Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors

"I don't know how you can overdose smoking them:" Perceptions of overdose risks among persons who use illicit fentanyl-laced counterfeit pills

AIMS

Illicitly manufactured fentanyl (IMF) remains the primary driver of overdose mortality in the US. Western states saw significant increases in IMF-laced counterfeit pain pills ("blues"). This qualitative study, conducted in Phoenix, Arizona, provides an in-depth understanding of how overdose-related risks are viewed and experienced by people who use "blues."

METHODS

Between 11/2022-12/2023, the study recruited 60 individuals who used "blues" using targeted and network-based recruitment. Qualitative interviews were recorded, transcribed, and analyzed using NVivo.

RESULTS

The sample included 41.7 % women, and 56.7 % whites. 55.3 % had prior overdose, but most (62.2 %) rated their current risk as none/low. Risk perceptions centered on a multi-level calculus of drug market conditions, individual vulnerabilities, and behavioral factors. Smoking was considered a "normative" way of using "blues", and most viewed it as protective against overdose in comparison to injection and other routes of use. Drug market conditions and the unpredictability of "blues" were emphasized as important factor of overdose risk. However, some believed that over time, the quality/consistency of "blues" improved, and they became less risky. Many also expressed fears about the emerging local availability of powder fentanyl and its risk. Views about safer dosing, polydrug use, tolerance, and health emphasized personal responsibility and individual vulnerability to overdose risks. Discussions of protective behaviors, including take-home naloxone, varied bases on the perceptions of overdose risks.

CONCLUSIONS

The findings emphasize the need for close monitoring of local IMF markets and design of comprehensive interventions and risk communication strategies to address perceptions that minimize IMF-laced counterfeit pill risks.

Systematic review on intentional non-medical fentanyl use among people who use drugs

Objectives

Fentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use.

Methods

The search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included.

Results

The search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability.

Conclusions

Among PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021272111.

Severe and Fatal Fentanyl Poisonings from Transdermal Systems after On-Skin and Ingestion Application

In recent years, the administration of fentanyl (FNTL) implicitly in transdermal drug delivery systems (TDDS) has vastly increased in chronic pain treatment. Non-medical and uncontrolled use of FNTL in TFDS (transdermal fentanyl delivery systems) may reveal toxic effects by the route of exposure, dermal or alternative, by ingestion of patches, and drug release in the stomach. The purpose of this study was to present three different cases of FNTL poisonings, two of which resulted in death due to TFDS abuse. The first case is a 66-year-old woman treated for accidental FTNL poisoning resulting in acute respiratory distress syndrome. Two remaining cases are a 31-year-old woman and a 25-year-old man who died as a result of FNTL overdose after on-skin and ingestion application of the drug patches. During the hospitalization of the 66-year-old patient, in blood samples, FNTL was confirmed at a concentration of 10.0 ng/mL. Tests run on blood taken from the corpses of 25- and 31-year-old patients exhibited FNTL presence in concentrations of 29.1 ng/mL and 38.7 ng/mL, respectively. The various routes of administration and ultimately toxic effects are important to present because, in TDDS, fentanyl can be a reason for severe to fatal poisoning, as shown by the three cases above.

The motives and methods of methamphetamine and 'heroin' co-use in West Virginia

BACKGROUND

Opioid and methamphetamine co-use is increasing across the USA with overdoses involving these drugs also rising. West Virginia (WV) has led the US in opioid overdose death rates since at least 2013 and rising co-use of methamphetamine with opioids has played a greater role in deaths over the last 5 years.

METHODS

This study used rapid ethnography to examine methods and motivations behind opioids and methamphetamine co-use from the viewpoint of their consumers. Participants (n = 30) were people who injected heroin/fentanyl also using methamphetamine who participated in semi-structured interviews.

RESULTS

We found multiple methods of co-using opioids and methamphetamine, whether alternately or simultaneously and in varying order. Most prioritized opioids, with motives for using methamphetamine forming three thematic categories: 'intrinsic use', encompassing both inherent pleasure of combined use greater than using both drugs separately or for self-medication of particular conditions; 'opioid assisting use' in which methamphetamine helped people manage their existing heroin/fentanyl use; and 'reluctant or indifferent use' for social participation, reflecting methamphetamine's low cost and easy availability.

CONCLUSIONS

Methamphetamine serves multiple functions among people using opioids in WV. Beliefs persist that methamphetamine can play a role in preventing and reversing opioid overdose, including some arguments for sequential use being protective of overdose. 'Reluctant' uptake attests to methamphetamine's social use and the influence of supply. The impact on overdose risk of the many varied co-use patterns needs further investigation.

