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Rivera BD, Friedman SR. What would it really take to solve the overdose epidemic in the United States? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 128:104435. [PMID: 38729061 DOI: 10.1016/j.drugpo.2024.104435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024]
Abstract
The high overdose mortality rates in the United States poses several questions: Why have they been increasing exponentially since 1979? Why are they so high? And how can they be greatly reduced? Building on past research, the causes of the increase seem to be deeply rooted in US social and economic structures and processes, rather than due only to opioid prescription patterns or the advent of synthetic opioids. Given this, we consider what changes might be needed to reverse the exponentially-increasing overdose mortality. We use a path dependency argument to argue that the United States political, economic, and public health systems have helped create this crisis and, unfortunately, continue to heighten it. These same systems suggest that proposals to expand harm reduction and drug treatment capacity, to decriminalize or legalize drugs, or to re-industrialize the country sufficiently to reduce "communities of despair" will not be enacted at a scale sufficient to end the overdose crisis. We thus suggest that in the United States serious improvements in overdose rates and related policies and structures require massive social movements with a broad social change agenda.
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Affiliation(s)
- Bianca D Rivera
- SUNY Downstate Health Sciences University School of Public Health, Brooklyn, NY, USA
| | - Samuel R Friedman
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, USA.
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Ezell JM, Pho MT, Ajayi BP, Simek E, Shetty N, Goddard-Eckrich DA, Bluthenthal RN. Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model. Drug Alcohol Rev 2024. [PMID: 38646735 DOI: 10.1111/dar.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 04/23/2024]
Abstract
ISSUES To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors. APPROACH Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors. KEY FINDINGS Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder. IMPLICATIONS There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement. CONCLUSION There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.
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Affiliation(s)
- Jerel M Ezell
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
- Berkeley Center for Cultural Humility, University of California Berkeley, Berkeley, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, USA
| | - Babatunde P Ajayi
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
| | - Elinor Simek
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
- Berkeley Center for Cultural Humility, University of California Berkeley, Berkeley, USA
| | - Netra Shetty
- University of California Berkeley, Berkeley, USA
| | | | - Ricky N Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Ondocsin J, Holm N, Mars SG, Ciccarone D. The motives and methods of methamphetamine and 'heroin' co-use in West Virginia. Harm Reduct J 2023; 20:88. [PMID: 37438812 PMCID: PMC10339587 DOI: 10.1186/s12954-023-00816-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/22/2023] [Indexed: 07/14/2023] Open
Abstract
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.
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Affiliation(s)
- Jeff Ondocsin
- Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, MU3E, San Francisco, CA, 94143, USA.
| | - Nicole Holm
- Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, MU3E, San Francisco, CA, 94143, USA
| | - Sarah G Mars
- Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, MU3E, San Francisco, CA, 94143, USA
| | - Daniel Ciccarone
- Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, MU3E, San Francisco, CA, 94143, USA
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Fink DS, Keyes KM, Branas C, Cerdá M, Gruenwald P, Hasin D. Understanding the differential effect of local socio-economic conditions on the relation between prescription opioid supply and drug overdose deaths in US counties. Addiction 2023; 118:1072-1082. [PMID: 36606567 PMCID: PMC10175115 DOI: 10.1111/add.16123] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Both local socio-economic conditions and prescription opioid supply are associated with drug overdose deaths, which exhibit substantial geographical heterogeneity across the United States. We measured whether the associations of prescription opioid supply with drug overdose deaths vary by local socio-economic conditions. DESIGN Ecological county-level study, including 3109 US counties between 2006 and 2019 (n = 43 526 county-years) using annual mortality data. SETTING United States. CASES A total of 711 447 drug overdose deaths. MEASUREMENTS We modeled overdose counts using Bayesian hierarchical Poisson models, estimating associations between four types of drug overdose deaths (deaths involving any drugs, any opioid, prescription opioids only and heroin), prescription opioid supply and five socio-economic indicators: unemployment, poverty rate, income inequality, Rey index (components include mean household income, % high school graduates, % blue-collar workers and unemployment rate), and American human development index (HDI; an indicator of community wellbeing). FINDINGS Drug overdose deaths and all substance-specific overdose deaths were higher in counties with higher income inequality [adjusted odds ratios (aORs) = 1.09-1.13], Rey index (aORs = 1.15-1.21) and prescription opioid supply (aORs = 1.14-1.21), and lower in counties with higher HDI scores (aORs = 0.75-0.92). Poverty rate, income inequality and HDI scores were found to modify the effect of prescription opioid supply on heroin overdose deaths. The plot of the interactions showed that when disadvantage is high, increasing prescription opioid supply does not increase heroin overdose deaths. The less disadvantage there is, indicated by lower poverty rates, higher HDI scores and lower income inequality, the greater the effect of increasing prescription opioid supply relative to population size on heroin overdose deaths in US counties. CONCLUSIONS In the United States, prescription opioid supply is associated with higher drug overdose deaths; associations are stronger in counties with less disadvantage and less income inequality, but only for heroin overdose deaths.
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Affiliation(s)
- David S. Fink
- New York State Psychiatric Institute, New York, NY, USA
| | | | - Charles Branas
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Magdalena Cerdá
- Department of Population Health, New York University, New York, NY, USA
| | - Paul Gruenwald
- Prevention Research Centre, Pacific Institute for Research and Evaluation, Berkeley, CA, USA
| | - Deborah Hasin
- New York State Psychiatric Institute, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
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Nygaard-Christensen M, Søgaard TF. What's in Stock? Drug drought anticipation during COVID-19 among people who use drugs and service providers. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 117:104048. [PMID: 37182349 PMCID: PMC10165055 DOI: 10.1016/j.drugpo.2023.104048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 04/15/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND As with other areas of life, drug markets have been impacted by the COVID-19 pandemic and related restrictions. This article examines how structurally vulnerable people who use drugs (PWUD) experienced and adapted to changes in street drug markets caused by lockdown measures. METHODS The article builds on ethnographic fieldwork in two Danish cities in 2020, including in-depth interviews with 22 PWUD, and interviews with 20 service providers, including low-threshold service providers and outreach workers. RESULTS The most consistently reported effect of lockdown measures on local drug markets related to increases in cannabis prices. Accounts of changes in drug availability varied greatly, with some participants reporting changing availability while others described the situation as similar to pre-lockdown conditions. Rather than a long-term drug shortage, changes reported by participants related to the anticipated disruption of local markets and drug scarcity, restrictions in access to cash and sellers seeking to capitalize on the crisis. CONCLUSION Although no long-term drug scarcity was seen, the anticipation of a shortage was sufficient to impact on local drug market dynamics. Heterogeneity in PWUDs' experiences of access to drug markets during lockdown can to some degree be explained in terms of their varied embeddedness in social networks. While local markets proved resilient to lockdown measures, PWUD less embedded in social networks were more vulnerable to shifts in drug availability and to sellers' over-pricing of drugs.
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Affiliation(s)
- Maj Nygaard-Christensen
- Centre for Alcohol and Drug Research, Aarhus University, Bartholins Alle 10, 8000 Aarhus C, Denmark.
| | - Thomas Friis Søgaard
- Centre for Alcohol and Drug Research, Aarhus University, Bartholins Alle 10, 8000 Aarhus C, Denmark
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Loh J, Buxton J, Kaida A, Voon P, Grant C, Milloy MJ. Estimating the prevalence and correlates of pain among people living with HIV who use unregulated drugs in a Canadian setting. J Opioid Manag 2023; 19:225-237. [PMID: 37145925 PMCID: PMC10811581 DOI: 10.5055/jom.2023.0778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Although prevalent among people living with human immunodeficiency virus (HIV) (PLWH) and people who use unregulated drugs (PWUD), pain and its possible links to substance use patterns and engagement in HIV treatment remains poorly characterized. We sought to evaluate the prevalence and correlates of pain among a cohort of PLWH who use un-regulated drugs. Between December 2011 and November 2018, 709 participants were recruited, and data were analyzed using generalized linear mixed-effects (GLMM). At baseline, 374 (53 percent) individuals reported moderate-to-extreme pain in the previous 6 months. In a multivariable model, pain was significantly associated with nonmedical prescrip-tion-opioid use (adjusted odds ratio (AOR) = 1.63, 95 percent confidence interval (CI): 1.30-2.05), nonfatal overdose (AOR = 1.46, 95 percent CI: 1.11-1.93), self-managing pain (AOR = 2.25, 95 percent CI: 1.94-2.61), requesting pain medication in the previous 6 months (AOR = 2.01, 95 percent CI: 1.69-2.38), and ever being diagnosed with a mental illness (AOR = 1.47, 95 percent CI: 1.11-1.94). Establishing accessible pain management interventions that address the complex intersection of pain, drug use, and HIV-infection has potential to improve quality of life outcomes among this population.
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Affiliation(s)
- Jane Loh
- British Columbia Centre on Substance Use, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, British Columbia Centre for Disease Control, Vancouver, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Pauline Voon
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Department of Medicine, University of British Columbia, Vancouver, Canada
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van Draanen J, Jamula R, Karamouzian M, Mitra S, Richardson L. Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 113:103971. [PMID: 36822011 DOI: 10.1016/j.drugpo.2023.103971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs. METHODS We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach. RESULTS The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1). CONCLUSION SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.
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Affiliation(s)
- Jenna van Draanen
- BC Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; University of British Columbia, Faculty of Arts, Department of Sociology, 6303 NW Marine Drive, Vancouver, BC, V6T 1Z1, Canada; Department of Child, Family, and Population Health Nursing; School of Nursing; University of Washington, Seattle, WA, USA; Department of Health Systems and Population Health; School of Public Health; University of Washington, Seattle, WA, USA
| | - Ryan Jamula
- BC Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; University of British Columbia, Faculty of Arts, Department of Sociology, 6303 NW Marine Drive, Vancouver, BC, V6T 1Z1, Canada
| | - Mohammad Karamouzian
- BC Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Brown School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA; HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, 7616913555, Iran; Centre On Drug Policy Evaluation, St. Michael's Hospital, Toronto, ON, Canada
| | - Sanjana Mitra
- BC Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; University of British Columbia, Interdisciplinary Studies Graduate Program, 270, 2357 Main Mall, H. R. MacMillan Building, Vancouver, BC, V6T 1Z4, Canada; Centre On Drug Policy Evaluation, St. Michael's Hospital, Toronto, ON, Canada
| | - Lindsey Richardson
- BC Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; University of British Columbia, Faculty of Arts, Department of Sociology, 6303 NW Marine Drive, Vancouver, BC, V6T 1Z1, Canada.
