers a summative content analysis of Emergency Medical Service (EMS) responses to opioid overdose (OOD) events before and after the institution of COVID-19 restrictions. Specifically, the study investigates three Texas counties to evaluate changing OOD rates, patient demographics, and OOD event features. The analysis uses a previously validated machine learning tool to identify OOD events and conducted a summative content analysis of identified events.

RESULTS

A total of 1170 OOD responses events were identified in the three-county dataset. This includes 874 in Travis County, 242 in El Paso County, and 54 in Williamson County. Each county experienced modest changes in EMS calls for OOD events between the pre-restriction and public health restriction time periods. Travis County's OOD event rate declined from 454 to 420. El Paso's increased from 103 to 139, and Williamson County's increased from 23 to 31. These changes were not significant as percentage of possible OOD events or based on by-month comparison. The notable differences between pre-restriction and public health restriction periods were significant decreases in documentation of patient race/ethnicity in Travis and Williamson Counties, significant decreases in housing insecurity and use alone in Travis County, and an increase in transport refusal after treatment in the field in Travis County.

CONCLUSIONS

Ultimately the results presented here problematize prevailing analyses about the so-called opioid-COVID-19 "twindemic." The data further support emerging trends about substantial geographic variation and show some ways that COVID-19 mitigation measures may have improved conditions for some populations, particularly in terms of housing security. Additionally, the results presented here indicate that further attention should be paid to the effects of first responder stress on documentation quality.

Preoperative Narcotic Education in Spine Surgery: A Retrospective Study

Background/Objectives: The objective of this study was to determine whether preoperative opioid education reduces opioid consumption after spine surgery and which educational methods are the most effective. Orthopedists are the most likely to prescribe opioids among all specialists. To alleviate the prescription opioid crisis, studies have identified ways to taper narcotic dosage and use following surgery. The role of preoperative education and its varying modalities on opioid consumption following spine surgery has yet to be reported in the literature. Methods: The study group received formal education describing the use of opioids, side effects, and alternatives to pain management. Patients were to choose their preferred modality of a 2 min narrated video and two handouts to be watched and read in their individual time, attending a small class led by a physician assistant where they watched the 2 min narrated video along with reading the two handouts or receiving a one-on-one session with the treating spine surgeon. Meanwhile, the control group received standard preoperative education. Refill prescriptions were collected from patients' electronic medical record charts at the 2-week, 1-month, 3-month, and 6-month postoperative follow-ups. The primary outcome measure was morphine equivalents (MME) of prescription opioids at six months following spine surgery. Results: At 2 weeks postoperatively, there were no statistically significant differences between patients who received any formal narcotic education and those who did not. At 1 and 3 months postoperatively, the video education group (p-value < 0.001), class education group (p-value < 0.001), and the one-on-one education group (p-value < 0.05) all had significant reductions in opioid consumption. At 6 months postoperatively, only the video education group (p-value < 0.001) and the class education group (p-value < 0.01) had significant reductions in opioid consumption. Conclusions: A two-fold approach with a video and handouts significantly decreases the prescription dosage at six months postoperatively and allows for early opioid cessation after undergoing spine surgery.

Prevalence and predictors of HIV among patients presenting to US emergency departments with opioid overdose

INTRODUCTION

Opioid overdose deaths in the U.S. have risen dramatically in the past decade, largely due to the surge in illicitly manufactured fentanyl. Injection drug use is a known risk factor for HIV, further complicating the long-term consequences of opioid use. The baseline prevalence of HIV among adults in the US is 0.46 %. The primary purpose of this study was to determine the prevalence and risk factors of HIV among patients presenting to the emergency departments (ED) with an acute opioid overdose.

METHODS

This study is a prospective observational cohort study from the ToxIC Fentalog Study group. Patients age 18 years of age or older are included if they present to one of 10 participating U.S. hospitals in 9 states between September 2020 and May 2023 with a suspected opioid overdose and had waste serum available after routine laboratory testing. Clinical data is collected from the medical record and patient serum is sent for comprehensive toxicologic analysis via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect the presence of over 1200 substances including illicit opioids, novel synthetic opioids, medications, and adulterants. Logistic multivariable regression was performed to examine the association between demographic, behavioral, and serum toxicology data with risk factors and HIV status.

RESULTS

Among the total cohort (n=1690), 1062 cases had known HIV status (62.8 % of total sample). Among patients with a known HIV status, 60 (5.6 % [95 % CI: 4.2 %, 7.0 %]) were HIV positive. Patients with HIV reported stimulant use more frequently (13.3 %) than those without HIV (6.8 %; p=0.003). After controlling for confounding, bipolar psychiatric history was a significant independent predictor of HIV positivity (aOR: 1.08; 95 % CI: 1.02, 1.13) in this population.

CONCLUSIONS

In this large multicenter cohort, the prevalence of HIV for ED patients with illicit opioid overdose was 9 times higher than that expected by the general population. Bipolar disorder appears to be a novel risk factor for HIV positivity in this patient population.

Buprenorphine use among non-hospital residential programs

BACKGROUND

The purpose of this study is to investigate the use of buprenorphine within non-hospital residential programs. We hypothesize that programs offering long-term treatment will be less likely to accept or prescribe buprenorphine, but those that accept public insurance will demonstrate relative increased likelihood of buprenorphine availability.

METHOD

This study analyzed data from the 2021 National Substance Use and Mental Health Services Survey. The analytic sample (n=3654) included a subset of facilities that reported providing only substance use treatment, including three non-mutually exclusive service types: detox, short-term, and long-term. A logistic regression examined the association between buprenorphine availability and residential service type, holding constant characteristics associated with the outcome of interest. We then tested an interaction between public insurance and long-term service type on the outcome of interest.

