Notes from the Field: Opioid Overdose Deaths Before, During, and After an 11-Week COVID-19 Stay-at-Home Order - Cook County, Illinois, January 1, 2018-October 6, 2020

A Nationwide Survey Study of Recovery Community Centers Supporting People in Recovery From Substance Use Disorder

OBJECTIVE

The medical community has become aware of its role in contributing to the opioid epidemic and must be part of its resolution. Recovery community centers (RCCs) represent a new underused component of recovery support.

METHODS

This study performed an online national survey of all RCCs identified in the United States, and used US Census ZIP code tabulation area data to describe the communities they serve.

RESULTS

Residents of areas with RCCs were more likely to be Black (16.5% vs 12.6% nationally, P = 0.005) and less likely to be Asian (4.7% vs 5.7%, P = 0.005), American Indian, or Alaskan Native (0.6% vs 0.8%, P = 0.03), or live rurally (8.5% vs 14.0%, P < 0.0001). More than half of RCCs began operations within the past 5 years. Recovery community centers were operated, on average, by 8.8 paid and 10.2 volunteer staff; each RCC served a median of 125 individuals per month (4-1,500). Recovery community centers successfully engaged racial/ethnic minority groups (20.8% Hispanic, 22.5% Black) and young adults (23.5% younger than 25 years). Recovery community centers provide addiction-specific support (eg, mutual help, recovery coaching) and assistance with basic needs, social services, technology access, and health behaviors. Regarding medications for opioid use disorder (MOUDs), RCC staff engaged members in conversations about MOUDs (85.2%) and provided direct support for taking MOUD (77.0%). One third (36.1%) of RCCs reported seeking closer collaboration with prescribers.

CONCLUSIONS

Recovery community centers are welcoming environments for people who take MOUDs. Closer collaboration between the medical community and community-based peer-led RCCs may lead to significantly improved reach of efforts to end the opioid epidemic.

Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities

BACKGROUND

Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities.

METHODS

PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals.

RESULTS

Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23).

CONCLUSIONS

The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

Understanding Regional Patterns of Overdose Deaths Related to Opioids and Psychostimulants

BACKGROUND

As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures.

METHODS

A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile.

RESULTS

There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region.

CONCLUSION

Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

The impact of COVID-19 shelter-in-place policy responses on excess mortality

As a way of slowing COVID-19 transmission, many countries and U.S. states implemented shelter-in-place (SIP) policies. However, the effects of SIP policies on public health are a priori ambiguous. Using an event study approach and data from 43 countries and all U.S. states, we measure changes in excess deaths following the implementation of COVID-19 shelter-in-place (SIP) policies. We do not find that countries or U.S. states that implemented SIP policies earlier had lower excess deaths. We do not observe differences in excess deaths before and after the implementation of SIP policies, even when accounting for pre-SIP COVID-19 death rates.

Changes in opioid prescribing in veterans with headache during the COVID-19 pandemic: A regression discontinuity in time analysis

OBJECTIVE

To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID-19) pandemic by comparing the stay-at-home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020).

BACKGROUND

Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID-19 pandemic among veterans with headaches remain unknown.

METHODS

This retrospective cohort study utilized regression discontinuity in time and difference-in-differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period. We measured the weekly number of opioid prescriptions, the number of days supplied, the daily dose in morphine milligram equivalents (MMEs), and the number of prescriptions with ≥50 morphine equivalent daily doses (MEDD).

RESULTS

A total of 81,376 veterans were analyzed with 589,950 opioid prescriptions. The mean (SD) age was 51.6 (13.5) years, 57,242 (70.3%) were male, and 53,464 (65.7%) were White. During the pre-pandemic period, 323.6 opioid prescriptions (interquartile range 292.1-325.8) were dispensed weekly, with an median (IQR) of 24.1 (24.0-24.4) days supplied and 31.8 (31.2-32.5) MMEs. Transition to stay-at-home was associated with a 7.7% decrease in the number of prescriptions (incidence rate ratio [IRR] 1.077, 95% confidence interval [CI] 0.866-0.984) and a 9.8% increase in days supplied (IRR 1.098, 95% CI 1.078-1.119). Similar trends were observed during the reopening period. Subgroup analysis among veterans on long-term opioid therapy also revealed 1.7% and 1.4% increases in days supplied during the stay-at-home (IRR 1.017, 95% CI 1.009-1.025) and reopening phase (IRR 1.014, 95% CI 1.007-1.021); however, changes in the total number of prescriptions, MME/day, or the number of prescriptions >50 MEDD were insignificant.

CONCLUSION

Prescription opioid access was maintained for veterans within VHA during the pandemic. The de-escalation of opioid prescribing observed prior to the pandemic was not seen in our study.

Community Mobility and Depressive Symptoms During the COVID-19 Pandemic in the United States

Importance

Marked elevation in levels of depressive symptoms compared with historical norms have been described during the COVID-19 pandemic, and understanding the extent to which these are associated with diminished in-person social interaction could inform public health planning for future pandemics or other disasters.

Objective

To describe the association between living in a US county with diminished mobility during the COVID-19 pandemic and self-reported depressive symptoms, while accounting for potential local and state-level confounding factors.

Design, Setting, and Participants

This survey study used 18 waves of a nonprobability internet survey conducted in the United States between May 2020 and April 2022. Participants included respondents who were 18 years and older and lived in 1 of the 50 US states or Washington DC.

Main Outcome and Measure

Depressive symptoms measured by the Patient Health Questionnaire-9 (PHQ-9); county-level community mobility estimates from mobile apps; COVID-19 policies at the US state level from the Oxford stringency index.

Results

The 192 271 survey respondents had a mean (SD) of age 43.1 (16.5) years, and 768 (0.4%) were American Indian or Alaska Native individuals, 11 448 (6.0%) were Asian individuals, 20 277 (10.5%) were Black individuals, 15 036 (7.8%) were Hispanic individuals, 1975 (1.0%) were Pacific Islander individuals, 138 702 (72.1%) were White individuals, and 4065 (2.1%) were individuals of another race. Additionally, 126 381 respondents (65.7%) identified as female and 65 890 (34.3%) as male. Mean (SD) depression severity by PHQ-9 was 7.2 (6.8). In a mixed-effects linear regression model, the mean county-level proportion of individuals not leaving home was associated with a greater level of depression symptoms (β, 2.58; 95% CI, 1.57-3.58) after adjustment for individual sociodemographic features. Results were similar after the inclusion in regression models of local COVID-19 activity, weather, and county-level economic features, and persisted after widespread availability of COVID-19 vaccination. They were attenuated by the inclusion of state-level pandemic restrictions. Two restrictions, mandatory mask-wearing in public (β, 0.23; 95% CI, 0.15-0.30) and policies cancelling public events (β, 0.37; 95% CI, 0.22-0.51), demonstrated modest independent associations with depressive symptom severity.

Conclusions and Relevance

In this study, depressive symptoms were greater in locales and times with diminished community mobility. Strategies to understand the potential public health consequences of pandemic responses are needed.

The impact of the implementation of medication for opioid use disorder and COVID-19 in a statewide correctional system on treatment engagement, postrelease continuation of care, and overdose

BACKGROUND

People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for overdose after release. Medications for OUD (MOUD) are highly efficacious but not available to most incarcerated individuals. In 2018, Vermont began providing MOUD for all incarcerated individuals with OUD statewide. In 2020, the COVID-19 state of emergency began. We assessed the impact of both events on MOUD utilization and treatment outcomes.

METHODOLOGY

Analyses linked Vermont Department of Corrections administrative data and Medicaid claims data between 07/01/2017 and 03/31/2021. The study used logistic regression to analyze treatment engagement among all incarcerated individuals in Vermont. Multilevel modeling assessed change in clinical outcomes among release episodes that occurred among individuals with an OUD diagnosis Medicaid claim.

