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

Impact of Fentanyl Test Strips as Harm Reduction for Drug-Related Mortality

This study examines the impact of legalizing fentanyl test strips (FTSs) on drug-related mortality in the United States from 2018 to 2022. Using a difference-in-differences approach with state-level data, we find that FTS legalization is associated with a significant reduction in drug-overdose deaths. Across the population, FTS legalization corresponds to a 7% decrease in overdose mortality, with an even more pronounced 13.5% reduction among Black individuals. Our analysis employs two-way fixed effects models and triple differences specifications to isolate the effect of FTS legalization from other factors. The results suggest that FTS legalization is particularly effective in reducing unintentional drug-overdose deaths. These findings underscore the potential of FTS as a critical harm reduction tool in addressing the opioid crisis, especially in mitigating racial disparities in overdose mortality. The study provides evidence to support expanding access to FTS as part of comprehensive public health strategies.

Impact of recent stimulant use on treatment outcomes amongst individuals initiating medications for opioid use disorders: Secondary analysis of a multisite randomized controlled trial

Introduction

Illicit stimulant use among individuals initiating medication for opioid use disorder (MOUD) has significantly increased over the past decade. Co-use of these substances is associated with increased risk of mortality as well as worse treatment outcomes. This study examines the potential predictive role of stimulant urinalysis result at baseline on treatment retention and opioid and stimulant use outcomes amongst individuals initiating MOUD treatment.

Methods

This is a cross-sectional secondary analysis of data from a multi-site randomized clinical trial (CTN-0027). A total of 1269 individuals were randomized to receive 24 weeks of buprenorphine (n = 740) or methadone (n = 529) treatment across nine sites. Multiple linear and logistic regressions were conducted to determine the impact of baseline stimulant urinalysis results on treatment retention, and stimulant and opioid use outcomes.

Results

Individuals initiating MOUD with a stimulant negative urinalysis result at baseline submitted more negative stimulant (ꞵ=7.8; 95 % CI 6.8-8.7) and opioid (ꞵ=2.8; 95 % CI 1.8-3.8) urinalyses during treatment, were more likely to complete treatment (aOR=1.4; 95 % CI 1.1-1.7), and had better outcomes at six-month follow-up, measured as negative urinalysis for stimulant (aOR=5.3; 95 % CI 3.6-7.7), and opioid (aOR=1.8; 95 % CI 1.3-2.6).

Conclusion

Baseline stimulant use is associated with worse MOUD treatment outcomes, underscoring the need for novel integrated interventions designed to address opioid and stimulant co-use.

Monoamine receptors targeted by methamphetamine differentially modulate basal and fentanyl-depressed respiration in mice

RATIONALE

Fentanyl remains the primary cause of fatal overdoses, and its co-use with methamphetamine is a growing concern. Our lab previously demonstrated that racemic methamphetamine could have either respiratory stimulant or depressant effects depending on dose and separately determined by its enantiomers, dextromethamphetamine, and levomethamphetamine, respectively. Enantiomeric separation of methamphetamine's stimulant and depressant effects indicates that differences in their pharmacology might be exploited to develop novel respiratory stimulants. It is presently unknown which of methamphetamine's monoamine receptor mechanisms mediate these respiratory effects. Thus, systematic evaluation of monoamine receptor-selective agents may identify treatment targets for OIRD.

METHODS

Six selective agonists at monoamine receptors involved in methamphetamine's activity [phenylephrine (PNE; α1), clonidine (CLON; α2), SKF-82958 (SKF; D1), quinpirole (QPR; D2-like), 8-OH-DPAT (8-OH; 5HT1A), and DOI (5HT2)] were tested in adult male mice to determine their effects on basal and fentanyl-depressed minute volume (MVb; i.e., respiratory frequency x tidal volume) using whole-body plethysmography. Agonists were initially tested at three behaviorally active doses for their effects on basal MVb. Agonists that stimulated respiration or did not decrease respiration were then tested in combination with fentanyl.

RESULTS

The α1 and D1 agonists PNE and SKF dose-dependently increased basal MVb while the α2 and D2-like agonists CLON and QPR depressed basal MVb. Neither serotonin receptor agonist significantly altered basal MVb. Under fentanyl-depressed conditions, SKF produced transient but significant increases in MVb, while PNE more persistently elevated it. Interestingly, DOI transiently elevated depressed MVb, while 8-OH further exacerbated OIRD.

CONCLUSIONS

Selective activation of monoamine receptors alters basal respiration and OIRD, with D1 and α1 receptors representing potential targets as respiratory stimulants, whereas α2, D2-like, and 5HT1A receptors may mediate the exacerbation of OIRD by methamphetamine.

Psychostimulant and opioid abuse: A perspective from Uruguay

The number of people suffering from substance use disorder (SUD) worldwide has increased 45 % compared to the last decade according to the latest United Nations World Drug Report. This staggering increase, partly due to the recent COVID-19 pandemic, further raises the social and economic burden for nations. Prevention and treatment, two of the main strategies employed to curb the increase in SUD, have shown limited success despite our increasing understanding of the underlying processes of SUD. This review will focus on two main drug categories, psychostimulants, especially cocaine, and opioids since these are two of the most prevalent illicit drugs abused by the general public in low, middle, and high-income countries. The use of active adulterants (e.g. caffeine and illegally manufactured fentanyl, IMF) commonly employed in the preparation of illicit drugs will also be covered considering recent data which has shown that these adulterants may increase the health risk of psychostimulant and opioid users. Especially the high risk of the combined use of cocaine and IMF is detailed. An additional section will address drug abuse in women during pregnancy, as it constitutes a major public health concern due to the negative consequences on newborns and infants. Data from Uruguay is presented and compared to illegal drug use in other countries of South and North America. The rapidly changing drug market, together with the current prevalence of SUD, establishes the urgent need for new strategies and innovative treatments to manage this issue.

Evaluating the predictive performance of different data sources to forecast overdose deaths at the neighborhood level with machine learning in Rhode Island

OBJECTIVES

To evaluate the predictive performance of different data sources to forecast fatal overdose in Rhode Island neighborhoods, with the goal of providing a template for other jurisdictions interested in predictive analytics to direct overdose prevention resources.

METHODS

We evaluated seven combinations of data from six administrative data sources (American Community Survey (ACS) five-year estimates, built environment, emergency medical services non-fatal overdose response, prescription drug monitoring program, carceral release, and historical fatal overdose data). Fatal overdoses in Rhode Island census block groups (CBGs) were predicted using two machine learning approaches: linear regressions and random forests embedded in a nested cross-validation design. We evaluated performance using mean squared error and the percentage of statewide overdoses captured by CBGs forecast to be in top percentiles from 2019 to 2021.

RESULTS

Linear models trained on ACS data combined with one other data source performed well, and comparably to models trained on all available data. Those including emergency medical service, prescription drug monitoring program, or carceral release data with ACS data achieved a priori goals for percentage of statewide overdoses captured by CBGs prioritized by models on average.

CONCLUSIONS

Prioritizing neighborhoods for overdose prevention with forecasting is feasible using a simple-to-implement model trained on publicly available ACS data combined with only one other administrative data source in Rhode Island, offering a starting point for other jurisdictions.

Spatiotemporal analysis of substance use disorder mortality in the United States: an observational study of emerging hotspots and vulnerable populations (2005-2020)

Background

The escalating substance use disorder (SUD) crisis in the contiguous United States (US), with rising mortality since 1999, necessitates a spatiotemporal analysis to identify high-risk areas and vulnerable populations. This study examines the geospatial distribution and clustering patterns of SUD mortality, assessing disparities by race and urban-rural status.

Methods

We analyzed county-level ecological data on SUD-related deaths from the Centers for Disease Control and Prevention (CDC) from 2005 to 2020. Using spatial scan statistics, we identified significant clusters of elevated SUD mortality and assessed shifts over time. The analysis stratified results by race (White and Black subpopulations) and urban-rural classification to explore disparities.

Findings

Among 3142 U.S. counties, we identified 27 significant spatiotemporal clusters of elevated SUD mortality, primarily emerging post-2013 and persisting until 2020. The epidemic's epicenter shifted from the western to the eastern U.S. around 2016. Clusters in the White population (n = 26) had an estimated mortality rate of 28.42 per 100,000 person-years (95% confidence interval [CI]: 28.30-28.54), compared to 14.83 per 100,000 person-years (95% CI: 14.74-14.92) outside clusters. For the Black population (n = 17), the mortality rate was 33.16 per 100,000 person-years (95% CI: 32.80-33.51) within clusters, versus 13.36 per 100,000 person-years (95% CI: 13.14-13.59) outside. Clusters in the Black population emerged later, mostly after 2013, while White clusters followed a pattern similar to the general population. The urban SUD mortality rate was 1.30 per 10,000 per year, while the rural mortality rate was 1.03 per 10,000 per year. Within clusters, urban counties had a mortality rate of 1.61 per 10,000, compared to 0.97 per 10,000 outside. Rural counties had 1.43 per 10,000 in clusters, while non-clustered rural areas had 0.81 per 10,000.

Interpretation

The shifting geographic and racial patterns of SUD mortality underscore the need for targeted, region-specific interventions. The increasing impact on Black populations and urban centers in the East highlights the importance of equitable access to treatment and harm reduction services. Real-time surveillance and tailored urban-rural strategies are essential to mitigate the evolving crisis.

