COVID-19 and the Drug Overdose Crisis: Uncovering the Deadliest Months in the United States, January‒July 2020

Examining the association of rurality with opioid-related morbidity and mortality in Georgia: A geospatial analysis

INTRODUCTION

The US opioid epidemic continues to escalate, with overdose deaths being the most-used metric to quantify its burden. There is significant geographic variation in opioid-related outcomes. Rural areas experience unique challenges, yet many studies oversimplify rurality characterizations. Contextual factors, such as area deprivation, are also important to consider when understanding a community's need for treatment services and prevention programming. This study aims to provide a geospatial snapshot of the opioid epidemic in Georgia using several metrics of opioid-related morbidity and mortality and explore differences by rurality across counties.

METHODS

This was a spatial ecologic study. Negative binominal regression was used to model the relationship of county rurality with four opioid-related outcomes - overdose mortality, emergency department visits, inpatient hospitalizations, and overdose reversals - adjusting for county-level sex, racial/ethnic, and age distributions. Area Deprivation Index was also included.

RESULTS

There was significant geographic variation across the state for all four opioid-related outcomes. Counts remained highest among the metro areas. For rates, counties in the top quartile of rates varied by outcome and were often rural areas. In the final models, rurality designation was largely unrelated to opioid outcomes, with the exception of medium metro areas (inversely related to hospitalizations and overdose reversals) and non-core areas (inversely related to hospitalizations), as compared to large central metro areas. Higher deprivation was significantly related to increased ED visits and hospitalizations, but not overdose mortality and reversals.

CONCLUSIONS

When quantifying the burden of the opioid epidemic in a community, it is essential to consider multiple outcomes of morbidity and mortality. Understanding what outcomes are problematic for specific communities, in combination with their demographic and socioeconomic context, can provide insight into gaps in the treatment continuum and potential areas for intervention. Additionally, compared to demographic and socioeconomic factors, rurality may no longer be a salient predictor of the severity of the opioid epidemic in an area.

Estimating changes in overdose death rates from increasing methamphetamine supply in Ohio: Evidence from crime lab data

Background

We investigate the relationship between the supply of methamphetamine and overdose death risk in Ohio. Ohio and the overall US have experienced a marked increase in overdose deaths from methamphetamine combined with fentanyl over the last decade. The increasing use of methamphetamine may be increasing the risk of overdose death. However, if people are using it to substitute away from more dangerous synthetic opioids, it may reduce the overall risk of overdose death.

Methods

Ohio's Bureau of Criminal Investigation's crime lab data include a detailed list of the content of drug samples from law enforcement seizures, which are used as a proxy for drug supply. We use linear regressions to estimate the relationship between the proportion of methamphetamine in lab samples and unintentional drug overdose death rates from January 2015 through September 2021.

Results

Relatively more methamphetamine in crime lab data in a county-month has either no statistically significant relationship with overdose death rates (in small and medium population counties) or a negative and statistically significant relationship with overdose death rates (in large population counties). Past overdose death rates do not predict future increases in methamphetamine in crime lab data.

Conclusions

The results are consistent with a relatively higher supply of methamphetamine reducing the general risk of overdose death, possibly due to substitution away from more dangerous synthetic opioids. However, the supply of methamphetamine appears unrelated to the past illicit drug risk environment. The non-lethal and yet serious health effects of MA use were not explored and, thus, even if the presence of MA reduces the population-level overdose mortality rate, the rise of other adverse health effects may counteract any public health benefits of fewer deaths.

Postoperative Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Postdischarge Opioid Use

BACKGROUND

Many institutions have developed operation-specific guidelines for opioid prescribing. These guidelines rarely incorporate in-hospital opioid consumption, which is highly correlated with consumption. We compare outcomes of several patient-centered approaches to prescribing that are derived from in-hospital consumption, including several experimental, rule-based prescribing guidelines and our current institutional guideline.

STUDY DESIGN

We performed a retrospective, cohort study of all adults undergoing surgery at a single-academic medical center. Several rule-based guidelines, derived from in-hospital consumption (quantity of opioids consumed within 24 hours of discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared with 3 references: an approximation of our institution's tailored prescribing guideline; prescribing all patients the typical quantity of opioids consumed for patients undergoing the same operation; and a representative rule-based, tiered framework. For each scenario, we calculated the penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for overprescribing) and the proportion of opioids consumed relative to prescribed.

RESULTS

A total of 1,048 patients met inclusion criteria. Mean (SD) and median (interquartile range [IQR]) quantity of opioids consumed within 24 hours of discharge were 11.2 (26.9) morphine milligram equivalents and 0 (0 to 15) morphine milligram equivalents. Median (IQR) postdischarge consumption was 16 (0 to 150) morphine milligram equivalents. Our institutional guideline and the previously validated rule-based guideline outperform alternate approaches, with median (IQR) differences in prescribed vs consumed opioids of 0 (-60 to 27.25) and 37.5 (-37.5 to 37.5), respectively, corresponding to penalized residual sum of squares of 39,817,602 and 38,336,895, respectively.

CONCLUSIONS

Rather than relying on fixed quantities for defined operations, rule-based guidelines offer a simple yet effective method for tailoring opioid prescribing to in-hospital consumption.

Excess Fatal Overdoses in the United States During the COVID-19 Pandemic by Geography and Substance Type: March 2020-August 2021

Objectives. To assess heterogeneity in pandemic-period excess fatal overdoses in the United States, by location (state, county) and substance type. Methods. We used seasonal autoregressive integrated moving average (SARIMA) models to estimate counterfactual death counts in the scenario that no pandemic had occurred. Such estimates were subtracted from actual death counts to assess the magnitude of pandemic-period excess mortality between March 2020 and August 2021. Results. Nationwide, we estimated 25 668 (95% prediction interval [PI] = 2811, 48 524) excess overdose deaths. Specifically, 17 of 47 states and 197 of 592 counties analyzed had statistically significant excess overdose-related mortality. West Virginia, Louisiana, Tennessee, Kentucky, and New Mexico had the highest rates (20-37 per 100 000). Nationally, there were 5.7 (95% PI = 1.0, 10.4), 3.1 (95% PI = 2.1, 4.2), and 1.4 (95% PI = 0.5, 2.4) excess deaths per 100 000 involving synthetic opioids, psychostimulants, and alcohol, respectively. Conclusions. The steep increase in overdose-related mortality affected primarily the southern and western United States. We identified synthetic opioids and psychostimulants as the main contributors. Public Health Implications. Characterizing overdose-related excess mortality across locations and substance types is critical for optimal allocation of public health resources. (Am J Public Health. 2024;114(6):599-609. https://doi.org/10.2105/AJPH.2024.307618).

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Motivations for Misusing Opioids Among African Americans

BACKGROUND

A wide range of opioid misuse motives have been documented in the literature, including to relieve physical pain, feel good/get high, relax, manage feelings/emotions, sleep, and moderate the effects of other substances. Despite a rise in opioid misuse among African Americans over the last 2 decades, their motivations for misuse remain unclear. Much of the research on opioid misuse motivations either rely on samples with little racial diversity or do not stratify their findings by race. As a result, less is known about the specific reasons why African Americans engage in opioid misuse. The objective of this study, therefore, was to identify and explain the most common motives for misusing opioids among African Americans. Qualitative interview data are also presented to explain/contextualize the most prevalent motivations.