"I don't want to die": a qualitative study of coping strategies to prevent fentanyl-related overdose deaths among people who inject drugs and its implications for harm reduction policies

BACKGROUND

Fentanyl and fentanyl-related analogues are the main drivers of overdose death in the USA, particularly among people who inject drugs (PWID). Despite the fact that non-Hispanic whites exhibit higher population rates of synthetic opioid mortality, overdose deaths have increased among African American and Latinos in urban areas. Yet little attention has been paid to the introduction of fentanyl among rural PWID in Puerto Rico.

METHODS

We conducted N = 38 in-depth interviews with PWID in rural Puerto Rico to document participants' experiences of injection drug use after the arrival of fentanyl and the strategies they implemented to manage overdose death risks.

RESULTS

Participants suggest that the arrival of fentanyl in large scale happened after Hurricane Maria in 2017; this coincided with a dramatic increase in overdose episodes and deaths. Fear of overdose deaths motivated some participants to substitute intravenous drug use for other forms of substance use or to seek MOUD. PWID that continued injection use resorted to conducting "hit tests," avoiding injecting alone, using naloxone, and employing fentanyl testing strips.

CONCLUSIONS

While overdose deaths would have been higher without participants' willingness to adopt harm-reduction strategies, this paper illustrates the limits of these policies to address the current epidemic of fentanyl-related overdose deaths among this population. More studies are needed to understand how health disparities shape overdose risks for minority populations. However, major policy changes, in particular the revision of the harmful role of the War on Drugs and the termination of failed neoliberal economic policies that contribute to deaths of despair, should be addressed if we are to make a dent in this epidemic.

Using Social Media to Examine Themes Surrounding Fentanyl Misuse and Risk Indicators

Background: Opioid misuse is a crisis in the United States, and synthetic opioids such as fentanyl pose risks for overdose and mortality. Individuals who misuse substances commonly seek information and support online due to stigma and legal concerns, and this online networking may provide insight for substance misuse prevention and treatment. We aimed to characterize topics in substance-misuse related discourse among members of an online fentanyl community. Method: We investigated posts on a fentanyl-specific forum on the platform Reddit to identify emergent substance misuse-related themes potentially indicative of heightened risk for overdose and other adverse health outcomes. We analyzed 27 posts and 338 comments with a qualitative codebook established using a subset of user posts via inductive and deductive methods. Posts and comments were independently reviewed by two coders with a third coder resolving discrepancies. The top 200 subreddits with the most activity by r/fentanyl members were also inductively analyzed to understand interests of r/fentanyl users. Results: Functional/quality of life impairments due to substance misuse (29%) was the most commonly occurring theme, followed by polysubstance use (27%) and tolerance/dependence/withdrawal (20%). Additional themes included drug identification with photos, substances cut with other drugs, injection drugs, and past overdoses. Media-focused subreddits and other drug focused communities were among the communities most often followed by r/fentanyl users. Conclusion: Themes closely align with DSM-V substance use disorder symptoms for fentanyl and other substances. High involvement in media-focused subreddits and other substance-misuse-related communities suggests digital platforms as acceptable for overdose prevention and recovery support interventions.

Comparative analysis of opioid use between robotic and open pancreatoduodenectomy

BACKGROUND/PURPOSE

Risk-stratified pancreatectomy clinical pathways using regional anesthesia and multimodality analgesia have decreased overall opioid use, but the additional benefits of robotic surgery in opioid reduction for pancreatoduodenectomy (PD) are unknown. We compared the inpatient opioid use between robotic PD and open PD.

METHODS

Patients undergoing open PD within a protocol evaluating preincisional regional anesthetic block bundles were compared to consecutively-treated patients undergoing robotic PD identified from a prospectively maintained single-institutional database. Clinical characteristics, operative outcomes, pain scores and inpatient oral morphine equivalent (OME) use were compared between patients treated with robotic or open PD. Patients with a history of continuous-release opioid dependence were excluded.

RESULTS

Of 114 total patients, 25 underwent robotic PD and 89 underwent open PD. Intraoperative opioid use was not different (P = .87), nor were cumulative pain scores. Robotic PD patients used significantly fewer OMEs per day on postoperative days 1-4 (P = .039), used fewer total OMEs during hospitalization (robotic: median = 79, IQR 42.5-141; open: median = 126, IQR 61.3-203.8; P = .0036) and were discharged with fewer OMEs (robotic: median = 0, IQR 0-43.8; open: median = 25, IQR 0-75; P = .009) despite a shorter length of stay (robotic: median = 4, open: median = 5, P = .002).

CONCLUSIONS

Robotic PD patients required fewer inpatient OMEs than open PD while maintaining similar pain scores. A higher percentage of robotic PD patients tapered off of opioids prior to discharge than open surgery patients treated with a standardized opioid reduction protocol despite a shorter length of stay. These results provide a rationale for choosing robotic PD when feasible to minimize opioid use.