RESULTS

Prescriptions for MOUD while incarcerated increased from 0.8% to 33.9% of the incarcerated population after MOUD implementation (OR = 67.4) and subsequently decreased with the onset of COVID-19 to 26.6% (OR = 0.7). After MOUD implementation, most prescriptions (63.1%) were to individuals who had not been receiving MOUD prior to incarceration, but this figure decreased to 53.9% with the onset of COVID-19 (OR = 0.7). Prescriptions for MOUD within 30 days after release increased from 33.9% of those with OUD before to 41.0% after MOUD implementation (OR = 1.4) but decreased to 35.6% with the onset of COVID-19 (OR = 0.8). Simultaneously, opioid-related nonfatal overdoses within 30 days after release decreased from 1.2% before to 0.8% after statewide MOUD implementation (OR = 0.3) but increased to 1.9% during COVID-19 (OR = 3.4). Fatal overdoses within 1 year after release decreased from 27 deaths before to ≤10 after statewide MOUD implementation and remained ≤10 during COVID-19.

CONCLUSIONS

This longitudinal evaluation demonstrated increased treatment engagement and a decrease in opioid-related overdose following implementation of MOUD in a statewide correctional system. In contrast, these improvements were somewhat attenuated with the onset of COVID-19, which was associated with decreased treatment engagement and an increase in nonfatal overdoses. Considered together, these findings demonstrate the benefits of statewide MOUD for incarcerated individuals as well as the need to identify and address barriers to continuation of care following release from incarceration in the context of COVID-19.

Estimating the uncertain effect of the COVID pandemic on drug overdoses

OBJECTIVE

U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both.

METHODS

We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends.

RESULTS

Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods.

CONCLUSION

The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes.

Racial, Ethnic, and Sex Differences in Methadone-Involved Overdose Deaths Before and After the US Federal Policy Change Expanding Take-home Methadone Doses

Importance

In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) permitted states to relax restrictions on take-home methadone doses for treatment-adherent patients to minimize COVID-19 exposures.

Objective

To assess whether the methadone take-home policy change was associated with drug overdose deaths among different racial, ethnic, and sex groups.

Design, Setting, and Participants

Interrupted time series analysis from January 1, 2018, to June 30, 2022. Data analysis was conducted from February 18, 2023, to February 28, 2023. In this population-based cohort study of drug overdose mortality including 14 529 methadone-involved deaths, monthly counts of methadone-involved drug overdose deaths were obtained for 6 demographic groups: Hispanic men and women, non-Hispanic Black men and women, and non-Hispanic White men and women.

Exposure

On March 16, 2020, in response to the first wave of the COVID-19 pandemic, SAMHSA issued an exemption to the states that permitted up to 28 days of take-home methadone for stable patients and 14 days for less stable patients.

Main Outcome Measures

Monthly methadone-involved overdose deaths.

Results

From January 1, 2018, to June 30, 2022 (54 months), there were 14 529 methadone-involved deaths in the United States; 14 112 (97.1%) occurred in the study's 6 demographic groups (Black men, 1234; Black women, 754; Hispanic men, 1061; Hispanic women, 520; White men, 5991; and White women, 4552). Among Black men, there was a decrease in monthly methadone deaths associated with the March 2020 policy change (change of slope from the preintervention period, -0.55 [95% CI, -0.95 to -0.15]). Hispanic men also experienced a decrease in monthly methadone deaths associated with the policy change (-0.42 [95% CI, -0.68 to -0.17]). Among Black women, Hispanic women, White men, and White women, the policy change was not associated with a change in monthly methadone deaths (Black women, -0.27 [95% CI, -1.13 to 0.59]; Hispanic women, 0.29 [95% CI, -0.46 to 1.04]; White men, -0.08 [95% CI, -1.05 to 0.88]; and White women, -0.43 [95% CI, -1.26 to 0.40]).

Conclusions and Relevance

In this interrupted time series study of monthly methadone-involved overdose deaths, the take-home policy may have helped reduce deaths for Black and Hispanic men but had no association with deaths of Black or Hispanic women or White men or women.

Impact of COVID-19 Pandemic, Social Vulnerability, and Opioid Overdoses in Chicago

Introduction

This research was undertaken to examine the individual and neighborhood drivers that contributed to increases in opioid overdose deaths during the COVID-19 pandemic.

Methods

The incident location and Centers for Disease Control and Prevention Social Vulnerability Index (along with the individual indicators) were then geocoded to 1 of the 77 Chicago Community Areas. Changes in opioid overdose death rates were calculated and compared for each Chicago Community Area using linear regression between 2019 and 2020.

Results

Opioid overdose deaths increased by 45% from 2019 to 2020. Chicago Community Areas in the highest 25th percentile of social vulnerability before the pandemic had a 2.8 times higher rate of opioid overdose deaths than Chicago Community Areas in the lowest 25th percentile. The increase in opioid overdose death rate observed from 2019 to 2020 was 10.2 times higher in the most socially vulnerable Chicago Community Areas than in the least vulnerable communities. Chicago Community Areas with the highest degree of social vulnerability had a higher baseline and disproportionate relative increase in opioid overdose death rate compared with the least vulnerable Chicago Community Areas.

Conclusions

COVID-19 has revealed the urgent need for policies that better support the social and economic security of disadvantaged communities, particularly for residents who use opioids.

Application of The Consolidated Framework for Implementation Research to inform understanding of barriers and facilitators to the implementation of opioid and naloxone training on college campuses

BACKGROUND

The opioid epidemic in the US continues to worsen. Opioid-only and polysubstance-involved opioid overdose deaths are increasing among adolescents and young adults, who have limited knowledge of opioid overdose prevention, including recognition and response. College campuses have infrastructure to support national-level implementation of evidence-based public health strategies for providing opioid overdose prevention and naloxone training programs among this priority population. However, college campuses are an underutilized, understudied setting for this programming. To address this gap, we conducted research assessing barriers and facilitators to planning and implementing this programming on college campuses.

METHODS

We held 9 focus groups among purposively selected campus stakeholders whose perceptions were important to understand in planning for the dissemination and implementation of opioid overdose prevention and naloxone training. Focus group scripts were informed by The Consolidated Framework for Implementation Research (CFIR) to query about perceptions of opioid and other substance use, opioid and other substance use-related resources, and naloxone administration training. We used a deductive-inductive, iterative approach to thematic analysis.

RESULTS

Themes about implementation barriers included (1) the perception that problematic use of other (non-opioid) substances was more prevalent than opioid use on campus and focus on those substances would be a greater priority on college campuses; (2) student schedules were overwhelmed with academic commitments and extracurricular activities, making delivery of additional training challenging; (3) barriers related to the perceived complexity and decentralization of communication on campus, preventing students from knowing how to access substance use-related resources. Themes about implementation facilitators included (1) framing naloxone training as important in becoming a responsible leader on campus and in the broader community and (2) leveraging existing infrastructure, champions within existing campus groups, and tailored messaging to facilitate participation in naloxone training.

CONCLUSIONS

This is the first study to provide in-depth insights into potential barriers and facilitators to widespread, routine implementation of naloxone/opioid education on undergraduate college campuses. The study captured diverse stakeholder perspectives and was theoretically grounded in CFIR, contributing to the growing literature on the application and refinement of CFIR across diverse community and school contexts.

The Impact of Naloxone Coprescribing Mandates on Opioid-Involved Overdose Deaths

INTRODUCTION

Since 2017, a total of 10 states have mandated naloxone coprescribing intended to prevent fatal opioid overdoses. This study aims to assess the association between naloxone coprescribing/offering mandates and opioid-involved overdose deaths on the basis of the opioid type.