Funding

None.

Polysubstance Use Profiles Among the General Adult Population, United States, 2022

Objectives. To characterize present-day polysubstance use patterns in the general adult population. Methods. From a 2022 nationally representative survey in the United States, we defined polysubstance use as last 12-month use of 2 or more drugs (n = 15 800). Latent class analyses included medical (as indicated) and nonmedical (not as directed) use of prescription opioids, stimulants, benzodiazepines, and antidepressants; recreational use of cannabis, psilocybin or mushrooms, other psychedelics, cocaine, methamphetamine, and illicit opioids; and concomitant use with alcohol, cannabis, prescriptions, or recreational drugs. Results. The national prevalence of polysubstance use was 20.9% (95% confidence interval = 20.5%, 21.3%), broken down into the following 4 latent classes: (1) medically guided polysubstance use (11.5% prevalence, 6.1% substance use disorder [SUD]): prescribed drug use, some cannabis, and no concomitant use; (2) principal cannabis use variety (4.0% prevalence, 31.9% SUD): high probability of cannabis use with various drugs concomitantly used; (3) self-guided polysubstance use (3.4% prevalence, 14.5% SUD): nonmedical use of prescriptions and concomitant use; and (4) indiscriminate coexposures (2.1% prevalence, 58.9% SUD): concomitant drug use with indiscriminate drug preference. Conclusions. Different polysubstance profiles show adults with untreated SUDs, and there are 2 previously unrecognized classes. Prevention and treatment strategies addressing polysubstance use should take a personalized perspective and tailor to individuals' use profile. (Am J Public Health. 2025;115(5):747-757. https://doi.org/10.2105/AJPH.2024.307979).

A multi-method spatial examination of factors associated with changes in geographic accessibility to buprenorphine providers in HEALing communities study states Kentucky, Massachusetts, and Ohio

Objectives

Access to substance use treatment is critical to reduce the risk of opioid overdose. However, analyzing geographic accessibility using singular measures may provide imprecise estimates. Our objective was to examine changes in geographic accessibility to buprenorphine providers across three HEALing Communities Study (HCS) states, Kentucky, Massachusetts, and Ohio in the US, using multiple spatial analyses and determining whether disparities in access existed across geographic regions and sociodemographic indicators.

Methods

We used buprenorphine provider data from the Drug Enforcement Administration database in January 2020 (reference point) and June 2022. We used four methods to examine changes in geographic accessibility to buprenorphine: 1) kernel density analysis; 2) change in rates analysis (at the county or municipality level); 3) minkowski distance (drive-time to the nearest provider); 4) enhanced 2-step floating catchment area (E2SFCA) and spatial regression analyses, controlling for HCS communities (Wave 1 or Wave 2) and other sociodemographic factors.

Results

We identified an increase in geographic accessibility to buprenorphine across all three states. Improvements in accessibility were concentrated in areas that had higher reference point access. While our regression model of change in the E2SFCA accessibility index shows that Wave 1 communities in Kentucky had a higher increase in access compared to the state average increase, we were not able to establish consistent associations between HCS communities and changes in the E2SFCA index.

Conclusion

Since geographic accessibility to buprenorphine treatment is critical, additional efforts are needed to improve access to buprenorphine providers in rural areas and areas with limited baseline access.

Patterns of Drugs Involved in Fatal Overdose and Demographic Correlates: A Latent Class Analysis of Polysubstance-Involved Deaths in the Urban Midwest

BACKGROUND

Fentanyl contributes to the majority of overdose deaths in the United States but the risk of fatal overdose increases when other substances are involved. Although polysubstance overdose involving fentanyl and stimulants has been characterized as increasing nationally and in urban coastal cities, little is known about patterns of drugs involved in fatal overdose in the urban Midwest.

METHODS

The current study examined drug-involved death data from St. Louis City and County. Cases included were drug overdose deaths occurring from 2016 to 2021 (N = 4088; 73% male; 50% white, 49% black). Latent class analysis was used to examine prototypical patterns and demographic associations.

RESULTS

Results indicated fentanyl was involved in the majority (75.0%) of overdose deaths. A five-class solution best fit the data, characterized by deaths involving: predominant fentanyl (48.5%), fentanyl and heroin (20.0%), fentanyl and psychostimulants (12.8%), prescription opioid/undifferentiated (10.6%), and predominant cocaine (8.0%). Relative to predominant fentanyl, decedents in the fentanyl and heroin class and predominant cocaine class were more likely to be black (Ps < .05) whereas those in the fentanyl and methamphetamine class and prescription opioid/undifferentiated class were more likely to be white (Ps < .05). Females comprised a larger proportion of decedents in the fentanyl and heroin, predominant cocaine, and prescription opioid/undifferentiated classes (Ps < .05). Deaths in the predominant fentanyl class were more likely to occur in urban versus suburban environments (Ps < .05).

CONCLUSIONS

Findings diverge from previous research and national patterns highlighting the importance of local data for informing health care and policy in mid-sized and Midwest cities. Overdose prevention that addresses both intentional ingestion and unintentional ingestion of fentanyl with other substances, particularly stimulants, are warranted as its ubiquity in the drug supply persists.

"Everyone says 'safe sex' but no one ever says 'safe drugs', you know?": Perspectives on the intersection of drug checking services, drug policy and the overdose crisis

BACKGROUND

Overdose deaths have continued to rise in the US despite heightened public attention and resources. Drug checking shows promise for integration into existing services for people who use drugs (PWUD) across North America. Amidst the backdrop of rising overdose deaths and emerging funds for harm reduction initiatives, this manuscript explores the landscape of drug checking services in North America and perspectives on improved integration with a diverse set of PWUD based in San Francisco and North American drug checking experts.

METHODS

Two separate samples of drug checking stakeholders, 'providers' and 'clients' were recruited. Providers participated in in-depth semi-structured qualitative interviews over Zoom on their experiences advocating for and operating drug checking services in the US and Canada. Clients were people who used drugs and lived in or commuted to the San Francisco Bay Area and participated in semi-structured interviews in November 2022. Interviews were transcribed fully and analyzed using thematic analysis methods.

RESULTS

Providers and clients identified ongoing instability in the North American drug supply that is exacerbating overdose risk while also identifying groups that would benefit from greater access to drug checking services. Both groups believed the paradoxical impacts of the fentanyl crisis at the core of drug checking services created barriers to the implementation and expansion of these services, hurting PWUD and their providers. Additionally, clients and providers reflected on the social and policy challenges to expansion and improvement of drug checking in their communities.

CONCLUSION

Drug checking remains underleveraged, particularly with respect to the most vulnerable PWUD. Clients and providers contended that these services must become more responsive to an ever changing and dangerous drug supply in North America.

The impact of psychostimulant use on office based buprenorphine treatment retention

BACKGROUND

Over a million people have died from overdose since 1999, over 600,000. of which involved opioids. Treatment options that focus on overdose prevention are desperately needed and buprenorphine treatment is a form of opioid prevention if provided in a harm reduction setting. Co-morbid opioid and stimulant use disorders have increased at a higher rate than other co-morbid combinations between 2011 and 2019. The objective of this study was to identify the effects of psychostimulant use on buprenorphine treatment retention.

METHODS

We conducted an analysis of a cohort of 143 individuals with opioid use disorder that initiated treatment in a low-threshold, urban office based opioid treatment (OBOT) clinic located in Nashville Tennessee between 2018 and 2020. Retention was measured at 1, 3, and 6-months. Logistic regression was used to identify differences between people who tested positive for stimulants and people who did not.

RESULTS

The majority of the patients were white (83%), male (64%), unhoused (59%) and uninsured (70%). There was moderate psychostimulant use in the sample with 19% testing positive for cocaine and 13% testing positive for methamphetamine at baseline. Patients testing positive for cocaine prior to their six month retention point had 0.279 lower odds of being retained in treatment. Further, testing positive for either cocaine or methamphetamine resulted in 0.284 and 0.258 odds of retention at 3 and 6-months respectively.

CONCLUSION

This study examined the impact of stimulant use on retention in buprenorphine treatment within a low-threshold OBOT clinic. Our findings differ from previous research that reported significant decreases in retention among methamphetamine users. Instead, results suggest that patients using psychostimulants can be effectively retained in care within a low-resource, low-threshold setting, though increased clinical engagement may be beneficial for those testing positive for cocaine or methamphetamine. Given the limited access to buprenorphine treatment, these findings underscore the urgent need for expanded, accessible treatment models that can effectively serve individuals with co-occurring stimulant use.