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Ray B, Hedden BJ, Carroll JJ, Del Pozo B, Wagner K, Kral AH, O'Donnell D, Victor G, Huynh P. Prevalence and correlates of incarceration following emergency medical services response to overdose. Drug Alcohol Depend 2022; 238:109571. [PMID: 35868181 DOI: 10.1016/j.drugalcdep.2022.109571] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND To describe the prevalence of incarceration among survivors of non-fatal overdose addressed through an emergency medical services (EMS) response, and compare incarceration by whether the emergency was for opioid-involved or stimulant-involved overdose. METHODS Administrative records on 192,113 EMS incidents and 70,409 jail booking events occurring between January 1, 2019 and December 31, 2020 in Indianapolis, Indiana were record-linked at the event level. Incarceration taking place within 6-hours of an EMS incident was associated with that incident. Logistic regression was used to calculate adjusted odds ratios (AOR) of incarceration after an overdose. RESULTS Among all EMS incidents, 2.6% were followed by incarceration. For overdose EMS incidents, the prevalence of incarceration was 10.0%. Overdose incidents had higher odds than non-overdose incidents of leading to a charge of felony, booked on a warrant, and transferred to another law enforcement agency upon release. Prevalence of incarceration following a stimulant-involved overdose was 21.3%, compared to 9.3% for opioid-involved overdose survivors. Compared to persons from other EMS incidents, overdose survivors had greater odds of incarceration (AOR=3.48, 95% confidence interval (CI)= 3.22, 3.75, p < .001), with opioid-involved overdoses (AOR=3.03, 95% CI=2.76, 3.33, p < .001) and stimulant-involved overdoses (AOR=6.70, 95% CI=5.26, 8.55, p < .001) leading to higher odds of incarceration. CONCLUSION Incarceration in county jail followed one in ten overdose-involved EMS responses. As illicit drug consumption increasingly involves stimulants, the frequency of incarceration following these events is likely to increase. Policy changes and interventions are needed to reduce incarceration after overdose emergencies.
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Affiliation(s)
- Bradley Ray
- RTI International, Division for Applied Justice Research, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA.
| | - Bethany J Hedden
- Center for Behavioral Health and Justice, Wayne State University, School of Social Work, 5447 Woodward Avenue, Detroit, MI 48202, USA
| | - Jennifer J Carroll
- North Carolina State University, Department of Sociology and Anthropology, 10 Current Drive, Suite 334, Raleigh, NC 27606-8017, USA
| | - Brandon Del Pozo
- The Warren Alpert School of Medicine of Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Karla Wagner
- University of Nevada, Reno, School of Public Health, 1644 N. Virginia St., Reno, NV 89557, USA
| | | | - Daniel O'Donnell
- Indiana University School of Medicine, Indianapolis Emergency Medical Services, 3930 Georgetown Rd., Indianapolis, IN 46254, USA
| | - Grant Victor
- Rutgers University, School of Social Work, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Phil Huynh
- Center for Behavioral Health and Justice, Wayne State University, School of Social Work, 5447 Woodward Avenue, Detroit, MI 48202, USA
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Magee LA, Ray B, Huynh P, O'Donnell D, Ranney ML. Dual public health crises: the overlap of drug overdose and firearm injury in Indianapolis, Indiana, 2018-2020. Inj Epidemiol 2022; 9:20. [PMID: 35781347 PMCID: PMC9252058 DOI: 10.1186/s40621-022-00383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/24/2022] [Indexed: 12/01/2022] Open
Abstract
Background Drug overdose and firearm injury are two of the United States (US) most unrelenting public health crises, both of which have been compounded by the COVID-19 pandemic. Programs and policies typically focus on each epidemic, alone, which may produce less efficient interventions if overlap does exist. The objective is to examine whether drug overdose correlates with and is associated with firearm injury at the census tract level while controlling for neighborhood characteristics. Methods An ecological study of census tracts in Indianapolis, Indiana from 2018 to 2020. Population rates per 100,000 and census tracts with the highest overlap of overdose and firearm injury were identified based on spatial clusters. Bivariate association between census tract characteristic and drug overdose and firearm violence rate within spatial clusters. Zero-inflated negative binominal regression was used to estimate if the drug overdose activity is associated with higher future firearm injury. Results In high overdose—high firearm injury census tracts, rates of firearm injury and drug overdose are two times higher compared to city wide rates. Indicators of structural disadvantage and structural racism are higher in high overdose—high firearm injury census tracts compared to city-wide averages. Drug overdoses are associated with higher rates of firearm injury in the following year (IRR: 1.004, 95% CI 1.001, 1.007, p < 0.05), adjusting for census tract characteristics and spatial dependence. Conclusions Drug overdose and firearm injury co-spatially concentrate within census tracts. Moreover, drug overdoses are associated with future firearm injury. Interventions to reduce firearm injuries and drug overdoses should be a co-response in high drug overdose—high firearm injury communities.
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Affiliation(s)
- Lauren A Magee
- O'Neill School of Public and Environmental Affairs, Indiana University Purdue University Indianapolis, 801 W Michigan St, Rm 4058, Indianapolis, IN, 46202, USA.
| | - Bradley Ray
- Division for Applied Justice Research, RTI International, 3040 Cornwallis Road, Research Triangle Park, Durham, NC, 27709, USA
| | - Philip Huynh
- Center for Behavioral Health and Justice, Wayne State University School of Social Work, 5201 Cass Avenue, Prentis, Suite 226, Detroit, MI, 48202, USA
| | - Daniel O'Donnell
- Indiana University School of Medicine, Indianapolis Emergency Medical Services, 3930 Georgetown Rd., Indianapolis, IN, 46254, USA
| | - Megan L Ranney
- School of Public Health and Alpert School of Medicine, Brown University, 121 S Main St, Providence, RI, 02903, USA
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Simsek M, Yucebas S, Ogel K. Behavioral changes observed in substance users in Turkey during the COVID-19 pandemic. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2069609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Walker DM, Childerhose JE, Chen S, Coovert N, Jackson RD, Kurien N, McAlearney AS, Volney J, Alford DP, Bosak J, Oyler DR, Stinson LK, Behrooz M, Christopher MC, Drainoni ML. Exploring perspectives on changing opioid prescribing practices: A qualitative study of community stakeholders in the HEALing Communities Study. Drug Alcohol Depend 2022; 233:109342. [PMID: 35151024 PMCID: PMC8957585 DOI: 10.1016/j.drugalcdep.2022.109342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Community-based perspectives are needed to more broadly inform policy-makers, public health practitioners, prescribers, and pharmacists about community-led and broader efforts to reduce opioid overprescribing, and ultimately reduce prescription opioid use disorder, overdoses and fatalities. The aim of this study is to explore community-based perspectives on efforts to change opioid prescribing practices in their communities. METHODS Semi-structured interviews were conducted with 388 community stakeholders across four states (Kentucky, Massachusetts, New York, Ohio) from November 2019 to January 2020 about community approaches and goals of community-led responses to the opioid crisis. Data analysis combined deductive and inductive approaches to identify themes and sub-themes related to improving opioid prescribing practices. RESULTS Three major themes and different subthemes were characterized: (1) acknowledging progress (i.e., healthcare providers being part of the solution, provider education, and prescription drug monitoring programs); (2) emergent challenges (i.e., physician nonadherence with safer opioid prescribing guidelines, difficulty identifying appropriate use of opioids, and concerns about accelerating the progression from opioid misuse to drug abuse); and (3) opportunities for change (i.e., educating patients about safer use and proper disposal of opioids, expanding prescriber and pharmacist education, changing unrealistic expectations around eliminating pain, expanding and increasing insurance coverage for alternative treatment options). CONCLUSIONS Community stakeholders appeared to support specific opportunities to reduce prescription opioid misuse and improve safer prescribing. The opportunities included culture change around pain expectations, awareness of safe disposal, additional provider education, and increased coverage and acceptability of non-opioid treatments.
