Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: An observational analysis

Spirituality in Addiction Recovery: A Narrative Review

In the area of addiction, Canada has been in a public health crisis since 2016. Addiction takes a toll on an individual's self-worth and identity. In this narrative literature review, the distinct nature of spirituality was addressed. Next, individualized conceptualizations of spirituality were outlined. Subsequently, the importance of fellowship in addiction recovery was detailed. Next, the significance of being of service was presented. Meaningful and authentic spirituality were discussed in the context of recovery identity. Lastly, spirituality as a personal journey is described. A narrative literature review of 70 manuscripts published between 1999 and 2021 was undertaken to determine multiple approaches to treating addiction recovery in the context of spiritual development. An understanding of spirituality can inform counsellors regarding spiritual development in addiction recovery. Implications for counselling include a roadmap to support clients developing an individualized spiritual connection and operating as a functional system.

High Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among Urban Syringe Service Program Participants

BACKGROUND

Injectable opioid agonist treatment with hydromorphone (iOAT-H) is effective for persons who inject drugs (PWID) with opioid use disorder (OUD) but remains unavailable in the United States. Our objective was to determine interest in iOAT-H among syringe services program (SSP) participants.

METHODS

We recruited PWID with OUD from SSPs in New York City. Interest in iOAT-H was assessed on a 4-point scale. We compared participants who were and were not interested in iOAT-H regarding sociodemographic characteristics and self-reported variables (past 30 days): heroin use, public injection practices, and participation in illegal activity other than drug possession. Participants reported their preferred OUD treatment and reasons for these preferences.

RESULTS

Of 108 participants, most were male (69%), Hispanic (68%), and median age was 42 years. The median number of prior OUD treatment episodes was 6 (interquartile range: 2-12). Most (65%) were interested in iOAT-H. Interested participants (vs not interested) reported, over the prior 30 days, greater heroin use days (mean, 26.4 vs 22.3), injecting in public more times (median, 15 vs 6), and a higher percentage having participated in illegal activity (40% vs 16%). Preferences for OUD treatment were: iOAT-H (43%), methadone (39%), and buprenorphine (9%). Participants who preferred iOAT-H to conventional OUD treatments reported preferring injection as a route of administration and that available OUD treatments helped them insufficiently.

CONCLUSIONS

SSP participants with OUD reported high interest in iOAT-H. Participants had attempted conventional treatments but still used heroin almost daily. We identified PWID at risk for opioid-related harms who potentially could benefit from iOAT-H.

Medical examiner response to the drug overdose epidemic in King County Washington: "Real-time" surveillance, data science, and applied forensic epidemiology

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with "real-time" fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In-house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in-house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose-specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.

Kim H, Gratzer D, George TP, Le Foll B, Castle DJ. Marked Increase in Amphetamine-Related Emergency Department Visits and Inpatient Admissions in Toronto, Canada, 2014-2021

BACKGROUND

We report emergency department and inpatient amphetamine-related trends focusing on co-occurring substance use and psychiatric diagnoses at the Centre for Addiction and Mental Health, the largest mental health teaching hospital in Canada.

METHODS

We describe yearly trends in amphetamine-related Centre for Addiction and Mental Health emergency department visits and inpatient admissions out of all emergency department visits and inpatient admissions between 2014 and 2021, along with proportions of concurrent substance-related admissions and mental/psychotic disorders emergency department visits and inpatient admissions among amphetamine-related contacts; joinpoint regression analyses assessed changes in amphetamine-related emergency department visits and inpatient admissions.

RESULTS

Amphetamine-related emergency department visits rose from 1.5% in 2014 to 8.3% in 2021, with a peak of 9.9% in 2020. Amphetamine-related inpatient admissions rose from 2.0% to 8.8% in 2021, with a peak of 8.9% in 2020. Significant increasing trends in the percentage of amphetamine-related emergency department visits happened especially between the second and the fourth quarter of 2014 (quarterly percent change =  + 71.4, P <0.01). Similarly, the percentage of amphetamine-related inpatient admissions increased mostly between the second quarter of 2014 and the third quarter of 2015 (quarterly percent change  =  + 32.6, P <0.01). The proportion of concurrent opioid-related contacts among amphetamine-related emergency department visits and inpatient admission increased markedly between 2014 and 2021; psychotic disorders in amphetamine-related inpatient admissions more than doubled from 2015 to 2021.

DISCUSSION

Prevalence of amphetamine use, mostly from methamphetamine, has been increasing in Toronto as have co-occurring psychiatric disorders and opioid use. Our findings highlight the need for increases in accessible efficacious treatments for complex populations with polysubstance use and co-occurring disorders.

Evaluation of "Real-Time" Fatal Drug Overdose Surveillance by King County Medical Examiner's Office, Seattle, Washington

ABSTRACT

To address the challenges in monitoring the continuously accelerating drug overdose epidemic, the King County Medical Examiner's Office in Seattle, Washington, instituted a "real-time" fatal drug overdose surveillance project, depending on scene investigations, autopsy findings, and in-house testing of blood, urine, and drug evidence collected from death scenes. Validation of the project's rapid death certification methodology from 2019 through 2021 was performed at the following 3 levels: blood testing, urine testing, and death certification, and for the following 4 drugs: fentanyl, opiate, methamphetamine, and cocaine. For blood testing, sensitivity ranged from 90% to 99%, and specificity ranged from 86% to 97%. For urine testing, sensitivity ranged from 91% to 92%, and specificity ranged from 87% to 97%. The positive predictive value for cocaine was poor for both blood testing (57%) and urine testing (72%). Of 1034 deaths, 807 were certified as overdose by rapid methodology, and 803 (99.5%) were confirmed by formal toxicology results. Manners of death were changed from accident to natural in 3 of 1034 cases (0.29%). Results of this study indicate that the rapid overdose surveillance methodology described in this study offers benefits to families and provides useful, timely information for responding law enforcement and public health agencies.