RESULTS

While long-term service type was associated with reduced odds of buprenorphine availability (OR=.288, p <.05), programs that both offered long-term residential programs and accepted public health insurance had 3.5 higher odds of accepting or prescribing buprenorphine (OR=4.586, p<.01) compared to long-term programs without public insurance.

IMPLICATIONS

Patients who require treatment of longer duration may face barriers to buprenorphine availability; however, public insurance acceptance may increase odds of availability of buprenorphine among long-term programs.

Association of genetic variants in CYP3A5, DRD2 and NK1R with opioid overdose

In 2023, 3651 Ohioans died because of an opioid overdose. Of those opioid overdoses, 3579 (98%) of which were attributed to fentanyl. We evaluated the association between 180 candidate single nucleotide polymorphisms (SNPs) and self-reported, nonfatal opioid overdose history from a prospective sample of 1301 adult patients (≥18 years of age) seen in three urban emergency departments in Ohio. Candidate SNPs included 120 related to the dopamine reward pathway and 60 related to pharmacokinetics. Of the 821 patients who reported having been exposed to opioids in their lifetime, 95 (11.6%) also reported having experienced an opioid-related overdose. Logistic regression, adjusting for age and biologic sex, was used to characterize the association between each SNP and opioid overdose, correcting for multiple comparisons. Three SNPs, located in three different genes were associated with opioid overdose: increased odds with CYP3A5 (rs776746) and DRD2 (rs4436578), and decreased odds with NKIR (rs6715729). Homozygotic CYP3A5 (rs776746) had the highest adjusted odds ratio (OR) of 6.96 (95% CI [2.45, 29.23]) and homozygotic NK1R (rs6715729) had the lowest OR of 0.28 (95% CI [0.14, 0.54). Given that CYP3A5 (rs776746) has been associated with increased plasma concentrations of fentanyl, rs776746 could potentially be utilized as a prognostic risk indicator for the potential of an opioid overdose. NK1R regulates the expression of the neurokinin-1 receptor, a regulator of respiration and NK1R (rs6715729) represents a novel genetic marker for a decreased risk of opioid overdose risk.

Prevalence and correlates of fentanyl test strip use among people who use drugs in Rhode Island

BACKGROUND

Illicitly manufactured fentanyl accounts for a majority of overdose fatalities in the US. Research has demonstrated that fentanyl test strips (FTS) help people who use drugs (PWUD) avoid unintended exposure to fentanyl and overdose. This study assesses characteristics associated with FTS use among PWUD in Rhode Island. Such findings may shed light on whether there are subgroups of PWUD who are less likely to be using FTS and therefore may benefit from their use.

METHODS

From September 2020 - February 2023, participants were recruited to participate in RAPIDS, a clinical trial assessing whether FTS provision can reduce overdose rates. Baseline data were used to assess correlates of lifetime FTS use through bivariable and multivariable analyses. We also examined drug testing patterns relating to FTS use in the past month.

RESULTS

Of 509 people enrolled, 376 (73.9 %) had heard of FTS before enrollment. Among this group, 189 (50.3 %) reported lifetime FTS use and 98 (26.1 %) reported use in the last month. In bivariable analyses, lifetime injection drug use, responding to an overdose, and drug selling were associated with FTS use. Solitary drug use was not associated with FTS uptake. In the multivariable analysis, gender and lifetime naloxone administration were associated with FTS use. Of those who used FTS in the past month, 76.5 % had at least one test that was positive for fentanyl.

CONCLUSIONS

We found high uptake of FTS use among PWUD in Rhode Island. Our results also suggest a need for targeted outreach to increase FTS uptake among sub-groups of PWUD.

CLINICAL TRIAL REGISTRATION

The Rhode Island Prescription and Illicit Drug Study is a registered clinical trial, NCT043722838.

Prevalence and Correlates of Alcohol and Drug Harms to Others: Findings From the 2020 U.S. National Alcohol Survey

OBJECTIVE

The purpose of this study was to measure the prevalence and overlap of secondhand harms from other people's use of alcohol, cannabis, opioids, or other drugs and examine sociodemographic and other correlates of these secondhand harms.

METHOD

This cross-sectional analysis used data from 7,799 respondents (51.6% female; 12.9% Black, 15.6% Hispanic/Latiné; mean age = 47.6 years) in the 2020 U.S. National Alcohol Survey. Secondhand harms included family/marriage difficulties, traffic accidents, vandalism, physical harm, and financial difficulties. Weighted prevalence estimates provided nationally representative estimates of these harms. Logistic regression assessed associations between individual characteristics and secondhand harms.

RESULTS

Lifetime prevalence of secondhand harms from alcohol, cannabis, opioids, or other drugs was 34.2%, 5.5%, 7.6%, and 8.3%, respectively. There was substantial overlap among lifetime harms: Almost 30% of those reporting secondhand alcohol harms also reported secondhand drug harms. Significant correlates of secondhand substance harms included female sex (alcohol, other drugs); White (alcohol, opioids), American Indian/Alaska Native (opioids), and Black (cannabis) race/ethnicity; and separated/divorced/widowed marital status (opioids). Those reporting a family history of alcohol problems had significantly higher odds of reporting secondhand harms across substance types. Individuals who reported frequent cannabis use had higher odds of reporting secondhand alcohol and opioid harms compared to those with no cannabis use (aOR = 1.55; aOR = 2.38) but lower odds of reporting secondhand cannabis harms (aOR = 0.51).

CONCLUSIONS

Although less prevalent than secondhand alcohol harms, 14% of participants reported secondhand harms from someone else's drug use and frequently experienced secondhand harms attributed to multiple substances. Population-focused interventions are needed to reduce the total burden of alcohol and other drug use.