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Affiliation(s)
- Daniel M. Walker
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, 460 Medical Center Dr., Suite 530, Columbus, OH, 43210, USA,CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA
| | - Janet E. Childerhose
- CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA,Department of Internal Medicine, College of Medicine, The Ohio State University, Martha Morehouse Pavilion, 2050 Kenny Road, Suite 2428, Columbus, OH, 43221, USA
| | - Sadie Chen
- CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA
| | - Nicolette Coovert
- CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA
| | - Rebecca D. Jackson
- Center for Clinical and Translational Science and the Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University, 376 W. 10 Ave, Suite 205, Columbus, OH, 43210, USA
| | - Natasha Kurien
- CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA
| | - Ann Scheck McAlearney
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, 460 Medical Center Dr., Suite 530, Columbus, OH, 43210, USA,CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA
| | - Jaclyn Volney
- CATALYST, The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, College of Medicine, The Ohio State University, 700 Ackerman Road, Suite 4000, Columbus, OH, 43202, USA
| | - Daniel P. Alford
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, Rm 2060, Boston, MA, 02118, USA
| | - Julie Bosak
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, Rm 2060, Boston, MA, 02118, USA
| | - Douglas R. Oyler
- Pharmacy Practice and Science Department, College of Pharmacy, University of Kentucky, 780 S. Limestone, Lee T. Todd, Jr. Bldg, Rm 285, Lexington, KY, 40506, USA
| | - Laura K. Stinson
- Pharmacy Practice and Science Department, College of Pharmacy, University of Kentucky, 780 S. Limestone, Lee T. Todd, Jr. Bldg, Rm 285, Lexington, KY, 40506, USA
| | - Melika Behrooz
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY, 10027, USA
| | - Mia-Cara Christopher
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY, 10027, USA
| | - Mari-Lynn Drainoni
- Boston Medical Center and Boston University School of Medicine, Boston, MA, 801 Massachusetts Ave, Rm 2014, Boston, MA, 02118, USA
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12
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State-Level Prevalence and Associates of Opioid Dependence in the USA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073825. [PMID: 35409508 PMCID: PMC8997413 DOI: 10.3390/ijerph19073825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022]
Abstract
Traditionally, opioid-related disease burden was primarily due to heroin use. However, increases in extra-medical (or non-medicinal use of prescription opioids; NMPOs) use has precipitated the current overdose epidemic in North America. We aim to examine the state-level prevalence of heroin and NMPO dependence and their associations with opioid-related mortality and state-level socio-demographic profiles. Data were pooled from the 2005-2014 National Survey on Drug Use and Health (NSDUH). We examine opioid-related mortality from CDC WONDER (Cause of Death database) by the past year prevalence of DSM-IV heroin and NMPO dependence, by age and sex, and their associations with state-level socio-demographic characteristics from census data. State-level rates of heroin dependence were associated with opioid-related death rates in young and mid-aged adults, while rates of NMPO dependence were associated with opioid-related death rates across all ages. The prevalence of heroin dependence was positively associated with state-level GDP/capita and urbanity. State-level NMPO dependence prevalence was associated with higher unemployment, lower GDP/capita, and a lower high-school completion rate. The prevalence of heroin and NMPO dependence are associated with a broad range of geographical and socio-demographic groups. Taking a wider view of populations affected by the opioid epidemic, inclusive interventions for all are needed to reduce opioid-related disease burden.
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13
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Perception of Resource Allocations to Address the Opioid Epidemic. J Addict Med 2022; 16:563-569. [PMID: 36201678 PMCID: PMC9537727 DOI: 10.1097/adm.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Despite billions of dollars spent on opioid policy initiatives, public knowledge of evidence-based policies to reduce opioid-related morbidity remain low. Consequences of this knowledge gap for support of initiatives remains understudied. Our objective was to evaluate how participants with and without lived experience allocate funding for initiatives to address the opioid epidemic. A secondary objective was to collect proof-of-concept data of an informational intervention designed to improve support for evidence-based policies. METHODS Participants (N = 284; 57.2% female) without lifetime nonmedical opioid use (n = 98) and those with lifetime use (past year [n = 81] or nonpast year [n = 105]) of nonmedical opioids were recruited. All participants reported how they would allocate funds to demand reduction, supply reduction, harm reduction, and treatment policies. Half of all participants were then randomized to a brief informational intervention designed to emphasize evidence-based harm reduction and treatment programs. RESULTS Funding allocations were highest for policies related to community services and treatment and lowest for those related to harm reduction. Participants with lived experience allocated less to supply reduction policies. Participants (12%) who reallocated funds after information exposure increased funding to supervised consumption sites, dz = 0.77, naloxone distribution, dz = 0.85, syringe exchange programs, dz = 0.63, and medications for opioid use disorder access, dz = 0.70. CONCLUSIONS This study illustrates how people with and without lived experience prioritize various policies to address the opioid epidemic and emphasize comparably low support for harm reduction policies. Proof-of-concept data suggest that brief informational interventions may increase funding support for harm reduction strategies, at least in a subset of people.
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14
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Andersen JM, Bogen IL, Karinen R, Brochmann GW, Mørland J, Vindenes V, Boix F. Does the preparation for intravenous administration affect the composition of heroin injections? A controlled laboratory study. Addiction 2021; 116:3104-3112. [PMID: 33739552 DOI: 10.1111/add.15492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/27/2020] [Accepted: 03/10/2021] [Indexed: 11/28/2022]
Abstract
AIMS To study whether the preparation procedure, and its acidic and heating conditions, used by heroin users to prepare heroin for intravenous administration affects the final composition of the fluid to be injected. METHODS Samples from different seizures of illegal heroin provided by the Norwegian police were prepared by adding water and ascorbic acid before heating under controlled conditions in the laboratory. Further, three seizures were prepared with different amounts of ascorbic or citric acid relative to their diacetylmorphine content. Pure diacetylmorphine base or salt was also submitted to the procedure applying two different heating intensities. The seizures and the final product after preparation were analysed for diacetylmorphine, 6-acetylmorphine and morphine using liquid chromatography with tandem mass spectrometry (LC-MS-MS). RESULTS After preparation, a decrease of 19.8% (25th and 75th percentiles = -29.2 and -15.3) in the initial diacetylmorphine content was observed. Both the 6-acetylmorphine and morphine content increased but, due to their low content in the initial product, diacetylmorphine still represented 83.9% (25th and 75th percentiles = 77.3 and 88.0) of the sum of these three opioids in the final solution. The loss of water during preparation caused an increase in the concentration of diacetylmorphine, 6-acetylmorphine and morphine, depending on the heating intensity applied. The content of these opioids was affected by the quantity and type of acid added in relation to the heroin purity and the level of diacetylmorphine dissolved being proportional to the amount of ascorbic acid, but not citric acid, in the sample with high heroin purity. CONCLUSIONS Preparation of heroin for intravenous injection appears to change the amount or concentration of diacetylmorphine and its active metabolites, 6-acetylmorphine and morphine in the final product, depending on heroin purity, amount and type of acid used or heating conditions. These circumstances can contribute to unintentional variations in the potency of the final injected solution, and therefore affect the outcome after injection.
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Affiliation(s)
- Jannike M Andersen
- Section for Drug Abuse Research, Dept. of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Norway
| | - Inger Lise Bogen
- Section for Drug Abuse Research, Dept. of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway
| | - Ritva Karinen
- Section for Drug Abuse Research, Dept. of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Gerd Wenche Brochmann
- Section for Drug Abuse Research, Dept. of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Jørg Mørland
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.,Division of Health Data and Digitalization, Norwegian Institute of Public Health, Oslo, Norway
| | - Vigdis Vindenes
- Section for Drug Abuse Research, Dept. of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Fernando Boix
- Section for Drug Abuse Research, Dept. of Forensic Sciences, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
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Abstract
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.
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Affiliation(s)
- Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, California, USA
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16
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Past 12-month nonfatal overdose among people who inject drugs in Ukraine: City-level estimates and risk factors from a cross-sectional study. Drug Alcohol Depend 2021; 220:108513. [PMID: 33556695 DOI: 10.1016/j.drugalcdep.2021.108513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Nonfatal overdose contributes to high morbidity and is among the strongest proxies for the occurrence of overdose fatality - the leading cause of death among those who use opioids. In Ukraine, a majority of people who inject drugs (PWID) use opioids, but little is known about the relationship between drug market characteristics, nonfatal overdose (NFOD) prevalence, and risk factors for NFOD. METHODS We used cross-sectional respondent-driven sampling (RDS) data to explore the variability of recent (past 12 months) NFOD among PWID across Ukrainian cities and associations with individual factors. The population-averaged -cross-sectional associations were estimated and compared using generalized linear models for the binary outcome (NFOD vs. not) with robust variance estimates. RESULTS Recent self-reported NFOD varied between 1% and 14 % across Ukrainian cities. In adjusted analyses, overdose was associated with fewer years of injecting drugs; a higher number of types of drugs used in the past 12 months; using desomorphine, methadone, tramadol, heroin, amphetamine-type drugs or cocaine within past 12 months; using alcohol daily or weekly; recent drug treatment; and history of incarceration. Buying drugs or their ingredients through "stashes" (i.e., drugs secretly hidden in various places) and the perception of drug price increase were associated with higher odds of reporting NFOD. CONCLUSION The identified risk factors underscore the importance of evidence-based prevention efforts, such as scaling-up opioid agonist therapy, providing naloxone in the community and upon prison release, targeting those most likely to witness overdose and sharing overdose prevention strategies with them, and continuous monitoring of trends and contributing factors.
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17
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Mueller SR, Glanz JM, Nguyen AP, Stowell M, Koester S, Rinehart DJ, Binswanger IA. Restrictive opioid prescribing policies and evolving risk environments: A qualitative study of the perspectives of patients who experienced an accidental opioid overdose. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 92:103077. [PMID: 33423916 DOI: 10.1016/j.drugpo.2020.103077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes' Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events. METHODS Semi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems. RESULTS We identified three interrelated factors that emerged within an evolving risk environment and may have increased patients' vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids. CONCLUSION For some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.
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Affiliation(s)
- Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Department of Epidemiology, Colorado School of Public Health, 13001 E 17th Place, Mail Stop B-119, Aurora CO 80045, United States
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA
| | - Melanie Stowell
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States
| | - Stephen Koester
- Anthropology, Health & Behavioral Sciences, University of Colorado Denver, 777 Lawrence St, Denver, CO 80204, United States
| | - Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States; Colorado Permanente Medical Group, 10350 E. Dakota Ave, Denver CO 80247, United States
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18
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Volkow ND, Blanco C. The changing opioid crisis: development, challenges and opportunities. Mol Psychiatry 2021; 26:218-233. [PMID: 32020048 PMCID: PMC7398847 DOI: 10.1038/s41380-020-0661-4] [Citation(s) in RCA: 157] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/02/2020] [Accepted: 01/23/2020] [Indexed: 12/16/2022]
Abstract
The current opioid epidemic is one of the most severe public health crisis in US history. Responding to it has been difficult due to its rapidly changing nature and the severity of its associated outcomes. This review examines the origin and evolution of the crisis, the pharmacological properties of opioids, the neurobiology of opioid use and opioid use disorder (OUD), medications for opioid use disorder (MOUD), and existing and promising approaches to prevention. The results of the review indicate that the opioid epidemic is a complex, evolving phenomenon that involves neurobiological vulnerabilities and social determinants of health. Successfully addressing the epidemic will require advances in basic science, development of more acceptable and effective treatments, and implementation of public health approaches, including prevention. The advances achieved in addressing the current crisis should also serve to advance the science and treatment of other substance use disorders.