METHODS

This study used data from the Florida Minority Health Survey, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of African Americans. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida.

RESULTS

Analyses revealed that while some (33.9%) misused opioids for purposes of recreation/sensation seeking (eg, feel good/get high), the majority (66.1%) were attempting to self-treat perceived medical symptoms (eg, physical pain, anxiety/trauma, withdrawals, insomnia).

CONCLUSIONS

This study contributes to a better understanding of why some African Americans engage in opioid misuse and findings highlight the need for interventions to be trauma informed and address unmanaged physical pain among African Americans. Given that most studies on motivations are quantitative in nature, the study contributes to the literature by capturing the voices of African Americans who use drugs.

Excellent hepatitis C virus cure rates despite increasing complexity of people who use drugs: Integrated-Test-stage Treat study final outcomes

Achieving hepatitic C virus (HCV) elimination requires linking people who use drugs (PWUD) into care. We report final direct-acting antivirals (DAAs)-based outcomes from the Integrated-Test-stage -Treat (ITTREAT) study. Project ITTREAT (2013-2021), based at an addiction centre, was a 'one-stop' service with innovative linkage to care strategies. Primary outcome was sustained virological response (SVR12) (intention to treat ITT) including whether individuals were recruited in first (period 1) versus last four (period 2 included the COVID-19 pandemic) years of the study. Number recruited were n = 765, mean age 40.9 ± 10.1 years, 78% males, history of current/past injecting drug use (IDU) and alcohol use being 77% and 90%, respectively. Prevalence of a positive HCV PCR was 84% with 19% having cirrhosis. Comparing those recruited in period 2 versus period 1, there was increasing prevalence of IDU, 90% versus 72% (p < .001); homelessness, 67% versus 50% (p < .001); psychiatric diagnosis, 84% versus 50% (p < .001); overdose history 71% versus 31% (p < .001), receiving opioid agonist treatment (OAT) 75% versus 52% (p < .001) and comorbidity 44% versus 25% (p < .001). Of those treated with DAAs (n = 272), ITT SVR rates were 86% (95% CI: 81%-90%), being similar in period 2 versus period 1. Predictors of non-SVR were receiving OAT (OR 0.33, 95% CI: 0.12-0.87, p = .025) and ≥80% adherence (OR 0.01, 95% CI: 0.003-0.041, p < .001). Reinfection rates period 2 versus period 1 (per 100 person-years) were 1.84 versus 1.70, respectively. In the treated cohort, mortality was 15%, being mostly drug-related. Despite increasing complexity of PWUD, high SVR12 rates are achievable with use of OAT and good adherence.

Forecasting drug-overdose mortality by age in the United States at the national and county levels

The drug-overdose crisis in the United States continues to intensify. Fatalities have increased 5-fold since 1999 reaching a record high of 108,000 deaths in 2021. The epidemic has unfolded through distinct waves of different drug types, uniquely impacting various age, gender, race, and ethnic groups in specific geographical areas. One major challenge in designing interventions and efficiently delivering treatment is forecasting age-specific overdose patterns at the local level. To address this need, we develop a forecasting method that assimilates observational data obtained from the CDC WONDER database with an age-structured model of addiction and overdose mortality. We apply our method nationwide and to three select areas: Los Angeles County, Cook County, and the five boroughs of New York City, providing forecasts of drug-overdose mortality and estimates of relevant epidemiological quantities, such as mortality and age-specific addiction rates.

Navigating addiction treatment during COVID-19: policy insights from state health leaders

To mitigate pandemic-related disruptions to addiction treatment, US federal and state governments made significant changes to policies regulating treatment delivery. State health agencies played a key role in implementing these policies, giving agency leaders a distinct vantage point on the feasibility and implications of post-pandemic policy sustainment. We interviewed 46 state health agency and other leaders responsible for implementing COVID-19 addiction treatment policies across 8 states with the highest COVID-19 death rate in their census region. Semi-structured interviews were conducted from April through October 2022. Transcripts were analyzed using summative content analysis to characterize policies that interviewees perceived would, if sustained, benefit addiction treatment delivery long-term. State policies were then characterized through legal database queries, internet searches, and analysis of existing policy databases. State leaders viewed multiple pandemic-era policies as useful for expanding addiction treatment access post-pandemic, including relaxing restrictions for telehealth, particularly for buprenorphine induction and audio-only treatment; take-home methadone allowances; mobile methadone clinics; and out-of-state licensing flexibilities. All states adopted at least 1 of these policies during the pandemic. Future research should evaluate these policies outside of the acute COVID-19 pandemic context.

Understanding the Public Health Role, Motivations, and Perceptions of Community Health Workers Deployed to Low-Income Housing in Richmond, Virginia

BACKGROUND

For the US health indicators to improve to the level of other developed countries, the use of Community Health Workers (CHWs) in vulnerable populations has been indicated as a possible long-term intervention. There are few models of long-term deployment of CHWs as part of the district level public health system in the US.

METHOD

In this study we interviewed CHWs who served as neighborhood-integrated health district staff assigned to low-income housing in Richmond, Virginia for 10 years. Qualitative analyses of their taped and transcribed interviews resulted in 5 themes from the interviews. The themes were Activities, Satisfaction, Strengths, Facilitation/Resources and Challenges. We highlighted quotes from the CHWs interviews for themes and summarized the findings from each theme.

RESULTS

CHWs carried out a variety of activities daily and these were described. The CHWs were generally satisfied with their job because it enabled them to assist others. The strength of their communities was resilience, and the resources they needed more included physical resources, human resources, political support, and more comprehensive programming. Their client's challenges include transportation, mental health, and physical safety and the CHWs challenge to effectively carrying out their work with clients was trust by community members.

CONCLUSION

The information garnered from the CHWs would be useful in designing CHW programs at other health districts.

"It's Also Pushed People to a New Level of Desperation:" COVID-19 Impacts on Experiences of Persons Who Use Illicit Opioids

The purpose of this qualitative study is to characterize the impacts of the COVID-19 pandemic on drug use experiences among persons who use illicit opioids (PWUO) in Arizona. Between 12/2020 and 05/2021, interviews were conducted via Zoom with 22 PWUO from across Arizona. Participants were recruited through Craigslist and social media ads, referrals by a local harm reduction organization, and other participants. The interviews were transcribed and analyzed using NVivo. Participants were 25-51 years of age, 36% were female, and 55% non-Hispanic White. Most reported past month use of heroin, and/or counterfeit (pressed) non-pharmaceutical fentanyl (NPF) pills. Nearly all reported changes in their drug use during the pandemic. Participants discussed profound negative impacts of social isolation with escalating mental health problems, boredom, and ease of hiding drug use from others, leading to increases in drug use. Loss of daily routines, employment difficulties, and challenges of accessing treatment due to COVID-19 restrictions were also driving factors for increased drug use. The growing availability of NPF pills during the pandemic led many individuals to transition from heroin to more frequent NPF pill use. The results emphasize the need for quality behavioral care services with an increased focus on economic and social support systems.

