We Can't Arrest Our Way Out of Overdose: The Drug Bust Paradox

Strategies used to reduce harms associated with fentanyl exposure among rural people who use drugs: multi-site qualitative findings from the rural opioid initiative

AIM

Illicitly manufactured fentanyl and its analogs are the primary drivers of opioid overdose deaths in the United States (U.S.). People who use drugs may be exposed to fentanyl or its analogs intentionally or unintentionally. This study sought to identify strategies used by rural people who use drugs to reduce harms associated with unintentional fentanyl exposure.

METHODS

This analysis focused on 349 semi-structured qualitative interviews across 10 states and 58 rural counties in the U.S conducted between 2018 and 2020. Interview guides were collaboratively standardized across sites and included questions about drug use history (including drugs currently used, frequency of use, mode of administration) and questions specific to fentanyl. Deductive coding was used to code all data, then inductive coding of overdose and fentanyl codes was conducted by an interdisciplinary writing team.

RESULTS

Participants described being concerned that fentanyl had saturated the drug market, in both stimulant and opioid supplies. Participants utilized strategies including: (1) avoiding drugs that were perceived to contain fentanyl, (2) buying drugs from trusted sources, (3) using fentanyl test strips, 4) using small doses and non-injection routes, (5) using with other people, (6) tasting, smelling, and looking at drugs before use, and (7) carrying and using naloxone. Most people who used drugs used a combination of these strategies as there was an overwhelming fear of fatal overdose.

CONCLUSION

People who use drugs living in rural areas of the U.S. are aware that fentanyl is in their drug supply and use several strategies to prevent associated harms, including fatal overdose. Increasing access to harm reduction tools (e.g., fentanyl test strips, naloxone) and services (e.g., community drug checking, syringe services programs, overdose prevention centers) should be prioritized to address the polysubstance-involved overdose crisis. These efforts should target persons who use opioids and other drugs that may contain fentanyl.

Revisiting the opioid and naloxone education (ONE) program: Program evaluation using the RE-AIM model four years later

OBJECTIVE

The Opioid and Naloxone Education (ONE) Program focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The purpose of this paper is to reevaluate the ONE Program performance using the RE-AIM model, in comparison to the review performed in 2019.

METHODS

The program performance of the ONE Program was evaluated from January 1, 2021 to December 31, 2022 was evaluated using the five domains of the RE-AIM model. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk who received a pharmacist intervention. Adoption was defined as the proportion of community pharmacies who enrolled in the ONE Program. Implementation was defined as the proportion of pharmacies that enrolled that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that completed at least one screening three months. These results were compared against evaluation of the program from October 12, 2018 to June 1, 2019.

RESULTS

Approximately 7.28 % of patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose (Reach). Of the patients screened, 97.4 % of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention (Efficacy). Additionally, 49.6 % of the pharmacist that enrolled in the ONE Program completed at least five screenings (79 %) and of those, 86.4 % maintained the program three months later.

CONCLUSIONS

In years four and five of implementation, the ONE Program demonstrated improvement in four of the five domains of the RE-AIM model compared to years one and two. However, Reach declined over time. This reevaluation has demonstrated the importance of longitudinal program assessment, and the possibility of improved program performance over time.

Xylazine is an agonist at kappa opioid receptors and exhibits sex-specific responses to opioid antagonism

Xylazine is in the unregulated drug supply at increasing rates, usually combined with fentanyl, necessitating understanding of its pharmacology. Despite commentary from politicians, and public health officials, it is unknown how xylazine impacts naloxone efficacy, and. few studies have examined it alone. Here, we examine the impact of xylazine alone and in combination with fentanyl on several behaviors in mice. Surprisingly, naloxone precipitates withdrawal from xylazine and fentanyl/xylazine coadministration, with enhanced sensitivity in females. Further, xylazine is a full agonist at kappa opioid receptors, a potential mechanism for its naloxone sensitivity. Finally, we demonstrate surprising effects of xylazine to kappa opioid antagonism, which are relevant for public health considerations. These data address an ongoing health crisis and will help inform critical policy and healthcare decisions.

A scoping review of law enforcement drug seizures and overdose mortality in the United States

BACKGROUND

Leveraging law enforcement drug seizure data to better respond to the overdose crisis requires an understanding of available evidence and knowledge gaps regarding relationships between drug seizures and overdose mortality.

OBJECTIVE

This scoping review summarized peer-reviewed literature on associations between law enforcement drug seizures and drug-related mortality in the United States (US) in the era of illicitly-manufactured fentanyl, comparing study data sources, measures, methodologies, settings, and findings.

METHODS

We identified 388 non-duplicate records from three online databases searched on May 23, 2023. After title/abstract and full-text screening by two independent reviewers, 14 studies met the criteria for inclusion. The included studies tested the association between a measure related to law enforcement drug seizures and an overdose mortality outcome in the US and were published in English, in peer-reviewed journals, during or after 2013.

RESULTS

Four of 14 studies (29%) included data from the entire US, while the remaining studies focused on an individual state/city/county or a group of states/cities/counties. Synthetic opioid/fentanyl seizures represented the most frequently examined drug seizure category, and overdose deaths overall (involving any drugs) represented the most frequently examined outcome. Most studies used counts/rates of drug seizures, with fewer studies examining dosage/weight, drug combinations, the proportion of drug seizures involving a specific drug, or spatiotemporal distribution. The majority (86%) of studies reported at least one statistically significant positive association between a law enforcement drug seizure measure and an overdose mortality outcome, most consistently for fentanyl-related seizures. Results were relatively less consistent for seizures involving stimulants and other drugs.

CONCLUSIONS

Studies in this review provided consistent evidence that fentanyl-related seizure measures are positively associated with overdose mortality outcomes, despite the limitations inherent in drug seizure data, even in the absence of available information regarding seizure weight or dosage.

Xylazine in Drug Seizure Reports and Overdose Deaths in the US, 2018-2022

Xylazine is increasingly reported in street drugs and fatal overdoses in the United States (US), often in combination with synthetic opioids, yet state-level xylazine data are limited, hampering local public health responses. The present study analyzed 2018-2022 state-level data from the National Forensic Laboratory Information System (xylazine-positive reports of seized drugs analyzed by forensic laboratories), the Centers for Disease Control and Prevention (population estimates, synthetic opioid overdose mortality rates), and individual states' medical examiner/public health agency reports (numbers of xylazine-involved overdose deaths). An ordinary least squares regression model predicted state-level synthetic opioid overdose mortality rates by xylazine seizure report rates, adjusting for US Census Region. In 2018, relatively low rates of xylazine seizure reports were observed, with 21 states reporting zero xylazine seizures. In 2022, only three states reported zero xylazine seizures, and the highest xylazine seizure report rates (per 100,000 residents) were observed in New Jersey (30.4), Rhode Island (22.7), Maryland (18.9), Virginia (15.5), New Hampshire (13.0), and Ohio (10.9). Data on 2019-2022 xylazine-involved overdose deaths were available for 21 states/DC (60 state-years), with the highest 2022 xylazine-involved overdose death rates (per 100,000 residents) in Vermont (10.5) and Connecticut (9.8). Finally, in 2021, at the state level, each additional reported xylazine seizure per 100,000 residents was associated with a 2% higher synthetic opioid overdose mortality rate (b=0.02, robust standard error=0.01; p=0.049). Overall, study results emphasize xylazine's increasing involvement in US law enforcement drug seizure reports and overdose deaths, primarily in the East, yet also extending across the country.