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Affiliation(s)
| | - Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, 20892, USA.
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19
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Schneider S, Richter C, Niethammer R, Beisel L. Fatal and Non-Fatal Heroin-Related Overdoses: Circumstances and Patterns. Subst Use Misuse 2021; 56:1997-2006. [PMID: 34470589 DOI: 10.1080/10826084.2021.1963986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Heroin overdose is a leading cause of mortality among drug users. This paper aims to identify individual and contextual factors associated with lethal and non-lethal heroin-related overdoses on the basis of case reports and semi-structured proxy interviews. Typical patterns within these cases are determined by means of cluster analysis. METHODS Within the CaRe (Case Reports of heroin-related overdoses) study, case reports (100 proxy reports of overdose events from 36 different facilities) were gathered and evaluated as part of a nationwide survey of experts conducted in Germany in 2019. Following initial descriptive analyses a two-step cluster analysis with the four binary variables of gender, age, time and place was conducted to identify patterns within the reported cases. RESULTS The case reports grouped into five clusters: 1) Younger male drug users, found in a public space during the daytime; 2) Female drug users; 3) Older male drug users, found in a public space during the daytime; 4) Drug users found at home at night; 5) Drug users found outside at night. Overdoses by female drug users and those which occurred at home and/or at night were significantly more likely to have a fatal outcome. CONCLUSION Future prevention and intervention measures should aim to consider the context, i.e. typical constellations of risk, and attempt to inhibit this through appropriate counter measures.
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Affiliation(s)
- Sven Schneider
- Mannheim Institute of Public Health, Social and Preventive Medicine, Heidelberg University, Mannheim, Germany
| | - Christian Richter
- Drug Counselling Centre "Abrigado", Drug Consumption Room, Hamburg, Germany
| | - Rainer Niethammer
- Clinic for Psychiatry and Psychotherapy, Hospital "Zum Guten Hirten", Ludwigshafen, Germany
| | - Larissa Beisel
- Mannheim Institute of Public Health, Social and Preventive Medicine, Heidelberg University, Mannheim, Germany
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20
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Tamargo JA, Campa A, Martinez SS, Li T, Sherman KE, Zarini G, Meade CS, Mandler RN, Baum MK. Cognitive Impairment among People Who Use Heroin and Fentanyl: Findings from the Miami Adult Studies on HIV (MASH) Cohort. J Psychoactive Drugs 2020; 53:215-223. [PMID: 33225878 DOI: 10.1080/02791072.2020.1850946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Cognitive impairment is common in people living with HIV (PLWH). Opioid drugs exert direct and indirect effects on cognitive processes, which may contribute to cognitive dysfunction among PLWH. This study was designed to determine if opioid use is associated with cognitive impairment and whether the effect differs between PLWH and HIV-uninfected adults. Other neuropsychiatric symptoms, such as depression and apathy, were also examined. We conducted a cross-sectional analysis of 265 PLWH and 284 HIV-uninfected participants from the Miami Adult Studies on HIV (MASH) cohort. The Mini-Mental State Examination (MMSE) was used to assess cognitive impairment. Substance use was self-reported. Overall, 26.8% of PLWH and 15.1% of HIV-uninfected used opioids. Cognitive impairment was more frequent among people who used heroin and/or fentanyl than those who misused prescription opioids (31.6% vs. 10.5%, p = .005). The use of heroin/fentanyl was associated with increased odds for cognitive impairment (adjusted OR: 2.21, 95% CI 1.05-4.64, p = .036). Among PLWH only, the misuse of opioids was associated with a higher frequency of neuropsychiatric symptoms such as depression and apathy. A higher risk for cognitive impairment was seen among people who used heroin and fentanyl. PLWH who misuse opioids may be at an increased risk for neuropathology, but elucidation of mechanisms for opioid-induced cognitive deficits is needed.
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Affiliation(s)
- Javier A Tamargo
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Adriana Campa
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Sabrina S Martinez
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Tan Li
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | | | - Gustavo Zarini
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | | | - Raul N Mandler
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Marianna K Baum
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
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21
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Betsos A, Valleriani J, Boyd J, Bardwell G, Kerr T, McNeil R. "I couldn't live with killing one of my friends or anybody": A rapid ethnographic study of drug sellers' use of drug checking. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102845. [PMID: 33246303 DOI: 10.1016/j.drugpo.2020.102845] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/03/2020] [Accepted: 06/11/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Drug sellers are often represented as morally bereft actors and as being, in part, responsible for North America's overdose crisis. In Canada and the United States, drug sellers selling fentanyl and fentanyl-adulterated drugs have been charged with manslaughter when their clients fatally overdose, representing a retrenchment of drug war tactics. However, targeting drug sellers for drug checking interventions may have potential for reducing fentanyl-related harms. This study explores drug sellers' negotiation of and engagement with drug checking technologies in Vancouver, Canada. METHODS Rapid ethnographic fieldwork was conducted from November 2018 to January 2019, including 26 semi-structured interviews with people who tested their drugs at an overdose prevention site to examine perceptions of the efficacy of drug checking. As drug sellers were also using the drug checking services, we specifically examined their perceptions of drug checking and the market aspects of the overdose crisis. Data were analyzed using Nvivo 12 and interpreted drawing on the concept of structural vulnerability. FINDINGS Drug sellers accessing drug checking services were concerned about the safety of their customers, and drug checking was one way of reducing the likelihood of harm. Drug sellers were embedded in the community, thereby, enmeshing practices of community care and ethics with the selling of drugs. When they had access to drug checking knowledge, sellers were able to modify risks related to the fentanyl market, including tailoring drugs sold to clients, returning dangerous batches and modifying fentanyl in order to make it safer to consume. CONCLUSIONS Our findings reposition drug sellers as embedded within their communities and demonstrate their potential role in alleviating the dangers of the volatile fentanyl market. Policies that target people who sell drugs, particularly murder or manslaughter charges, are likely to make the crisis worse, and serious consideration should be put into harm reduction approaches with drug sellers.
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Affiliation(s)
- Alex Betsos
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Jenna Valleriani
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada; Yale School of Medicine, 367 Cedar Street, New Haven, CT, 06510, United States; Social & Behavioral Sciences, Yale School of Public Health, 60 College St, New Haven, CT 06510, United States.
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22
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Fozouni L, Khan S, Bearnot B. Spatiotemporal Trends in Discarded Needle Reports in San Francisco Over a 10-year Period, 2010-2019. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:103018. [PMID: 33142160 DOI: 10.1016/j.drugpo.2020.103018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND To describe the geographic and spatiotemporal distribution of needle reports in San Francisco, and examine spatial relationships between needle reports and needle disposal boxes, needle disposal kiosks, and homeless shelters. METHODS We conducted multiple geospatial analyses of a crowdsourced database of non-emergency service requests. We describe changes in discarded needle and bulky item reports across San Francisco between 2010 and 2019, and compared changes in the reporting patterns of these items, while 200-meter Euclidean buffers captured needle reports in close proximity to needle deposit boxes, needle deposit kiosks, and homeless shelters in 2019. RESULTS 34,912 needle reports were included. Yearly needle reports increased by 3827.1%, with a markedly different geospatial distribution from bulky item reports. 45.6% of needle reports originated in the five downtown neighborhoods with the highest needle report density, and 33.8% were identified within 200 meters of boxes, kiosks, or homeless shelters. CONCLUSIONS Reports of discarded needles in San Francisco increased dramatically over the last decade, and more than one third of 2019 reports were adjacent to harm reduction and homeless shelter locations. Needle reports provide an opportunity to understand changes in public injection drug use and target harm reduction services.
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Affiliation(s)
- Laila Fozouni
- University of California San Francisco School of Medicine, 533 Parnassus Ave, San Francisco, California, 94143 USA
| | - Saira Khan
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, Massachusetts, 02115 USA
| | - Benjamin Bearnot
- Division of General Internal Medicine and Mongan Institute, Massachusetts General Hospital, 55 Fruit St, Boston, Massachusetts, 02114 USA; Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, Massachusetts, 02115 USA.
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23
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Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLoS One 2020; 15:e0232538. [PMID: 32365132 PMCID: PMC7197848 DOI: 10.1371/journal.pone.0232538] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/16/2020] [Indexed: 01/08/2023] Open
Abstract
Background After decades of increased opioid pain reliever prescribing, providers are rapidly reducing prescribing. We hypothesized that reduced access to prescribed opioid pain relievers among patients previously reliant upon opioid pain relievers would result in increased illicit opioid use. Methods and findings We conducted a retrospective cohort study among 602 publicly insured primary care patients who had been prescribed opioids for chronic non-cancer pain for at least three consecutive months in San Francisco, recruited through convenience sampling. We conducted a historical reconstruction interview and medical chart abstraction focused on illicit substance use and opioid pain reliever prescriptions, respectively, from 2012 through the interview date in 2017–2018. We used a nested-cohort design, in which patients were classified, based on opioid pain reliever dose change, into a series of nested cohorts starting with each follow-up quarter. Using continuation-ratio models, we estimated associations between opioid prescription discontinuation or 30% increase or decrease in dose, relative to no change, and subsequent frequency of heroin and non-prescribed opioid pain reliever use, separately. Models controlled for demographics, clinical and behavioral characteristics, and past use of heroin or non-prescribed opioid pain relievers. A total of 56,372 and 56,484 participant-quarter observations were included from the 597 and 598 participants available for analyses of heroin and non-prescribed opioid pain reliever outcomes, respectively. Participants discontinued from prescribed opioids were more likely to use heroin (Adjusted Odds Ratio (AOR) = 1.57, 95% CI: 1.25–1.97) and non-prescribed opioid pain relievers (AOR = 1.75, 1.45–2.11) more frequently in subsequent quarters compared to participants with unchanged opioid prescriptions. Participants whose opioid pain reliever dose increased were more likely to use heroin more frequently (AOR = 1.67, 1.32–2.12). Results held throughout sensitivity analyses. The main limitations were the observational nature of results and limited generalizability beyond safety-net settings. Conclusions Discontinuation of prescribed opioid pain relievers was associated with more frequent non-prescribed opioid pain reliever and heroin use; increased dose was also associated with more frequent heroin use. Clinicians should be aware of these risks in determining pain management approaches.