Impact of the COVID-19 Pandemic on the Management of Juvenile Idiopathic Arthritis: Analysis of United States Commercial Insurance Data

BACKGROUND/OBJECTIVE

Given limited information on health care and treatment utilization for juvenile idiopathic arthritis (JIA) during the pandemic, we studied JIA-related health care and treatment utilization in a commercially insured retrospective US cohort.

METHODS

We studied rates of outpatient visits, new disease-modifying antirheumatic drug (DMARD) initiations, intra-articular glucocorticoid injections (iaGC), dispensed oral glucocorticoids and opioids, DMARD adherence, and DMARD discontinuation by quarter in March 2018-February 2021 (Q1 started in March). Incident rate ratios (IRR, pandemic vs prepandemic) with 95% confidence intervals (CIs) were estimated using multivariable Poisson or Quasi-Poisson models stratified by diagnosis recency (incident JIA, <12 months ago; prevalent JIA, ≥12 months ago).

RESULTS

Among 1294 children diagnosed with JIA, total and in-person outpatient visits for JIA declined during the pandemic (IRR, 0.88-0.90), most markedly in Q1 2020. Telemedicine visits, while higher during the pandemic, declined from 21% (Q1) to 13% (Q4) in 2020 to 2021. During the pandemic, children with prevalent JIA, but not incident JIA, had lower usage of iaGC (IRR, 0.60; 95% CI, 0.34-1.07), oral glucocorticoids (IRR, 0.47; 95% CI, 0.33-0.67), and opioids (IRR, 0.44; 95% CI, 0.26-0.75). Adherence to and discontinuation of DMARDs was similar before and during the pandemic.

CONCLUSIONS

In the first year of the pandemic, visits for JIA dropped by 10% to 12% in commercially insured children in the United States, declines partly mitigated by use of telemedicine. Pandemic-related declines in intra-articular glucocorticoids, oral glucocorticoids, and opioids were observed for children with prevalent, but not incident, JIA. These changes may have important implications for disease control and quality of life.

Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model

BACKGROUND

Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY).

METHODS

To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations.

RESULTS

Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program.

CONCLUSIONS

These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic

OBJECTIVES

Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic.

DESIGN

Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases.

SETTING

USA.

PARTICIPANTS

Patients who were dispensed methadone at US opioid treatment programmes (OTPs).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone.

RESULTS

Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p<0.001) and from 2015 to 2020 (+26.22%, p<0.001). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%, p=0.491). There was considerable state-level variation in methadone prescribing to Medicaid patients with four states having no prescriptions.

CONCLUSIONS

There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.

The association between community social vulnerability and prescription opioid availability with individual opioid overdose

BACKGROUND

This study aims to assess the association of community social vulnerability and community prescription opioid availability with individual non-fatal or fatal opioid overdose.

METHODS

We identified patients 12 years of age or older from the Oregon All Payer Claims database (APCD) linked to other public health datasets. Community-level characteristics were captured in an exposure period (EP) (1/1/2018-12/31/2018) and included: census tract-level social vulnerability domains (socio-economic status, household composition, racial and ethnic minority status, and housing type and transportation), census tract-level prescriptions and community-level opioid use disorder (OUD) diagnoses per 100 capita binned into quartiles or quintiles. We employed Cox models to estimate the risk of fatal and non-fatal opioid overdoses events in the 12 months following the EP.

MAIN FINDINGS

We identified 1,548,252 individuals. Patients were mostly female (54%), White (61%), commercially insured (54%), and lived in metropolitan areas (81%). Of the total sample, 2485 (0.2%) experienced a non-fatal opioid overdose and 297 died of opioid overdose. There was higher hazard for non-fatal overdose in communities with greater OUD per 100 capita. We also found higher non-fatal and fatal hazards for opioid overdose among patients in communities with higher housing type and transportation-related vulnerability compared to the lowest quintile. Conversely, patients were at less risk of opioid overdose when living in communities with greater prevalence of the young or the elderly, the disabled, single parent families or low English proficiency.

CONCLUSION

These findings underscore the importance of the environmental context when considering public health policies to reduce opioid harms.

Telemedicine Buprenorphine Initiation and Retention in Opioid Use Disorder Treatment for Medicaid Enrollees

Importance

Early COVID-19 mitigation strategies placed an additional burden on individuals seeking care for opioid use disorder (OUD). Telemedicine provided a way to initiate and maintain transmucosal buprenorphine treatment of OUD.

Objective

To examine associations between transmucosal buprenorphine OUD treatment modality (telemedicine vs traditional) during the COVID-19 public health emergency and the health outcomes of treatment retention and opioid-related nonfatal overdose.

Design, Setting, and Participants

This retrospective cohort study was conducted using Medicaid claims and enrollment data from November 1, 2019, to December 31, 2020, for individuals aged 18 to 64 years from Kentucky and Ohio. Data were collected and analyzed in June 2022, with data updated during revision in August 2023.

Exposures

The primary exposure of interest was the modality of the transmucosal buprenorphine OUD treatment initiation. Relevant patient demographic and comorbidity characteristics were included in regression models.

Main Outcomes and Measures

There were 2 main outcomes of interest: retention in treatment after initiation and opioid-related nonfatal overdose after initiation. For outcomes measured after initiation, a 90-day follow-up period was used. The main analysis used a new-user study design; transmucosal buprenorphine OUD treatment initiation was defined as initiation after more than a 60-day gap in buprenorphine treatment. In addition, uptake of telemedicine for buprenorphine was examined, overall and within patients initiating treatment, across quarters in 2020.

Results

This study included 41 266 individuals in Kentucky (21 269 women [51.5%]; mean [SD] age, 37.9 [9.0] years) and 50 648 individuals in Ohio (26 425 women [52.2%]; mean [SD] age, 37.1 [9.3] years) who received buprenorphine in 2020, with 18 250 and 24 741 people initiating buprenorphine in Kentucky and Ohio, respectively. Telemedicine buprenorphine initiations increased sharply at the beginning of 2020. Compared with nontelemedicine initiation, telemedicine initiation was associated with better odds of 90-day retention with buprenorphine in both states (Kentucky: adjusted odds ratio, 1.13 [95% CI, 1.01-1.27]; Ohio: adjusted odds ratio, 1.19 [95% CI, 1.06-1.32]) in a regression analysis adjusting for patient demographic and comorbidity characteristics. Telemedicine initiation was not associated with opioid-related nonfatal overdose (Kentucky: adjusted odds ratio, 0.89 [95% CI, 0.56-1.40]; Ohio: adjusted odds ratio, 1.08 [95% CI, 0.83-1.41]).

Conclusions and Relevance

In this cohort study of Medicaid enrollees receiving buprenorphine for OUD, telemedicine buprenorphine initiation was associated with retention in treatment early during the COVID-19 pandemic. These findings add to the literature demonstrating positive outcomes associated with the use of telemedicine for treatment of OUD.