Controlled Substance Prescribing Patterns Among Fatal Overdose Decedents with an Opioid, Stimulant, or Both Contributing to Death - Pennsylvania, 2017-2022

Psychostimulant (stimulant)-related overdose death rates have increased sharply in the United States since 2010, and in 2022, 32% of all U.S. overdose deaths involved stimulants. Data on deaths during 2017-2022 from CDC's State Unintentional Drug Overdose Reporting System were linked to 2014-2022 Pennsylvania Prescription Drug Monitoring Program data; the Pennsylvania Department of Health's Office of Drug Surveillance and Misuse Prevention analyzed controlled substance dispensation patterns during the 3 years preceding death among overdose decedents for whom opioids, stimulants, or both contributed to death; statistical analyses were performed on prescription drug dispensation patterns. Comparing overdose deaths in 2022 with those in 2017, deaths involving opioids without stimulants decreased from 2,974 to 1,995, deaths involving stimulants without opioids increased from 300 to 549, and deaths involving both opioids and stimulants increased from 1,703 to 2,346. Irrespective of whether an opioid, stimulant, or both contributed to death, decedents filled more opioid (67.7%, 74.1%, and 63.9%, respectively) than stimulant (10.6%, 11.6%, and 13.4%, respectively) prescriptions preceding death. A higher proportion of stimulant overdose decedents without an opioid contributing to death (74.1%) filled opioid prescriptions compared with decedents whose deaths involved opioids without stimulants or both opioids and stimulants (67.7% and 63.9%, respectively). Opioid prescribing, rather than stimulant prescribing, might be an important potential risk factor for stimulant-related overdose death.

Percentage of Opioid Tests Available in US Injury Death Investigations, 2021

This study uses 2021 data on the percentage of unavailable opioid tests in the US to examine how opioid involvement informs injury death investigations.

"You take care of people, people will take care of you": Moral Economies and an Unpredictable Drug Market

INTRODUCTION

Fentanyl is the leading cause of opioid-related overdose deaths in the United States. Given the exogenous market shock of fentanyl and subsequent transition in the illicit opioid supply, our analysis sought to explore the social and relational experiences of people who use opioids (PWUO).

METHODS

We conducted qualitative interviews with 30 PWUO (n = 30) in Los Angeles, CA from July 2021 to April 2022. To be eligible for this study, participants had to report being 18 years of age or older and any self-reported opioid, cannabis, and injection drug use within the past 30 days. We used constructivist grounded theory to analyze the contexts that contribute to lived experiences surrounding opioid use behaviors within social networks.

RESULTS

Within an unpredictable drug market contaminated by fentanyl, participants reported: 1) avoiding opioid withdrawal symptoms by sharing financial and material resources within social networks, 2) securing and cultivating known, predictable social ties to prioritize safe/ safer supply of opioids, and 3) avoiding and mitigating risk of overdose fatality by using opioids within peer groups.

CONCLUSIONS

Our findings emphasize that while peer support plays a critical role in safety within moral economies of PWUO, structural changes are needed to address the additional harms from an unregulated drug supply. Harm reduction interventions such as fentanyl test strip and naloxone distribution, as well as medication for opioid use disorders may improve safety. However, with a fentanyl-contaminated drug supply increasing risk for PWUO, safer opioid distribution of pharmaceutical-grade opioids and overdose prevention programs are needed to effectively address the burden of withdrawal, overdose, and fatality prevention within peer groups.

Drug Overdose Death among Residents of Urban Census Tracts: How Granular Geographical Analyses Uncover Socioenvironmental Correlates in Cuyahoga County, Ohio

Geostatistical data aggregated at state, county, municipality, or ZIP code levels often are utilized for assessing drug overdose epidemic impact and planning resource distribution. Data aggregated at these levels may obscure critical disparities among populations experiencing high rates of drug-related mortality (DRM), especially in densely populated urban areas. Our research was centered on Cuyahoga County (Cleveland), OH, which ranks 15th in the USA for drug-related mortality. This study built on recent efforts that adopted a finer geographical lens by examining DRM rates at the census tract level. Our investigation used Cuyahoga County census tracts with high and low DRM rates and compared them with Cuyahoga County census tracts with high and low levels of opportunity as developed by a publicly available, statewide opportunity index. Analyzing DRM data from 2014 to 2022, we found that the odds of an individual experiencing DRM in low-opportunity areas were quadruple the odds for someone in high-opportunity zones. Our findings highlight the critical need for more granular geographic analysis in urban areas, where heterogenous socioenvironmental conditions appear to correlate with significant heterogeneity in the ways in which residents experience the risk of dying from a drug overdose. By focusing on smaller areas, this approach provides a clearer understanding of the DRM landscape that could facilitate the prioritization of more targeted, culturally centered, public health interventions.

Explaining the high mortality among opioid-cocaine co-users compared to opioid-only users. A systematic review

RATIONALE

The opioid crisis in North America has recently seen a fourth wave, which is dominated by drug-related deaths due to the combined use of illicitly manufactured fentanyl [IMF] and stimulants such as cocaine and methamphetamine.

OBJECTIVES

A systematic review addressing the question why drug users combine opioids and stimulants and why the combination results in such a high overdose mortality: from specific and dangerous pharmacokinetic or pharmacodynamic interactions or from accidental poisoning?

RESULTS

Motives for the combined use include a more intensive high or rush when used at the same time, and some users have the unfounded and dangerous belief that co-use of stimulants will counteract opioid-induced respiratory depression. Overdose deaths due to combined (intravenous) use of opioids and stimulants are not likely to be caused by specific pharmacokinetic or pharmacodynamic interactions between the two drugs and it is unlikely that the main cause of overdose deaths is due to accidental poisoning.

CONCLUSION

The unexpectedly high overdose rates in this population could not be attributed to accidental overdosing or pharmacokinetic/pharmacodynamic interactions. The most likely explanation for the high rate of drug-related deaths in opioid-cocaine co-users is careless overdosing with either cocaine, opioid(s) or both, probably facilitated by the high level of preexisting impulsivity in these co-users and a further acute increase in impulsivity following cocaine use. The primary corollary is that cocaine users should avoid IMF use in the same time window. In addition, IMF users should refrain from cocaine use to avoid impulsive IMF overdosing.

Intersectional Racial and Sex Disparities in Unintentional Overdose Mortality

Importance

There are several apparent research gaps based on the intersectional sociodemographic dimensions of drug-related mortality disparities. Relatively marginal evidence exists on the potential roles of intersecting forms of race and sexual marginalization on the disparities across drug-related mortality.

Objective

To examine intersectional sex-specific White and Black racial disparities in drug poisoning mortality across states from 2010 to 2020.

Design, Setting, and Participants

This cross-sectional study used unintentional fatal drug poisoning mortality data from the Centers for Disease Control and Prevention's Web-Based Injury Statistics Query and Reporting System. Trends from 2010 through 2020 were analyzed by Black men, Black women, White men, and White women across states. One-sided Mann-Kendall trend analysis was used to examine statistically significant increasing or decreasing trends in age-adjusted mortality rates. Statistical analysis was performed from June to July 2024.

Exposures

White and Black groups intersecting with male and female sex.

Main Outcomes and Measures

Analysis of age-adjusted mortality rates, excess years of potential life lost (reference group: White men), years of potential life lost ratios (reference group: White men), and percentage change to highlight state differences.

Results

From a total sample of 518 724 unintentional fatal drug poisoning deaths (9.0% in Black men, 3.9% in Black women, 29.0% in White women, and 58.1% in White men), 11 820 781 years of potential life lost were recorded. Black men had the highest mean (SD) age-adjusted mortality rate (23.25 [22.65]), followed by White men (22.49 [14.32]), with lower rates for White women (11.71 [5.96]) and Black women (9.01 [8.04]) (P < .001). Compared with White men, both Black men (τ = 0.298, slope = 0.002, intercept = 0.381, P < .001) and Black women (τ = 0.157, slope = 0.0004, intercept = 0.271, P < .001) had worsening YPLL over time, while White women (τ = -0.146, slope = -0.0003, intercept = 0.5252, P < .001) showed improvement in their YPLL over time compared with White men. At the state level, there was a disproportionate burden of deaths due to drug poisonings, with Maryland showing the highest increase in mortality rates among Black men (485.4%), while decreases were observed for White women in states such as Alaska (-23.0%).

Conclusions and Relevance

In this cross-sectional study of overdose deaths, disparities in overdose mortality were evident, with Black men and Black women experiencing a pronounced and increasing burden of mortality compared with their White counterparts. Addressing these disparities will require a multipronged approach targeting the social, physical, economic, and policy risk environments.

Patterns of polydrug use among Black Americans who misuse opioids

In the United States, opioid-related deaths involving polydrug use are now more prevalent than those involving only opioids. What often goes unnoticed is that deaths involving more than one substance are increasing more rapidly among Black Americans than Whites. Unfortunately, little research attention is paid to understanding opioid-related polydrug use patterns among Black Americans. As a result, less is known regarding which drug combinations are most common among this population and their reasons for co-using certain drugs. Therefore, the objective of this mixed methods study was to identify which substances were most commonly co-used with opioids among Black Americans, while also capturing their motives for combining opioids with other drugs. This study used data from the Florida Minority Health Study, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of Black Americans who misuse opioids. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. Analyses revealed that opioids were most commonly combined with alcohol, cocaine, and methamphetamine, respectively. Opioids were co-used with alcohol in an attempt to enhance the desired effect (i.e., intoxication), while stimulants and opioids were combined to counteract the undesirable side effects of the other. This study begins to answer the question of which/why substances are combined with opioids among Black Americans and should inform behavioral health interventions targeted at this population. Data on this topic are especially timely as the United States goes through the current fourth wave of the opioid crisis that is characterized by deaths due to polydrug use. These findings invite further study using nationally representative data to determine the extent to which polydrug using patterns differ across racial/ethnic groups.