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Age and generational patterns of overdose death risk from opioids and other drugs. Nat Med 2020; 26:699-704. [PMID: 32367060 DOI: 10.1038/s41591-020-0855-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 03/25/2020] [Indexed: 12/25/2022]
Abstract
The ongoing substance misuse epidemic in the United States is complex and dynamic and should be approached as such in the development and evaluation of policy1. Drug overdose deaths (largely attributable to opioid misuse) in the United States have grown exponentially for almost four decades, but the mechanisms of this growth are poorly understood2. From analysis of 661,565 overdose deaths from 1999 to 2017, we show that the age-specific drug overdose mortality curve for each birth-year cohort rises and falls according to a Gaussian-shaped curve. The ascending portion of each successive birth-year cohort mortality curve is accelerated compared with that of all preceding birth-year cohorts. This acceleration can be attributed to either of two distinct processes: a stable peak age, with an increasing amplitude of mortality rate curves from one birth-year cohort to the next; or a youthward shift in the peak age of the mortality rate curves. The overdose epidemic emerged and increased in amplitude among the 1945-1964 cohort (Baby Boomers), shifted youthward among the 1965-1980 cohort (Generation X), and then resumed the pattern of increasing amplitude in the 1981-1990 Millennials. These shifting age and generational patterns are likely to be driven by socioeconomic factors and drug availability, the understanding of which is important for the development of effective overdose prevention measures.
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Kahn LS, Wozniak M, Vest BM, Moore C. “Narcan encounters:” overdose and naloxone rescue experiences among people who use opioids. Subst Abus 2020; 43:113-126. [DOI: 10.1080/08897077.2020.1748165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Linda S. Kahn
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, New York, USA
| | - Monika Wozniak
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, New York, USA
| | - Bonnie M. Vest
- Primary Care Research Institute, Department of Family Medicine, University at Buffalo, New York, USA
| | - Cheryll Moore
- Erie County Department of Health, University at Buffalo, Buffalo, New York, USA
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Ataiants J, Roth AM, Mazzella S, Lankenau SE. Circumstances of overdose among street-involved, opioid-injecting women: Drug, set, and setting. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102691. [PMID: 32086154 PMCID: PMC7302961 DOI: 10.1016/j.drugpo.2020.102691] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Current discourses about the causes of the overdose crisis largely focus on the harmful effects of drugs. Prior research, however, indicates that drug use experience is shaped by complex interactions of drugs with physiological and mental "sets" of people who use drugs and the wider social and physical "setting." Zinberg's "drug, set, and setting" theoretical framework was applied to identify patterns in circumstances leading up to women's overdose. METHODS In-depth semi-structured interviews were conducted with 29 opioid-injecting street-involved women, clients of a Philadelphia harm reduction program. Qualitative analysis with deductive and inductive coding was utilized to examine transcripts for theory-driven and emerging themes. RESULTS Ten out of 29 women attributed their overdose to "drugs," reporting the unpredictable quality of street opioids, concurrent use of benzodiazepines, or chasing the "high." Thirteen women reported "set" as a type of circumstance where their emotional states were affected by a "good" or "bad" day, leading them to unusual drug consumption practices. Six women described "setting" type of circumstances where their overdose was preceded by a recent change in context, such as release from prison, which prompted unsafe drug use to address physiological or psychological dependence on drugs. CONCLUSION While all overdoses result from the pharmacological action of drugs, some overdoses were triggered by circumstances occurring in women's set or setting. Overdose prevention policies should embrace not only individual-level behavioral interventions, but also structural measures to address stress, social isolation, and risky drug use contexts that plague the lives of street-involved women who inject opioids.
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Affiliation(s)
- Janna Ataiants
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market St, Philadelphia, PA 19104, USA.
| | - Alexis M Roth
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market St, Philadelphia, PA 19104, USA
| | - Silvana Mazzella
- Prevention Point Philadelphia, 2913 Kensington Ave, Philadelphia, PA 19134, USA
| | - Stephen E Lankenau
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market St, Philadelphia, PA 19104, USA
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Carroll JJ, Rich JD, Green TC. The protective effect of trusted dealers against opioid overdose in the U.S. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102695. [PMID: 32143185 DOI: 10.1016/j.drugpo.2020.102695] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/22/2020] [Accepted: 01/29/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioid overdose has become the leading cause of death among adults between 25 and 54 years old in the U.S. The purpose of this study is to explore the social and relational factors that shape the current opioid overdose epidemic. METHODS Between January 2016 and February 2017, adults in Providence, Rhode Island, who use opioids were recruited to complete structured survey and semi-structured interview about the social context of their substance use. RESULTS A total of 92 individuals completed a survey and an interview. Of those, 51 individuals (68.6% male, 49.0% white) discussed their relationships with drug suppliers in their interview and were included in this sub-study. Many of these participants indicated that long-term relationships with trusted dealers represent a key strategy for reducing the risk of substance use-related harm due to suppliers' alleged adoption of consumer protection strategies (e.g. refusing to sell fentanyl) and quality assurance measures (e.g. testing batches of drugs for fentanyl prior to sale). CONCLUSION Interpersonal relationships between individuals who use drugs and their suppliers strongly influence the risk and protective factors experienced by people who use drugs in today's opioid overdose epidemic. Evidence-based prevention strategies that are based on an awareness of-or even designed to harness-those positive and/or protective relationships that people who use drugs have already constructed for themselves are likely merited.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology & Anthropology, Elon University, 100 Campus Dr. 2035 Campus Box, Elon, NC 27244, USA; The Warren Alpert School of Medicine of Brown University, 222 Richmond St, Providence, RI 02903, USA.
| | - Josiah D Rich
- The Warren Alpert School of Medicine of Brown University, 222 Richmond St, Providence, RI 02903, USA; Division of Infectious Diseases, The Miriam Hospital, 164 Summit Ave. Providence, RI 02906, United States; Center for Prisoner Health and Human Rights, The Miriam Hospital, 8 Third St. Second Floor, Providence, RI 02906, USA
| | - Traci C Green
- The Warren Alpert School of Medicine of Brown University, 222 Richmond St, Providence, RI 02903, USA; Department of Emergency Medicine, Boston University School of Medicine, 771 Albany St, Room 1208, Boston, MA 02118, USA
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Estimating the impact of drug use on US mortality, 1999-2016. PLoS One 2020; 15:e0226732. [PMID: 31940370 PMCID: PMC6961845 DOI: 10.1371/journal.pone.0226732] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/04/2019] [Indexed: 01/07/2023] Open
Abstract
The impact of rising drug use on US mortality may extend beyond deaths coded as drug-related to include excess mortality from other causes affected by drug use. Here, we estimate the full extent of drug-associated mortality. We use annual death rates for 1999–2016 by state, sex, five-year age group, and cause of death to model the relationship between drug-coded mortality—which serves as an indicator of the population-level prevalence of drug use—and mortality from other causes. Among residents aged 15–64 living in the 50 US states, the estimated number of drug-associated deaths in 2016 (141,695) was 2.2 times the number of drug-coded deaths (63,000). Adverse trends since 2010 in midlife mortality are largely attributable to drug-associated mortality. In the absence of drug use, we estimate that the probability of dying between ages 15 and 65 would have continued to decline after 2010 among men (to 15% in 2016) and would have remained at a low level (10%) among women. Our results suggest that an additional 3.9% of men and 1.8% of women died between ages 15 and 65 in 2016 because of drug use. In terms of life expectancy beyond age 15, we estimate that drug use cost men 1.4 years and women 0.7 years, on average. In the hardest-hit state (West Virginia), drug use cost men 3.6 and women 1.9 life years. Recent declines in US life expectancy have been blamed largely on the drug epidemic. Consistent with that inference, our results imply that, in the absence of drug use, life expectancy at age 15 would have increased slightly between 2014 and 2016. Drug-associated mortality in the US is roughly double that implied by drug-coded deaths alone. The drug epidemic is exacting a heavy cost to American lives, not only from overdoses but from a variety of causes.
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Changes in mental health, pain, and drug misuse since the mid-1990s: Is there a link? Soc Sci Med 2020; 246:112789. [PMID: 31978637 DOI: 10.1016/j.socscimed.2020.112789] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/26/2019] [Accepted: 01/04/2020] [Indexed: 11/21/2022]
Abstract
Drug-related mortality in the US grew dramatically in recent years, while mental health deteriorated among disadvantaged Americans and reported levels of pain increased over the same period. Here we investigate whether increased prevalence of drug misuse between the mid-1990s and early-2010s is associated with higher levels of mental distress and pain. Our results demonstrate higher drug misuse over this period, particularly for older and for socioeconomically disadvantaged Americans. After adjusting for sociodemographic characteristics, we estimate that the prevalence of drug misuse increased by 19 percentage points among those aged 50-76 in the bottom percentile of socioeconomic status (SES). Misuse increased much more at older than at younger ages for all drug types except sedatives, which increased to a similar degree in both age groups. Compared with measures of mental health, pain consistently accounted for a greater share of the period differential in drug misuse among both age groups and across all drug types. Misuse of prescription painkillers exhibited the largest difference in the contributions of pain versus mental health: among older individuals with the lowest SES, pain explained three times as much of the period trend as mental health (60% vs. 19%). Pain was more closely linked with the rise in misuse of prescription painkillers than other drugs. Mental health is a strong correlate of drug misuse (particularly sedative use), but growing drug misuse since the mid-1990s was more strongly linked with rising levels of reported pain than with deterioration in mental health. Pain could be a key factor underlying the association between trends in mental health and drug use: higher levels of pain may contribute to both mental distress and drug misuse. Given that pain, mental distress, and drug misuse are intertwined, successful intervention may require addressing all three factors.