New Synthetic Opioids: Clinical Considerations and Dangers

Since the early 2010s, synthetic opioids have significantly contributed to overall opioid-related overdose mortalities. For point of reference, of the 68,630 opioid-related deaths recorded in 2020, 56,516 involved synthetic opioids. During much of this period, fentanyl has been the most commonly used synthetic opioid. This time when fentanyl was the most popular opioid has been called the "third wave" of the opioid crisis, partly because it led to a sharp rise in deaths from overdoses. Other synthetic opioids, such as carfentanil, protonitazene, and isotonitazene, have also become more widely diverted for nonmedical used. Carfentanil is an even more potent fentanyl derivative that was initially used in the mid-1980s as a general anesthetic for large animals such as elephants. Related to its strong affinity for mu opioid receptors, carfentanil is still utilized in medicine and science today as a radiotracer for positron emission tomography imaging. Protonitazene and isotonitazene belong to a novel class of synthetic opioids called benzimidazoles that were manufactured in the 1950s as novel analgesics. These agents have come under recent scrutiny as designer synthetic opioids becoming more prevalent. However, to date, there is incomplete data regarding the prevalence of synthetic opioids, as traditional toxicology screenings may not be sensitive to detect these compounds at such low doses post-mortem, particularly when blood is drawn from the periphery instead of central tissues such as the brain, lung, or heart. This narrative review aims to highlight the clinical challenges presented by these new synthetic opioids.

Day-to-day impact of COVID-19 and other factors associated with risk of nonfatal overdose among people who use unregulated drugs in five cities in the United States and Canada

BACKGROUND

The COVID-19 pandemic has compounded the longstanding drug poisoning crisis in Canada and the United States (US). Research is needed to understand the contributions of COVID-19 and subsequent infection control measures. We sought to estimate the prevalence of and factors associated with nonfatal overdose among participants in nine prospective cohorts of people who use unregulated drugs (PWUD) in Canada and the US.

METHODS

Data were derived from nine cohorts of PWUD in urban centres in Canada (Vancouver, BC) and the US (Baltimore, MD; Miami, FL; Chicago, IL; Los Angeles, CA) between May, 2020 and April, 2021. Multivariable logistic regression was used to identify factors associated with nonfatal overdose among participants who used unregulated drugs in the past month.

RESULTS

Among 885 participants (including 253 females), 41 (4.6 %) experienced a non-fatal overdose in the past month, and 453 (51.2 %) reported being highly impacted day-to-day by the pandemic. In multivariable analyses, people who experienced a non-fatal overdose were more likely to be female (Adjusted Odds Ratio [AOR]=2.18;95 % Confidence Interval [CI]=1.10-4.30); unstably housed/homeless (AOR=2.16;95 % CI=1.11-4.26); engaged in medications for opioid use disorder (AOR=2.45;95 % CI=1.19-4.97); and highly impacted day-to-day (AOR=2.42;95 % CI=1.22-5.10).

CONCLUSION

Our findings may reflect characteristics of participants who experienced a compounding of vulnerabilities during the pandemic and thus are vulnerable to overdose, including women, those unstably housed/homeless, and those who perceived their daily lives were highly impacted by the pandemic. Multi-level interventions are needed to remediate the vulnerabilities and address the main driver of poisoning crisis.

Fentanyl preference among people who use opioids in New York City

BACKGROUND

Several studies have pointed to a sub-sample of people who use drugs (PWUD) who prefer the use of non-pharmaceutical fentanyl (NPF) and, as such, pose a unique challenge for public health initiatives amidst the continued rise in overdose mortality. However, matters of drug preference and autonomy of choice remain under-studied and often misunderstood. This paper examined the experiences of PWUD reporting a preference for NPF or an NPF-heroin mixture, specifically how they navigate the perceived benefits of NPF and its established risks.

METHODS

22 in-depth interviews were conducted in New York City between March 2018 and August 2019 with PWUD who self-reported a preference for NPF or an NPF-heroin mix. Interviews were audio-recorded, and the resulting transcripts analyzed using a thematic approach.

RESULTS

Participants highlighted various factors that contributed to expressed preference for NPF or an NPF-heroin mix, including a desire to feel good, financial resources, drug availability, decreased consumer autonomy, and physiological demand. Participants reported practicing several risk reduction strategies; however, they highlighted that many, particularly carrying naloxone and always using with someone else, were difficult to implement in the context of illicit drug use.

CONCLUSIONS

Our results demonstrate participants' decreased consumer agency and greater exposure to systemic factors in the illicit markets, highlighting the need for expansion of various services, including drug checking resources and systems of outreach for PWUD who do not use intravenously. To promote tailored interventions, continued efforts in overdose prevention ought to more thoughtfully consider the context, perceptions, preferences, and behaviors of PWUD.