METHODS

Data on overdose deaths from 1999 to 2020 came from the National Center for Health Statistics CDC WONDER Online Database. This study examined deaths stratified by illicit/synthetic opioids and prescription/treatment opioids. Difference-in-difference negative binomial regression models estimated average marginal effects and 95% CIs. Covariates included opioid dispensing rate, Good Samaritan law, pharmacy-based naloxone access law, mandatory use of prescription drug monitoring program, and recreational cannabis dispensaries. Data collection and analysis were conducted in 2022.

RESULTS

Ten states implemented naloxone coprescribing/offering mandates during the period. Coprescribing/offering mandates significantly reduced the number of prescription/treatment overdose deaths by 8.61 per state per quarter (95% CI= -15.13, -2.09), a 16% reduction from the counterfactual estimates. Coprescribing/offering mandates did not significantly impact illicit/synthetic overdose deaths (average marginal effect=0.32; 95% CI= -18.27, 18.91).

CONCLUSIONS

Coprescribing/offering mandates prevent overdose deaths for its target population, individuals using prescription/treatment opioids. These mandates do not appear to impact populations using illicit/synthetic opioids; thus, expanded efforts are needed to reach these individuals.

Long-Term Prospects for Telemedicine in Opioid Use Disorder (OUD) Treatment: Results from a Longitudinal Survey of OUD Clinicians

BACKGROUND

During the pandemic, there was a dramatic shift to telemedicine for opioid use disorder (OUD) treatment. Little is known about how clinician attitudes about telemedicine use for OUD treatment are evolving or their preferences for future use.

OBJECTIVE

To understand OUD clinician views of and preferences regarding telemedicine.

DESIGN

Longitudinal survey (wave 1, December 2020; wave 2, March 2022).

SUBJECTS

National sample of 425 clinicians who treat OUD.

MAIN MEASURES

Self-reported proportion of OUD visits delivered via telemedicine (actual vs. preferred), comfort in using video visits for OUD, impact of telemedicine on work-related well-being.

KEY RESULTS

The mean reported percentage of OUD visits delivered via telemedicine (vs. in person) dropped from 56.9% in December 2020 to 41.5% in March 2022; the mean preferred post-pandemic percentage of OUD visits delivered via telemedicine was 34.8%. Responses about comfort in using video visits for different types of OUD patients remained similar over time despite clinicians having substantially more experience with telemedicine by spring 2022 (e.g., 35.8% vs. 36.0% report being comfortable using video visits for new patients). Almost three-quarters (70.9%) reported that most of their patients preferred to have the majority of their visits via telemedicine, and 76.7% agreed that the option to do video visits helped their patients remain in treatment longer. The majority (58.7%) reported that telemedicine had a positive impact on their work-related well-being, with higher rates of a positive impact among those who completed training more recently (68.5% of those with < 10 years, 62.1% with 10-19 years, and 45.8% with 20 + years, p < 0.001).

CONCLUSIONS

While many surveyed OUD clinicians were not comfortable using telemedicine for all types of patients, most wanted telemedicine to account for a substantial fraction of OUD visits, and most believed telemedicine has had positive impacts for themselves and their patients.

Open-label, rapid initiation pilot study for extended-release buprenorphine subcutaneous injection

Background: For patients with opioid use disorder, buprenorphine extended-release injection (BUP-XR) achieves sustained therapeutic plasma concentrations, controls craving and withdrawal symptoms, and improves patient outcomes. Given retention challenges during transmucosal buprenorphine (BUP-TM) induction, assessing methods to quickly achieve sustained buprenorphine concentrations is important.Objectives: This open-label, single-group, single-center pilot study (NCT03993392) evaluated safety and tolerability of initiating BUP-XR following a single BUP-TM 4 mg dose.Methods: Eligible participants abstained from short and long-acting opioids for 6 and 24  hours, respectively. If the Clinical Opiate Withdrawal Scale (COWS) was ≥8, BUP-TM 4 mg was administered. Participants not exhibiting hypersensitivity, precipitated opioid withdrawal (POW), or sedation symptoms within 1 hour received BUP-XR 300 mg (assessed as inpatients for 48 hours and outpatients to Day 29). Endpoints were COWS score increase ≥6, independent adjudication of POW, and opioid use.Results: Twenty-six participants (14 male) received BUP-TM, 24 received BUP-XR, and 20 completed the study. After injection, COWS scores decreased from pre-BUP-TM baseline of 14.6 ± 4.1 to 6.9 ± 4.1 at 6 hours and 4.2 ± 3.2 at 24 hours. Most participants (62.5%) experienced maximum COWS scores pre-BUP-XR; 2 experienced a COWS score increase ≥6, occurring at 1 and 2 hours post-BUP-XR. By adjudication, 2/24 participants experienced POW. Irritability, anxiety, nausea, and pain were the most frequent adverse events (AEs) with no serious AEs.Conclusions: Results support increased flexibility for initiating BUP-XR. Initiating BUP-XR 300 mg following a single BUP-TM 4 mg dose was well tolerated. Although some participants initially experienced withdrawal symptoms after injection, significant symptomatic improvement was observed in all participants within 24 hours.

Impact of the COVID-19 pandemic on opioid overdose and other adverse events in the USA and Canada: a systematic review

Importance

The COVID-19 pandemic impacted healthcare beyond COVID-19 infections. A better understanding of how COVID-19 worsened the opioid crisis has potential to inform future response efforts.

Objective

To summarize changes from the COVID-19 pandemic on outcomes regarding opioid use and misuse in the USA and Canada.

Evidence review

We searched MEDLINE via PubMed, EMBASE, and CENTRAL for peer-reviewed articles published between March 2020 and December 2021 that examined outcomes relevant to patients with opioid use, misuse, and opioid use disorder by comparing the period before vs after COVID-19 onset in the USA and Canada. Two reviewers independently screened studies, extracted data, assessed methodological quality and bias via Newcastle-Ottawa Scale, and synthesized results.

Findings

Among 20 included studies, 13 (65%) analyzed service utilization, 6 (30%) analyzed urine drug testing results, and 2 (10%) analyzed naloxone dispensation. Opioid-related emergency medicine utilization increased in most studies (85%, 11/13) for both service calls (17% to 61%) and emergency department visits (42% to 122%). Urine drug testing positivity results increased in all studies (100%, 6/6) for fentanyl (34% to 138%), most (80%, 4/5) studies for heroin (-12% to 62%), and most (75%, 3/4) studies for oxycodone (0% to 44%). Naloxone dispensation was unchanged and decreased in one study each.

Interpretation

Significant increases in surrogate measures of the opioid crisis coincided with the onset of COVID-19. These findings serve as a call to action to redouble prevention, treatment, and harm reduction efforts for the opioid crisis as the pandemic evolves.

PROSPERO registration number

CRD42021236464.

Syringe Service Program Perspectives on Barriers, Readiness, and Programmatic Needs to Support Rollout of the COVID-19 Vaccine

BACKGROUND

We explored syringe service program (SSP) perspectives on barriers, readiness, and programmatic needs to support coronavirus disease 2019 (COVID-19) vaccine uptake among people who use drugs.

METHODS

We conducted an exploratory qualitative study, leveraging an existing sample of SSPs in the United States. Semistructured, in-depth interviews were conducted with SSP staff between February and April 2021. Interviews were analyzed using a Rapid Assessment Process, an intensive, iterative process that allows for rapid analysis of time-sensitive qualitative data.

RESULTS

Twenty-seven SSPs completed a qualitative interview. Many SSP respondents discussed that COVID-19 vaccination was not a priority for their participants because of competing survival priorities, and respondents shared concerns that COVID-19 had deepened participant mistrust of health care. Most SSPs wanted to participate in COVID-19 vaccination efforts; however, they identified needed resources, including adequate space, personnel, and training, to implement successful vaccine programs.

