Trends in substances involved in polysubstance overdose fatalities in Maryland, USA 2003-2019

Substance use patterns, sociodemographics, and health profiles of harm reduction service recipients in Burlington, Vermont

BACKGROUND

Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision.

METHODS

Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test.

RESULTS

Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits).

CONCLUSIONS

Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.

Quantifying drug overdose deaths: A troubled path from start to finish

Between 1999 and 2019, according to the Centers for Disease Control and Prevention (CDC), nearly 450,000 people died from overdoses involving prescribed opioids. This review examines how drug overdose deaths are compiled by the CDC using the coding system of the International Classification of Diseases (ICD). When it comes to drug-involved deaths, the ICD may not tell the whole story or even the right story. To learn why, the authors examined the CDC's source data and the standard death certificate. In fatal drug overdose cases, death certificates are issued often before the results of post-mortem toxicology are known by the certifier. The CDC believes that this delay in the death investigation process may account for errors when, for example, certifiers list ambiguous terms such as "suspected acute drug intoxication" or "possible drug overdose" as a cause of death. When incomplete data are coded according to the ICD, the error is passed along while potentially useful information is lost. The result may reflect accurately the annual total of drug-involved overdose deaths while obscuring the lethality of individual substances, consumed alone or in combination, which contributed to, or caused, drug-involved deaths. The true cause of most fatal drug overdoses-polysubstance abuse-often is lost in this process. A key objective of this paper is to describe the process used by the CDC to report drug-involved mortality and how the current iteration of the ICD may be ill-suited for this important task.

Differential risks of syringe service program participants in Central Ohio: a latent class analysis

BACKGROUND

Significant heterogeneity exists among people who use drugs (PWUD). We identify distinct profiles of syringe service program (SSP) clients to (a) evaluate differential risk factors across subgroups and (b) inform harm reduction programming.

METHODS

Latent class analysis (LCA) was applied to identify subgroups of participants (N = 3418) in a SSP in Columbus, Ohio, from 2019 to 2021. Demographics (age, sex, race/ethnicity, sexual orientation, housing status) and drug use characteristics (substance[s] used, syringe gauge, needle length, using alone, mixing drugs, sharing supplies, reducing use, self-reported perceptions on the impact of use, and treatment/support resources) were used as indicators to define latent classes. A five-class LCA model was developed, and logistic regression was then employed to compare risk factors at program initiation and at follow-up visits between latent classes.

RESULTS

Five latent classes were identified: (1) heterosexual males using opioids/stimulants with housing instability and limited resources for treatment/support (16.1%), (2) heterosexual individuals using opioids with stable housing and resources for treatment/support (33.1%), (3) individuals using methamphetamine (12.4%), (4) young white individuals using opioids/methamphetamine (20.5%), and (5) females using opioids/cocaine (17.9%). Class 2 served as the reference group for logistic regression models, and at the time of entry, class 1 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs, with persistently higher odds of sharing supplies and mixing drugs at follow-up. Class 3 was more likely to report history of overdose, sharing supplies, and mixing drugs, but outcomes at follow-up were comparable. Class 4 was the least likely to report history of overdose, HCV, and mixing drugs, but the most likely to report HIV. Class 5 was more likely to report history of substance use treatment, overdose, HCV, sharing supplies, and mixing drugs at entry, and higher reports of accessing substance use treatment and testing positive for HCV persisted at follow-up.

CONCLUSIONS

Considerable heterogeneity exists among PWUD, leading to differential risk factors that may persist throughout engagement in harm reduction services. LCA can identify distinct profiles of PWUD accessing services to tailor interventions that address risks, improve outcomes, and mitigate disparities.

Associations between Circumstances Surrounding Overdose and Underlying Classes of Polysubstance Overdose Deaths

BACKGROUND

The overdose crisis is worsening, with polysubstance overdose deaths involving psychostimulants increasing in the U.S. Substance-specific prevention and intervention activities may not be as effective for polysubstance use, so we sought to classify substances used among overdose decedents to identify unique factors related to these classes.