Prevalence of adults with stimulant misuse and/or stimulant use disorder in Massachusetts, USA, 2014-2021

BACKGROUND AND AIMS

Stimulant-involved overdose deaths are increasing throughout the United States. Because stimulant misuse (i.e. taking a prescribed medicine not as directed) and stimulant use disorder contribute to the surging number of stimulant-related deaths, knowing the prevalence of stimulant misuse and use disorder is important. We aimed to estimate the prevalence of stimulant misuse and/or use disorder in Massachusetts from 2014 to 2021.

DESIGN, SETTING AND PARTICIPANTS

This was a cohort study using a multiple systems estimation approach (previously known as 'capture-recapture'), using multiple individually linked epidemiological data sources, located in the Commonwealth of Massachusetts, 2014-2021. People aged 18-64 years from administrative databases were linked at the individual level and included in the analysis.

MEASUREMENTS

Measurements included known and estimated counts of people with stimulant misuse and/or use disorder (as defined in each individual database) as well as total count and prevalence in Massachusetts. We performed both a stratified analysis using log-linear models to estimate the unknown population with stimulant misuse/use disorder and a single model analysis in which demographics were used as covariates. Uncertainty is characterized using 95% confidence intervals (95% CI) on the total counts and prevalence estimates.

FINDINGS

The number of known individuals increased during the study period from 31 037 in 2014 to 42 612 in 2021. Using the multiple systems estimation approach, the estimated prevalence of underlying stimulant misuse and/or use disorder population ranged from 4.1 to 7.1% during the study period in the stratified analysis and 4.2 to 6.8% in the single model. By race, the highest prevalence estimates were among the Black non-Hispanic population, which showed a prevalence of up to 14.5% (95% CI = 14.32%, 14.57%) in 2021.

CONCLUSIONS

The estimated prevalence of stimulant misuse and/or use disorder in Massachusetts from 2014 to 2021 ranged from 4% to nearly 7% of the population. People from racial minorities appear to be disproportionately affected compared with the white non-Hispanic population. The unknown population accounted for large proportions of the total estimated population.

Exploring Xylazine Awareness, Health Impacts, and Harm Reduction Strategies: Findings From a Multimethods Study in Lowell, Massachusetts

BACKGROUND

Xylazine, an adulterant in local drug supplies, has been detected in approximately 30% of opioid samples submitted for testing in Massachusetts. A better understanding of local risks, harms, and use preferences is needed to combat xylazine-related impacts on local communities.

METHODS

Through the STOP-OD Lowell study, we aimed to assess local xylazine awareness through in-depth interviews with local community stakeholders (n = 15) and local people who use drugs (PWUD; n = 15) and surveys with local PWUD (n = 94). The qualitative interviews focused on the current drug landscape and knowledge of adulterants in Lowell, and the results informed subsequent survey design. Through our survey, we examined whether PWUD were aware of xylazine and their willingness to use xylazine test strips.

RESULTS

Most community stakeholders and PWUD had limited awareness about the presence and impact of xylazine as an adulterant. Forty-seven (50%) survey respondents were aware of xylazine. When provided with more information about xylazine, 65% of all respondents expressed a willingness to use xylazine test strips. PWUD who had received naloxone training, reported using with others, and using tester shots were more willing to use xylazine test strips.

CONCLUSION

Our findings are congruent with existing literature that indicates that there is limited awareness of xylazine among PWUD, and they consider xylazine an unwanted adulterant. We also found that PWUD who use other harm reduction measures are more willing to use xylazine test strips. The increase in xylazine warrants additional community-level interventions such as wound management and local testing infrastructure. Further research is needed to understand better the impacts associated with xylazine use, effective harm reduction techniques, and perceptions of xylazine test strips.

Naloxone distribution amidst shifting drug use patterns: Insights from a needs-based syringe services program

OBJECTIVE

In the context of rising overdose deaths among people smoking opioids and stimulants nationally, we aimed to evaluate naloxone distribution within a needs-based syringe services program in Southern California.

METHODS

Using service delivery data spanning January-June 2024, we examined the distribution of pipes for safer smoking, sterile syringes, and naloxone. Modified Poisson regression estimated prevalence ratios (PRs) of encounters involving pipes only, syringes only, pipes and syringes together, and neither pipes nor syringes, and whether these encounters included naloxone. Negative binomial regression examined relationships between supplies acquired by participants and the number of overdoses to which they responded with naloxone in the past 14 days.

RESULTS

Among 1260 service delivery encounters, 50 % involved pipes only, 33 % involved pipes/syringes distributed together, 11 % involved syringes only and 7 % involved neither pipes nor syringes. Overall, nearly half (44 %) of encounters included naloxone. Compared to encounters involving pipe-only distribution, encounters involving syringe-only distribution (PR=1.41; 95 % confidence interval [CI]: 1.12, 1.78), combined pipe/syringe distribution (PR=1.90; 95 % CI: 1.64, 2.20), and neither (PR=2.39; 95 % CI: 1.92, 2.99) were more likely to include naloxone. There was no significant relationship between supply type and the 14-day rate of overdose responses involving naloxone.

CONCLUSION

Harm reduction service delivery encounters involving pipe-only distribution were less likely to involve naloxone than other types of encounters in this setting. To curb overdose deaths in communities shifting from injecting to smoking unregulated substances, specific strategies may be needed to promote naloxone uptake.

Connecticut Pediatric Opioid Poisoning Trends Surrounding the COVID-19 Pandemic

OBJECTIVE

Opioids are common substances involved in poisonings with increasing rates in fentanyl-related mortality since 2014. The COVID-19 pandemic compromised school attendance and supervision, which may have increased the risk of opioid ingestions in children. Our objective was to evaluate pediatric opioid poisonings in Connecticut before and during the COVID-19 pandemic.

METHODS

This cross-sectional retrospective study used emergency department (ED) discharges involving children aged 0-17 years captured in the Connecticut Injury Surveillance System. International Classification of Diseases, 10th Revision, Clinical Modification codes were used to identify discharges involving opioids (T40.0-T40.4, T40.60, T40.69, F11). The χ 2 test was used to identify differences by pre-COVID (2017-2019) and COVID (2020-2022) periods. Rates were examined by age, sex, race/ethnicity, insurance, and discharge status.

RESULTS

There were 1,386,796 ED discharges during the study period. Less than 1% involved opioid (N = 257) or fentanyl (N = 31) poisonings; no discharges were coded for both. The rate of opioid poisonings decreased 28.6%, from 2.1 to 1.5 per 10,000 ED visits. Subanalysis showed that the rate of fentanyl poisonings remained the same (0.2 per 10,000 ED visits). The rate of opioid poisonings was highest among non-Hispanic White children during both periods. However, there was a 57.7% increase in the rate of opioid poisonings in non-Hispanic Black children. The rate decreased for all other race/ethnic groups.

CONCLUSIONS

Results of our study showed a rise in opioid poisonings among non-Hispanic Black and elementary school-aged children during the COVID-19 pandemic. Future prevention efforts may choose to further investigate and understand the trends in the more vulnerable groups.

Ecological momentary assessment study of same-hour polysubstance use among people who use opioids and additional substances

BACKGROUND

Polysubstance use is a defining feature of the opioid overdose epidemic in the United States today. Most quantitative studies of polysubstance use rely on 30-day retrospective measures. Understanding how drugs are co-used in shorter (daily and hourly) timeframes enhances our understanding of polysubstance-related overdose risk.

METHODS

We used ecological momentary assessment (EMA) to assess polysubstance in community-based sample of people who use drugs in Oakland, CA (N = 117). Participants provided data on substance use three times daily over 28 days, using a smartphone app. We created binary variables of same-day and same-hour polysubstance use and estimated its prevalence with mixed-effects logistic regression models.

RESULTS

The response rate to thrice-daily prompts was 64.6 %. The prevalence of same-day polysubstance use on any given day was 0.77 (95 % CI 0.73, 0.82), and the prevalence of same-hour polysubstance use was 0.71 (95 % CI 0.66, 0.76). Defined as the combination of opioids with stimulants, opioids with alcohol, opioids with benzodiazepines, or more than one opioid in the same hour, the probability of risky polysubstance use on a given day was 0.59 (95 % CI 0.52, 0.65). Excluding methadone from a treatment program, the probability of risky polysubstance use on a given day was 0.51 (95 % CI 0.44, 0.58).

CONCLUSIONS

Our findings highlight the importance of targeted prevention efforts addressing the diverse substance combinations that increase overdose risk. It is crucial to develop and test substance use treatment and overdose prevention strategies that address the complexities of polysubstance use, in partnership with people who use drugs.

Introduction to the special issue on legislative-driven responses to the opioid crisis: Expanding research and implementation through federal and state funding

This special issue focuses on legislative-driven responses to the opioid crisis in the United States, emphasizing the expansion of research and implementation through federal and state funding. Since 2017, federal, state, and local initiatives have allocated billions of dollars to combat the opioid epidemic. This issue comprises 10 articles that collectively demonstrate the critical role of federal and state funding in enhancing opioid-related prevention, treatment, and recovery services. They also bring to light ongoing challenges such as funding sustainability and equitable service access that can guide future funding initiatives.