Trends of repeated emergency department visits among adolescents and young adults for substance use: A repeated cross-sectional study

Emergency Department (ED) visits for substance-related concerns among young people have been increasing in recent years. Understanding the factors related to repeated ED visits (two or more ED visits per year) for substance use concerns among young people is critical to developing a more efficient mental healthcare system that does not overburden ED and that provides efficient care for substance use patients. This study examined trends of substance use-related ED visits and factors related to repeated ED visits (two or more ED visits per year, in comparison to one ED visit per year) among adolescents and young adults (aged 13 to 25 years) in the province of Ontario, Canada. Binary logistic regression models were conducted to examine associations between hospital-related factors (hospital size, urbanicity, triage level, ED wait time) and visit status (2+ vs 1 ED visit/year), controlling for patient characteristics (age/sex). A population-based, repeated cross-sectional data over a 10-year period (2008, 2013, and 2018) was used. The proportion of substance use-related repeated ED visits significantly and consistently increased in the year 2013 and 2018 compared to 2008 (2008 = 12.52%, 2013 = 19.47%, 2018 = 20.19%). Young adult, male, medium-sized hospital, urban location, wait times longer than 6 hours, and symptom severity was associated with increased numbers of repeated ED visits. Furthermore, polysubstance use, opioid use, cocaine use, and stimulant use were strongly associated with repeated ED visits compared with the use of substances such as cannabis, alcohol and sedatives. Current findings suggest that repeated ED visits for substance use concerns could be reduced by policies that reinforce evenly distributed mental health and addiction treatment services across the provinces in rural areas and small hospitals. These services should put special efforts into developing specific (e.g., withdrawal/treatment) programming for substance-related repeated ED patients. The services should target young people using multiple psychoactive substances, stimulants and cocaine.

The association between methamphetamine use and number of sexual partners in men who have sex with men: a systematic review and meta-analysis

Background

Methamphetamine use in men who have sex with men population is significantly higher than that in the general population. Meth use can cause high-risk sexual behaviors, such as having sex with a variety of sexual partners. The aim of this study was to determine the association between meth use and the number of sexual partners in MSM.

Methods

Searching international databases (PubMed (Medline), Scopus, Web of Sciences, Embase (Elsevier), PsycInfo (Ovid), Cochrane CENTRAL (Ovid)) until March 2021 was performed in this meta-analysis using appropriate keywords terms to identify related articles. After retrieving articles in these databases, screening was performed based on the title, abstract and full text of the articles, and the final related studies were selected and evaluated using the Newcastle Ottawa scale checklist.

Results

The sample size consisted 18,455 people in this study, including four cohort studies with a sample size of 15,026 MSM and four case–control studies with a sample size of 3429 MSM. The results of meta-analysis showed that meth use increased the number of sexual partners in MSM (RR: 3.70; % 95 CI: 2.04—6.70). The results of subgroup analyze based on the number of sexual partners showed that in MSM taking meth, the risks of having one to three, four to five, and six or more than six sexual partners were respectively 2.82, 2.98 and 5.89 times higher than those in MSM who did not take meth.

Conclusion

The results showed that meth uses in MSM increased the number of their sexual partners. Due to the fact that increasing the number of sexual partners and high-risk sexual behaviors increase the risk of contracting sexually transmitted diseases such as HIV, it is necessary to adopt control programs to prevent meth use by this group, or to implement programs of reduction in the risk of STIs for this group.

Crack cocaine use frequency is associated with HIV disease severity independent of antiretroviral therapy exposure: a prospective cohort study

We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. In multivariable adjusted models, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (β = 0.8, 95% confidence interval: 0.1, 1.5) as compared to none. Our finding suggests that daily or greater frequency of crack cocaine use exacerbates HIV disease severity independent of ART exposure. The observed effect may reflect an underlying biological mechanism or other factors linked with crack cocaine use; further investigation is warranted.

Trends in dispensing of individual prescription opioid formulations, Canada 2005-2020

Background

Canada has experienced a distinctly bifurcated pattern of (strong) opioid utilization post-2000, with multifold increases rendering it one of the world’s highest opioid consumption rates, followed by subsequent substantive declines since 2011/2012. Several interventions to control especially high-risk opioid use have been implemented post-2010 at different levels, yet with their effects assessed mostly for overall opioid utilization. Little knowledge exists for over-time patterns of individual opioid formulations.

Methods

Raw information on community-based prescription opioid dispensing for years 2005–2020 were obtained from a large national database based on a stratified sample of 6500 retail pharmacies across Canada (IQVIA/Compuscript), These data were converted into Defined-Daily-Doses/1000 population/day (DDD/1000/day) for individual (strong and weak) opioid formulations—specifically: fentanyl, hydromorphone, hydrocodone, morphine, oxycodone, codeine—per standard methods. Descriptive data on individual opioid dispensing were computed, and segmented regression (or ‘broken-stick’) analysis was applied to the overtime dispensing towards assessing potentially significant ‘breakpoints’ interrupting linear utilization trends. Akaike information criterion (AIC) values were computed to assess the resulting models’ quality-of-fit.

Results

Five of the six opioid formulations featured a lower dispensing level in 2020 compared with 2005, but mostly with peak values in years between, contributing to the overall inversion pattern. For five of the six opioid formulations, a three-segmented model emerged as the best fit for the dispensing observed; only hydrocodone presented a linear (downward) dispensing trend. Among the five interrupted trend models for individual formulations, four (fentanyl, morphine, oxycodone, codeine but not hydromorphone) indicated their initial breakpoint during 2011–2014 introducing a downward dispensing trend. Inconsistently, morphine also featured a recent breakpoint (2018) towards a dispensing increase.

Conclusions

While all opioids showed marked declines, we found heterogeneous patterns of dispensing for individual opioid formulations. While we cannot estimate direct causal effects, opioid control interventions appear to have had differential impacts on dispensing of individual formulations. The earliest breakpoint occurred towards substantive decreases for oxycodone dispensing in 2011; subsequently, there were increases in dispensing of hydromorphone and fentanyl likely due to substitution effects, followed by across-the-board declines post-2015/2016. Recent ‘safer opioid’ distribution programs to reduce illicit/toxic opioid exposure linked with high levels of poisoning fatalities seem to fuel resurgences in select opioid (e.g., morphine) dispensing.

National trends in population rates of opioid-related mortality, hospitalization and emergency department visits in Canada between 2000 and 2017. A population-based study

BACKGROUND AND AIMS

Existing assessments of the time-trends of opioid-related mortality, hospitalization and emergency department visits in Canada have relied mainly on provincial databases, while national assessments generally do not provide information before 2016. We aimed to estimate Canadian national time trends in opioid-related mortality from 2000 to 2017 and opioid-related hospitalization and emergency department visits between 2000 and 2012.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents of all Canadian provinces and territories for which comparable data were available from 2000 to 2017.

MEASUREMENTS

We identified opioid-related mortality, hospitalization and emergency department visits using validated algorithms using ICD codes from administrative databases. We calculated crude rates and sex- and age-adjusted rates per million. For hospitalizations, we calculated case-fatality, 90-day and 365-day all-cause mortality and opioid-related re-hospitalization rates. We used Poisson regression to examine the significance of the time trend.