METHODS

We used data from the Nevada State Unintentional Drug Overdose Reporting System, Jan 2019-Jun 2021, which comes from death certificates, coroner/medical examiner reports, and postmortem toxicology. Latent class analysis, multinomial logistic regression, and Chi-squared tests determined underlying drug use classes, differences in characteristics and circumstances surrounding overdose, and assessed relationships between circumstances and drug use classes.

RESULTS

We identified four latent classes: (1) prescription drugs (19.1%), (2) predominately methamphetamine (31.4%), (3) multi-drug (28.9%), and (4) opioid and stimulant (20.6%). Compared to other classes, the prescription drug class had a higher percentage of female decedents, from rural counties, with mental health diagnoses, who died at home. The predominately methamphetamine class had a higher percentage of decedents experiencing homelessness. The multi-drug use class had higher percentage of younger and Hispanic decedents. Those in the opioid and stimulant class had higher odds of being recently released from an institutional setting, compared to the multi drug class.

CONCLUSIONS

These underlying classes were associated with several characteristics and circumstances that can prove useful for prevention, treatment, and harm reduction agencies when designing programs and interventions to target specific groups of people at-risk for drug overdose.

Factors Associated with HIV Testing Among People Who Inject Drugs: Findings from a Multistate Study at the Start of the COVID-19 Pandemic

Few studies have examined HIV testing among people who inject drugs (PWID) during the COVID-19 pandemic. This study examines factors associated with PWID who have been recently (past six months) tested for HIV during the COVID-19 pandemic. PWID were recruited between August 2020 and January 2021 from 22 drug treatment and harm reduction programs in nine states and the District of Columbia. We used logistic regression to identify correlates of recent HIV testing among PWID (n = 289). Most (52.9%) PWID reported having been recently tested for HIV. Factors associated with recent HIV testing included: having attended college [adjusted odds ratio (aOR) 2.32, 95% confidence interval (95% CI) 1.32-4.10], weekly hunger (aOR 2.08, 95% CI 1.20-3.60), crystal methamphetamine injection (aOR 2.04, 95% CI 1.05-3.97), and non-metropolitan residence (aOR 0.33, 95% CI 0.13, 0.88). Findings suggest HIV testing initiatives should be expanded during times of crisis, such as global pandemics.

Literal text analysis of poly-class and polydrug overdose deaths in North Carolina, 2015-2019

BACKGROUND

The literal text on death certificates was leveraged to enhance the examination of trends in the specific drugs and drug combinations involved in North Carolina (NC) overdose deaths from 2015 to 2019.

METHODS

Using NC death certificate data, overdose deaths included those with a drug poisoning as the underlying ICD-10 cause-of-death code (n = 10,117). The literal text from three death certificate fields were searched for drug mentions by integrating a tool developed by the Council of State and Territorial Epidemiologists Overdose Subcommittee with search terms originating from a National Center for Health Statistics/Food and Drug Administration collaboration. Descriptive statistics were calculated to evaluate substance classes, specific drugs, and drug combinations most frequently involved in these deaths over time.

RESULTS

From 2015-2019, polydrug involvement in NC overdose deaths increased (71% in 2015 to 75% in 2019). During the study period, opioid involvement shifted from heroin and/or oxycodone in 2015 to predominantly fentanyl in 2019, with fentanyl involvement increasing from 15% to 58%. Psychostimulant involvement increased for both cocaine (2015: 21%, 2019: 35%) and methamphetamine (2015: 3%, 2019: 13%). Benzodiazepine involvement, including alprazolam and clonazepam, declined during the study period, while the involvement of alcohol and antiepileptics/sedative-hypnotics, specifically gabapentin, remained stable. The top polydrug combinations in 2019 were fentanyl + cocaine (15% of all overdose deaths), fentanyl + heroin (10%), fentanyl + cocaine + heroin (6%), and fentanyl + methamphetamine (4%).

CONCLUSIONS

Incorporation of literal text methodology into ongoing overdose surveillance can facilitate the identification of specific, emerging drugs and combinations and inform targeted overdose prevention approaches.