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Silverstein SM, Daniulaityte R, Martins SS, Miller SC, Carlson RG. "Everything is not right anymore": Buprenorphine experiences in an era of illicit fentanyl. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:76-83. [PMID: 31563098 PMCID: PMC6914257 DOI: 10.1016/j.drugpo.2019.09.003] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/04/2019] [Accepted: 09/12/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Conducted in the Dayton Metropolitan area of Southwestern Ohio, this qualitative study explores the self-treatment practices of people who use illicit opioids (PWUIO) amidst the new risk environment produced by illicit, non-pharmaceutical fentanyl (NPF). We explore local perceptions of the presence of NPF in the Dayton area, and how this has both positively and negatively impacted practices of non-prescribed buprenorphine use among PWUIO. METHODS This study analyzes qualitative data from 63 interviews conducted between October 2018 and June 2019. Participants were selected from a larger longitudinal study on non-prescribed buprenorphine use among individuals with opioid use disorder. Qualitative interviews were transcribed in their entirety, and their transcriptions were analyzed using NVivo software, drawing on a mix of thematic and inductive coding. RESULTS Interview respondents ranged from 19 to 70 years old, with a mean age of 38.9 years. 54% of them were male, and 85.7% identified as non-Hispanic White. 98.4% of the sample had used heroin, and 93.7% of the sample reported use of NPF. Participants agreed NPF dominated the illicit opioids market in the area, and was perceived as both dangerous and desirable. The domination of NPF and associated overdose experiences prompted some to seek positive change and initiate self-treatment with non-prescribed buprenorphine. For others, NPF sabotaged established practices of harm reduction, as unanticipated experiences of precipitated withdrawals prompted some participants to give up non-prescribed buprenorphine use as a tactic of self-treatment. DISCUSSION The changing nature of heroin/NPF necessarily gives rise to new beliefs surrounding self-treatment attempts, treatment seeking behaviors, and harm reduction practices. While buprenorphine treatment continues to offer promising results for treating opioid use disorders, it is urgent to reconsider how the unpredictable biochemical mixture of NPFs circulating on the streets today may impact the initiation and success of treatment.
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Affiliation(s)
- Sydney M Silverstein
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3171 Research Blvd, Kettering, OH, United States.
| | - Raminta Daniulaityte
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3171 Research Blvd, Kettering, OH, United States.
| | - Silvia S Martins
- Columbia University Mailman School of Public Health, 722 West 168th Street 5th Floor Room 509, New York, NY, United States.
| | - Shannon C Miller
- Dayton VA Medical Center/Middletown CBOC, Mental Health Service, 4337 Union Road, Middletown, OH 45005, United States; Departments of Psychiatry & Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3171 Research Blvd, Kettering, OH, United States.
| | - Robert G Carlson
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, 3171 Research Blvd, Kettering, OH, United States.
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Martins SS, Ponicki W, Smith N, Rivera-Aguirre A, Davis CS, Fink DS, Castillo-Carniglia A, Henry SG, Marshall BDL, Gruenewald P, Cerdá M. Prescription drug monitoring programs operational characteristics and fatal heroin poisoning. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:174-180. [PMID: 31627159 PMCID: PMC6897357 DOI: 10.1016/j.drugpo.2019.10.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016. METHODS Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death. RESULTS After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98). CONCLUSION There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.
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Affiliation(s)
- Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States.
| | - William Ponicki
- Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, CA, United States
| | - Nathan Smith
- Violence Prevention Research Program, Department of Emergency Medicine, UC Davis School of Medicine, CA, United States
| | - Ariadne Rivera-Aguirre
- Violence Prevention Research Program, Department of Emergency Medicine, UC Davis School of Medicine, CA, United States; Department of Population Health, NYU School of Medicine, New York, NY, United States
| | - Corey S Davis
- Network for Public Health Law, Los Angeles, CA, United States
| | - David S Fink
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | | | - Stephen G Henry
- Department of Internal Medicine, University of California Davis, Sacramento, CA, United States
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
| | - Paul Gruenewald
- Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, CA, United States
| | - Magdalena Cerdá
- Department of Population Health, NYU School of Medicine, New York, NY, United States
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Preference for drugs containing fentanyl from a cross-sectional survey of people who use illicit opioids in three United States cities. Drug Alcohol Depend 2019; 204:107547. [PMID: 31536877 DOI: 10.1016/j.drugalcdep.2019.107547] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/13/2019] [Accepted: 07/14/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Death from fentanyl-related overdose is now a leading cause of mortality among US adults. We sought to characterize fentanyl preference among street-based people who use drugs (PWUD). METHODS Cross-sectional surveys were administered to PWUD (N = 308) who illicitly used heroin or prescription opioids in the prior six months. Recruitment occurred in 2017 in three US east coast cities with high overdose mortality: Baltimore, Boston, and Providence. Our main outcome was preference for fentanyl (yes/no); exposures included sociodemographics, drug use, and overdose history. Pearson's χ2, Shapiro-Wilk-Mann rank-sum tests, and tiered log-binomial regression determined sociodemographic and exposure-related factors associated with fentanyl preference. RESULTS Preference for nonmedical use of fentanyl was reported by 27% (n = 83) of the sample. Fentanyl preference was associated with non-Hispanic white race (adjusted risk ratio (ARR) = 1.68, 95% confidence interval (CI):1.18-2.40), daily illicit drug use (aRR = 2.2, CI:1.71-2.87), and overdose ≥1 year ago (aRR = 1.33, CI:1.18-1.50). Age (in decades; aRR = 0.77, CI:0.61-0.98) and overdose <1 year ago (aRR = 0.92, CI:0.87-0.97) were associated with a decreased likelihood of preference. In our model excluding sociodemographics, initiating opioid use with non-prescribed opioids was associated with fentanyl preference (aRR = 1.48, CI:1.26-1.73). CONCLUSION In three cities with high levels of opioid use and overdose, a quarter of street based PWUD reported preferring fentanyl. An opioid use age cohort effect and disproportionate access to prescription opioids by race could be contributing to preference. Frequency of opioid use, not route of administration, was associated with preference. Our data demonstrate the need to consider preferences for fentanyl when targeting services and interventions for PWUD.
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Compton WM, Jones CM. Epidemiology of the U.S. opioid crisis: the importance of the vector. Ann N Y Acad Sci 2019; 1451:130-143. [PMID: 31378974 DOI: 10.1111/nyas.14209] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/05/2019] [Accepted: 07/17/2019] [Indexed: 12/26/2022]
Abstract
The roots of the remarkably lethal U.S. opioid crisis are complex and inextricably entangled with healthcare, especially in its treatment of another serious health problem: pain. Failures of the healthcare system-including lack of both training in pain management and caution in using an addictive class of medications-precipitated the rise in opioid misuse and addiction over the past two decades, but a wider range of social and economic forces has helped perpetuate the crisis and altered its character. The classic epidemiologic host-agent-environment triad can be augmented for the purpose of elucidating the current opioid crisis by addition of the "vector" to emphasize the importance of purveyors of opioids (licit and illicit), leading to our proposing an expanded host-agent-vector-environment model. Interventions addressing multiple components are needed, including solutions that account for behaviors of all vectors associated with the crisis. For prescription opioids, the vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing, and dispensing opioid medications; for illicit opioids, they include drug manufacturing and distribution networks. Attending to the vectors of opioids, while simultaneously implementing a full range of public health, clinical, law enforcement, and other approaches to ending the opioid crisis, may help to improve public health outcomes.
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Affiliation(s)
- Wilson M Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Christopher M Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
Objectives: We evaluate the extent to which subjective and objective measures of economic distress account for differences in substance abuse between the mid-1990s and early-2010s. Methods: We use cross-sectional survey data for national samples of Americans aged 25-74 in 1995-96 (N = 3034) and 2011-14 (N = 2598). Using a logit model, we regress dichotomous indicators of drug and alcohol abuse on economic distress. Results: After adjusting for sociodemographic characteristics, the odds of drug abuse in the early-2010s among older individuals (aged 50+) were 2.9 times (95%CI 1.9-4.2) those of the mid-1990s, but there was no statistically significant period difference in drug abuse among younger individuals. Measures of model performance demonstrate that subjective measures of economic distress are better predictors of drug abuse than objective measures. The subjective measures also account for a larger share (26%) of the increase in drug abuse at ages 50+ than the objective measures (6%). We cannot draw clear conclusions regarding alcohol abuse because results are sensitive to specification. Conclusions: The rise in drug abuse among midlife Americans may relate to perceived economic distress that is not captured by standard economic measures.