Social Media and Selfie-Related Mortality Amid COVID-19: Interrupted Time Series Analysis

BACKGROUND

COVID-19 had a considerable impact on mortality, but its effect on behaviors associated with social media remains unclear. As travel decreased due to lockdowns during the pandemic, selfie-related mortality may have decreased, as fewer individuals were taking smartphone photographs in risky locations.

OBJECTIVE

In this study, we examined the effect of the COVID-19 pandemic on trends in selfie-related mortality.

METHODS

We identified fatal selfie-related injuries reported in web-based news reports worldwide between March 2014 and April 2021, including the deaths of individuals attempting a selfie photograph or anyone else present during the incident. The main outcome measure was the total number of selfie-related deaths per month. We used interrupted time series regression to estimate the monthly change in the number of selfie-related deaths over time, comparing the period before the pandemic (March 2014 to February 2020) with the period during the pandemic (March 2020 to April 2021).

RESULTS

The study included a total of 332 selfie-related deaths occurring between March 2014 and April 2021, with 18 (5.4%) deaths during the pandemic. Most selfie-related deaths occurred in India (n=153, 46.1%) and involved men (n=221, 66.6%) and young individuals (n=296, 89.2%). During the pandemic, two-thirds of selfie-related deaths were due to falls, whereas a greater proportion of selfie-related deaths before the pandemic were due to drowning. Based on interrupted time series regression, there was an average of 1.3 selfie-related deaths per month during the pandemic, compared with 4.3 deaths per month before the pandemic. The number of selfie-related deaths decreased by 2.6 in the first month of the pandemic alone and continued to decrease thereafter.

CONCLUSIONS

Our findings indicate that the COVID-19 pandemic led to a marked decrease in selfie-related mortality, suggesting that lockdowns and travel restrictions likely prevented hazardous selfie-taking. The decrease in selfie-related mortality occurred despite a potential increase in social media use during the pandemic.

Rural communities face more than an opioid crisis: Reimagining funding assistance to address polysubstance use, associated health problems, and limited rural service capacity

PURPOSE

Rural communities in the United States face unique challenges related to the opioid epidemic. This paper explores the substances and substance-related health problems that pose the greatest concern to rural communities that received funding to address the opioid epidemic and examines their reported capacity to address these challenges.

METHODS

This paper analyzed data collected as part of quarterly progress reporting from multisector consortiums across 2 cohorts of grantees funded to reduce the morbidity and mortality of opioids. Consortium project directors ranked the top 3 issues in their community in each of the following categories: (1) drugs of concern; (2) drugs with the least capacity to address; (3) related problem areas of concern (eg, neonatal abstinence syndrome [NAS]); and (4) related problem areas with the least capacity to address.

FINDINGS

Methamphetamines, fentanyl, and alcohol were the substances rated as most problematic in rural communities funded to address the opioid epidemic across all reporting periods. Over 40% of respondents ranked methamphetamine as a top concern and the substance they had the least capacity to address. This was nearly double the percentage of the next highest-ranked substance (fentanyl). Overdoses, NAS, and viral hepatitis constituted the top-ranking related concerns, with limited capacity to address them.

CONCLUSIONS

Multiple drug and concomitant problems coalesced on rural communities during the opioid epidemic. Funding communities to address substance use disorders and related problems of concern, rather than targeting funding toward a specific type of drug, may result in better health outcomes throughout the entire community.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development of a vaccine against the synthetic opioid U-47700

Opioid use disorders and overdose have become a major public health concern in recent years. U-47700, a New psychoactive substances (NPS) opioid, also known as "pinky" or "pink" has been identified as a new threat in the drug supply because of its potency and abuse potential. Conjugate vaccines that can produce antibodies against target drug molecules have emerged as a promising tool to treat substance use disorders. Herein, we report the design, synthesis, and in vivo characterization of a U-47700 vaccine. The vaccine demonstrated favorable results with rodents producing elevated levels of antibody titer and sub-micromolar affinity to U-47700. In addition, antibodies generated by the vaccine effectively mitigated drug-induced effects by preventing the drug from penetrating the blood-brain barrier, which was verified by antinociception and drug biodistribution studies. The development of a vaccine against U-47700 and other NPS opioids contributes to the continued advancement of non-conventional pharmacological treatments to address the global opioid epidemic.

The role of polysubstance use on criminal justice involvement in the United States

PURPOSE OF REVIEW

Polysubstance use, broadly defined as using more than one type of substance, disproportionately impacts those involved in the criminal justice system (CJS). This review synthesizes recent findings on polysubstance use among those involved in the CJS and highlights areas of particular concern and interventions.

RECENT FINDINGS

We use 18 recent articles to identify the prevalence and types of criminal justice involvement and correlates of polysubstance use and criminal justice involvement. We highlight latent patterns of polysubstance use among various criminal justice populations (adults, pregnant women, and youth) and differential associations with adverse substance use and criminal justice outcomes. Lastly, we discuss substance use treatment in the justice system, the role of polysubstance use in treatment access and outcomes, and substance use-related services for previously incarcerated individuals reentering society.

SUMMARY

Current research provides further evidence of the syndemic nature of polysubstance use, criminal justice involvement, and adverse outcomes, which are complicated by significant barriers to accessing evidence-based treatment in justice settings. Yet, current research is limited due to methodological inconsistency and limited focus on the social determinants of health, racial/ethnic disparities, and interventions to increase treatment and reentry services.

Disruptions to naloxone training among lay and occupational responders in Maryland during the emergence of COVID-19: early impacts, recovery, and lessons learned

Background

: Opioid overdose death rates increased during the COVID-19 pandemic. Disruptions in community-based naloxone trainings could have reduced the likelihood of overdose reversal and increased the chances of a fatal overdose. We investigated changes in the number of people trained in naloxone administration and distribution in Maryland before, during, and after COVID-related stay-at-home orders.

Methods

: Data on naloxone training are from the Maryland Department of Health. We used interrupted time series models to estimate changes in average monthly number of people trained: [1] pre-interruption (4/2019-3/2020), [2] 1-month post-interruption (4/2020-5/2020), and [3] 12-months post-interruption (4/2020-3/2021). Trainees were classified as lay (e.g., people who use drugs) or occupational (e.g., law enforcement officers and harm reduction workers) responders.

Results

: There were 101,332 trainees; 54.1% lay, 21.5% occupational, and 23.4% unknown responder status. We observed a decrease in the average monthly number of trainees in the pre-interruption period (-235, p<0.001), a larger decrease of 93.2% during the 1-month post-interruption (-846, p=0.013), and an increase 12-months post-interruption (+217, p<0.001). There was a significant decrease among occupational responders 1-month post-interruption, and a significant increase among lay responders in the 12-month post-interruption period.

Conclusions

: Findings suggest a marked decrease in naloxone trainees immediately after stay-at-home order, followed by a moderate rebound in the 12-months after stay-at-home order. The decrease in occupational responders trained may have limited access to naloxone, but would likely have been offset by increases in number of lay responders trained. Strengthening lay and occupational responder connections could maintain naloxone distribution during public health crises.

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.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

Importance

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).

Objective

To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.

Design, Setting, and Participants

This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.

Exposure

Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.