FINDINGS

From 2000 to 2017, the adjusted opioid mortality rate in Canada (outside Quebec) increased significantly by 592.9% (from 20.0 opioid deaths per million in 2000 to 118.3 in 2017). The highest year-to-year increases were from 2015 to 2016 (31.8%) and from 2016 to 2017 (52.2%). The adjusted hospitalizations doubled significantly during the study period (an increase of 103.7%, from 159.7 opioid hospitalizations per million Canadians in 2000 to 325.3 in 2012). The adjusted rate of emergency department visits increased significantly by 188.7% (from 280.6 per million in 2000 to 810.1 in 2012). Case-fatality was 2.3% overall and was mainly constant during the study period. Both 90- and 365-day all-cause mortality increased significantly between 2000 and 2011 (from 1.7 to 3.1% and 3.9 to 7.4%, respectively), while re-hospitalization for opioid-related diagnoses was reduced (from 7.8 to 6.4% and 14.2 to 12.9%, respectively).

CONCLUSIONS

Opioid-related mortality, hospitalization and emergency department visits in Canada have been increasing gradually since 2000.

Towards cross-Canada monitoring of the unregulated street drug supply

Background

The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions.

Methods

The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018–March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use.

Results

The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal.

Conclusions

This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.

The effect of depressive symptoms on pain in a substance-using population with persistent pain: a cross-sectional cohort study

BACKGROUND

In light of the ongoing opioid overdose crisis, there is an urgent need for research on the impacts of mental health among people presenting with concurrent pain and substance use. This study examined the effect of depressive symptoms on pain severity and functional interference among people who use drugs (PWUD) during a community-wide overdose crisis.

METHODS

From December 1st 2016 to December 31st 2018, 288 participants in two cohort studies of PWUD in Vancouver, Canada completed interviewer-administered questionnaires that included the Brief Pain Inventory and PROMIS Emotional Distress-Depression instruments. Generalized linear regression modelling (GLM) was used to examine the cross-sectional effect of depressive symptoms and other confounding factors on pain severity and interference.

RESULTS

Moderate to severe depressive symptoms were significantly associated with greater pain-related functional interference (adjusted β = 1.24, 95% confidence interval [CI] = 0.33-2.15), but not significantly associated with greater average pain severity (adjusted β = 0.22, 95% CI = - 0.3 - 0.82), when controlling for confounding variables. Reported daily heroin use (adjusted β = 1.26, 95% CI = 0.47-2.05) and non-fatal overdose (adjusted β = 1.02, 95% CI = 0.08-1.96) were also significantly associated with greater pain-related functional interference.

CONCLUSIONS

In a substance-using population, greater pain-related functional interference was positively associated with depressive symptoms as well as overdose and daily heroin use. These findings emphasize the need to address the functional impact of pain, mental health comorbidity, and high-risk substance use that may contribute to overdose and other harms.

Retention in opioid agonist treatment: a rapid review and meta-analysis comparing observational studies and randomized controlled trials

BACKGROUND

Although oral opioid agonist therapies (OATs), buprenorphine and methadone, are effective first-line treatments, OAT remains largely underutilized due to low retention rates and wide variation across programs. This rapid review therefore sought to summarize the retention rates reported by randomized controlled trials (RCTs) and controlled observational study designs that compared methadone to buprenorphine (or buprenorphine-naloxone).

METHODS

We searched four electronic databases (EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, up to April 2018) for RCTs and controlled observational studies that compared oral fixed-dose methadone to buprenorphine versus methadone (or buprenorphine-naloxone). Data were extracted separately for two different definitions of retention in treatment: (1) length of time retained in the study and (2) presence on the final day of a study. Separate random effects meta-analyses were performed for RCTs and controlled observational studies. Data from controlled observational studies where retention was measured as the length of time retained in the study were not amenable to meta-analysis.

RESULTS

Among 7603 studies reviewed, 10 RCTs and 3 observational studies met inclusion criteria (n = 5065) and compared fixed-dose oral buprenorphine with methadone. Across studies, the average retention rate was highly variable (RCTs: buprenorphine 20.0-82.5% and methadone 30.7-83.8%; observational studies: buprenorphine 20.2-78.3% and methadone 48.3-74.8%). For time period retained in the study, we observed no significant difference in treatment retention for buprenorphine versus methadone in RCTs (standardized mean difference [SMD] =  - 0.07; 95% CI - 0.35-0.21, p = 0.63; quality of evidence: low). For presence on the final study day, we observed no significant difference between buprenorphine and methadone treatment retention in RCTs (risk ratio [RR] = 0.89; 95% CI 0.73-1.08, p = 0.24; quality of evidence: low) and controlled observational studies (RR = 0.75; 95% CI 0.36-1.58, p = 0.45).

CONCLUSION

Meta-analysis of existing RCTs suggests retention in oral fixed-dose opioid agonist therapy with methadone appears to be generally equal to buprenorphine (or buprenorphine-naloxone), with wide variation across studies. Similarly, a meta-analysis of three controlled observational studies indicated no difference in treatment retention although there was significant heterogeneity among the included studies. The length of follow-up did not appear to affect the retention rate.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018104452 .

Opioid prescribing practice standard in British Columbia, Canada: Rationale, controversies, and directions

British Columbia (BC) has been the hardest hit province in Canada's ongoing overdose epidemic. As part of the province-level response, the College of Physicians and Surgeons of British Columbia (CPSBC) implemented the "Safe Prescribing of Drugs with Potential for Misuse/Diversion" practice standard in June 2016. The practice standard established specific dose and quantity thresholds for opioid prescribing as professional and ethical conduct expectations for physicians in BC. This supply side intervention was based on expert interpretation of available evidence of non-superiority of opioid treatments to non-opioid treatments. However, the potential for misinterpretation of dosage ceiling thresholds and the negative repercussions to patients that could follow raised concerns among both physicians and patients. We provide a comprehensive overview of the rationale, early impact, controversies, and potential shortcomings of the CPSBC's practice standard.