The Fourth Wave of the Opioid Epidemic: Increasing Combination of Fentanyl With Stimulants

Objectives. To identify drug prevalence through the analysis of drug material and paraphernalia (DMP) collected from scenes of fentanyl-involved fatal accidental drug overdoses in San Francisco, California, throughout 2022. Methods. We conducted gas chromatography-mass spectrometry testing on 409 items of DMP (e.g., glass pipes, syringes, aluminum foil, powders) from 137 cases, and we further tested 132 DMP items using liquid chromatography-tandem mass spectrometry in context with decedent information and toxicology findings. Results. We detected fentanyl in 106 cases (77%); 35 (33%) contained fentanyl either alone or with fentanyl precursors or breakdown products. Of the 106 fentanyl-positive cases, we codetected cocaine in 29 (27%) and methamphetamine in 16 (15%). Overall, we detected methamphetamine in 58 (42%) cases (25 in isolation), cocaine in 68 (50%) cases (18 in isolation), and fentanyl analogs in 33 (24%) cases (4 in isolation). We detected 38 novel fentanyl analogs and precursors of analogs. Conclusions. We observed fentanyl use in combination with stimulants (a characteristic pattern of the opioid epidemic fourth wave). Smoking fentanyl powder using aluminum foil or snorting were the most inferred. We established polysubstance use and emerging potent novel fentanyl analogs use. (Am J Public Health. 2025;115(4):555-565. https://doi.org/10.2105/AJPH.2024.307948).

Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S

INTRODUCTION

People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD.

METHODS

From 01/2018-03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]).

RESULTS

The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66-14.2 and RR = 5.09, CI = 2.79-9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06-2.35 and RR = 1.85, CI = 1.38-2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68-7.47 and RR = 2.63, CI = 1.81-3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23-1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23-1.69), and experiencing an overdose (RR = 1.32, CI = 1.12-1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050).

CONCLUSIONS

Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

When Public Will Meets Legislative Resistance: Five Lessons from Ohio's Issue 2 Cannabis Legalization Controversy

In this paper, I explore the challenges of legalizing cannabis in Ohio, focusing on the passing of the Issue 2 Bill, legislative resistance, and public response. I propose five strategies for effective policy change: persistent advocacy post policy change success, establishing strong coalitions, empowering grassroots movements, promoting rigorous data-driven research, and launching public education campaigns. I offer a detailed analysis of the interaction between public opinion and legislative action in cannabis legalization and its implications for substance-related policy change.

Co-occurring illicit fentanyl use and psychiatric disorders in emergency department patients

This paper sought to describe the characteristics of emergency department (ED) patients with illicit fentanyl use and concurrent psychiatric disorders, as studies within this population of patients is limited. ED patients with a fentanyl-positive urine drug screen were identified, and patient characteristics, medical histories, and test results were extracted. Among the fentanyl positive drug screens of ED patients, the majority were between the ages of 25 and 44, male, white, and uninsured. Additionally, more than one third of these patients had concurrent psychiatric disorders with mood disorders being the most prevalent, followed by psychotic disorders. Patients with co-occurring psychiatric disorders were found to have higher rates of marijuana use, repeat ED visits and/or hospital admissions at six months, and more admissions to psychiatry inpatient settings compared to those patients without co-occurring psychiatric disorders. Concurrent other substance use and rates of buprenorphine prescribing at discharge were not different between the groups; however, rates of naloxone provision at discharge were lower in patients with co-occurring psychiatric disorders. This cohort demonstrates higher healthcare recidivism and utilization.

Opioid overdoses following use of cocaine and methamphetamine in New South Wales, and the public health responses

OBJECTIVE

Recent years have seen sporadic reports in Australia of stimulants being contaminated with opioids. Since late 2023, there has been an increase in opioid overdoses among individuals in New South Wales (NSW) using substances believed to be cocaine or methamphetamine. We analysed the frequency and characteristics of these cases and describe our public health responses.

METHODS

The Prescription, Recreational & Illicit Substance Evaluation (PRISE), operated by NSW health since July 2018, is a statewide surveillance, epidemiology, and toxicity response programme. We did a retrospective analysis of each case of opioid toxicity following use of cocaine or methamphetamine submitted to the PRISE programme from January 2022 to June 2024, categorising cases into confirmed, probable, and suspected.

RESULTS

Thirty-four cases were found, 19 involving cocaine and 15 involving methamphetamine. Twenty-two (65%) were classified as confirmed, and 12 (35%) as probable. There were two deaths (6%). Twenty-three cases (68%) were in Sydney. Multiple stakeholders reviewed trends and formulated public health responses, leading to the distribution of public drug warnings and media releases in November 2023 and February 2024 because of ongoing case detections.

CONCLUSIONS

The increase in detections, which continued in the months following the public health responses, underscores the need for comprehensive surveillance, response, monitoring, and reporting of this phenomenon in NSW. Engagement with clinicians and the community is essential for the success of this programme.

A cryptic pocket in CB1 drives peripheral and functional selectivity

The current opioid overdose epidemic highlights the urgent need to develop safer and more effective treatments for chronic pain1. Cannabinoid receptor type 1 (CB1) is a promising non-opioid target for pain relief, but its clinical use has been limited by centrally mediated psychoactivity and tolerance. We overcame both issues by designing peripherally restricted CB1 agonists that minimize arrestin recruitment. We achieved these goals by computationally designing positively charged derivatives of the potent CB1 agonist MDMB-Fubinaca2. We designed these ligands to occupy a cryptic pocket identified through molecular dynamics simulations-an extended binding pocket that opens rarely and leads to the conserved signalling residue D2.50 (ref. 3). We used structure determination, pharmacological assays and molecular dynamics simulations to verify the binding modes of these ligands and to determine the molecular mechanism by which they achieve this dampening of arrestin recruitment. Our lead ligand, VIP36, is highly peripherally restricted and demonstrates notable efficacy in three mouse pain models, with 100-fold dose separation between analgesic efficacy and centrally mediated side effects. VIP36 exerts analgesic efficacy through peripheral CB1 receptors and shows limited analgesic tolerance. These results show how targeting a cryptic pocket in a G-protein-coupled receptor can lead to enhanced peripheral selectivity, biased signalling, desired in vivo pharmacology and reduced adverse effects. This has substantial implications for chronic pain treatment but could also revolutionize the design of drugs targeting other G-protein-coupled receptors.

Not just fentanyl: Understanding the complexities of the unregulated opioid supply through results from a drug checking service in British Columbia, Canada

INTRODUCTION

This study examines illicit opioid samples submitted to a drug checking service in British Columbia, Canada. By employing a method capable of identifying and quantifying compounds at low concentrations, the analysis focused on identifying trends in notable compounds such as fentanyl, its analogues, and benzodiazepines. The findings aim to address gaps in supply monitoring and inform public health and drug policies.

METHODS

Opioid samples were collected and analyzed over three years using fentanyl and benzodiazepine test strips, Fourier-transform infrared (FTIR) spectroscopy and Paper-Spray Mass Spectrometry (PS-MS). PS-MS was employed to conduct trace-level analysis, provide targeted composition results, and quantify notable ingredients within the samples. The concentrations of fentanyl and benzodiazepines, among other components, were examined.

RESULTS

The dataset includes 8122 opioid samples analyzed from January 2021 to December 2023. Analysis revealed that heroin was replaced by fentanyl and its analogues in the opioid supply, as heroin was detected in only 4 % of opioid samples while fentanyl and analogues were detected in 88 %. Fluorofentanyl was found in 70 % of opioid samples, occasionally in combination with fentanyl. Benzodiazepines and their analogues were detected in 49 % of opioid samples, with a notable shift from etizolam to bromazolam. The median fentanyl concentration was 10.6 % (weight/weight), ranging from less than 0.1 % to over 80 %. The median bromazolam concentration was 3.2 %, with a range of less than 0.1 % to over 25 %.

CONCLUSION

The study highlights the volatility in the supply and mentions the necessity for a safer opioid supply and robust drug checking methodologies to address the challenges posed by the heterogenous market.

Implementation determinants of safer smoking supplies in U.S. syringe services programs

BACKGROUND

The prevalence of smoking opioids and other unregulated drugs has increased across the United States (U.S.) since 2000. Improved access to safer smoking supplies may reduce the health consequences of inhalation while helping to engage more people who use drugs in syringe services programs (SSPs); however, the landscape of safer smoking supply implementation is understudied.

METHODS

From November 2023-January 2024, we surveyed representatives of U.S. SSPs to assess safer smoking supply implementation across contextual domains of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Descriptive statistics were used to describe determinants across the phases of safer smoking supply implementation. Poisson regression identified factors associated with implementation.

RESULTS

Among 118 organizations responding to the survey, most received state funding (83%), were community-based organizations (CBOs; 74%), and served urban jurisdictions (62%). The majority (67%) were already providing safer smoking supplies; 16% were exploring implementation and 11% were not. On average, safer smoking supply implementation occurred more recently than the provision of syringes (1-2 years ago vs. > 5 years ago), with participant request being the most common motivation for implementation (84%). Additional facilitators of safer smoking supply implementation were organizational prioritization (65%) and internal leadership support (57%). Factors significantly associated with safer smoking supply implementation included being from the Northeastern or Western regions (vs. the U.S. South), serving exurban communities, being a CBO, receiving foundation funding, receiving private donations from fundraising, and offering syringes and other injection alternatives (e.g., safer snorting supplies). Receiving federal funding, fear of external community opposition, internal leadership opposition, and respondent uncertainty about changing demand for safer smoking supplies (vs. perceiving that demand has not changed) were negatively associated with implementation.

