Loneliness and fearfulness are associated with non-fatal drug overdose among people who inject drugs

BACKGROUND

People who inject drugs (PWID) experience high rates of drug overdose death with the risk of mortality increasing after each non-fatal event. Racial differences exist in drug overdose rates, with higher rates among Black people who use drugs. Psychological factors may predict drug overdose.

METHODS

Cross-sectional data from a survey administered to PWID in Baltimore, MD enrolled in a social network-based intervention were analyzed. Linear regression methods with generalized estimating equations were used to analyze data from indexes and network members to assess for psychological factors significantly associated with self-reported number of lifetime drug overdoses. Factors associated with number of overdoses were assessed separately by race.

RESULTS

Among 111 PWID enrolled between January 2018 and January 2019, 25.2% were female, 65.7% were Black, 98.2% reported use of substances in addition to opioids, and the mean age was 49.0 ± 8.3 years. Seventy-five individuals (67.6%) had a history of any overdose with a mean of 5.0 ± 9.7 lifetime overdoses reported. Reports of feeling fearful (β = 9.74, P = 0.001) or feeling lonely all of the time (β = 5.62, P = 0.033) were independently associated with number of drug overdoses. In analyses disaggregated by race, only the most severe degree of fearfulness or loneliness was associated with overdose among Black participants, whereas among White participants, any degree of fearfulness or loneliness was associated with overdose.

CONCLUSIONS

In this study of PWID loneliness and fearfulness were significantly related to the number of reported overdose events. These factors could be targeted in future interventions.

Exploring trauma and wellbeing of people who use drugs after witnessing overdose: A qualitative study

BACKGROUND

The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior.

METHODS

We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti.

RESULTS

A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices.

CONCLUSION

Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.

Years of life lost due to deaths of despair and COVID-19 in the United States in 2020: patterns of excess mortality by gender, race and ethnicity

BACKGROUND

In 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen-which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020.

METHODS

This cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation.

RESULTS

In 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes.

CONCLUSIONS

This study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.

“It's my frenemy”: A qualitative exploration of knowledge and perceptions of fentanyl use during the COVID-19 pandemic in people who use drugs at a syringe services program in Philadelphia, PA

Background

Exacerbated by the COVID-19 pandemic and the proliferation of fentanyl and fentanyl analogs, overdose deaths have surged in the United States, making it important to understand how individuals who use drugs experience and perceive the risks of fentanyl use and how it has changed during the COVID-19 pandemic.

Methods

Twenty clients from a Philadelphia syringe services program completed a questionnaire and in-depth interview about their fentanyl experiences from January to March 2021. These interviews were transcribed and analyzed using thematic analysis methods.

Results

Sixty percent of participants were female and racial/ethnic minority. Participants indicated they believed fentanyl use accounted for most Philadelphia opioid-related overdoses and understood that fentanyl was different from other opioids. Fentanyl use was characterized as “all-consuming” by taking over lives and inescapable. While most perceived their risk of fentanyl overdose as high, there was low interest in and reported use of harm reduction strategies such as fentanyl test strips. The COVID-19 pandemic was noted to have negative effects on fentanyl availability, use and overdose risk, as well as mental health effects that increase drug use.

Conclusions

The divide between perceived risk and uptake of protective strategies could be driven by diminished self-efficacy as it relates to acting on and engaging with resources available at the syringe services program and represents a potential intervention target for harm reduction intervention uptake. But the COVID-19 pandemic has exacerbated risks due to fentanyl use, making an effective, accessible, and well-timed intervention important to address the disconnect between perceived overdose risk and use of preventive behaviors.

Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event

Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders' feelings about helping in an overdose situation in the future. Methods: For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Results: Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. Conclusions: The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.

The discounting of death: Probability discounting of heroin use by fatal overdose likelihood and drug purity

As fatal overdoses from synthetic opioids continue to rise, we need to understand decision-making processes underlying heroin and synthetic opioid use. This study evaluated the influence of sample impurity and fatal overdose risk on hypothetical heroin use. Individuals who currently use heroin (n = 69) were recruited online. Participants completed two probability-discounting tasks evaluating the likelihood of using a sample of heroin based on the likelihood of sample impurity and likelihood of fatal overdose, where greater discounting represented reduced use likelihood. Prior to completing the probability-discounting tasks, participants were randomized to read one of four prompts varying by the presence of information on heroin effects and active (e.g., fentanyl) or inert impurities. Influence of prompts on discounting processes and associations among probability-discounting measures, opioid use behaviors, and dependence severity were evaluated. Heroin use likelihood decreased with increased impurity or overdose risk and in a generally orderly fashion. Discounting was greater (i.e., reduced heroin use likelihood) when overdose risk, compared to sample impurity, was manipulated. Less discounting was associated with more severe opioid dependence. Discounting did not differ among prompts for either task. Individuals might adjust their heroin-use behavior to reduce harm with risk-related information. Greater discounting elicited by overdose relative to impurity risk suggests that equating adulteration and overdose risk is essential for harm reduction. Expanded access to drug checking services, which inform impurity and overdose risk, can reduce fatal overdoses. Due to fear of legal sanctions for these services, legislation and judicial decisions should explicitly protect these services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Exploration of Overdose Risk Score and Postoperative Complications and Health Care Use After Total Knee Arthroplasty