Main Outcomes and Measures

Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.

Results

Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.

Conclusions and Relevance

In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Thematic Analysis of State Medicaid Buprenorphine Prior Authorization Requirements

Importance

Prior authorization (PA) requirements for buprenorphine are associated with lower provision of the medication for the treatment of opioid use disorder (OUD). While Medicare plans have eliminated PA requirements for buprenorphine, many Medicaid plans continue to require them.

Objective

To describe and classify buprenorphine coverage requirements based on thematic analysis of state Medicaid PA forms.

Design, Setting, and Participants

This qualitative study used a thematic analysis of 50 states' Medicaid PA forms for buprenorphine between November 2020 and March 2021. Forms were obtained from the jurisdiction's Medicaid websites and assessed for features suggesting barriers to buprenorphine access. A coding tool was developed based on a review of a sample of forms, including fields for behavioral health treatment recommendations or mandates, drug screening requirements, and dosage limitations.

Main Outcomes and Measures

Outcomes included PA requirements for different buprenorphine formulations. Additionally, PA forms were evaluated for various criteria such as behavioral health, drug screenings, dose-related recommendations or mandates or patient education.

Results

Among the total of 50 US states in the analysis, most states' Medicaid plans required PA for at least 1 formulation of buprenorphine. However, the majority did not require a PA for buprenorphine-naloxone. Four key themes of coverage requirements were identified: restrictive surveillance (eg, requirements for urine drug screenings, random drug screenings, pill counts), behavioral health treatment recommendations or mandates (eg, mandatory counseling or 12-step meeting attendance), interfering with or restricting medical decision-making (eg, maximum daily dosages of 16 mg, requiring additional steps for dosages higher than 16 mg), and patient education (eg, information about adverse effects and interactions with other medications). Eleven states (22%) required urine drug screenings, 6 states (12%) required random urine drug screenings, and 4 states (8%) required pill counts. Fourteen states' forms (28%) recommended therapy, and 7 (14%) required therapy, counseling, or participation in group sessions. Eighteen states (36%) specified dosage maximums; among them, 11 (22%) required additional steps for a daily dosage higher than 16 mg.

Conclusion

In this qualitative study of state Medicaid PA requirements for buprenorphine, themes were identified that included patient surveillance with drug screenings and pill counts, behavioral health treatment recommendations or mandates, patient education, and dosing guidance. These results suggest that state Medicaid plans' buprenorphine PA requirements for OUD are in conflict with existing evidence and may negatively affect states' efforts to address the opioid overdose crisis.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Impact of COVID-19 on poisoning-related mortality in Iran: An interrupted time series study

BACKGROUND

The COVID-19 pandemic had many negative effects worldwide. These effects involved mental health status issues such as suicide, depression, and the pattern of death associated with drug/poisonings. One of the major concerns of the healthcare community during the pandemic was mortality from poisonings. This study aimed to investigate the trends of mortality from different types of poisonings before and after COVID-19.

METHODS

The patients who died from six different categories of drugs or poisons were identified by forensic analysis of body fluids/tissues in Tehran, Iran. The pandemic was separated into the pre-COVID-19 period (April 2018 to January 2020), and the COVID pandemic (February 2020-April 2022). Demographic characteristics were collected from each victim, and comparisons of death trends before and after the pandemic were conducted using the interrupted time series analysis. The absolute number of deaths and proportion of deaths from each type of drug/poisoning were used for the analyses.

RESULTS

A total of 6,316 deaths from drugs/poisoning were identified between April 2018-Mar 2022). During this period, 2,485 deaths occurred pre-COVID, and 3,831 were during the COVID-19 era. There were no statistical differences in terms of demographic characteristics before and after the pandemic, except for job status. There was a sharp increase in proportion of methanol death among all poisonings after the start of the pandemic (16.5%, p-value = 0.025), while there was a decreasing trend during the pandemic (-0.915 deaths monthly, p-value = 0.027). The trends for opioids, stimulants, and drug-related deaths changed from decreasing to increasing. No change was seen in the trends for ethanol and volatile substance deaths. This pattern was mirrored in the proportion of each type of poisoning relative to the total number.

CONCLUSION

Changes in poisoning-related mortality patterns showed dramatic changes after the start of the pandemic, especially deaths from methanol. Other poisonings such as opioids, stimulants, and drugs should also be addressed as there was an increasing trend during the COVID-19 period, compared to the pre-COVID data.

Impact of COVID-19 & Response Measures on HIV-HCV Prevention Services and Social Determinants in People Who Inject Drugs in 13 Sites with Recent HIV Outbreaks in Europe, North America and Israel

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011-2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

A patient-centered nurse-supported primary care-based collaborative care program to treat opioid use disorder and depression: Design and protocol for the MI-CARE randomized controlled trial

BACKGROUND

Opioid use disorder (OUD) contributes to rising morbidity and mortality. Life-saving OUD treatments can be provided in primary care but most patients with OUD don't receive treatment. Comorbid depression and other conditions complicate OUD management, especially in primary care. The MI-CARE trial is a pragmatic randomized encouragement (Zelen) trial testing whether offering collaborative care (CC) to patients with OUD and clinically-significant depressive symptoms increases OUD medication treatment with buprenorphine and improves depression outcomes compared to usual care.

METHODS

Adult primary care patients with OUD and depressive symptoms (n ≥ 800) from two statewide health systems: Kaiser Permanente Washington and Indiana University Health are identified with computer algorithms from electronic Health record (EHR) data and automatically enrolled. A random sub-sample (50%) of eligible patients is offered the MI-CARE intervention: a 12-month nurse-driven CC intervention that includes motivational interviewing and behavioral activation. The remaining 50% of the study cohort comprise the usual care comparison group and is never contacted. The primary outcome is days of buprenorphine treatment provided during the intervention period. The powered secondary outcome is change in Patient Health Questionnaire (PHQ)-9 depression scores. Both outcomes are obtained from secondary electronic healthcare sources and compared in "intent-to-treat" analyses.

CONCLUSION

MI-CARE addresses the need for rigorous encouragement trials to evaluate benefits of offering CC to generalizable samples of patients with OUD and mental health conditions identified from EHRs, as they would be in practice, and comparing outcomes to usual primary care. We describe the design and implementation of the trial, currently underway.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05122676. Clinical trial registration date: November 17, 2021.

Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Enumerating contributions of fentanyls and other factors to the unprecedented 2020 rise in opioid overdose deaths: model-based analysis

In 2020, the ongoing US opioid overdose crisis collided with the emerging COVID-19 pandemic. Opioid overdose deaths (OODs) rose an unprecedented 38%, due to a combination of COVID-19 disrupting services essential to people who use drugs, continued increases in fentanyls in the illicit drug supply, and other factors. How much did these factors contribute to increased OODs? We used a validated simulation model of the opioid overdose crisis, SOURCE, to estimate excess OODs in 2020 and the distribution of that excess attributable to various factors. Factors affecting OODs that could have been disrupted by COVID-19, and for which data were available, included opioid prescribing, naloxone distribution, and receipt of medications for opioid use disorder. We also accounted for fentanyls' presence in the heroin supply. We estimated a total of 18,276 potential excess OODs, including 1,792 lives saved due to increases in buprenorphine receipt and naloxone distribution and decreases in opioid prescribing. Critically, growth in fentanyls drove 43% (7,879) of the excess OODs. A further 8% is attributable to first-ever declines in methadone maintenance treatment and extended-released injectable naltrexone treatment, most likely due to COVID-19-related disruptions. In all, 49% of potential excess OODs remain unexplained, at least some of which are likely due to additional COVID-19-related disruptions. While the confluence of various COVID-19-related factors could have been responsible for more than half of excess OODs, fentanyls continued to play a singular role in excess OODs, highlighting the urgency of mitigating their effects on overdoses.