Correlations between Changes in Medical Opioid Dispensing and Contributions of Fentanyl to Opioid-Related Overdose Fatalities: Exploratory Analyses from Canada

Canada is experiencing an epidemic of opioid-related mortality, with increasing yet heterogeneous fatality patterns from illicit/synthetic (e.g., fentanyl) opioids. The present study examined whether differential provincial reductions in medical opioid dispensing following restrictive regulations (post-2010) were associated with differential contributions of fentanyl to opioid mortality. Annual provincial opioid dispensing totals in defined daily doses/1000 population/day, and change rates in opioid dispensing for the 10 provinces for (1) 2011-2018 and (2) "peak-year" to 2018 were derived from a pan-Canadian pharmacy-based dispensing panel. Provincial contribution rates of fentanyl to opioid-related mortality (2016-2019) were averaged. Correlation values (Pearson's R) between provincial changes in opioid dispensing and the relative fentanyl contributions to mortality were computed for the two scenarios. The correlation between province-based changes in opioid dispensing (2011-2018) and the relative contribution of fentanyl to total opioid deaths (2016-2019) was -0.70 (t = 2.75; df = 8; p = 0.03); the corresponding correlation for opioid dispensing changes ("peak-year" to 2018) was -0.59 (t = -2.06; df = 8; p = 0.07). Provincial reductions in medical opioid dispensing indicated (near-)significant correlations with fentanyl contribution rates to opioid-related death totals. Differential reductions in pharmaceutical opioid availability may have created supply voids for nonmedical use, substituted with synthetic/toxic (e.g., fentanyl) opioids and leading to accelerated opioid mortality. Implications of these possible unintended adverse consequences warrant consideration for public health policy.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Crystal methamphetamine use in British Columbia, Canada: A cross-sectional study of people who access harm reduction services

INTRODUCTION

Increased use of crystal methamphetamine ("crystal meth") has been observed across North America and international jurisdictions, including a notable increase in the presence of methamphetamines in illicit drug toxicity deaths in British Columbia (BC), Canada. We used data from a cross-sectional survey and urine toxicology screening to report the prevalence, correlates, and validity of self-reported crystal meth use among clients of harm reduction sites in BC.

MATERIALS AND METHODS

Survey data were collected from 1,107 participants across 25 communities in BC, through the 2018 and 2019 Harm Reduction Client Survey. We described reported substance use and used a multivariate logistic regression model to characterize crystal meth use. Urine samples provided by a subset of participants were used to derive validity of self-reported three-day crystal meth use compared to urine toxicology screening.

RESULTS

Excluding tobacco, crystal meth was the most frequently reported substance used in the past three days in 2018 and 2019 (59.7% and 71.7%, respectively). Smoking was the dominant route of administration for crystal meth, crack, heroin, and fentanyl. Multivariate analysis determined significantly higher odds of crystal meth use among those who used opioids (Adjusted Odds Ratio [AOR] = 3.13), cannabis (AOR = 2.10), and alcohol (1.41), and among those who were not regularly housed (AOR = 2.08) and unemployed (AOR = 1.75). Age ≥50 was inversely associated with crystal meth use (AOR = 0.63). Sensitivity of self-reported crystal meth use was 86%, specificity was 86%, positive predictive value was 96%, and negative predictive value was 65%.

CONCLUSIONS

Crystal meth was the most commonly used substance among clients of harm reduction sites in BC in 2018 and 2019, and was frequently used concurrently with opioids. Comparison to urine samples demonstrated high validity of self-reported crystal meth use. Understanding evolving patterns of substance use will be imperative in tailoring harm reduction and substance use services for individuals that use crystal meth.

Sensitive and reliable identification of fentanyl citrate in urine and serum using chloride ion-treated paper-based SERS substrate

Recently, the phenomenon of fentanyls overdose leading to death is emerging in an endless stream. There is an urgent requirement to quickly identify fentanyl content in body fluids for medical and judicial purposes. With this in mind, we present a paper-based SERS substrate decorated with uniform gold nanospheres treated by chloride ion for the detection of fentanyl citrate in urine and serum. In particular, the paper-based SERS sensor was prepared by liquid/liquid self-assembly technique and chloride ion was introduced to clean and modify the substrate surface, which improved the sensitivity of the solid substrate with an enhancement factor (EF) as high as 1.64 × 10⁵. Moreover, the uniformity of each paper-based substrate and the repeatability on different batches of substrate were excellent, and there was no obvious change in the intensity response of Raman spectra within a month. As a result, the quantitative analysis of fentanyl citrate in artificial urine and rat serum were performed based on the modified paper-based substrate with the limit of detection as low as 0.59 μg/mL and 2.78 μg/mL, respectively. Both the concentrations of the two biological samples with the Raman signal intensity were linearly plotted and the recovery of the spiked samples with different concentrations was collected to verify the accuracy of the quantitative curves. All the results suggest that this work makes SERS method available for the rapid identification and quantitative analysis of illicit drug in the real biological samples.

'Resurgent', 'twin' or 'silent' epidemic? A select data overview and observations on increasing psycho-stimulant use and harms in North America

In the early 2000s, increasing prevalence of psycho-stimulant (e.g., crack/cocaine, methamphetamine) use and related harms, including severe adverse health outcomes, was observed among - mostly marginalized - populations of persons using illicit drugs in North America, underscoring an urgent need for interventions options towards improved prevention and treatment. By about 2010, however, the 'opioid crisis', featuring unprecedented use and public health burden, had accelerated into full force in North America, largely muting attention to the psycho-stimulant issue until recently. Recent surveillance data on drug use and related mortality/morbidity from the present decade has documented a marked resurgence of psycho-stimulant use and harms especially in at-risk populations, commonly in direct combination with opioids, across North America, resulting in a 'twin epidemic' comprised of opioids and psycho-stimulants We briefly review select epidemiological data indicators for these developments from the United States and Canada; in the latter jurisdiction, related evidence has been less prevalent and systematic but corroborating the same trends. Evidently, the (widely ongoing) focus on the 'opioid epidemic' as a 'mono-type' drug problem has become an anachronism that requires urgent and appropriate correction. We then briefly consider existing, evidence-based options for - prevention and treatment - interventions targeting psycho-stimulant use and harms, which are substantially more limited and/or less efficacious than those available for problematic opioid use, while presenting major gaps and challenges. The observed resurgence of psycho-stimulants may, indirectly, relate to recent efforts towards curtailing (medical) opioid availability, thereby accelerating demand and supply for both illicit opioids and psycho-stimulants. The presently unfolding 'twin epidemic' of opioids and psycho-stimulants, combined with limited intervention resources, presents an acute challenge for public health and may crucially undermine actively extensive efforts to reduce opioid-related health harms in North America.

‘Safer opioid distribution’ as an essential public health intervention for the opioid mortality crisis – Considerations, options and examples towards broad-based implementation

•

Canada experiences excessive opioid mortality, mainly from toxic opioid exposure.