CONCLUSIONS

Determinants in the inner context, like organizational prioritization of safer smoking supplies and internal leadership support, may facilitate safer smoking supply implementation, while specific outer context factors (e.g., funding, regional policies) may inhibit implementation. Flexible policies and funding structures and further research to build and disseminate evidence on the benefits of safer smoking supplies are needed to expand the implementation and scale-up of this prevention service within U.S. SSPs.

"A safe place to use": People who use drugs' perceptions and preferences prior to the implementation of Rhode Island's first overdose prevention center

INTRODUCTION

In July 2021, Rhode Island became the first state in the United States (US) to legalize overdose prevention centers (OPCs). To inform the design and implementation of an OPC in Providence, Rhode Island's capital, we explored perceptions of OPCs and programmatic needs among people who use drugs.

METHODS

The study conducted in-depth qualitative interviews from December 2023 to March 2024 with 25 people who use drugs. Thematic analysis explored OPC implementation considerations, with a focus on perceived social and structural barriers and facilitators for use. The study shared findings iteratively with the future OPC's operating organization.

RESULTS

Overall, participants were aware of plans to open an OPC locally and were largely supportive. Participant narratives underscored social, spatial, and programmatic needs to facilitate OPC accessibility and uptake, including the site's hours of operation, environment, and ancillary services provided. Participants further underscored concerns and considerations that would affect their willingness to use the site, including police presence, preferred substances and use modalities, use routines, and housing status. These considerations and concerns were grounded in participants' own social locations and levels of structural vulnerability.

CONCLUSION

Our findings underscore the need for inclusive services that ensure the OPC's accessibility and uptake as a safer environment for a variety of key populations.

What does a dollar mean to you? utilizing intrinsic rewards within contingency management

Substance Use Disorders (SUDs) pose a significant public health challenge. Medications used for treatment of SUDs are limited in their efficacy, particularly in cannabis and stimulant use disorders, and non-pharmacological interventions have shown, at most, moderate effectiveness, leaving a continuing need for improved treatments. Contingency management (CM) is an evidence-based treatment with promising results, operationalized in SUD treatment programs by using monetary rewards to help patients achieve target behaviors such as abstinence. Several factors limit the viability of CM as a sustainable, effective treatment, suggesting insufficiency of monetary reinforcement alone. Implementation can be costly, requiring increased monetary reinforcers over time to reach target behaviors, and effects do not endure. We propose an integrative model of CM that explicitly incorporates intrinsic rewards into CM to enhance its effectiveness. This model involves redirecting salience attribution of monetary rewards towards goals and activities that are personally relevant and motivating for the individual that do not involve substance use. This integrative model of CM may address current challenges of and some of the barriers to implementation of CM in clinical practice.

Developing predictive models for µ opioid receptor binding using machine learning and deep learning techniques

Opioids exert their analgesic effect by binding to the µ opioid receptor (MOR), which initiates a downstream signaling pathway, eventually inhibiting pain transmission in the spinal cord. However, current opioids are addictive, often leading to overdose contributing to the opioid crisis in the United States. Therefore, understanding the structure-activity relationship between MOR and its ligands is essential for predicting MOR binding of chemicals, which could assist in the development of non-addictive or less-addictive opioid analgesics. This study aimed to develop machine learning and deep learning models for predicting MOR binding activity of chemicals. Chemicals with MOR binding activity data were first curated from public databases and the literature. Molecular descriptors of the curated chemicals were calculated using software Mold2. The chemicals were then split into training and external validation datasets. Random forest, k-nearest neighbors, support vector machine, multi-layer perceptron, and long short-term memory models were developed and evaluated using 5-fold cross-validations and external validations, resulting in Matthews correlation coefficients of 0.528-0.654 and 0.408, respectively. Furthermore, prediction confidence and applicability domain analyses highlighted their importance to the models' applicability. Our results suggest that the developed models could be useful for identifying MOR binders, potentially aiding in the development of non-addictive or less-addictive drugs targeting MOR.

Public Understanding and Perception of Harm Reduction and Prevention Messaging About Fentanyl Overdoses

BACKGROUND

Fentanyl-related opioid fatalities have risen drastically in the United States, indicating a "new wave" of the opioid crisis and highlighting the urgent need for more effective public health interventions to address its harms. Despite an increasing number of public communication campaigns focused on the general public, evidence on how people perceive fentanyl-related harm reduction strategies and prevention messaging is still nascent.

METHODS

We conducted a cross-sectional survey with a national sample (N = 1,044). Fentanyl-related information seeking, risk perception, and message perception were measured. Specifically, message perception was compared between three harm reduction strategies-carrying naloxone, using fentanyl test strips, and never using drugs alone and between two prevention message taglines-One Pill Kills and One Pill Can Kill.

RESULTS

Respondents preferred healthcare providers and the Internet as sources if they would seek information about fentanyl. Risk perception of fentanyl was high; however, there is room to improve public awareness of naloxone as an opioid antagonist. Respondents' perception was most favorable for the message about carrying naloxone, followed by the message about using fentanyl test strips, and finally, the message about never using drugs alone. Also, One Pill Can Kill was associated with a higher level of perceived effectiveness than One Pill Kills.

CONCLUSIONS

Findings indicate that harm reduction and prevention messages hold the potential to be effective in reducing the harmful consequences of fentanyl overdoses. Future research should examine whether favorable message perceptions can translate into actual effectiveness and behavioral changes, which could have implications for the development of public health interventions.

Lessons from the National institutes of health innovation corps program: defining barriers to developing and commercializing novel solutions for persons with opioid use disorder

BACKGROUND

Translating innovative research advancements into commercially viable medical interventions presents well-known challenges. However, there is limited understanding of how specific patient, clinical, social, and legal complexities have further complicated and delayed the development of new and effective interventions for Opioid Use Disorder (OUD). We present the following case studies to provide introductory clinical, social, and business insights for researchers, medical professionals, and entrepreneurs who are considering or are currently developing medical.

METHODS

Four small business recipients of National Institute on Drug Abuse (NIDA) small business grant funding collected a total of 416 customer discovery interviews during the 2021 National Institutes of Health (NIH) Innovation-Corps (I-Corps) program. Each business received funding to advance an OUD-specific innovation: therapeutics (2 companies), medical device (1 company), and Software as a Medical Device (SaMD) (1 company). Interview participants included stakeholders from a variety of disciplines of Substance Use Disorders (SUD) healthcare including clinicians, first responders, policymakers, relevant manufacturers, business partners, advocacy groups, regulatory agencies, and insurance companies.

RESULTS

Agnostic to the type of product (therapeutic, device, or SaMD), several shared barriers were identified: (1) There is a lack of standardization across medical providers for managing patients with OUD, resulting in diverse implementation practices due to a fragmented healthcare policy; (2) Underlying Social Determinants of Health (SDOH) present unique challenges to medical care and contribute to poor outcomes in OUD; (3) Stigma thwarts adoption, implementation, and the development of innovative solutions; (4) Constantly evolving public health trends and legal policies impact development and access to OUD interventions.

CONCLUSION

It is critical for innovators to have early interactions with the full range of OUD stakeholders to identify and quantify true unmet needs and to properly position development programs for commercial success. The NIH I-Corps program provides a framework to educate researchers to support their product design and development plans to increase the probability of a commercially successful outcome to address the ongoing opioid epidemic.

Beliefs of US chiefs of police about substance use disorder, fentanyl exposure, overdose response, and use of discretion: results from a national survey

BACKGROUND

To inform the feasibility and acceptability of evidence-informed police practices related to substance use, addiction, and overdose, we sought to better understand how US police chiefs perceive substance use and related policing practices.

METHODS

A national sample of randomly selected US police chiefs (N = 276) completed a 37-item survey about substance use and policing. Nine items assessed chiefs' perceptions of: officers' discretion in making arrests, effectiveness of overdose responses, risks of fentanyl exposure, de-escalation practices, harmful drugs in their community, and illicitly-obtained buprenorphine. Data were analyzed with descriptive statistics and exploratory ordinal logistic regressions.

RESULTS

Most chiefs (72.5%) agreed that arrest for any nonviolent misdemeanor was at the discretion of their officers, and they overwhelmingly (94.9%) trusted their officers to make the right arrest decision. The majority of chiefs (87.7%) felt their officers could effectively respond to an opioid overdose, and 83.7% reported their officers carried naloxone on patrol. Chiefs in the Northeast were significantly less likely to be confident in their officers' ability to respond to a methamphetamine overdose than chiefs in the West. Most (90.0%) were receptive to implementing methamphetamine de-escalation strategies (i.e., techniques to resolve crises short of force). Almost all chiefs (91.2%) agreed with the inaccurate statement that fentanyl exposure at a drug overdose scene could harm officers.

CONCLUSIONS

Police chiefs express interest in several types of evidence-based public health approaches to policing. Critically, there is a need to curtail fentanyl misinformation and to improve officer knowledge about medications for treating opioid use disorder.