CONCLUSIONS

Although SSPs are trusted resources for people who use drugs, many require additional structural and personnel support to address barriers to COVID-19 vaccination among their participants. Funding and supporting SSPs in the provision of COVID-19 prevention education and direct vaccine services should be a top public health priority.

Opioid poisoning cases aged 50+ in the 2015-2020 National Poisoning Data System: suspected suicides versus unintentional poisoning and other intentional misuse/abuse

High rates of opioid overdose and suicide among the 50+ age group call for an examination of suicidal intent in overdose incidents. Using 2015-2020 National Poison Data System opioid poisoning cases aged 50+ (n = 83 153), we examined the types of opioids and other substances associated with suspected suicides compared to intentional misuse/abuse without suicidal intent. During the six years, prescription opioid cases decreased, while illicit opioid cases increased. Among both types of opioid poisoning cases, the proportions of suspected suicides decreased and those of intentional misuse/abuse without suicidal intent increased. However, due to the large increase in illicit opioid cases, the number of suspected suicide cases involving illicit opioids increased. Multivariable analyses showed that among prescription opioids, acetaminophen with opioid (IRR = 1.17, 95% CI = 1.11-1.24) and tramadol (IRR = 1.12, 95% CI = 1.06-1.47) were associated with higher risk of suspected suicides than intentional misuse/abuse without suicidal intent. Among illicit opioid cases, fentanyl poisoning cases were associated with lower risk of suspected suicides (IRR = 0.40, 95% CI = 0.17-0.94). Of other medications, use of benzodiazepines and antipsychotics was consistently associated with higher risk of suspected suicides in both prescription and illicit opioid cases. Alcohol and cocaine were also associated with higher risk of suspected suicide. Along with continued reductions in opioid prescribing, more effective monitoring of individual patient misuse/abuse behaviors and suicide risk assessment are needed. Healthcare professionals should also review other prescription medications frequently co-prescribed with opioids that may have additive effects on suicidal behaviors among older adults.

Have Deaths of Despair Risen during the COVID-19 Pandemic? A Systematic Review

This systematic review synthesized literature on potential impacts of protracted isolation and other disruptions during the COVID-19 pandemic on deaths of despair (suicide, overdoses, and drug-related liver diseases). Five electronic databases were searched yielding 70 eligible articles. Extant evidence mostly from high-income countries indicates COVID-19-related disruption may not have influenced suicide rates so far, but there have been reports of increased drug-related and liver disease mortality. Minority groups and women were more vulnerable, indicating the need for stronger equity focus on pandemic recovery and resilience strategies. Further high-quality studies with longer-term follow-up, especially from low-income countries, will inform these strategies.

Variability in Opioid-Related Drug Overdoses, Social Distancing, and Area-Level Deprivation during the COVID-19 Pandemic: a Bayesian Spatiotemporal Analysis

Monitoring the spatial and temporal course of opioid-related drug overdose mortality is a key public health determinant. Despite previous studies exploring the evolution of drug-related fatalities following the stay-at-home mandates during the COVID-19 pandemic, little is known about the spatiotemporal dynamics that mitigation efforts had on overdose deaths. The purpose of this study was to describe the spatial and temporal dynamics of overdose death relative risk using a 4-week interval over a span of 5 months following the implementation of the COVID-19 lockdown in the city of Chicago, IL. A Bayesian space-time model was used to produce posterior risk estimates and exceedance probabilities of opioid-related overdose deaths controlling for measures of area-level deprivation and stay-at-home mandates. We found that area-level temporal risk and inequalities in drug overdose mortality increased significantly in the initial months of the pandemic. We further found that a change in the area-level deprivation from the first to the fourth quintile increased the relative risk of a drug overdose risk by 44.5%. The social distancing index measuring the proportion of persons who stayed at home in each census block group was not associated with drug overdose mortality. We conclude by highlighting the importance of contextualizing the spatial and temporal risk in overdose mortality for implementing effective and safe harm reduction strategies during a global pandemic.

Opioid Overdoses Increase at Home During the COVID-19 Stay-At-Home Order Period in Cook County, Illinois

Introduction

Stay-at-home orders during the COVID-19 pandemic decreased population mobility to reduce SARS-CoV-2 infection rates. We empirically tested the hypothesis that this public health measure was associated with a higher likelihood of opioid- and stimulant-involved deaths occurring in homes located in Cook County, Illinois.

Methods

The stay-at-home period was from March 21, 2020 to May 30, 2020. We analyzed overdose data from the Cook County Medical Examiner's Office using a death location description from case investigations categorized as home, medical, motel, scene, and other. Two groups of decedents were defined as either having an opioid or stimulant listed in the primary cause of death field. We modeled a weekly time series to detect changes in deaths (number) and trends during segmented time periods. Chi-square or Fisher's exact and adjusted logistic regression was used for testing the differences between the stay-at-home and a 13-week preceding period.

Results

There were 4,169 and 2,012 opioid- and stimulant-involved deaths, respectively, from 2018 to 2020. Both groups were demographically similar: 75% male, 52% White, and aged 45 years (mean). In the 13 weeks before stay-at-home orders, 51% of opioid-involved deaths occurred in homes, which increased to 59% (p<0.0001) during the 10 weeks of the order and decreased back to 51% in the 18 weeks after the order expired. For stimulant-involved deaths, 51% were residential immediately before the orders, with a nonsignificant increase to 52% during the stay-at-home period. Before the pandemic, there were 20 deaths/week, increasing to 37 deaths/week (p<0.0001) during stay-at-home enactment. Deaths involving fentanyl among the opioid-involved group increased from 76% to 89%, whereas those involving heroin decreased from 55% to 37%. The adjusted OR for opioid-involved fatal overdoses occurring at home during this period compared with that occurring the 13 weeks before was 1.37 (95% CI=1.05, 1.79).

Conclusions

The likelihood of a death occurring at home, especially for people using opioids, increased during the stay-at-home order period. Findings have implications for mitigating overdose risks during social isolation.

Impact of COVID-19 on the characteristics of opioid overdose deaths in Arkansas

Background

In the US, spikes in drug overdose deaths overlapping with the COVID-19 pandemic create concern that persons who use drugs are especially vulnerable. This study aimed to compare the trends in opioid overdose deaths and characterize opioid overdose deaths by drug subtype and person characteristics pre-COVID (2017-2019) and one-year post-COVID-19 emergence (2020).

Methods

We obtained death certificates on drug overdose deaths in Arkansas from January 1, 2017, through December 31, 2020. Our analyses consisted of an interrupted time-series and segmented regression analysis to assess the impact of COVID-19 on the number of opioid overdose deaths.

Results

The proportion of opioid overdose deaths increased by 36% post-COVID emergence (95% CI: 14%, 59%). The trend in overdose deaths involving synthetic narcotics other than methadone, such as fentanyl and tramadol, has increased since 2018 (74 in 2018 vs 79 in 2019; p =0.02 and 79 in 2019 versus 158 in 2020; p = 0.03). Opioid overdose deaths involving methamphetamine have more than doubled (36 in 2019 vs 82 in 2020; p = 0.06) despite remaining steady from 2018 to 2019. Synthetic narcotics have surpassed methamphetamine (71% vs. 37%) as the leading cause of opioid overdose deaths in Arkansas during the pandemic. This study found that synthetic narcotics are the significant drivers of the increase in opioid overdose deaths in Arkansas during the pandemic.

Conclusions

The co-occurrence of the COVID-19 pandemic and the drug abuse epidemic further highlights the increased need for expanding awareness and availability of resources for treating substance use disorders.