Trends in characteristics of fentanyl-related poisonings in the United States, 2015-2021

Background: Fentanyl-related deaths continue to increase in the United States; however, most national studies focus on fatal overdose. More research, including data on nonfatal overdose, is needed.Objective: We examined trends in characteristics of fatal and nonfatal fentanyl-related poisonings ("exposures") in the US.Methods: National Poison Control data were examined to estimate trends in characteristics of reported exposures between 2015 and 2021 (N = 15,391; 38.7% female). We also delineated correlates of experiencing a major adverse effect or death.Results: The proportion of exposures increased among all age groups between ages 13 and 39 (ps < .05) with the largest increase among those age 13-19 (a 127.8% increase). With respect to reasons for use, the proportion of cases involving fentanyl "abuse" increased by 63.8% (p < .001). The proportion involving fentanyl inhalation increased 427.6% from 5.7% to 29.9% and injection increased from 6.7% to 9.6%, a 42.3% increase (ps < .01). The proportion also increased for co-use of methamphetamine (by 669.0%), cocaine (by 374.0%), and heroin (by 159.5%). The proportion of major adverse effects increased from 15.5% to 39.6% (p < .001). In the multivariable model, "abuse", suspected suicide attempts, and use via inhalation were risk factors for experiencing a major effect or death, and misuse, ingestion, dermal use, and co-use of methamphetamine were associated with lower risk.Conclusion: Poison Control data suggest that characteristics of individuals exposed to fentanyl continue to shift, with use via inhalation increasing and medical outcomes of nonfatal poisonings becoming more severe. These results complement mortality data and inform prevention and harm reduction efforts.

Mental disorder and opioid overdose: a systematic review

PURPOSE

This systematic review summarizes and presents the current state of research quantifying the relationship between mental disorder and overdose for people who use opioids.

METHODS

The protocol was published in Open Science Framework. We used the PECOS framework to frame the review question. Studies published between January 1, 2000, and January 4, 2021, from North America, Europe, the United Kingdom, Australia, and New Zealand were systematically identified and screened through searching electronic databases, citations, and by contacting experts. Risk of bias assessments were performed. Data were synthesized using the lumping technique.

RESULTS

Overall, 6512 records were screened and 38 were selected for inclusion. 37 of the 38 studies included in this review show a connection between at least one aspect of mental disorder and opioid overdose. The largest body of evidence exists for internalizing disorders generally and mood disorders specifically, followed by anxiety disorders, although there is also moderate evidence to support the relationship between thought disorders (e.g., schizophrenia, bipolar disorder) and opioid overdose. Moderate evidence also was found for the association between any disorder and overdose.

CONCLUSION

Nearly all reviewed studies found a connection between mental disorder and overdose, and the evidence suggests that having mental disorder is associated with experiencing fatal and non-fatal opioid overdose, but causal direction remains unclear.

Predictors of intentional fentanyl use: Market availability vs consumer demand

BACKGROUND

Attempts to reduce opioid overdoses have been complicated by the dramatic rise in fentanyl use. While market forces contributing to fentanyl proliferation in the illicit drug supply have increased inadvertent exposure to the drug, rising fentanyl use may also be driven by growing consumer demand. Interventions to reduce the spread of fentanyl must be based on an understanding of the motivations underlying its use.

METHODS

Data for this cross-sectional study were derived from a computerized self-administered survey completed by a convenience sample of 432 people who use illicit opioids (PWUO) recruited from methadone and detoxification programs in NJ. The anonymous survey was based on a prior qualitative study of attitudes and behaviors surrounding opioid use. Multivariate analysis identified correlates of intentional fentanyl use in the full sample and among sub-populations of white and non-white PWUO.

RESULTS

In the full sample, intentional fentanyl use was associated with white race/ethnicity, younger age, polydrug use, and a preference for the drug effects of fentanyl, which more than tripled the probability of intentional use (AOR=3.02; 95% CI=1.86-4.89; p=.000). Among whites, a preference for the fentanyl drug effects was also the strongest predictor of intentional use (AOR=5.34; 95% CI=2.78-10.28; p=.000). Among non-whites, however, exposure, not preference, was the primary driver of use, with intentional use more than doubling (AOR=2.48; 95% CI=1.04-5.91; p<.05) among those living in high fentanyl dispersion counties.

CONCLUSION

The motivations underlying fentanyl use are multifactorial and vary across populations of PWUO, indicating a need for targeted interventions to counter the increasing spread and adverse consequences of fentanyl use. In order to counteract the increasing spread and adverse consequences of fentanyl use, these findings indicate a need for harm-reduction interventions, like drug testing or supervised injection sites, that address the differing motivations for fentanyl use among PWUO.

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

PURPOSE OF REVIEW

This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

RECENT FINDINGS

Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

SUMMARY

A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.