•

Many interventions have been implemented, but are limited in reach and impact.

•

‘Safer opioid distribution’ (SOD) is a crucial preventive measure for overdose.

•

SOD needs to be implemented for a large, ‘at-risk’ opioid user population.

•

Other community-based public health interventions may guide SOD organization.

Withdrawal-associated injury site pain prevalence and correlates among opioid-using people who inject drugs in Vancouver, Canada

BACKGROUND

Pain can return temporarily to old injury sites during opioid withdrawal. The prevalence and impact of opioid withdrawal-associated injury site pain (WISP) in various groups is unknown.

METHODS

Using data from observational cohorts, we estimated the prevalence and correlates of WISP among opioid-using people who inject drugs (PWID). Between June and December 2015, data on WISP and opioid use behaviours were elicited from participants in three ongoing prospective cohort studies in Vancouver, Canada, who were aged 18 years and older and who self-reported at least daily injection of heroin or non-medical presciption opioids.

RESULTS

Among 631 individuals, 276 (43.7 %) had a healed injury (usually pain-free), among whom 112 (40.6 %) experienced WISP, representing 17.7 % of opioid-using PWID interviewed. In a multivariable logistic regression model, WISP was positively associated with having a high school diploma or above (Adjusted Odds Ratio [AOR] = 2.23, 95 % Confidence Interval [CI]: 1.31-3.84), any heroin use in the last six months (AOR = 2.00, 95 % CI: 1.14-3.57), feeling daily pain that required medication (AOR = 2.06, CI: 1.18-3.63), and negatively associated with older age at first drug use (AOR = 0.96, 95 % CI: 0.93-0.99). Among 112 individuals with WISP, 79 (70.5 %) said that having this pain affected their opioid use behaviour, of whom 57 (72.2 %) used more opioids, 19 (24.1 %) avoided opioid withdrawal, while 3 (3.8 %) no longer used opioids to avoid WISP.

CONCLUSIONS

WISP is prevalent among PWID with a previous injury, and may alter opioid use patterns. Improved care strategies for WISP are warrented.

Prescription opioid dispensing in Canada: an update on recent developments to 2018

Canada has been home to comparatively extreme developments in prescription opioid (PO) availability and related harms (e.g. morbidity, mortality) post-2000. Following persistent pan-Canadian increases in PO use, select control measures were implemented and PO dispensing levels—while only inconsistently by province—inverted, and began to plateau or decrease post-2012. We examined annual PO dispensing levels in Canada up until 2018, based on representative prescription sample data from community-based retail pharmacies. Annual prescription-based dispensing data were converted into defined daily doses/1000 population/day by province, and mainly categorized into ‘weak’ and ‘strong’ opioids. All provinces indicated decreasing trends in strong PO levels in most recent years, yet with inter-provincial differences of up to one magnitude in 2018; in about half the provinces, dispensing fell to below-2005 levels. British Columbia had the largest decline in strong PO dispensing from its peak rate (− 48.5%) in 2011. Weak opioid dispensing trends remained more inconsistent and bifurcated across Canada. The distinct effects of individual—including many provincially initiated and governed—PO control measures urgently need to be evaluated. In the meantime, recent reductions in general PO availability across Canada appear to have contributed to shortages in opioid supply for existent, sizable (including non-medical) user populations and may have contributed to recent marked increases in illicit opioid use and harms (including rising deaths).

To what extent do supervised drug consumption services incorporate non-injection routes of administration? A systematic scoping review documenting existing facilities

BACKGROUND

Most of the existing research on supervised consumption services (SCS) is focused on injection drug use. Less is known about the applicability of SCS for people who consume drugs orally, intranasally, or through inhalation. This is problematic because people who use drugs through modes other than injection are also at risk of overdose death and other harm, and experience barriers accessing health and social services. We aimed to describe existing SCS models that accommodate these alternate routes of drug consumption, and synthesize available information on characteristics of program participants.

METHODS

We conducted a systematic scoping review of 9 peer-reviewed and 13 grey literature databases on SCS that incorporate non-injection routes of consumption. We screened 22,882 titles, and excluded 22,843 (99.8%) articles. We ultimately included 39 (0.2%) full-text articles; 28 (72%) of these articles explicitly identified SCS that permit alternate routes of consumption and 21 (54%) discussed characteristics of participants who consume drugs through non-injection routes. Data on study characteristics, terms and definitions, and site and program participant characteristics were extracted and double-coded. Extracted data were analyzed using descriptive statistics and narrative synthesis.

RESULTS

Included articles describe 48 SCS that permit non-injection routes of consumption, most of which were located in Germany. The majority of these SCS were legally sanctioned and had models of care that were largely comparable to supervised injection services. Notable differences included physical infrastructure such as ventilated rooms or outdoor areas to accommodate inhalation, and shorter time limits on non-injection drug consumption episodes. Program participants engaging in non-injection forms of consumption were typically men over the age of 30 and structurally vulnerable (e.g., experiencing homelessness or unstable housing).

CONCLUSIONS

Extant academic and grey literature indicates that site characteristics and demographics of program participants of SCS that permit non-injection routes of consumption largely reflect those of supervised injection services. Further research on the range of existing SCS that incorporate non-injection routes of consumption is needed to ensure high quality service provision, and improved health outcomes for people who consume drugs via oral, intranasal, and inhalation routes.

Examining correlations between opioid dispensing and opioid-related hospitalizations in Canada, 2007-2016

BACKGROUND

High levels of opioid-related mortality, as well as morbidity, contribute to the excessive opioid-related disease burden in North America, induced by high availability of opioids. While correlations between opioid dispensing levels and mortality outcomes are well-established, fewer evidence exists on correlations with morbidity (e.g., hospitalizations).

METHODS

We examined possible overtime correlations between medical opioid dispensing and opioid-related hospitalizations in Canada, by province, 2007-2016. For dispensing, we examined annual volumes of medical opioid dispensing derived from a representative, stratified sample of retail pharmacies across Canada. Raw dispensing information for 'strong opioids' was converted into Defined Daily Doses per 1000 population per day (DDD/1000/day). Opioid-related hospitalization rates referred to opioid poisoning-related admissions by province, for fiscal years 2007-08 to 2016-17, drawn from the national Hospital Morbidity Database. We assessed possible correlations between opioid dispensing and hospitalizations by province using the Pearson product moment correlation; correlation values (r) and confidence intervals were reported.