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Affiliation(s)
- Dana A Glei
- Senior Research Investigator, Georgetown University, Center for Population and Health, Washington, DC;,
| | - Maxine Weinstein
- Distinguished Professor, Georgetown University, Center for Population and Health, Washington, DC
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Mars SG, Rosenblum D, Ciccarone D. Illicit fentanyls in the opioid street market: desired or imposed? Addiction 2019; 114:774-780. [PMID: 30512204 PMCID: PMC6548693 DOI: 10.1111/add.14474] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/25/2018] [Accepted: 10/08/2018] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Sarah G. Mars
- Department of Family and Community Medicine, University of California San Francisco, CA, USA
| | - Daniel Rosenblum
- Department of Economics, Dalhousie University, Halifax, NS, Canada
| | - Daniel Ciccarone
- Department of Family and Community Medicine, University of California San Francisco, CA, USA
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Stoicea N, Costa A, Periel L, Uribe A, Weaver T, Bergese SD. Current perspectives on the opioid crisis in the US healthcare system: A comprehensive literature review. Medicine (Baltimore) 2019; 98:e15425. [PMID: 31096439 PMCID: PMC6531094 DOI: 10.1097/md.0000000000015425] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The administration of opioids has been used for centuries as a viable option for pain management. When administered at appropriate doses, opioids prove effective not only at eliminating pain but further preventing its recurrence in long-term recovery scenarios. Physicians have complied with the appropriate management of acute and chronic pain; however, this short or long-term opioid exposure provides opportunities for long-term opioid misuse and abuse, leading to addiction of patients who receive an opioid prescription and/or diversion of this pain medication to other people without prescription. Several reviews attempted to summarize the epidemiology and management of opioid misuse, this integrative review seeks to summarize the current literature related with responsible parties of this opioid abuse crisis and discuss potential associations between demographics (ethnicity, culture, gender, religion) and opioid accessibility, abuse and overdose. METHODS We performed an extensive literature search in Google Scholar and Pub Med databases that were published between December 7, 1999 and January 9, 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and meta-Analysis (PRISMA) guidelines. Searches were referenced using medical subject headings (MeSH) that included "opioids", "over-prescription", "opioid consumption", or "opioid epidemic". The final review of all data bases was conducted on July 24, 2018. RESULTS A total of 7160 articles were originally identified. After 3340 duplicate articles were removed, 3820 manuscripts were removed after title and abstract screening. Following this, 120 manuscripts underwent eligibility selection with only 70 publications being selected as reliable full-texts addressing related factors surrounding the opioid crisis. CONCLUSION With approximately 100 million people suffering from both chronic and acute pain in the United States (US) in 2016, opiates will continue to remain a prominent class of medication in healthcare facilities and homes across the US. Over 66% of total overdose episodes in 2016 were opioid-related, a figure that attests to the severity and wide-spread nature of this issue. A three-point approach accentuating the prevention, treatment, and rehabilitation of both those currently affected and at-risk in the future may be the comprehensive solution.
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Affiliation(s)
| | | | | | | | - Tristan Weaver
- Department of Anesthesiology
- Department of Anesthesiology, Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
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Abstract
In 2014, Russian authorities in occupied Crimea shut down all medication-assisted treatment (MAT) programs for patients with opioid use disorder. These closures dramatically enacted a new political order. As the sovereign occupiers in Crimea advanced new constellations of citizenship and statehood, so the very concept of "right to health" was re-tooled. Social imaginations of drug use helped single out MAT patients as a population whose "right to health," protected by the state, would be artificially restricted. Here, I argue that such acts of medical disenfranchisement should be understood as contemporary acts of statecraft.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, Elon University , Elon , North Carolina , USA
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Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science 2018. [PMID: 30237320 DOI: 10.1126/science.aaull84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Better understanding of the dynamics of the current U.S. overdose epidemic may aid in the development of more effective prevention and control strategies. We analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death. By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process. The 38+ year smooth exponential curve of total U.S. annual accidental drug poisoning deaths is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.
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Affiliation(s)
- Hawre Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeanine M Buchanich
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark S Roberts
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren C Balmert
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Preventive Medicine (Biostatistics), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kun Zhang
- Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Donald S Burke
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science 2018; 361:eaau1184. [PMID: 30237320 PMCID: PMC8025225 DOI: 10.1126/science.aau1184] [Citation(s) in RCA: 334] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/09/2018] [Indexed: 12/17/2022]
Abstract
Better understanding of the dynamics of the current U.S. overdose epidemic may aid in the development of more effective prevention and control strategies. We analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death. By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process. The 38+ year smooth exponential curve of total U.S. annual accidental drug poisoning deaths is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.
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Affiliation(s)
- Hawre Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeanine M Buchanich
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark S Roberts
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren C Balmert
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Preventive Medicine (Biostatistics), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kun Zhang
- Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Donald S Burke
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Habecker P, Welch-Lazoritz M, Dombrowski K. Rural and Urban Differences in Nebraskans’ Access to Marijuana, Methamphetamine, Heroin, and Prescription Pills. JOURNAL OF DRUG ISSUES 2018. [DOI: 10.1177/0022042618786717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ability of a user to access a given type of drug is related to the configuration of the market for that drug, and a range of economic and criminal justice concerns. This study focuses on Nebraskan’s “ready access” to four types of drugs (marijuana, methamphetamine, heroin, and prescription pills) in 2016, using a statewide survey of housed Nebraskan adults. Ready access is defined as a participant knowing at least one person from whom they could obtain a given type of drug if they wanted to. We found that 35% of adult Nebraskans knew at least one person from whom they could obtain marijuana, 8.9% for methamphetamine, 4.5% for heroin, and 17.8% knew at least one source for prescription pills. Relationships between knowing a source for each type of drug and rurality, sex, race, religious attendance, mental health symptoms, and education are explored.
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Wilson‐Poe AR, Morón JA. The dynamic interaction between pain and opioid misuse. Br J Pharmacol 2018; 175:2770-2777. [PMID: 28602044 PMCID: PMC6016619 DOI: 10.1111/bph.13873] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/21/2017] [Accepted: 05/09/2017] [Indexed: 12/22/2022] Open
Abstract
In 2014, drug overdose surpassed automobile accidents as the number one cause of accidental death for the first time in the history of the United States. The overdose epidemic is largely driven by opioids, and genuine prescription opioid analgesics play the biggest role in this phenomenon. Despite advancements in abuse deterrent formulations, prescription drug monitoring programmes and clinical assessments for the detection of abuse potential, drug overdoses continue to escalate. The Center for Disease Control has recently issued new guidelines for opioid prescription, yet even these recommendations have their shortcomings. Furthermore, undertreated pain in patients with comorbid substance use disorder poses a major clinical challenge, particularly for patients on opioid replacement therapy. Despite the seemingly obvious interaction between the presence of pain and the abuse of pain-relieving opioids, there is surprisingly little mechanistic data to further our understanding of this vitally important topic. The need for novel pain interventions that minimize abuse liability is critical. Without a fundamental characterization of pain neurobiology and the interaction between chronic pain and the brain's reward system, we are unlikely to make progress in the alleviation of the opioid epidemic. LINKED ARTICLES This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.
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Affiliation(s)
- Adrianne R Wilson‐Poe
- Pain Center, Department of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
| | - Jose A Morón
- Pain Center, Department of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
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Mars SG, Ondocsin J, Ciccarone D. Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore, MD. J Psychoactive Drugs 2017; 50:167-176. [PMID: 29211971 DOI: 10.1080/02791072.2017.1394508] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Since 2001, heroin-related overdose deaths in the United States have risen six-fold, a rise unaccounted for by the expanding user population. Has heroin become a more dangerous drug? Reports of fentanyl and its analogs, often concealed in or sold as heroin, have also increased sharply. This article investigates heroin injectors' perceptions and experiences of changes in the heroin supply in the East Coast city of Baltimore, Maryland, currently facing an epidemic in heroin- and fentanyl-related overdose deaths. Unusually, Baltimore's heroin market is divided between two types: "Raw," believed to be Colombian in origin and relatively pure, and the more adulterated "Scramble" (raw heroin traditionally blended with quinine and lactose). Users reported that Scramble heroin, while gaining market share, has become a highly unstable product, varying dramatically in appearance, intensity of onset, duration of action, and effect. Some considered that Scramble was no longer "heroin," but was heavily adulterated or even replaced, mentioning fentanyl, benzodiazepines, and crushed opioid pills as additives. There was intense awareness of overdose as a present danger in users' lives, which they linked to the recent adulteration of the heroin supply. Responses to this perceived adulteration varied, including information gathering, attraction, avoidance, taking precautions, and acceptance.
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Affiliation(s)
- Sarah G Mars
- a Qualitative Project Director, Heroin in Transition, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
| | - Jeff Ondocsin
- b Ethnographer, Heroin in Transition, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
| | - Daniel Ciccarone
- c Professor of Family and Community Medicine, Department of Family and Community Medicine , University of California , San Francisco , CA , USA
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Kazemi DM, Borsari B, Levine MJ, Dooley B. Systematic review of surveillance by social media platforms for illicit drug use. J Public Health (Oxf) 2017; 39:763-776. [PMID: 28334848 PMCID: PMC6092878 DOI: 10.1093/pubmed/fdx020] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 12/23/2016] [Indexed: 11/14/2022] Open
Abstract
Background The use of social media (SM) as a surveillance tool of global illicit drug use is limited. To address this limitation, a systematic review of literature focused on the ability of SM to better recognize illicit drug use trends was addressed. Methods A search was conducted in databases: PubMed, CINAHL via Ebsco, PsychINFO via Ebsco, Medline via Ebsco, ERIC, Cochrane Library, Science Direct, ABI/INFORM Complete and Communication and Mass Media Complete. Included studies were original research published in peer-reviewed journals between January 2005 and June 2015 that primarily focused on collecting data from SM platforms to track trends in illicit drug use. Excluded were studies focused on purchasing prescription drugs from illicit online pharmacies. Results Selected studies used a range of SM tools/applications, including message boards, Twitter and blog/forums/platform discussions. Limitations included relevance, a lack of standardized surveillance systems and a lack of efficient algorithms to isolate relevant items. Conclusion Illicit drug use is a worldwide problem, and the rise of global social networking sites has led to the evolution of a readily accessible surveillance tool. Systematic approaches need to be developed to efficiently extract and analyze illicit drug content from social networks to supplement effective prevention programs.
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Affiliation(s)
- Donna M Kazemi
- School of Nursing, College of Health and Human Services,University of North Carolina at Charlotte, 9201 University City Blvd., CHHS 444C, Charlotte, NC 28223, USA
| | - Brian Borsari
- Center for Alcohol and Addiction Studies, Brown School of Public Health, Department of Psychiatry, University of California, San Francisco, CA 94121, USA
| | - Maureen J Levine
- Department of Psychology, Central Michigan University, Mount Pleasant, MI 48859, USA
| | - Beau Dooley
- Center for Wellness Promotion, UNC Charlotte, Charlotte, NC, USA
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Ciccarone D, Ondocsin J, Mars SG. Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:146-155. [PMID: 28735775 PMCID: PMC5577861 DOI: 10.1016/j.drugpo.2017.06.004] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/01/2017] [Accepted: 06/12/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use. METHODS A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin. RESULTS (1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports. CONCLUSION Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.