A Qualitative Exploration of the Functional, Social, and Emotional Impacts of the COVID-19 Pandemic on People Who Use Drugs

Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia over a one-year period. Using semi-structured interviews with 20 participants in a Housing First, low-barrier medication for opioid use (MOUD) program in Philadelphia, the effects of the first year of the COVID-19 pandemic on the daily lives, resources, functioning, substance use, and treatment of PWUD were explored. Interviews were analyzed using a combination of directed and conventional content analysis. Six overarching themes emerged during data analysis: (1) response to the pandemic; (2) access to MOUD and support services; (3) substance use; (4) impacts on mental health, physical health, and daily functioning; (5) social network impacts; and (6) fulfillment of basic needs. Participants reported disruptions in every domain of life, challenges meeting their basic needs, and elevated risk for adverse events. MOUD service providers offset some risks and provided material supports, treatment, social interaction, and emotional support. These results highlight how there were significant disruptions to the lives of PWUD during the first year of the COVID-19 pandemic and identified critical areas for future intervention and policies.

Illicit Substance Use and the COVID-19 Pandemic in the United States: A Scoping Review and Characterization of Research Evidence in Unprecedented Times

We carried out a scoping review to characterize the primary quantitative evidence addressing changes in key individual/structural determinants of substance use risks and health outcomes over the first two waves of the COVID-19 pandemic in the United States (US). We systematically queried the LitCovid database for US-only studies without date restrictions (up to 6 August 2021). We extracted quantitative data from articles addressing changes in: (a) illicit substance use frequency/contexts/behaviors, (b) illicit drug market dynamics, (c) access to treatment and harm reduction services, and (d) illicit substance use-related health outcomes/harms. The majority of 37 selected articles were conducted within metropolitan locations and leveraged historical timeseries medical records data. Limited available evidence supported changes in frequency/behaviors/contexts of substance use. Few studies point to increases in fentanyl and reductions in heroin availability. Policy-driven interventions to lower drug use treatment thresholds conferred increased access within localized settings but did not seem to significantly prevent broader disruptions nationwide. Substance use-related emergency medical services’ presentations and fatal overdose data showed a worsening situation. Improved study designs/data sources, backed by enhanced routine monitoring of illicit substance use trends, are needed to characterize substance use-related risks and inform effective responses during public health emergencies.

Estimating Weekly National Opioid Overdose Deaths in Near Real Time Using Multiple Proxy Data Sources

IMPORTANCE

Opioid overdose is a leading public health problem in the United States; however, national data on overdose deaths are delayed by several months or more.

OBJECTIVES

To build and validate a statistical model for estimating national opioid overdose deaths in near real time.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, signals from 5 overdose-related, proxy data sources encompassing health, law enforcement, and online data from 2014 to 2019 in the US were combined using a LASSO (least absolute shrinkage and selection operator) regression model, and weekly predictions of opioid overdose deaths were made for 2018 and 2019 to validate model performance. Results were also compared with those from a baseline SARIMA (seasonal autoregressive integrated moving average) model, one of the most used approaches to forecasting injury mortality.

EXPOSURES

Time series data from 2014 to 2019 on emergency department visits for opioid overdose from the National Syndromic Surveillance Program, data on the volume of heroin and synthetic opioids circulating in illicit markets via the National Forensic Laboratory Information System, data on the search volume for heroin and synthetic opioids on Google, and data on post volume on heroin and synthetic opioids on Twitter and Reddit were used to train and validate prediction models of opioid overdose deaths.

MAIN OUTCOMES AND MEASURES

Model-based predictions of weekly opioid overdose deaths in the United States were made for 2018 and 2019 and compared with actual observed opioid overdose deaths from the National Vital Statistics System.

RESULTS

Statistical models using the 5 real-time proxy data sources estimated the national opioid overdose death rate for 2018 and 2019 with an error of 1.01% and -1.05%, respectively. When considering the accuracy of weekly predictions, the machine learning-based approach possessed a mean error in its weekly estimates (root mean squared error) of 60.3 overdose deaths for 2018 (compared with 310.2 overdose deaths for the SARIMA model) and 67.2 overdose deaths for 2019 (compared with 83.3 overdose deaths for the SARIMA model).

CONCLUSIONS AND RELEVANCE

Results of this serial cross-sectional study suggest that proxy administrative data sources can be used to estimate national opioid overdose mortality trends to provide a more timely understanding of this public health problem.

Coprescribing of opioids and high-risk medications in the USA: a cross-sectional study with data from national ambulatory and emergency department settings

OBJECTIVE

Describe trends in opioid plus high-risk medication coprescribing in the USA.

DESIGN

Analyses of serial, cross-sectional, nationally representative data of the National Ambulatory Medical Care Survey (NAMCS) over 2007-2016 and the National Hospital Ambulatory Medical Care Survey (NHAMCS) over 2007-2018.

SETTING

US ambulatory (NAMCS) and emergency department (ED, NHAMCS) settings.

PARTICIPANTS

Patient visits in which the patient was 18 years and older with an opioid prescription in the NAMCS or NHAMCS databases.

PRIMARY AND SECONDARY OUTCOME MEASURES

Frequency of opioid plus high-risk medication coprescribing.

RESULTS

From a combined sample of 700 499 visits over 2007-2018, there were 105 720 visits (15.1%) where opioids were prescribed. n=31 825 were from NAMCS and n=73 895 were from NHAMCS. The mean prevalence of coprescription of opioids and high-risk medications for the combined NAMCS and NHAMCS sample was 18.4% in 2007, peaked at 33.2% in 2014 and declined to 23.8% in 2016. Compared with adults receiving opioid prescriptions alone, those coprescribed opioids and high-risk medications were older, more likely female, white and using private or Medicare insurance (p<0.0001).

CONCLUSIONS

Coprescribing is more common in ambulatory than ED settings and has been declining, yet one in four patient visits where opioids were prescribed resulted in coprescribed, high-risk medications in 2016. Efforts and research to help lower the rates of high-risk prescribing are needed.

Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach

Background

Opioid-related overdose deaths have surged in the USA over the last two decades. Overdose fatalities are preventable with the timely administration of naloxone. Syringe service programs (SSP) have pioneered community-based naloxone distribution through overdose prevention and naloxone distribution (OEND) programs. There is a dearth of information with regards to best practices for community-based OEND.

Methods

We utilized a modified Delphi approach to develop a set of best practices for OEND delivery. Starting with an initial list of best practices, we engaged 27 experts, in the field of OEND programming who reviewed, made recommendations for changes, and assigned a priority to each best practice.

Results

Two rounds of input resulted in a final list of 20 best practices organized into four categories. The mean priority scores ranged from 1.17 to 2.17 (range 1 to 3). The top 5 ranked best practices were ensuring that SSP participants have low barrier, consistent, needs-based access to naloxone and that there is ample naloxone available within communities. While the remaining fifteen best practices were deemed important, they had more to do with organizational culture and implementation climate.

Conclusions

Increasing community-based OEND delivery is essential to reduce opioid overdose deaths; however, it will be insufficient to add programs without an eye toward quality of implementation and fidelity to the model upon which the evidence is based. This list of best practices summarizes the consensus among OEND experts and can serve as a tool for SSPs providing OEND programming to improve services.

Heroin and fentanyl overdose deaths among cases age 50+ in the National Poison Data System, 2015-2020

CONTEXT

Illicit opioid use and heroin treatment admissions among individuals age 50+ have increased. Little research has, however, examined correlates of illicit opioid overdose deaths in this age group before or during the COVID-19 pandemic or the healthcare services used in these cases.

METHODS

The sample included illicit opioid (heroin, fentanyl, or other synthetic, nonpharmaceutical opioids) poisoning cases age 50+ (N = 5576) in the National Poison Data System (NPDS), 2015-2020. Using descriptive statistics and logistic regression models, we report changes in overdose death rates during the study period and associations of death with healthcare service use, naloxone administration, and clinical and demographic characteristics.