IMPORTANCE

The adverse outcomes after total knee arthroplasty (TKA) associated with preoperative prescription drug use (ie, use of narcotics, sedatives, and stimulants) have been established but are not well quantified.

OBJECTIVE

To test the association of preoperative overdose risk score (ORS) with postoperative health care use.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data on a consecutive sample of individuals who underwent primary TKA from November 2018 through March 2020 at a tertiary care health system. Data were collected using the Orthopaedic Minimal Data Set Episode of Care, a validated data-collection system for all elective orthopedic surgical interventions taking place within the health care system. Outcomes were assessed at 90 days postoperatively. Individuals whose preoperative baseline characteristics or ORS were not provided or who declined to participate were excluded. Data were analyzed from September through October 2020.

EXPOSURE

Patient-specific preoperative ORS, as measured using NarxCare, associated with patterns of prescription drug use.

MAIN OUTCOMES AND MEASURES

Associations between patient-specific ORS categories and 90-day postoperative health care use (ie, prolonged hospital length of stay [LOS; ie, >2 days], nonhome discharge, all-cause 90-day readmission, emergency department [ED] visits, and reoperation) were evaluated. Outcomes were also compared between a group of individuals with ORS less than 300 vs those with ORS 300 or greater who were propensity score matched (4:1; caliper, 0.1) using demographic characteristics (ie, age, sex, race, body mass index, and smoking status) and baseline comorbidities.

RESULTS

Among 4326 individuals who underwent primary TKA, 2623 (60.63%) were women, 3602 individuals (83.26%) were White, the mean (SD) BMI was 32.8 (6.9), and the mean (SD) age was 66.6 (9.2) years; 90-day follow-up was available for the entire cohort. The predominant preoperative diagnosis was osteoarthritis, occurring among 4170 individuals (96.4%). For individuals with an ORS of 300 to 399, there were significantly higher odds of a prolonged LOS (odds ratio [OR], 2.03; 95% CI, 1.46-2.82; P < .001), nonhome discharge (OR, 2.01; 95% CI, 1.37-2.94; P < .001), all-cause 90-day readmission (OR, 1.56; 95% CI, 1.01-2.42; P < .001), and ED visits (OR, 1.62; 95% CI, 1.11-2.38; P = .01) compared with individuals who were prescription drug naive (ie, ORS = 0). Individuals in the highest ORS category (ie, ORS ≥ 500) had the highest ORs for prolonged LOS (OR, 3.71; 95% CI, 2.00-6.87; P < .001), nonhome discharge (OR, 4.09; 95% CI, 2.02-8.29; P < .001), 90-day readmission (OR, 4.41; 95% CI, 2.23-8.71; P < .001), and 90-day reoperation (OR, 6.09; 95% CI, 1.44-25.80; P = .01). Propensity score matching confirmed the association between an ORS of 300 or greater and the incidence of prolonged LOS (244 individuals [11.6%] vs 130 individuals [23.0%]; P < .001), nonhome discharge (176 individuals [8.4%] vs 93 individuals [16.4%]; P < .001), all-cause 90-day readmission (119 individuals [5.7%] vs 65 individuals [11.5%]; P < .001), and all-cause ED visits (198 individuals [9.4%] vs 76 individuals [13.4%]; P = .006).

CONCLUSIONS AND RELEVANCE

This study found that higher ORS was associated with increased health care use after primary TKA. These findings suggest that an ORS of 300 or greater could be used to designate increased risk and guide the preoperative surgeon-patient discussion to modify prescription drug use patterns.

Trends in overdose experiences and prevention behaviors among people who use opioids in Baltimore, MD, 2017-2019

BACKGROUND

Little is known about trends in overdose behaviors. This study explored non-fatal overdose and engagement in overdose prevention behaviors and compared these trends to city-wide overdose fatality rates from 2017 to 2019 in Baltimore, MD.

METHODS

The analysis included people who used opioids (PWUO; N = 502) recruited through a community-based study. Enrollment date was used to categorize participants into annual quarters. Logistic regression models examined change in overdose experiences and prevention behaviors with time. Baltimore's fatal overdoses were also mapped over the study period to assess overlaps in trends.