Methamphetamine-Related Mortality in the United States: Co-Involvement of Heroin and Fentanyl, 1999-2021

Objectives. To examine trends in methamphetamine-related mortality in the United States from 1999 to 2021 and the extent to which these deaths co-involved heroin or fentanyl. Methods. We obtained final and provisional data from the CDC WONDER (Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research) multiple causes of death database for deaths that involved methamphetamine and deaths that involved both methamphetamine and heroin or fentanyl mong US residents aged 15 to 74 years. We plotted the age-adjusted methamphetamine-related mortality rate by year and quantified the proportion of deaths with heroin or fentanyl co-involvement. Finally, we used joinpoint regression to quantify trends in the methamphetamine mortality rate and proportion of deaths with heroin or fentanyl co-involvement. Results. From 1999 to 2021, there was a 50-fold increase in the methamphetamine mortality rate, which was accompanied by an increasing proportion of deaths that co-involved heroin or fentanyl, peaking at 61.2% in 2021. Conclusions. Unprecedented increases in methamphetamine-related mortality have occurred during the last decade, and an increasing proportion of these deaths co-involved heroin or fentanyl. Public Health Implications. Stark increases in methamphetamine-related mortality and heroin or fentanyl co-involvement warrant robust harm reduction efforts, especially for people who engage in polysubstance use. (Am J Public Health. 2023;113(4):416-419. https://doi.org/10.2105/AJPH.2022.307212).

Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone

INTRODUCTION

Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey.

METHODS

We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic.

RESULTS

Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant.

CONCLUSIONS

Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.

Opioid overdose prevention education in Texas during the COVID-19 pandemic

BACKGROUND

Distribution of naloxone and training on its proper use are evidence-based strategies for preventing opioid overdose deaths. In-person naloxone training was conducted in major metropolitan areas and urban centers across Texas as part of a state-wide targeted opioid response program. The training program transitioned to a live, virtual format during the COVID-19 public health emergency declaration. This manuscript describes the impact of this transition through analyses of the characteristics of communities reached using the new virtual training format.

CASE PRESENTATION

Training participant addresses were compared to county rates of opioid overdose deaths and broadband internet access, and census block comparison to health services shortages, rural designation, and race/ethnicity community characteristics.

CONCLUSIONS

The virtual training format reached more learners than the in-person events. Training reached nearly half of the counties in Texas, including all with recent opioid overdose deaths. Most participants lived in communities with a shortage of health service providers, and training reached rural areas, those with limited broadband internet availability, and majority Hispanic communities. In the context of restrictions on in-person gathering, the training program successfully shifted to a live, online format. This transition increased participation above rates observed pre-pandemic and reached communities with the need for equipping those most likely to witness an opioid overdose with the proper use of naloxone.

Substance Use and the Self-Management of Persistent Symptoms of COVID-19

Background: Understanding the self-management practices of persistent symptoms of SARS-Cov-2 (COVID-19) is critical given the misinformation that has been presented about this disease in the U.S. The purpose of this descriptive study is to assess the self-management of persistent symptoms of COVID-19 with commonly used and misused substances (i.e., alcohol, marijuana and commonly prescribed medications) among adults in the U.S. Methods: The data for this study comes from a cross-sectional survey of U.S. adults that was designed to broadly assess symptom burden, persistent symptom patterns, self-efficacy for symptom management and self-management strategies among people who experienced persistent/Long COVID. Multiple logistic regression analyses were used to assess how symptom length of COVID-19 was associated with the use of several substances to manage these persistent symptoms. Results: The analysis found that adults who had COVID-19 symptoms that persisted for 13 weeks or longer had higher rates of using alcohol (27.3%), marijuana (30.9%) and prescription tranquilizers (21.4%) to manage these symptoms when compared to their adult peers who had COVID-19 symptoms persist for only 4 weeks or less. For instance, the odds of indicating the use of marijuana (AOR = 4.21 95% CI = 1.68,10.5) to manage COVID-19 related symptoms was roughly four times higher for respondents who had COVID-19 symptoms persist for 13 weeks or longer when compared to respondents whose COVID-19 symptoms persisted for only 4 weeks or less. Conclusion: The findings suggest that screening of substance use disorders should be considered among healthcare providers who are treating adults who have persistent symptoms of COVID-19.

Priming COVID-19's consequences can increase support for investments in public health

Can messaging that emphasizes the costs of COVID-19 increase popular support for more proactive public health policies? People who experience disasters often become more supportive of policies to address their underlying causes, and the pandemic may have similar spillover effects for public opinion. To test this idea, the study implements a survey experiment in Italy, Germany, and the United States in which half of the respondents were randomly assigned to a prime about the impact of the pandemic prior to answering questions about their support for public health policies. The results show that respondents who received the prime became more favorable toward increased government spending on domestic and foreign public health programs alike. These treatment effects were consistent across countries, across two different surveys in the United States conducted at different points in time, and across partisan subgroups. However, the treatment did not consistently increase support for more active and intrusive government policies to address specific public health challenges like smoking or HIV/AIDS. The results suggest that public health advocates may benefit from messaging that connects COVID-19 to the need for public health funding beyond the context of the pandemic.

A counterfactual analysis of opioid-involved deaths during the COVID-19 pandemic using a spatiotemporal random forest modeling approach

The global pandemic of SARS-CoV-2 (COVID-19) has been linked to adversely impacting individuals with opioid use disorder in the United States. This study focuses on analyzing opioid-involved mortality in the context of COVID-19 in the U.S. from a geospatial perspective. We investigated spatiotemporal patterns of opioid-involved deaths during 2020 and compared the spatiotemporal pattern of these deaths with patterns for the previous three years (2017-2019) to understand changes in the context of the COVID-19 pandemic. A counterfactual analysis framework together with a space-time random forest (STRF) model were used to estimate the increase in opioid-involved deaths related to the pandemic. To gain further insight into the relationship between opioid deaths and COVID-19-related factors, we built a space-time random forest model for the City of Chicago, that experienced a steep increase in opioid-related deaths during 2020. High ranking indicators identified by the model such as the number of positive COVID-19 cases adjusted by population and the change in stay-at-home dwell time during the pandemic were used to generate a vulnerability index for opioid overdoses during the COVID-19 pandemic in Chicago.

Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015-2020

BACKGROUND AND OBJECTIVES

Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine can reduce the risk of overdose, however they are underutilized. A better understanding of buprenorphine prescribing to youth will help inform interventions to expand access to treatment.