RESULTS

The 6-year average overdose death rate from illicit opioids among those age 50+ was 2.9%, increasing from 1.4% in 2015 to 4.0% in 2019 and 3.6% in 2020. Logistic regression results showed that exposure year was not a significant factor in the odds of overdose death; however, odds were significantly higher among cases that were not managed at any healthcare facility (HCF) (adjusted odds ratio [AOR] = 4.60, 95% confidence interval [CI] = 3.19-6.63) and lower among those who received naloxone therapy (AOR = 0.64, 95% CI = 0.45-0.92). The odds of death were also higher among cases involving exposure at own or another's home and co-use of prescription opioids, alcohol, and other illicit drugs.

CONCLUSIONS

Although the NPDS did not show increases in illicit opioid overdose death rates among cases age 50+ in 2020 compared to 2019, overdose deaths were greater among cases that were not managed at HCF and did not receive naloxone therapy. Many appear to have died before they received any intervention to prevent death. Improved access to healthcare services and social support and access to naloxone therapy for older adults with opioid use problems are needed.

Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis

BACKGROUND

Drug overdose rates in the United States have been steadily increasing, particularly in rural areas. The COVID-19 pandemic and associated mitigation strategies may have increased overdose risk for people who use drugs by impacting social, community, and structural factors.

METHODS

The study included a quantitative survey focused on COVID-19 administered to 50 people who use drugs and semi-structured qualitative interviews with 17 people who use drugs, 12 of whom also participated in the quantitative survey. Descriptive statistics were run for the quantitative data. Qualitative coding was line-by-line then grouped thematically. Quantitative and qualitative data were integrated during analysis.

RESULTS

Findings demonstrate how COVID-19 disruptions at the structural and community level affected outcomes related to mental health and drug use at the individual level. Themes that emerged from the qualitative interviews were (1) lack of employment opportunities, (2) food and housing insecurity, (3) community stigma impacting health service use, (4) mental health strains, and (5) drug market disruptions. Structural and community changes increased anxiety, depression, and loneliness on the individual level, as well as changes in drug use patterns, all of which are likely to increase overdose risk.

CONCLUSION

The COVID-19 pandemic, and mitigation strategies aimed at curbing infection, disrupted communities and lives of people who use drugs. These disruptions altered individual drug use and mental health outcomes, which could increase risk for overdose. We recommend addressing structural and community factors, including developing multi-level interventions, to combat overdose. Trial registration Clinicaltrails.gov: NCT04427202. Registered June 11, 2020: https://clinicaltrials.gov/ct2/show/NCT04427202?term=pho+mai&draw=2&rank=3.

The impact of a provider motivational interviewing-based training on chronic pain management in a federally-qualified health center

BACKGROUND

While the issue of opioid misuse is very complex, pharmacists have a unique opportunity to participate in interprofessional, team-based care. Motivational interviewing (MI) has been shown to be effective in chronic disease management and could improve patient engagement and chronic pain outcomes.

OBJECTIVES

To determine the impact of an MI-based provider training on changes in chronic pain management prescribing and on provider and patient perceptions.

METHODS

Providers participated in a pharmacist-led, 4-session educational intervention covering the CDC opioid prescribing guidelines, pain management, clinical pearls, and MI. Providers were then asked to implement the training in patient appointments for chronic pain management and refer appropriate patients for follow-up on goals. In the follow-up, student pharmacists called patients twice monthly for three months using MI. To address the primary outcome, the number of opioid prescriptions, morphine daily equivalents, and naloxone prescriptions were recorded and compared from the electronic medical record for the year preceding and following the intervention. Patients and providers completed surveys to assess the impact of these interventions.

RESULTS

Providers (n = 11) reported increased confidence in MI from baseline to 12 months following the intervention but no change in satisfaction. Patients (n = 19) were able to set and accomplish 20 goals throughout the phone call intervention. Meanwhile, the number of opioid prescriptions significantly decreased from 569 to 368 prescriptions per year before and after the intervention, respectively. Morphine daily equivalents per prescription decreased from 26.8 to 26.4 for the year before versus the year following the intervention.

CONCLUSIONS

MI interventions for providers and patients may positively impact goal setting and opioid prescribing. However, MI alone may not successfully address provider satisfaction and patient physical functioning. Pain management is an area that may benefit from a multi-faceted, interprofessional approach.

Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021

Objectives. To explore the implementation and effectiveness of the British Columbia, Canada, risk mitigation guidelines among people who use drugs, focusing on how experiences with the illicit drug supply shaped motivations to seek prescription alternatives and the subsequent impacts on overdose vulnerability. Methods. From February to July 2021, we conducted qualitative interviews with 40 people who use drugs in British Columbia, Canada, and who accessed prescription opioids or stimulants under the risk mitigation guidelines. Results. COVID-19 disrupted British Columbia's illicit drug market. Concerns about overdose because of drug supply changes, and deepening socioeconomic marginalization, motivated participants to access no-cost prescription alternatives. Reliable access to prescription alternatives addressed overdose vulnerability by reducing engagement with the illicit drug market while allowing greater agency over drug use. Because prescriptions were primarily intended to manage withdrawal, participants supplemented with illicit drugs to experience enjoyment and manage pain. Conclusions. Providing prescription alternatives to illicit drugs is a critical harm reduction approach that reduces exposure to an increasingly toxic drug supply, yet further optimizations are needed. (Am J Public Health. 2022;112(S2):S151-S158. https://doi.org/10.2105/AJPH.2021.306692).

Gastrointestinal symptoms and healthcare utilization have increased among patients with functional gastrointestinal and motility disorders during the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in healthcare. Functional gastrointestinal and motility disorders (FGIMD) are associated with significant healthcare utilization. The clinical implications of these healthcare disruptions due to the COVID-19 pandemic on clinical outcomes in patients with FGIMD are unclear.

METHODS

We performed a retrospective study of patients with three common FGIMD (irritable bowel syndrome [IBS], gastroparesis, functional dyspepsia [FD]) tested for SARS-CoV-2 to describe alterations in gastrointestinal symptoms, medication use, and healthcare utilization during and before the pandemic and factors associated with COVID-19.

KEY RESULTS

The prevalence of COVID-19 during the pandemic (03/2020-09/2020) was 3.20% (83/2592) among patients with FGIMD, 3.62% in IBS (57/1574), 3.07% in gastroparesis (23/749), and 2.44% in FD (29/1187) at our institution. Patients with FGIMD had increased abdominal pain, nausea/vomiting, diarrhea, constipation, and weight loss (p < 0.001) along with increased proton pump inhibitor, H2 blocker, and opioid use (p < 0.0001). Both inpatient hospitalizations and outpatient visits (p < 0.0001) and number of diagnostic tests including cross-sectional imaging (p = 0.002), and upper and lower endoscopies (p < 0.0001) were significantly higher during the pandemic as compared to 6 months prior. Diarrhea-predominant IBS was positively (OR 2.37, 95% CI 1.34-4.19, p = 0.003) associated with COVID-19, whereas functional dyspepsia was negatively (OR 0.46, 95% CI 0.27-0.79, p = 0.004) associated.

CONCLUSIONS & INFERENCES

Patients with common functional gastrointestinal and motility disorders have reported more gastrointestinal symptoms during the COVID-19 pandemic with concurrent increased medication use and healthcare utilization.

Naloxone therapy for prescription and illicit opioid poisoning cases aged 50 + in the national poison data system, 2015-2020

CONTEXT

Older adults are less likely than younger adults to receive naloxone therapy. Given high rates of prescription opioid use/misuse and increasing illicit opioid use among older adults, factors associated with naloxone administration for older opioid poisoning cases need examination.