Trends, characteristics, and circumstances surrounding stimulant toxicity deaths in Ontario, Canada from 2018 to 2021

INTRODUCTION

As the drug toxicity crisis continues to evolve globally, harms related to non-opioid substances, including stimulants, have risen in parallel. Our study aims were to describe trends in accidental stimulant toxicity deaths and to characterize demographic characteristics of decedents and the circumstances surrounding death.

METHODS

We conducted a population-based repeated cross-sectional study, of all accidental stimulant toxicity deaths between January 1, 2018, and December 31, 2021, in Ontario, Canada. We reported monthly rates of stimulant toxicity deaths per 100,000 people residing in Ontario and the circumstances surrounding death. All analyses were stratified by the type of stimulant(s) involved in death.

RESULTS

Between 2018 and 2021, we identified 5210 stimulant toxicity deaths with the monthly rate rising from 0.4 to 1.0 per 100,000. Both cocaine and methamphetamine were involved in 16.2 % of deaths, and 56.2 % and 27.7 % involved cocaine or methamphetamine (without other stimulants), respectively. Over 80 % of deaths also involved an opioid. Among all deaths, 75.2 % of decedents were male, 53.1 % were aged 25-44, and over half of all deaths occurred in private residences (64.7 %).

CONCLUSIONS

The rate of stimulant toxicity deaths has continued to grow, more than doubling over a three-year period. As stimulant-related deaths continue to rise, comprehensive social supports and mental health services, including harm reduction and treatment programs adapted to the unique needs of people who use stimulants alone or in combination with other substances, are urgently required to meet the changing needs of people who use drugs.

Receipt of medications for opioid use disorder among rural and urban veterans health administration patients

Aim

We examined differences in medications for opioid use disorder (MOUD) receipt between rural and urban veteran patients following initiatives within the US Department of Veterans Affairs (VA) to expand access to MOUD.

Methods

Data for this retrospective cohort study were obtained from the VA Corporate Data Warehouse, which contains national electronic health record data for all VA patients. The analytic sample included all patients diagnosed with OUD from 10/1/2018-9/30/20. Rurality was identified by the Rural Urban Commuting Area (RUCA) code of patients' home address. Associations between rurality and MOUD receipt, as well as type of MOUD received, were examined using logistic regression.

Results

Among 66,842 patients with OUD, 27.4 % were rural residents. Compared to urban patients, rural patients were slightly younger (50.1 vs. 52.5 years), more often white (87.7 % vs. 70.3 %) and less often received MOUD (42.6 % vs 45.5 %). Multivariable models confirmed that rural patients had a lower likelihood of accessing any form of MOUD (aOR= 0.84, 95 % CI: 0.81-0.87) relative to urban VA patients. Medication-specific analyses identified a lower likelihood of receiving methadone (aOR= 0.36, 95 % CI: 0.33-0.39) and naltrexone (aOR= 0.89, 95 % CI: 0.80-0.99) among rural patients, but higher likelihood of receiving buprenorphine (aOR= 1.05, 95 % CI: 1.01-1.09).

Conclusion

Rural VA patients have a lower likelihood of receiving methadone and naltrexone for OUD treatment relative to urban patients, but greater likelihood of receiving buprenorphine. Continued work is needed to ensure that rural Veterans have equitable access to the most appropriate medication for their health care needs.

Characteristics of supervised injection site clients and factors associated with requiring overdose intervention, Montreal, Canada, 2018-2022

BACKGROUND

Supervised injection sites (SIS) offer a hygienic environment in which people can inject drugs under observation; as such, these harm reduction services have been on the forefront of the overdose epidemic. We sought to understand factors predictive of an overdose requiring an emergency response intervention at SIS in Montréal, Canada.

METHODS

We used administrative data from all four Montréal SIS from 1 March 2018 - 31 October 2022 to first calculate the rate of onsite overdose requiring intervention (e.g., naloxone or oxygen administration, nurse or paramedic assessment, etc.) and descriptive statistics. We then used a logistic regression model, with generalized estimating equations to adjust for clients' repeat visits, to test associations between onsite overdose intervention and client gender, age, drug injected (fentanyl vs other opioid vs non-opioid), most frequent injection location, frequency of injecting, duration of injecting, housing stability, attendance at multiple SIS, and time period (before or after 15 March 2020).

RESULTS

During the observation period, Montréal SIS received 122,509 visits from 2,127 unique clients. The rate of overdose requiring intervention was 8.16 (95 % CI 7.66, 8.68) per 1000 visits. While 278 (13 %) of clients experienced an onsite overdose intervention, these clients accounted for 64,267 (52 %) SIS visits. Transgender clients (aOR = 2.28, 95 % CI 1.18, 4.41, compared to men) and clients younger than 25 were at greater risk of experiencing an onsite overdose requiring intervention (e.g., clients 35-44 had an aOR = 0.44, 95 % CI 0.30, 0.64, compared to clients younger than 25). Injecting most often in a public place was associated with greater risk of an onsite overdose requiring intervention (aOR = 3.62, 95 % CI 3.04, 4.30), while reporting unstable housing (aOR = 0.56, 95 % CI 0.47, 0.66) and attending more than one SIS (aOR = 0.13, 95 % CI 0.10, 0.16) predicted lesser risk. Compared to clients who reported injecting daily, greater risk of overdose requiring intervention was observed among those who reported injecting 3-6 days a week (aOR = 1.48, 95 % CI 1.18, 1.85), 1-2 days a week (aOR = 2.43, 95 % CI 1.90, 3.11), and "occasionally" (aOR = 2.60, 95 % CI 2.13, 3.18), but not those who reported not injecting in the past several months (aOR = 0.44, 95 % CI 0.25, 0.79). Compared to clients who had been injecting for five or more years, an injection duration of 1-4 years was associated with reduced risk of an overdose requiring intervention (aOR = 0.79, 95 % CI 0.64, 0.98), while those newer (<1 year) to injecting were at greater risk of such an intervention (aOR = 2.11, 95 % CI 1.50, 2.97). Compared to clients intending to inject fentanyl, we observed a lower risk of an overdose requiring intervention for those injecting other opioids (aOR = 0.22, 95 % CI 0.18, 0.26) or non-opioids (aOR = 0.06, 95 % CI 0.04, 0.08). Injecting after 15 March 2020 was also associated with greater risk (aOR = 1.99, 95 % CI 1.65, 2.41).

CONCLUSION

Across four Montréal SIS, site visits with an overdose requiring intervention were associated with transgender identity, younger age, stable housing, intending to inject fentanyl, injecting less frequently than daily, injecting for either more than five years or less than a year, single site attendance, and injecting most often in a public place. Montréal SIS serve a diverse clientele who inject drugs, with differing risks of onsite overdose.

Integrating Nursing Practice and Policy in Opioid Overdose Prevention: Analysis of the Opioid-Overdose Reduction Continuum of Care Approach Practice Guide

AIM

To present a comprehensive analysis of the Opioid-Overdose Reduction Continuum of Care Approach (ORCCA) Practice Guide 2023, evaluating its alignment with Russell and Fawcett's conceptual model of nursing and health policy and highlighting the implications for nursing practice and policy.

DESIGN

This paper employs a policy analysis framework to evaluate the ORCCA Practice Guide, using Russell and Fawcett's conceptual model as a lens to assess the policy's structure and implementation.

METHODS

The analysis is framed by Russell and Fawcett's conceptual model, focusing on the dimensions of efficacy, effectiveness, equity and justice. This framework assesses how well the ORCCA's strategies align with these dimensions in the context of nursing and health policy.

RESULTS

Key findings indicate that the ORCCA's strategies are integral to nursing practice, particularly in frontline interventions such as education, naloxone distribution and Medication for Opioid Use Disorder (MOUD) delivery. The integration of these strategies demonstrates a significant impact on the opioid crisis, enhancing the roles nurses play in opioid overdose prevention.

CONCLUSION

The ORCCA Practice Guide represents a multifaceted approach to addressing the opioid crisis, with strong alignment to the conceptual model used for analysis. It underscores the essential role of nurses in implementing and refining opioid overdose reduction strategies.

IMPLICATIONS

The study highlights the critical need for nursing involvement in policy formation and practice implementation, suggesting that nurses are key to advancing comprehensive opioid overdose prevention measures.

IMPACT

This study addresses the problem of opioid overdoses and the need for effective interventions. The main findings show the importance of nurse-driven strategies in opioid crisis management. The research impacts public health policy and practice, particularly influencing how nursing approaches are integrated into overall health strategies for overdose prevention.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, caregivers, or members of the public were involved in conducting this analysis.

Withdrawal Signs and Symptoms Among Patients Positive for Fentanyl With and Without Xylazine

BACKGROUND

Xylazine is not approved for human use, yet it has emerged as a common adulterant of illicit fentanyl. It is currently unclear whether there is a withdrawal syndrome associated with xylazine and the potential impact of fentanyl coexposure.

METHODS

A retrospective cohort study of patients with opioid use disorder admitted to an inpatient medically monitored withdrawal facility was performed. Patients positive for fentanyl were compared to patients copositive for fentanyl and xylazine. Outcomes were self-directed discharge and completion of treatment. Independent variables included Clinical Opioid Withdrawal Scale (COWS) scores, heart rate, and blood pressure. Associations between individuals with or without xylazine were measured.