RESULTS

Significant correlations for overtime correlations between population-levels of opioid dispensing and opioid-related hospitalizations were observed for three provinces: Quebec (r = 0.87, CI: 0.49-0.97; p = 0.002); New Brunswick (r = 0.85;CI: 0.43-0.97; p = 0.004) and Nova Scotia (r = 0.78; CI:0.25-0.95; p = 0.012), with an additional province, Saskatchewan, (r = 0.073; CI:-0.07-0.91;p = 0.073) featuring borderline significance.

CONCLUSIONS

The correlations observed further add to evidence on opioid dispensing levels as a systemic driver of population-level harms. Notably, correlations were not identified principally in provinces with reported high contribution levels (> 50%) of illicit opioids to mortality, which are not captured by dispensing data and so may have distorted or concealed potential correlation effects due to contamination.

A revised excretion factor for estimating ketamine consumption by wastewater-based epidemiology - Utilising wastewater and seizure data

The rate of drug excretion (excretion factor) is a critical parameter for monitoring drug consumption in the population by wastewater-based epidemiology (WBE). Previous studies have refined excretion factors for common illicit drugs, such as cocaine, amphetamine, methamphetamine, heroin, to improve the accuracy and reduce uncertainty in back-calculating consumption. Nevertheless, for ketamine, one of the most prevalent psychoactive substances, a careful review of its excretion factors has not been performed due to limited pharmacokinetic data. Here we review WBE studies and seizure data to refine and validate the excretion factors for ketamine and norketamine. The average ketamine/norketamine ratio in wastewater (5.36) was much higher than that found in urine (0.64), which means that the excretion factors derived only from pharmacokinetics data are not appropriate. Based on the comparison of the ratio between estimated consumptions of ketamine and methamphetamine by WBE with their corresponding ratio in official seizure data, a revised WBE excretion factor of 20% was proposed for ketamine following this review and applied to estimate the ketamine consumption in China. The revised estimates of ketamine consumption corresponded well with drug statistics. This suggests that the revised ketamine excretion factor is appropriate for estimating ketamine consumption by WBE. Systematic review of WBE studies is a suitable approach to refine the excretion factors for substances with inadequate pharmacokinetic data.

Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment

BACKGROUND

New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis.

METHODS

Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data.

RESULTS

Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs.

CONCLUSIONS

A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

"Am I gonna get in trouble for acknowledging my will to be safe?": Identifying the experiences of young sexual minority men and substance use in the context of an opioid overdose crisis

BACKGROUND

North America and other parts of the globe are in the midst of a public health emergency related to opioid overdoses and a highly contaminated illicit drug supply. Unfortunately, there is a substantial gap in our understandings about how this crisis affects key populations not conventionally identified within overdose-related surveillance data. This gap is particularly pronounced for gay, bisexual, and other men who have sex with men (sexual minority men)-a population that experiences substance use-related inequities across adolescence and young adulthood.

METHODS

We draw on in-depth semi-structured interviews conducted in 2018 with a diverse sample (N = 50) of sexual minority men ages 15-30 who use substances and live in Vancouver, Canada, to identify how patterns and contexts of substance use are occurring in the context of the opioid overdose crisis.

RESULTS

Our analysis revealed three themes: awareness, perceptions, and experiences of risk; strategies to mitigate risk; and barriers to safer substance use. First, participants described how they are deeply impacted by the contaminated illicit drug supply, and how there is growing apprehension that fatal and non-fatal overdose risk is high and rising. Second, participants described how procuring substances from "trustworthy" drug suppliers and other harm reduction strategies (e.g., drug checking technologies, Naloxone kits, not using alone) could reduce overdose risk. Third, participants described how interpersonal, service-related, and socio-structural barriers (e.g., drug criminalization and the lack of a regulated drug supply) limit opportunities for safer substance use.

CONCLUSIONS

Equity-oriented policies and programming that can facilitate opportunities for safer substance use among young sexual minority men are critically needed, including community- and peer-led initiatives, access to low-barrier harm reduction services within commonly frequented social spaces (e.g., Pride, night clubs, bathhouses), nonjudgmental and inclusive substance use-related health services, the decriminalization of drug use, and the provision of a safe drug supply.

Pharmacokinetic and pharmacodynamic considerations in developing a response to the opioid epidemic

Introduction: Opioids continue to be used widely for pain management. Widespread availability of prescription opioids has led to opioid abuse and addiction. Besides steps to reduce inappropriate prescribing, exploiting opioid pharmacology to make their use safer is important.Areas covered: This article discusses the pathology and factors underlying opioid abuse. Pharmacokinetic and pharmacodynamic properties affecting abuse liability of commonly abused opioids have been highlighted. These properties inform the development of ideal abuse deterrent products. Mechanisms and cost-effectiveness of available abuse deterrent products have been reviewed in addition to the pharmacology of medications used to treat addiction.Expert opinion: The opioid crisis presents unique challenges to managing pain effectively given the limited repertoire of strong analgesics. The 5-point strategy to combat the opioid crisis calls for better preventive, treatment, and recovery services, better data, better pain management, better availability of overdose-reversing drugs and better research. There is an urgent need to decrease the cost of abuse deterrent opioids which deters their cost-effectiveness. In addition, discovery of novel analgesics, further insight into central and peripheral pain mechanisms, understanding genomic risk profiles for efficient targeted efforts, and education will be key to winning this fight against the opioid crisis.

Correlations between opioid mortality increases related to illicit/synthetic opioids and reductions of medical opioid dispensing - exploratory analyses from Canada

Background

North America has been experiencing a persistent epidemic of opioid-related overdose mortality, which has increasingly been driven by fatalities from illicit, toxic opioids in most recent years. Patterns of synthetic opioid availability and related mortality are heterogeneous across Canada, and differing explanations exist as to their differentiated proliferation. We examined the perspective that heterogeneous province-based variations in prescription opioid availability, facilitated by various control strategies, post-2010 may have created regionally differential supply gaps for non-medical opioid use substituted by synthetic opioid products with differential impacts on mortality risks and outcomes in Canada.

Methods

We examined annual, prescription opioid dispensing rates and changes in the ten Canadian provinces (for the periods of 1) 2011–2018, 2) ‘peak-year’-to-2018) in Defined Daily Doses/1000 population/day, derived from data from a large representative, stratified sample of community pharmacies projected to a Canada total. Annual, provincial opioid-related mortality rates and changes for years 2016–2018 were calculated from federal data. We computed correlation values (Pearson’s R) between respective province-based change rates for prescription opioid dispensing and opioid-related mortality for the two over-time scenarios.