METHODS

We analyzed the 83,135 opioid-involved cases aged 50+ from the 2015-2020 National Poison Data System. Single-variable logistic regression was used to examine associations of naloxone administration with demographic factors, exposure site/reason, medical outcomes, management site/level of care, clinical effects, and other interventions. Multivariable logistic regression models were fit to examine associations of naloxone administration with different types of opioids.

RESULTS

Over the six years, the proportion of prescription opioid cases that received naloxone therapy increased steadily from 21.9% to 28.4%. The proportion of illicit opioid cases that received naloxone therapy was 51.9% in 2015 and 59.8% in 2020 with a high of 64.4% in 2019. In 2020, the death rate for illicit opioid cases without naloxone therapy was 31.4% compared to 2.3% for those with the therapy. Cases managed at healthcare facilities (HCF) had higher odds of receiving naloxone therapy. Among prescription opioid cases, naloxone therapy rates among older and female cases and those managed at non-HCF settings were especially low even for major medical outcomes. Cases involving oxycodone, morphine, methadone, prescription fentanyl, hydromorphone, oxymorphone, and other/unknown opioids had higher odds of naloxone administration.

DISCUSSION

Rates of naloxone therapy for older prescription opioid poisoning cases need improvement. While rates were higher among illicit opioid cases, the drop in 2020 and the sharp increase in deaths among illicit opioid cases without naloxone therapy confirm the importance of access to this life-saving intervention.

CONCLUSIONS

Increased naloxone co-prescribing and other means of facilitating access to naloxone are needed to prevent opioid poisoning deaths among older adults who use prescription opioids.

The Impact of Coronavirus Disease 2019 on US Emergency Departments

Behavioral emergencies in the United States have been increasing, with some studies reporting a doubling in the number of people experiencing symptoms related to mental health conditions, although overall visits to US emergency departments (EDs) decreased during the coronavirus disease 2019 (COVID-19) pandemic. The uncertainty surrounding the COVID-19 pandemic caused many people to avoid health care facilities, including EDs, even if they may have otherwise sought emergency care, and was associated with increases in new behavioral health diagnoses. Measures to limit the spread of COVID-19 led to people limiting their in-person contact with others, likely exacerbating preexisting mental health issues.

Exposure reasons, other substance use, and medical outcomes of poison control center cases aged 50+ involving opioids, 2015-2020

CONTEXT

Rates of prescription opioid (PO) prescribing and filling remain high, and illicit opioid (IO) use has increased among late middle-aged and older adults. Research on PO and IO poisoning and their impacts among these age groups is needed.

METHODS

Data came from 2015 to 2020 poison control center cases aged 50+ (N = 83,135). We used χ2 tests to examine changes over the study period in the numbers of PO and IO cases, type of opioids used, exposure reasons, and medical outcomes. We fit multinomial logistic regression models to examine the associations of medical outcomes with exposure reasons and other medication/substance involvement.

RESULTS

Between 2015/2016 and 2020, the numbers and shares of PO-only cases steadily declined, but IO cases, with or without PO, nearly tripled, constituting almost 10% of all PCC opioid cases aged 50+ in 2020. The rates of intentional misuse/abuse increased among both PO-only and IO (with/without PO) cases during the study period, and the death rate among IO cases sharply increased in 2020. Compared to adverse reactions or other unintentional exposures, intentional misuse/abuse and suspected suicides were associated with significantly higher risks of serious outcomes (e.g., risk of death from intentional misuse/abuse: RRR = 22.11, 95% CI = 16.74-29.20 in PO-only cases and RRR = 6.95, 95% CI = 2.37-20.39 in IO cases with/without PO). The use of most other medications and substances was also significantly associated with serious outcomes.

DISCUSSION

Among older adults, medical outcomes in opioid poisoning cases have become more serious in recent years as intentional misuse/abuse became more common. Opioid use disorder treatment should be readily available and accessible, and alternatives to PO prescribing should be considered.

CONCLUSIONS

Among individuals aged 50+, PO poisoning cases decreased, but IO cases increased sharply from 2015 to 2020 with concomitant increases in intentional misuse/abuse and serious medical outcomes.

Retrospective study of non-natural manners of death in Ontario: Effects of the COVID-19 pandemic and related public health measures

BACKGROUND

The effects of the COVID-19 pandemic on non-natural manners of death in Ontario is not known. Understanding the indirect consequences of the pandemic and related public health measures (i.e. lockdown) fills a vital need to inform best practice in public health and guide policy decisions.

METHODS

The Office of the Chief Coroner and the Ontario Forensic Pathology Service (OCC-OFPS) investigate sudden and unexpected deaths in the province of Ontario. The number of homicides, suicides, and accidental deaths (non-natural deaths=77,655) were extracted from the centralized Coroner's Information System database (total deaths=197,966), across four provincially defined stages of lockdown related to the COVID-19 pandemic (March 17 to December 31, 2020), and crude rates (per 100,000 people) were compared to the previous eleven years.

FINDINGS

There was no major change to the rate of homicides during 2020 compared to 2009-2019 (RR 1⋅1, 95% CI 0⋅95-1⋅2; p=0⋅19; estimated annual effect=21 more deaths in 2020). The rate of suicides also did not show an overall major change in 2020 (RR 1⋅02, 95% CI 0⋅96-1⋅1; p=0⋅50; estimated annual effect=27 more deaths in 2020). However, during the first stage of lockdown (Stage 0), there was a decrease in the rate of suicides compared to all combinations of recent years from 2013 onwards (RRs 0⋅82-0⋅86, combined 95% CI 0⋅69-0⋅99; max p=0⋅039; estimated effect of 30 less deaths in Stage 0). There was an excess of over 1,500 accidental drug-related deaths that occurred during 2020 (RR 2⋅5, 95% CI 2⋅4-2⋅7; p<0⋅001). This finding held up to 'interrupted time series' robustness testing, indicating that 2020 had substantially more drug-related deaths, even when accounting for the linear increasing trend over time. Although motor vehicle collision associated fatalities appeared to decrease slightly in 2020 (RR 0⋅89, 95% CI 0⋅81-0⋅96; p=0⋅0039; estimated annual effect of 78 less deaths), we could not conclude any lockdown-associated effect, particularly when compared to 2019 (RR 0⋅26, 95% CI 0⋅75-1⋅1; p=0⋅26).

INTERPRETATION

In Ontario, the short-term effects of the COVID-19 pandemic did not greatly increase homicide or suicide rates, nor decrease motor vehicle collision fatality rates; however, the longer-term impact of the pandemic remains to be elucidated and ongoing vigilance is warranted in the event that other trends emerge. Accidental drug-related fatalities substantially increased during all stages of the lockdown, marking an urgent need for consideration in policy. These results highlight the vital role of death investigation systems in providing high quality and timely data to inform public health recommendations.

U.S. older adults' heroin and psychostimulant use treatment admissions, 2012-2019: Sociodemographic and clinical characteristics

BACKGROUND

Increases in U.S. older adults' nonprescription opioid and psychostimulant use call for examining their treatment admissions for these substances.

METHODS

Using admissions age 55 + involving heroin (N = 299,073) from the 2012-2019 Treatment Episode Data Set-Admissions, we examined trends and sociodemographic and clinical characteristics of three groups: (1) heroin-only admissions (i.e., not involving cocaine or methamphetamine), (2) heroin-cocaine admissions, and (3) heroin-methamphetamine admissions. Bivariable and multivariable logistic regression analyses were conducted to examine the research questions.