METHODS

We used IQVIA data to examine buprenorphine dispensing trends among youth aged ≤19 years from 2015 to 2020. Dispensing was examined by prescriber specialty, age, and sex. Data were weighted to provide national estimates.

RESULTS

The rate of buprenorphine dispensed to youth decreased 25% over the study period, from 0.84 to 0.63 prescriptions per 1000 youth per year. The proportion of youth dispensed buprenorphine also decreased 45%, from 7.6 to 4.2 persons per 100 000 per year. Over the same time, the proportion of adults aged ≥20 years dispensed buprenorphine increased 47%, from 378 to 593 persons per 100 000. Differences in dispensing by sex and temporal trends were also noted. Pediatricians accounted for less-than 2% of all prescriptions dispensed.

CONCLUSIONS

Buprenorphine dispensing to youth is low and declining in recent years. Given rates of opioid use disorder among youth, these findings suggest that many youth who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving training in opioid use disorder treatment of pediatricians and encouraging all clinicians who care for adolescents and young adults to obtain waivers to prescribe buprenorphine for MOUD.

Discontinuation of Buprenorphine Treatment for Opioid Use Disorder During the Coronavirus Disease-2019 Pandemic: A Multilevel Framework

BACKGROUND

The coronavirus disease-2019 pandemic has been associated with large increases in opioid-related mortality, yet it is unclear whether specific subpopulations were especially likely to discontinue buprenorphine treatment for opioid use disorder as the pandemic ensued.

OBJECTIVE

The aim was to assess predictors of buprenorphine discontinuation in the early months of the coronavirus disease-2019 pandemic (April-July 2020) compared with a prepandemic period (April-July 2019).

DESIGN

In each time period, we estimated a multilevel regression models to assess risk of discontinuation in April-July for people who started buprenorphine in January-February. Models included person-level, prescriber-level, and area-level covariates.

SUBJECTS

Individuals age 18 years or older in the all-payer IQVIA Longitudinal Prescription Claims.

MEASURES

The primary outcome was buprenorphine discontinuation (ie, no filled prescriptions during the follow-up periods).

RESULTS

Overall, 13.98% of patients discontinued buprenorphine in April-July 2020, less than the 15.71% in 2019 (P<0.001). In 2020, patient-level factors associated with discontinuation included younger age, male sex, shorter baseline possession ratio, and payment by cash. Compared with patients with a primary care physician prescriber, specialties most associated with discontinuation were pain medicine and physician assistant/nurse practitioner. Compared with the South Atlantic region, discontinuation risk was lowest in New England and highest in the West South Central States. The association between patient, prescriber, and geographic variables to risk of discontinuation was very similar in 2019 and 2020.

CONCLUSIONS

While clinical and policy interventions may have mitigated opioid use disorder treatment discontinuation following the pandemic, such discontinuation is nevertheless common and varies by identifiable patient, provider and geographic factors.

The Critical Role of Pharmacists in Treating Older People in the Opioid Crisis

Pharmacy-based Opioid Use Disorder (OUD) treatment has been identified as a central pillar in curbing the spiraling opioid epidemic that claimed more than 100,000 lives in the United States in a one year period for the first time. This epidemic is also partially responsible for the plummeting US life expectancy that began prior to the COVID-19 pandemic and has now claimed more than 500,000 lives since 1999 with more than 70% of the 70,630 overdose deaths in 2019 involved with an opioid. Older people are at increased risk of both OUD and OUD-related complications. Recent studies have demonstrated that people older than 65 years of age were more likely to die of OUD-related complications, and - because of an increased likelihood of polypharmacy - are more likely to experience a drug interaction that magnifies the risk of an opioid-related misadventure.

Increases in drug overdose deaths in Norway and the United States during the COVID-19 pandemic

INTRODUCTION

Little international comparative work exists describing pandemic-related spikes in overdose and related implications for drug and public health policy. We compared increases in overdose deaths during the pandemic in Norway and the United States, two countries in the top 10 for per-capita overdose mortality, yet with very different approaches to the pandemic, healthcare and drug policy.

METHODS

We examined monthly overdoses in 2020 versus baseline rates (the monthly average across 2017-2019). We compared excess overdose mortality to shifts in human mobility and social interaction, measured using cellphone-based mobility data, an indicator of the societal response to the pandemic.

RESULTS

Both the US and Norway saw large magnitude exacerbations in overdose mortality during the pandemic-related lockdowns, reaching 46.8% and 57.0% above baseline, respectively. Maximum increases occurred 2-3 months after peak reductions in mobility, suggesting lagged mechanisms. While overdose mortality returned to baseline relatively quickly in Norway, rates remained elevated in the US to the end of 2020.

CONCLUSIONS

Spikes in overdose mortality in both contexts may relate to disruptions in healthcare access and the drug supply becoming more potent. Norway's quicker return to baseline may reflect more robust access to harm reduction and addiction-related healthcare services. Nevertheless, it is notable that even in Norway - with universal access to high-quality services, low COVID-19 rates, and a highly effective public health infrastructure - a greater than 50% spike in overdose deaths was still seen at the onset of lockdown measures. This may have important implications for future pandemic and disaster planning.

"The Drug Sellers Were Better Organized than the Government": A Qualitative Study of Participants' Views of Drug Markets during COVID-19 and Other Big Events

"Big events", such as wars, economic crises, pandemics, or natural disasters, affect the risk environment in which people use drugs. While the impact of big events on injection risk behaviors and access to drug-treatment services is well documented, less is known about the effects of big events on drug markets. Based on self-reporting data on drug availability among people who use drugs (PWUD) in the aftermath of Hurricane Maria in Puerto Rico and during the COVID-19 lockdown in a Midwestern US state, this study aims to document the effects of big events on drug markets. Qualitative data on the effects of Hurricane Maria on drug markets are based on participants' self-reporting (N = 31). Data collection started after the hurricane and ended in 2020. Data on changes to the drug supply during the COVID-19 lockdown were collected based on semi-structured interviews with PWUD (N = 40) in a Midwestern US state. Findings show that while the drug markets might have initially been affected by big events, most effects were temporary. Drug availability, pricing, and quality might have suffered some initial fluctuations but stabilized as the drug markets absorbed the initial shocks caused by the hurricane and the lockdown measures. In preparation for increasingly more frequent and virulent pandemics and natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also drug-related harms.

Not a waste: Wastewater surveillance to enhance public health

Domestic wastewater, when collected and evaluated appropriately, can provide valuable health-related information for a community. As a relatively unbiased and non-invasive approach, wastewater surveillance may complement current practices towards mitigating risks and protecting population health. Spurred by the COVID-19 pandemic, wastewater programs are now widely implemented to monitor viral infection trends in sewersheds and inform public health decision-making. This review summarizes recent developments in wastewater-based epidemiology for detecting and monitoring communicable infectious diseases, dissemination of antimicrobial resistance, and illicit drug consumption. Wastewater surveillance, a quickly advancing Frontier in environmental science, is becoming a new tool to enhance public health, improve disease prevention, and respond to future epidemics and pandemics.