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Affiliation(s)
- Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Ave., MU-3E, Box 900, San Francisco, CA 94143-0900, United States.
| | - Jeff Ondocsin
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Ave., MU-3E, Box 900, San Francisco, CA 94143-0900, United States
| | - Sarah G Mars
- Department of Family and Community Medicine, University of California, San Francisco, 500 Parnassus Ave., MU-3E, Box 900, San Francisco, CA 94143-0900, United States
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45
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Stein MD, Flori JN, Risi MM, Conti MT, Anderson BJ, Bailey GL. Overdose history is associated with postdetoxification treatment preference for persons with opioid use disorder. Subst Abus 2017; 38:389-393. [PMID: 28692407 DOI: 10.1080/08897077.2017.1353570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Without aftercare treatment, persons discharged from short-term inpatient detoxification for opioid use disorder are at high risk of relapse. In previous work, those who were recently homeless or had pending legal problems were more likely to prefer residential treatment for aftercare. Here, based on clinical experience, the authors hypothesize that a particular clinical factor, surviving an opioid overdose, will be associated with aftercare preference. METHODS Between May and December 2015, the authors surveyed consecutive persons seeking inpatient opioid detoxification. To assess aftercare treatment preference, participants were asked, "If you had unlimited treatment options and all were free, which one would work best for you when you leave here?" To assess overdose history, participants were asked about overdose "since your first drug use," and "in the last year." RESULTS Participants' (N = 440) mean age was 32.3 (± 8.7) years; 70.7% were male. More than half (51.1%) of participants expressed an aftercare preference for medication-assisted treatment (MAT), 12.7% for outpatient counseling only, 10.7% for residential treatment,18.6% for no formal treatment (Narcotics Anonymous/Alcoholics Anonymous only or a halfway house), and 6.8% did not want any postdetoxification treatment. About 40% reported a history of overdose, and 24.8% reported past year overdose. In the multivariate model, treatment preference was associated with sex (P < .001), homelessness (P = .01), and history of drug overdose (P = .02). CONCLUSIONS Although MAT was preferred by the majority of participants, the experience of a nonfatal overdose was associated with the choice of residential treatment as postdetoxification treatment.
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Affiliation(s)
- Michael D Stein
- a General Medicine Research Unit , Butler Hospital , Providence , Rhode Island , USA.,b Warren Alpert Medical School of Brown University , Providence , Rhode Island , USA
| | - Jessica N Flori
- a General Medicine Research Unit , Butler Hospital , Providence , Rhode Island , USA
| | - Megan M Risi
- a General Medicine Research Unit , Butler Hospital , Providence , Rhode Island , USA
| | - Micah T Conti
- a General Medicine Research Unit , Butler Hospital , Providence , Rhode Island , USA
| | - Bradley J Anderson
- a General Medicine Research Unit , Butler Hospital , Providence , Rhode Island , USA
| | - Genie L Bailey
- b Warren Alpert Medical School of Brown University , Providence , Rhode Island , USA.,c Stanley Street Treatment and Resources, Inc. , Fall River , Massachusetts , USA
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O'Halloran C, Cullen K, Njoroge J, Jessop L, Smith J, Hope V, Ncube F. The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:34-40. [PMID: 28586701 DOI: 10.1016/j.drugpo.2017.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/11/2017] [Accepted: 05/03/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Overdose is a major cause of death among PWID, and for opioid overdoses naloxone administration can reduce harm. However, globally there is limited national level data on the extent of non-fatal overdose and naloxone uptake. The first national level data on the extent of self-reported overdose and self-reported receipt of naloxone among UK PWID, providing a baseline to monitor the impact of the recent policy change regarding naloxone availability, is presented. METHODS Data on self-reported overdose and receipt of naloxone during the preceding year for 2013-2014 from a national survey of PWID was analysed. Participants who reported injecting during the preceding year were included. RESULTS Participants (3850) were predominantly male (75%); mean age was 36 years. The most commonly injected drugs were: heroin (91%), crack (45%) and amphetamine (29%). 15% (591) reported overdosing during the preceding year. There were no differences in the proportion reporting overdose by age or gender, but overdose was more common among those who: injected multiple drugs; recently ceased addiction treatment; injected with used needles/syringes; ever had transactional sex; had used a sexual health clinic or emergency department and lived in Wales or Northern Ireland. Among those reporting an overdose during the preceding year, a third reported two to four overdoses and 7.5% five or more overdoses; half reported receiving naloxone. Those reporting naloxone receipt in the preceding year were more likely to: live in Wales or Northern Ireland; ever received used needles/syringes; ever been imprisoned; and less likely to have injected two drug types. CONCLUSION These data provide a baseline for monitoring the impact of the 2015 UK policy change to improve take-home naloxone access. Interventions tackling overdose should promote naloxone awareness and access, and target those who; are poly-drug injectors, have ceased treatment, share needles/syringes and whose drug use links to sexual activity.
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Affiliation(s)
- Charlotte O'Halloran
- HIV & STI Department, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK.
| | - Katelyn Cullen
- HIV & STI Department, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Jaquelyn Njoroge
- HIV & STI Department, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Lucy Jessop
- Public Health Agency, Health Protection Service, 12-22 Linenhall Street, Belfast BT2 8BS, Northern Ireland, UK
| | - Josie Smith
- Public Health Wales, Temple of Peace & Health, Cathays Park, Cardiff CF10 3NW, UK
| | - Vivian Hope
- HIV & STI Department, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Fortune Ncube
- HIV & STI Department, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
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Suzuki J, El-Haddad S. A review: Fentanyl and non-pharmaceutical fentanyls. Drug Alcohol Depend 2017; 171:107-116. [PMID: 28068563 DOI: 10.1016/j.drugalcdep.2016.11.033] [Citation(s) in RCA: 249] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fentanyl and non-pharmaceutical fentanyls (NPFs) have been responsible for numerous outbreaks of overdoses all over the United States since the 1970s. However, there has been a growing concern in recent years that NPFs are contributing to an alarming rise in the number of opioid-related overdoses. METHODS The authors conducted a narrative review of the published and grey literature on fentanyl and NPFs in PubMed, Google Scholar, and Google using the following search terms: "fentanyl", "non-pharmaceutical fentanyl", "fentanyl analogs", "fentanyl laced heroin" and "fentanyl overdose". References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion. RESULTS The article reviews the emergence and misuse of fentanyl and NPFs, their clinical pharmacology, and the clinical management and prevention of fentanyl-related overdoses. CONCLUSIONS Fentanyl and NPFs may be contributing to the recent rise in overdose deaths in the United States. There is an urgent need to educate clinicians, researchers, and patients about this public health threat.
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Affiliation(s)
- Joji Suzuki
- Brigham and Women's Hospital, 60 Fenwood Rd., Boston, MA 02115, United States; Brigham and Women's Faulkner Hospital, 1153 Centre St., Boston, MA 02130, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States.
| | - Saria El-Haddad
- Brigham and Women's Hospital, 60 Fenwood Rd., Boston, MA 02115, United States; Brigham and Women's Faulkner Hospital, 1153 Centre St., Boston, MA 02130, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States
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Mars SG, Bourgois P, Karandinos G, Montero F, Ciccarone D. The Textures of Heroin: User Perspectives on "Black Tar" and Powder Heroin in Two U.S. Cities. J Psychoactive Drugs 2016; 48:270-8. [PMID: 27440088 DOI: 10.1080/02791072.2016.1207826] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Since the 1990s, U.S. heroin consumers have been divided from the full range of available products: east of the Mississippi River, Colombian-sourced powder heroin (PH) dominates the market while, to the west, Mexican-sourced "black tar" (BTH) is the main heroin available. By conducting qualitative research in two exemplar cities, Philadelphia (PH) and San Francisco (BTH), we compare users' experiences of heroin source-types, markets, health consequences, and consumption preferences. The strict division of heroin markets may be changing with novel forms of powder heroin appearing in San Francisco. Our researchers and interviewees perceived vein loss stemming from the injection of heroin alone to be a particular problem of BTH while, among the Philadelphia sample, those who avoided the temptations of nearby cocaine sales displayed healthier injecting sites and reported few vein problems. Abscesses were common across both sites, the Philadelphia sample generally blaming missing a vein when injecting cocaine and the San Francisco group finding several explanations, including the properties of BTH. Consumption preferences revealed a "connoisseurship of potency," with knowledge amassed and deployed to obtain the strongest heroin available. We discuss the reasons that their tastes take this narrow form and its relationship to the structural constraints of the heroin market.
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Affiliation(s)
- Sarah G Mars
- a Qualitative Project Director, Heroin in Transition, Department of Family and Community Medicine , University of California San Francisco , San Francisco , CA , USA
| | - Philippe Bourgois
- b Visiting Professor of Anthropology and Social Medicine, Director , Center for Social Medicine and Humanities and Semel Institute of Neuropsychiatry, Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles , Los Angeles , CA , USA
| | - George Karandinos
- c Paul and Daisy Soros New American Fellow , Harvard University , Boston , MA , USA
| | - Fernando Montero
- d Department of Anthropology , Columbia University , New York , NY , USA
| | - Daniel Ciccarone
- e Professor of Family and Community Medicine, Department of Family and Community Medicine , University of California San Francisco , San Francisco , CA , USA
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49
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Salani DA, Zdanowicz M, Joseph L. Heroin use. J Psychosoc Nurs Ment Health Serv 2016; 54:30-7. [DOI: 10.3928/02793695-20160518-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 04/04/2016] [Indexed: 11/20/2022]
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50
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Galanter M, Seppala M, Klein A. Medication-assisted treatment for opioid dependence in Twelve Step–oriented residential rehabilitation settings. Subst Abus 2016; 37:381-383. [DOI: 10.1080/08897077.2016.1187241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Marc Galanter
- Department of Psychiatry, New York University School of Medicine, New York, New York, USA
| | - Marvin Seppala
- Hazelden/Betty Ford Foundation, Center City, Minnesota, USA
| | - Audrey Klein
- Hazelden/Betty Ford Foundation, Center City, Minnesota, USA
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