RESULTS

Between 2012 and 2019, the numbers of both heroin-only and heroin-cocaine admissions increased 2.3-fold and heroin-methamphetamine admissions increased seven-fold. First time heroin-methamphetamine admissions increased 18-fold. Heroin-methamphetamine admissions were concentrated in the Western region and heroin-cocaine admissions in the Northeastern region. Multivariable analyses showed a nearly 6 times higher relative risk ratio (RRR; 95% CI=5.24-6.74) for heroin-methamphetamine vs. heroin-only admissions in 2019 compared to 2012. Being non-Hispanic Black, compared to non-Hispanic White, was associated with a RRR of 2.4 (95% CI=2.34-2.46) for heroin-cocaine admissions and a RRR of 0.14 (95% CI=0.12-0.15) for heroin-methamphetamine admissions. Late-onset heroin use, experience of homelessness and other psychiatric problems, and past 30-day arrest episodes were associated with a higher likelihood of heroin-cocaine and heroin-methamphetamine admissions, while injection drug use (IDU) was associated with a higher likelihood of heroin-methamphetamine admissions only.

CONCLUSIONS

Healthcare providers should assess and monitor psychostimulant, methamphetamine in particular, use among older adults. Those who use heroin and psychostimulants should receive substance use treatment and help to secure stable housing and meet other living needs.

Impact of an overdose reversal program in the context of a safe consumption site in Northern Mexico

Background

Drug overdoses are prevalent in low- and middle-income countries but are scarcely reported in the literature. We report on an opioid overdose reversal and naloxone distribution program that was instituted at the first safe consumption site in Latin America.

Methods

A cross-sectional analysis of witnessed drug overdoses and naloxone distribution between 1 June 2019 and 31 May 2021 in Mexicali, Mexico. Case report forms were entered in an electronic database. Trends in overdose and naloxone distribution were described. Comparisons were made before and after the COVID-19 pandemic was declared in the city. Maps were created to represent the geographic distribution of overdose in the city.

Results

During the study period 1,534 doses of naloxone were distributed throughout the community. In addition, there were 464 overdoses reported during this period, of which 4 were fatal. There was a 30% increase in reported overdoses from the period before the COVID-19 pandemic to the period after the pandemic was declared (p = 0.03). Most common substance reported included heroin (93%), sedatives (21%), methamphetamine (16%) and fentanyl (14%). Naloxone was given in 96% of cases (median 1 dose, IQR 1-2 doses) and emergency services were called in 20% of cases.

Conclusions

An opioid overdose reversal program in Mexicali, Mexico was able to distribute naloxone and register drug overdoses between 2019 and 2021 as a harm reduction strategy. This adds to the growing body of literature on the impact of community-based programs on preventing fatal overdoses and the potential for implementation in low-resource settings.

Closed-loop wearable naloxone injector system

Overdoses from non-medical use of opioids can lead to hypoxemic/hypercarbic respiratory failure, cardiac arrest, and death when left untreated. Opioid toxicity is readily reversed with naloxone, a competitive antagonist that can restore respiration. However, there remains a critical need for technologies to administer naloxone in the event of unwitnessed overdose events. We report a closed-loop wearable injector system that measures respiration and apneic motion associated with an opioid overdose event using a pair of on-body accelerometers, and administers naloxone subcutaneously upon detection of an apnea. Our proof-of-concept system has been evaluated in two environments: (i) an approved supervised injection facility (SIF) where people self-inject opioids under medical supervision and (ii) a hospital environment where we simulate opioid-induced apneas in healthy participants. In the SIF (n = 25), our system identified breathing rate and post-injection respiratory depression accurately when compared to a respiratory belt. In the hospital, our algorithm identified simulated apneic events and successfully injected participants with 1.2 mg of naloxone. Naloxone delivery was verified by intravenous blood draw post-injection for all participants. A closed-loop naloxone injector system has the potential to complement existing evidence-based harm reduction strategies and, in the absence of bystanders, help make opioid toxicity events functionally witnessed and in turn more likely to be successfully resuscitated.

Strategies Adopted by Addiction Facilities during the Coronavirus Pandemic to Support Treatment for Individuals in Recovery or Struggling with a Substance Use Disorder: A Scoping Review

This review aimed to identify and synthesize strategies and actions adopted by addiction facilities to support and maintain treatment during the coronavirus disease 2019 (COVID-19) pandemic. A scoping review was conducted using the following information sources: Virtual Health Library, SCOPUS, Web of Science, PubMed, CINAHL, and Latin American and Caribbean Health Science Literature. From a total of 971 articles, 28 studies were included. The strategies to maintain the care offer were telehealth/telemedicine, counselling/screening, 24-h telephone, webinars, conducting group therapy and support among users, adaptation for electronic health records, increased methadone/naloxone dispensing, restriction in the number of medication dispensing/day, and electronic prescription and home delivery medications. These strategies can be used to support health professionals in addressing the impact of the pandemic on the treatment of those in recovery or struggling with a substance use disorder when in-person treatment is not possible.

Opioid-related deaths before and after COVID-19 stay-at-home orders in Los Angeles County

BACKGROUND

Opioid-related morbidity and mortality has increased during the COVID-19 pandemic, yet specific information about the communities most affected remains unknown. Our objective is to evaluate decedent-level associations with an opioid-related death following the implementation of stay-at-home orders in Los Angeles County.

METHODS

This retrospective cohort study used data from the L.A. County Medical Examiner-Coroner to identify opioid-related deaths in 2019 and 2020. We used logistic regression to analyze the change in opioid-related deaths following a 30-day washout period after the start of stay-at-home orders. Independent variables included decedent age, gender, race and ethnicity, heroin or fentanyl present at the time of death, census tract-level education, and a scheduled drug prescription in the year before death.

RESULTS

Opioid-related deaths in L.A. County are most common in census tracts where a small percentage of the population has a Bachelor's degree. Following stay-at-home orders, Non-Hispanic Caucasian individuals had significantly more opioid-related deaths than Hispanic individuals (risk ratio (RR): 1.82 [95 % CI, 1.10-3.02]; P < 0.05) after adjusting for age, gender, and heroin or fentanyl use. Racial and ethnic differences in mortality were not explained by census tract-level education or recent scheduled drug prescriptions.

DISCUSSION

There has been an alarming rise in opioid-related deaths in L.A. County during 2020. The increase in opioid-related overdose deaths following the onset of COVID-19 and related policies occurred most often among Non-Hispanic Caucasian individuals. Further research on this trend's underlying cause is needed to inform policy recommendations during these simultaneous public health crises.

A crisis in my community? Local-level awareness of the opioid epidemic and political consequences

The opioid epidemic has had a profound effect on American public health, and studies suggest it has had a profound effect on American politics as well. Research suggests a relationship between the severity of the opioid crisis in a community and aggregate-level political behavior, including voting for Donald Trump in 2016, but there is very little individual-level data establishing the mechanism for this relationship. Using a question on a nationally representative survey fielded after the 2018 election, we explore Americans' perceptions of the severity of the opioid epidemic in their community, and whether these perceptions predict political behavior and attitudes. We find that relative estimates of local opioid overdoses are significantly influenced by the actual county-level overdose death rate, and that the relationship between reality and perception is strongest for the most knowledgeable and informed citizens. There is also evidence that the social construction of the opioid epidemic as a crisis primarily affecting White suburban or rural Americans affects these perceptions, as both White and non-urban respondents are significantly more attentive to objective mortality rates than others. Turning to political behavior, we find no evidence that these estimates affected validated voter turnout or U.S. House vote choice in the 2018 midterm election. Assessing public approval outcomes, we found a nonlinear effect of these estimates on support for President Trump, a pattern which is partially consistent with the existing literature. We also observed that those who believed the opioid epidemic to be worse than average in their communities reported lower approval of their state legislatures, though we found no such relationship for ratings of governors. These findings raise important questions about the micro-level mechanisms that link aggregate-level public health with political outcomes.