Results

All but one province featured reductions in prescription opioid dispensing 2011–2018; seven of the ten provinces had increases in opioid mortality 2016–2018. The correlation between changes in opioid dispensing (2011–2018) and in opioid-mortality (2016–2018) was r = 0.63 (df = 8, p-value: 0.05); the correlation was r = 0.57 (df = 8, p-value: 0.09) for changes in opioid dispensing ‘peak year’-to-2018, respectively.

Conclusions

Quasi-significant results indicate that recent increases in opioid-related deaths driven by illicit, synthetic opioids tended to be larger in provinces where reductions in prescription opioid availability have been more extensive. It is a plausible explanation that these reductions created supply gaps for non-medical opioid use increasingly filled by illicit, synthetic opioids differentially contributing to opioid-related deaths, generating un-intended adverse effects for previous interventions. General prevention measures to reduce opioid availability, and targeted prevention for at-risk opioid users exposed to toxic drug supply may be include counteractive effects and require coordinated reconciliation.

Known fentanyl use among clients of harm reduction sites in British Columbia, Canada

BACKGROUND

North America is in the midst of an opioid overdose epidemic and it is commonly suggested that exposure to fentanyl is unknown. Using a provincial survey of harm reduction site clients, we aimed to characterize known and unknown fentanyl use and their correlates among people who use drugs in British Columbia, Canada.

METHODS

We recruited 486 clients who were >18 years old and 316 agreed to provide a urine sample for substance use testing. Reported known fentanyl use was defined as a three-level categorical variable assessing recent (i.e., in the previous three days) fentanyl exposure: (i) known exposure; (ii) unknown exposure; and (iii) no exposure. We also assessed any exposure to fentanyl (Yes vs. No) confirmed by urinalysis. Survey data were summarized using descriptive statistics. Multinomial logistic regression and modified Poisson regression models were built to examine different correlates of exposure to fentanyl.

RESULTS

Median age of the participants was 40 (IQR: 32-49). Out of the 303 eligible participants, 38.7% (117) reported known fentanyl use, 21.7% (66) had unknown fentanyl use, and 39.6% (120) had no recent fentanyl use. In the adjusted multinomial logistic regression model and in comparison with unknown fentanyl use, recent known fentanyl use was significantly associated with self-report of methadone use (aRRR = 3.18), heroin/morphine use (aRRR = 4.40), and crystal meth use (aRRR = 2.95). Moreover, any recent exposure to fentanyl (i.e., positive urine test for fentanyl) was significantly associated with living in urban settings (aPR = 1.49), and self-reporting recent cannabis use (aPR = 0.73), crystal meth (aPR = 1.45), and heroin/morphine use (aPR = 2.48).

CONCLUSION

The landscape of illicit opioid use is changing in BC and more people are using fentanyl knowingly. The increasing prevalence of known fentanyl use is concerning and calls for further investments in public awareness and public policy efforts regarding fentanyl exposure and risks.

Police-related barriers to harm reduction linked to non-fatal overdose amongst sex workers who use drugs: Results of a community-based cohort in Metro Vancouver, Canada

BACKGROUND

High rates of overdose and overdose-related mortality in North America represent a pressing health and social concern. Women sex workers face severe health and social inequities, which have been linked to structural factors including negative police interactions; however, little is known regarding the burden of overdose or how policing impacts overdose risk amongst sex workers who use drugs. Given this, we aimed to explore the independent effects of experiencing police-related barriers to harm reduction on non-fatal overdose amongst women sex workers who use drugs in Metro Vancouver, Canada over a 7.5-year period.

METHODS

Data were drawn from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women sex workers in Metro Vancouver, from 2010 to 2017. Using multivariate logistic regression with generalized estimating equations (GEE), we used a confounder modeling approach to identify the independent effect of experiencing police-related barriers to harm reduction strategies on non-fatal overdose amongst sex workers using drugs within the last six months at each study visit.

RESULTS

Amongst 624 participants, 7.7% overdosed within the last six months at baseline and 27.6% overdosed during the study period, contributing 287 non-fatal overdose events over the 7.5-year period. 68.6% reported police-related barriers to harm reduction strategies during the study. In a multivariate confounder model, exposure to police-related barriers to harm reduction strategies [AOR: 2.15, CI: 1.60-2.90] was independently associated with higher odds of non-fatal overdose after adjustment for key confounders.

CONCLUSIONS

Our findings suggest that in the context of the current overdose crisis, adversarial policing practices may undermine access to lifesaving overdose prevention services and exacerbate overdose risks for marginalized women. Findings underscore the urgent need to scale-up access and remove barriers to progressive harm reduction strategies for women sex workers.

Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder

BACKGROUND

Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization.

METHODS

Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die).

RESULTS

Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood.

CONCLUSIONS

Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.

The risk of infective endocarditis among people who inject drugs: a retrospective, population-based time series analysis

BACKGROUND

Infective endocarditis is an increasingly common complication among people who inject drugs. We conducted this study to determine whether the removal of traditional controlled-release oxycodone from the Canadian market would be associated with an increase in the use of hydromorphone and an increased risk of infective endocarditis.

METHODS

We conducted a retrospective, population-based time series analysis using the linked health administrative databases of Ontario, Canada. We measured the quarterly risk of admissions for infective endocarditis related to injection drug use and changes in opioid prescription rates from 2006 to 2015. We set the intervention point at the fourth quarter of 2011, when traditional controlled-release oxycodone was removed from the Canadian market.

RESULTS

We observed an increase in the risk of admissions for infective endocarditis related to injection drug use during the study period. Before the intervention point, we observed a mean of 13.4 admissions per quarter, and after the intervention, we observed a mean of 35.1 admissions per quarter. However, no significant change in this risk occurred at the intervention point. Rather, the risk of infectious endocarditis appeared to have increased earlier and in parallel with the rise in hydromorphone prescriptions. Hydromorphone represented 16% of all opioid prescriptions at the start of the observation period and 53% by the end.

INTERPRETATION

The risk of infective endocarditis related to injection drug use is increasing and is temporally associated with increasing prescriptions for hydromorphone. This relation warrants further exploration.

Multi-drug cocktails: Impurities in commonly used illicit drugs seized by police in Queensland, Australia

BACKGROUND

Impurities in commonly used illicit drugs raise concerns for unwitting consumers when pharmacologically active adulterants, especially new psychoactive substances (NPS), are used. This study examines impurities detected in illicit drugs seized in one Australian jurisdiction.