Geographic information science and the United States opioid overdose crisis: A scoping review of methods, scales, and application areas

BACKGROUND

The Opioid Overdose Crisis (OOC) continues to generate morbidity and mortality in the United States, outpacing other prominent accident-related reasons. Multiple disciplines have applied geographic information science (GIScience) to understand geographical patterns in opioid-related health measures. However, there are limited reviews that assess how GIScience has been used.

OBJECTIVES

This scoping review investigates how GIScience has been used to conduct research on the OOC. Specific sub-objectives involve identifying bibliometric trends, the location and scale of studies, the frequency of use of various GIScience methodologies, and what direction future research can take to address existing gaps.

METHODS

The review was pre-registered with the Open Science Framework ((https://osf.io/h3mfx/) and followed the PRISMA-ScR guidelines. Scholarly research was gathered from the Web of Science Core Collection, PubMed, IEEE Xplore, ACM Digital Library. Inclusion criteria was defined as having a publication date between January 1999 and August 2021, using GIScience as a central part of the research, and investigating an opioid-related health measure.

RESULTS

231 studies met the inclusion criteria. Most studies were published from 2017 onward. While many (41.6%) of studies were conducted using nationwide data, the majority (58.4%) occurred at the sub-national level. California, New York, Ohio, and Appalachia were most frequently studied, while the Midwest, north Rocky Mountains, Alaska, and Hawaii lacked studies. The most common GIScience methodology used was descriptive mapping, and county-level data was the most common unit of analysis across methodologies.

CONCLUSIONS

Future research of GIScience on the OOC can address gaps by developing use cases for machine learning, conducting analyses at the sub-county level, and applying GIScience to questions involving illicit fentanyl. Research using GIScience is expected to continue to increase, and multidisciplinary research efforts amongst GIScientists, epidemiologists, and other medical professionals can improve the rigor of research.

Fatal drug use in the COVID-19 pandemic response: Changing trends in drug-involved deaths before and after stay-at-home orders in Louisiana

The effect of disaster events on increasing drug-involved deaths has been clearly shown in previous literature. As the COVID-19 pandemic led to stay-at-home orders throughout the United States, there was a simultaneous spike in drug-involved deaths around the country. The landscape of a preexisting epidemic of drug-involved deaths in the United States is one which is not geographically homogenous. Given this unequal distribution of mortality, state-specific analysis of changing trends in drug use and drug-involved deaths is vital to inform both care for people who use drugs and local policy. An analysis of public health surveillance data from the state of Louisiana, both before and after the initial stay-at-home order of the COVID-19 pandemic, was used to determine the effect the pandemic may have had on the drug-involved deaths within this state. Using the linear regression analysis of total drug-involved deaths, as well as drug-specific subgroups, trends were measured based on quarterly (Qly) deaths. With the initial stay-at-home order as the change point, trends measured through quarter 1 (Q1) of 2020 were compared to trends measured from quarter 2 (Q2) of 2020 through quarter 3 (Q3) of 2021. The significantly increased rate of change in Qly drug-involved deaths, synthetic opioid-involved deaths, stimulant-involved deaths, and psychostimulant-involved deaths indicates a long-term change following the initial response to the COVID-19 pandemic. Changes in the delivery of mental health services, harm reduction services, medication for opioid use disorder (MOUD), treatment services, withdrawal management services, addiction counseling, shelters, housing, and food supplies further limited drug-involved prevention support, all of which were exacerbated by the new stress of living in a pandemic and economic uncertainty.

Estimating the impact of the COVID-19 pandemic on rising trends in drug overdose mortality in the United States, 2018-2021

PURPOSE

During the COVID-19 pandemic, social and economic disruption such as social isolation, job and income losses, and increased psychological distress, may have contributed to the increase in drug-overdose mortality. This study aims to measure the impact of the pandemic on monthly trends in drug-overdose mortality in the United States.

METHODS

We used the 2018-2020 final and 2021 provisional monthly deaths from the National Vital Statistics System and monthly population estimates from the Census Bureau to compute monthly mortality rates by age, sex, and race/ethnicity. We use log-linear regression models to estimate monthly percent increases in mortality rates from January 2018 through November 2021.

RESULTS

The age-adjusted drug-overdose mortality rate among individuals aged older than or equal to 15 years increased by 30% between 2019 (70,459 deaths) and 2020 (91,536 deaths). During January 2018-November 2021, the monthly drug-overdose mortality rate increased by 2.05% per month for Blacks, 2.25% for American Indians/Alaska Natives, 1.96% for Hispanics, 1.33% for Asian/Pacific Islanders, and 0.96% for non-Hispanic Whites. Average monthly increases in mortality were most marked among those aged 15-24 and 35-44 years.

CONCLUSIONS

The COVID-19 pandemic had a substantial impact on the rising trends in drug-overdose mortality during the peak months in 2020 and 2021.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Characteristics of fatal drug overdoses among college age decedents in Tennessee, 2019-2020

Purpose

College age persons experienced unique disruptions to their regular lives during the COVID-19 pandemic, sometimes resulting in negative coping mechanisms. We examined changes in the number of and characteristics of college age fatal drug overdoses before and during the early COVID-19 pandemic.

Methods

We conducted a statewide cross-sectional study to determine the changes in the number and characteristics of college age fatal drug overdose decedents before and during the COVID-19 pandemic using 2019-2020 data from the Tennessee State Unintentional Drug Overdose Reporting System. We defined college age as 18-24 years. Frequencies and rates were generated to compare demographics, circumstances, and toxicology between 2019 and 2020.

Results

From 2019 to 2020, 336 college age persons experienced an unintentional or undetermined fatal drug overdose in Tennessee. Characteristics of college age decedents: mean age 21.7 years, 68.5% males, and 71.4% White. Rates of fatal overdoses among college age persons increased 50.0% overall, 150.1% for female decedents, and 141.7% for Black decedents. Fewer people were treated for substance use disorder or mental health conditions (p = 0.0243) in 2020.

Conclusion

This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts to curtail the overdose epidemic among college age persons in Tennessee.

The effects of the COVID-19 pandemic on drug and poison–related deaths in Gold Coast, Australia

Introduction

COVID-19 is postulated to impact drug- and poison-related deaths. America has reported an increased in drug-related deaths, whereas Australia has reported a decline. Regional studies are scant and may not mirror national data. Characterising drug and poison–related deaths during COVID-19 at a regional level would inform local interventions and policies on the current and future pandemics.

Methods

A 4-year retrospective study from January 1, 2018, to December 31, 2019 (pre-COVID-19 pandemic) and from January 1, 2020, to December 31, 2021 (COVID-19 pandemic) of all drug and poison–related deaths admitted to the Gold Coast University Hospital under Coronial investigation.

Results

Drug and poison–related deaths increased in both the proportion and absolute numbers before and during the COVID-19 pandemic. There was no statistical difference in age, sex, location of death, manner of death and classification of drugs and poison implicated.

Conclusions

Although there is an increase in drug and poison–related deaths, the overall demographic and pattern have not changed. Further studies to account for the variation may enable implementation of targeted public health interventions to address the burden of related deaths in regional settings in the context of future pandemics.