RESULTS

Among 71 patients admitted for opioid withdrawal management positive for fentanyl, 51.4% were copositive with xylazine. There was no difference detected in average COWS scores ( P = 0.12-0.78) or average heart rate ( P = 0.33-0.80) between groups. Xylazine copositive patients had higher average systolic blood pressure on days 1 (129.0 vs 123.0, P = 0.01) and 2 (127.9 vs 116.3, P = 0.04) although unclear if clinically meaningful. Individuals copositive for xylazine were less likely to complete treatment (43.2% vs 55.9%, P = 0.23) and more likely to have self-directed discharge (67.6% vs 44.1%; OR, 2.64; 95% CI, 1.0-6.9) although not statistically significant.

CONCLUSIONS

Among 71 patients admitted for medically monitored withdrawal, individuals who were copositive for xylazine at the time of admission had higher average blood pressure and were more likely to have a self-directed discharge. Additional research is needed to determine the impact of xylazine on withdrawal.

Characterization of xylazine-related overdose deaths in Maryland (2020-2023)

BACKGROUND

Xylazine is a fentanyl contaminant which has been increasingly detected in drug overdose deaths in Maryland. This study explored risk factors and time trends of xylazine-related overdose deaths (XRODs) in Maryland from 2020 to 2023.

METHODS

This serial cross-sectional study utilized data from the Maryland Office of the Chief Medical Examiner on fentanyl overdose deaths that occurred from 2020 to 2023. XROD was defined as someone who died from overdose and had a positive postmortem blood xylazine test. Multivariable logistic regression modeled associations between demographic variables and presence of co-occurring substances with XROD. Annual population-based XROD rates were calculated for the overall sample and by race, age group, and sex.

RESULTS

There were 8721 fentanyl overdose deaths in Maryland between 2020 and 2023. Among these, 1798 (20.6 %) were XRODs. Annual XROD rates peaked in 2021 and have declined since then. Although Black Marylanders experienced the highest overall burden of overdose, xylazine was significantly more likely to contribute to fentanyl overdose deaths among White individuals compared to Black individuals (aOR 1.18) and those aged 31-40 years compared to those 60 or older (aOR 1.25). Morphine (aOR 1.36), methadone (aOR 1.41), benzodiazepines (aOR 1.20), and tramadol (aOR 2.12) were associated with higher odds of XROD.

CONCLUSIONS

XRODs are a major problem in Maryland, and there are significant differences in XROD mortality by race, age, and co-occurring substance use. Efforts to reduce xylazine-related mortality in Maryland should provide overdose prevention education and harm reduction services to the most vulnerable populations.

Predicting fatal opioid-involved overdoses: A social-ecological framework matched to a linked-data warehouse

BACKGROUND

An estimated 60 million people used opioids non-medically worldwide in 2021. In 2019, opioid use disorder caused the loss of over 12.5 million healthy years of life due to disability and premature deaths, including those resulting from opioid-involved overdoses. Factors associated with opioid-involved overdoses are numerous, multi-layered, and interrelated. Using the social-ecological model as a foundation, we sought to comprehensively identify risk and preventive factors of fatal opioid-involved overdoses and operationalize them with quantifiable measures.

METHODS

With our Community Advisory Board, investigators' expertise, and an examination of the literature, we created an expansive, opioid-overdose specific social-ecological model structured as a matrix, with demographic, behavioral, environmental, and service domains and individual, interpersonal, community, and society/policy levels of influence. Factors contributed by the advisory board included those from two freelisting instruments. We used the resultant freelists to calculate a salience index of factors as a reference for prioritization. We organized the compiled factors in the social-ecological model matrix according to their theorized distal-proximal relationship with fatal opioid-involved overdoses. We operationalized the social-ecological model factors by matching them against measures in the Massachusetts Public Health Data Warehouse, which includes 26 individually-linkable datasets and 19 community-level datasets drawn from 85 data components.

RESULTS

We identified 224 factors potentially associated with fatal opioid-involved overdoses and organized them in the social-ecological model. Of these, 53 had matches to measures in the Public Health Data Warehouse. Of those factors identified by freelisting, salience indexing further identified 10 as most related to the risk of fatal opioid-involved overdose, including housing stability, increased risk substances such as fentanyl, xylazine, and polysubstances, and using alone.

CONCLUSION

The opioid-overdose specific social-ecological model points to the need both for analysis that penetrates the complexities of the opioid crisis and for multi-faceted interventions. Further, the social-ecological model can provide a foundation for simulation models for prevention and intervention efforts. Our matrix-structured social-ecological model, salience index, and data matching table provide a holistic and relationship-oriented view of the factors associated with fatal opioid-involved overdose and will inform subsequent data analysis, model development, and opioid-involved overdose policy and prevention efforts.

Time-space characteristics of emergency medical service attendance and layperson naloxone administration during non-fatal opioid overdoses in Rhode Island: A retrospective, event-level analysis

PURPOSE

As the opioid overdose crisis worsens in the United States (U.S.), emerging scholarship has uncovered time-and-place variations in substance use and overdose response efforts in community settings. Building on this work, we characterized spatio-temporal attributes of naloxone administration during non-fatal opioid overdoses attended by laypersons and emergency medical services (EMS) over a three-year period.

METHODS

Leveraging EMS encounter data across Rhode Island between January 2020 and December 2022, we quantified hour-by-hour variations in EMS deployment locations for non-fatal opioid-involved overdoses among adults (aged 18 + years). We used multivariable Poisson regression with robust standard errors to identify spatio-temporal patterns in EMS-attended overdoses by location type and evidence of layperson naloxone administration during these events.

RESULTS

Of the 5377 EMS non-fatal opioid overdose encounters, most occurred in residential housing (61.1 %) and outdoor public spaces (19.3 %). We identified substantial time-space variations in non-fatal overdoses, with EMS deployments to residential housing clustering in non-daylight hours (5:00PM-8:59AM) and to outdoor public spaces in daylight hours (9:00AM-8:59PM). Documented naloxone intervention by laypersons prior to EMS arrival was uncommon (10.6 %) but was most pronounced in overdoses occurring in residential housing and the early afternoon (1:00PM-4:59PM).

CONCLUSIONS

Despite the clustering of non-fatal opioid overdoses in housing environments, we identified substantial within-location variations in overdose-related EMS encounters over time and place.

Development of a Definition to Identify Severe Opioid Overdoses Treated in Emergency Departments, 2019-2022

BACKGROUND

Existing surveillance systems monitor nonfatal and fatal opioid overdoses but do not monitor severe nonfatal overdoses that require intensive medical interventions.

METHODS

The Centers for Disease Control and Prevention's Drug Overdose Surveillance and Epidemiology system was used to query emergency department data from local syndromic systems and the National Syndromic Surveillance Program from January 2019 to August 2022. Opioid overdoses were classified as not severe or severe using a definition from the patient's chief complaint terms and discharge diagnosis codes. The percentage of opioid overdoses treated in emergency departments classified as severe was described by patient demographics, US Census region, and month.

RESULTS

Among 503 156 opioid overdoses in 29 states and Washington, DC, from January 2019 to August 2022, 17.4% were classified as severe. Common key terms found among severe opioid overdoses were hypoxia (34.8%), unresponsive (32.9%), and naloxone/Narcan (20.9%). The largest severity percentage was in the South Census region (19.6%). The trends of severe opioid overdoses remained stable during the study period.

DISCUSSION

Based on the severe opioid overdose definition, there was minimal change in the severity of opioid overdoses during the study period. This definition can help monitor trends of severe opioid overdoses, guiding public health action such as focusing on naloxone and fentanyl test strip distribution to areas of need.

State sequence analysis of daily methadone dispensing trajectories among individuals at United States opioid treatment programs before and following COVID-19 onset

BACKGROUND AND AIMS

US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates.

DESIGN

Retrospective chart review of electronic health records.

SETTINGS

Nine opioid treatment programs (OTPs) across nine US states.

PARTICIPANTS

Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376).

MEASUREMENTS

Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics.

FINDINGS

Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing.

CONCLUSION

Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

The development of opioid vaccines as a novel strategy for the treatment of opioid use disorder and overdose prevention

Opioid use disorder (OUD) affects over 40 million people worldwide, creating significant social and economic burdens. Medication for opioid use disorder (MOUD) is often considered the primary treatment approach for OUD. MOUD, including methadone, buprenorphine, and naltrexone, is effective for some, but its benefits may be limited by poor adherence to treatment recommendations. Immunopharmacotherapy offers an innovative approach by using vaccines to generate antibodies that neutralize opioids, blocking them from crossing the blood-brain barrier and reducing their psychoactive effects. To date, only 3 clinical trials for opioid vaccines have been published. While these studies demonstrated the potential of opioid vaccines for relapse prevention, there is currently no standardized protocol for evaluating their effectiveness. We have reviewed recent preclinical studies that demonstrated the efficacy of vaccines targeting opioids, including heroin, morphine, oxycodone, hydrocodone, and fentanyl. These studies showed that vaccines against opioids reduced drug reinforcement, decreased opioid-induced antinociception, and increased survival rates against lethal opioid doses. These studies also demonstrated the importance of vaccine formulation and the use of adjuvants in enhancing antibody production and specificity. Finally, we highlighted the strengths and concerns associated with the opioid vaccine treatment, including ethical considerations.