METHODS

Queensland Health Forensic and Scientific Services provided analytical data. Data described the chemical composition of 9346 samples of 11 illicit drugs seized by police during 2015-2016. Impurities present in primary drugs were summarized and tabulated. A systematic search for published evidence reporting similar analyses was conducted.

RESULTS

Methamphetamine was the primary drug in 6608 samples, followed by MDMA (1232 samples) and cocaine (516 samples). Purity of primary drugs ranged from ∼30% for cocaine, 2-CB and GHB to >90% for THC, methamphetamine, heroin and MDMA. Methamphetamine and MDMA contained the largest variety of impurities: 22 and 18 variants, respectively. Drug adulteration patterns were broadly similar to those found elsewhere, including NPS, but in some primary drugs impurities were found which had not been reported elsewhere. Psychostimulants were adulterated with each other. Levamisole was a common impurity in cocaine. Psychedelics were adulterated with methamphetamine and NPS. Opioids were quite pure, but some samples contained methamphetamine and synthetic opioids.

CONCLUSIONS

Impurities detected were mostly pharmacologically active adulterants probably added to enhance desired effects or for active bulking. Given the designer nature of these drug cocktails, the effects of the adulterated drugs on users from possible complex multi-drug interactions is unpredictable. Awareness-raising among users, research into complex multi-drug effects and ongoing monitoring is required.

Supervised injectable opioid agonist therapy in a supported housing setting for the treatment of severe opioid use disorder

Currently, North America is facing a national opioid overdose crisis. Opioid use disorder (OUD) is a chronic, relapsing condition requiring varying intensities of treatment. Injectable opioid agonist therapy (iOAT) is an effective, high-intensity treatment option for people who are unsuccessful on conventional oral opioid agonist treatments (eg, methadone, buprenorphine). This case highlights the effectiveness of the provision of iOAT in a low-barrier setting. More specifically, we discuss a patient with severe OUD and untreated HIV infection, who was disengaged from medical care and, consequently, was prescribed iOAT in a supportive housing setting.

Illicit fentanyls in the opioid street market: desired or imposed?

BACKGROUND

Illicitly manufactured fentanyl and its analogues are appearing in countries throughout the world, often disguised as heroin or counterfeit prescription pills, with resulting high overdose mortality. Possible explanations for this phenomenon include reduced costs and risks to heroin suppliers, heroin shortages, user preferences for a strong, fast-acting opioid and the emergence of Dark Web cryptomarkets. This paper addresses these potential causes and asks three questions: (1) can users identify fentanyl; (2) do users desire fentanyl; and (3) if users want fentanyl, can they express this demand in a way that influences the supply?

ARGUMENT/ANALYSIS

Existing evidence, while limited, suggests that some users can identify fentanyl, although not reliably, and some desire it, but because fentanyl is frequently marketed deceptively as other drugs, users lack information and choice to express demand effectively. Even when aware of fentanyl's presence, drug users may lack fentanyl-free alternatives. Cryptomarkets, while difficult to quantify, appear to offer buyers greater information and competition than offline markets. However, access barriers and patterns of fentanyl-related health consequences make cryptomarkets unlikely sources of user influence on the fentanyl supply. Market condition data indicate heroin supply shocks and shortages prior to the introduction of fentanyl in the United States and parts of Europe, but the much lower production cost of fentanyl compared with heroin may be a more significant factor CONCLUSION: Current evidence points to a supply-led addition of fentanyl to the drug market in response to heroin supply shocks and shortages, changing prescription opioid availability and/or reduced costs and risks to suppliers. Current drug users in affected regions of the United States, Canada and Europe appear largely to lack both concrete knowledge of fentanyl's presence in the drugs they buy and access to fentanyl-free alternatives.

Determining spatial access to opioid use disorder treatment and emergency medical services in New Hampshire

This research presents an analysis of spatial access to both opioid use disorder treatment facilities and emergency medical services in New Hampshire during 2015-2016, a period during which there was a steep increase in unintentional overdoses involving fentanyl. For this research, spatial access was computed using the enhanced two-step floating catchment area model combined with the Huff model to assess access across New Hampshire and gives attention to supply-side parameters that can impact spatial access. The model is designed to measure access to healthcare services for opioid use disorder patients offered at treatment centers or from buprenorphine treatment practitioners, as well as from emergency medical services across New Hampshire. A composite index of accessibility is proposed to represent overall access to these different treatment services for opioid use disorder patients. Geospatial determinants of spatial access included street network distances, driving times and distance decay relationships, while other key factors were services availability and population demand. Among the towns with the highest composite access scores, approximately 40% were metropolitan locations while 16% were rural towns. The insights from this research showed that for this period, while the opioid crisis was impacting many towns in New Hampshire, high levels of access to treatment services were not uniform across the state. When comparing the access results with data on the towns of residence for individuals who died from unintentional overdoses involving fentanyl during 2015 and 2016, estimates found that approximately 40% of the towns were not estimated to be in the highest class of access to treatment services at the time. This research provides information for local public health officials to support planning strategies to address opioid use disorder treatment access in high-risk regions.

Fentanyl and fentanyl-analog involvement in drug-related deaths

BACKGROUND

To describe and analyze the involvement of fentanyl and fentanyl analogs (FAs) in drug-related deaths in West Virginia (WV), United States.

METHODS

Retrospective analyses of all WV drug-related deaths from 2005 to 2017 were performed, including comparisons of demographic and toxicological characteristics among total deaths, deaths in which fentanyl/FAs were present, deaths in which they were absent, heroin-related deaths, and prescription opioid-related deaths.

RESULTS

Most of the 8813 drug-related deaths were overdoses, with about 11% resulting from transportation/other injuries in which drugs were contributors. Prescription opioid presence (without fentanyl) decreased by 75% from 2005-14 to 2015-17 (3545 deaths to 859 deaths, respectively), while fentanyl involvement in the deaths increased by 122% between these periods (487 to 1082 deaths). Ten FAs were identified (427 instances) after 2015. Alprazolam and ethanol were among the top five most frequently identified substances across years. Fentanyl, heroin and cocaine replaced oxycodone, diazepam and hydrocodone in the top five beginning in 2015. Few decedents had a prescription for fentanyl after 2015, with fewer prescriptions also present for other controlled substances identified.

CONCLUSIONS

Fentanyl, rapidly emerging FAs, and other illicit drugs in recent years pose a serious health threat even though prescription opioid-related deaths decreased over the same time period.

Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016

Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.