RESULTS

The majority of the sample were male(68 %), Black(61 %), reported past 6 months homelessness(56 %), and were on average 45 years old. Most had witnessed(61 %), and 28 % had personally experienced an overdose in the past 6 months. Witnessing overdose marginally increased(aβ = 0.182;p = 0.058) while experiencing overdose did not significantly change by enrollment quarter. Most participants had or had been prescribed naloxone(72 %), and one fifth(22 %) regularly carried naloxone, with both access to(aβ = 0,408;p = 0.002) and carrying naloxone(aβ = 0.302;p = 0.006) increasing over time. Overdose communication remained stable, with 63 % of participants reporting discussing overdose sometimes/often. Among participants who injected (n = 376), regularly injecting alone decreased(aβ=-0.207;p = 0.055), and reporting others often/always having naloxone with them when injecting increased over time(aβ = 0.573;p < 0.001).

CONCLUSIONS

Witnessed overdose marginally increased from 2017 to 2019, aligning with city trends of fatal overdose. Overdose prevention behaviors significantly increased over time. Despite reporting having naloxone or a naloxone prescription, most PWUO did not regularly carry naloxone, and many used alone. Social network diffusion interventions may be a strategy to promote normative overdose prevention behaviors.

Association of Cannabis Use With Self-harm and Mortality Risk Among Youths With Mood Disorders

Importance

Cannabis use and cannabis use disorder (CUD) are common among youths and young adults with mood disorders, but the association of CUD with self-harm, suicide, and overall mortality risk is poorly understood in this already vulnerable population.

Objective

To examine associations of CUD with self-harm, suicide, and overall mortality risk in youths with mood disorders.

Design, Setting, and Participants

A population-based retrospective cohort study was performed using Ohio Medicaid claims data linked with death certificate data. The analysis included 204 780 youths (aged 10-24 years) with a diagnosis of mood disorders between July 1, 2010, and December 31, 2017, who were followed up to 365 days from the index diagnostic claim until the end of enrollment, the self-harm event, or death. Statistical analysis was performed from April 4 to July 17, 2020.

Exposure

Physician-diagnosed CUD defined using outpatient and inpatient claims from 180 days prior to the index mood disorder diagnostic claim through the 365-day follow-up period.

Main Outcomes and Measures

Nonfatal self-harm, all-cause mortality, and deaths by suicide, unintentional overdose, motor vehicle crashes, and homicide. Marginal structural models using inverse probability weights examined associations between CUD and outcomes.

Results

This study included 204 780 youths (133 081 female participants [65.0%]; mean [SD] age at the time of mood disorder diagnosis, 17.2 [4.10] years). Cannabis use disorder was documented for 10.3% of youths with mood disorders (n = 21 040) and was significantly associated with older age (14-18 years vs 10-13 years: adjusted risk ratio [ARR], 9.35; 95% CI, 8.57-10.19; and 19-24 years vs 10-13 years: ARR, 11.22; 95% CI, 10.27-12.26), male sex (ARR, 1.79; 95% CI, 1.74-1.84), Black race (ARR, 1.39; 95% CI, 1.35-1.44), bipolar or other mood disorders (bipolar disorders: ARR, 1.24; 95% CI, 1.21-1.29; other mood disorders: ARR, 1.20; 95% CI, 1.15-1.25), prior history of self-harm (ARR, 1.66; 95% CI, 1.52-1.82), previous mental health outpatient visits (ARR, 1.26; 95% CI, 1.22-1.30), psychiatric hospitalizations (ARR, 1.66; 95% CI, 1.57-1.76), and mental health emergency department visits (ARR, 1.54; 95% CI, 1.47-1.61). Cannabis use disorder was significantly associated with nonfatal self-harm (adjusted hazard ratio [AHR], 3.28; 95% CI, 2.55-4.22) and all-cause mortality (AHR, 1.59; 95% CI, 1.13-2.24), including death by unintentional overdose (AHR, 2.40; 95% CI, 1.39-4.16) and homicide (AHR, 3.23; 95% CI, 1.22-8.59). Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models.

Conclusions and Relevance

Cannabis use disorder is a common comorbidity and risk marker for self-harm, all-cause mortality, and death by unintentional overdose and homicide among youths with mood disorders. These findings should be considered as states contemplate legalizing medical and recreational marijuana, both of which are associated with increased CUD.

Sex differences in US emergency department non-fatal visits for benzodiazepine poisonings in adolescents and young adults

BACKGROUND

Benzodiazepine (BZD)-related overdose deaths have risen in the past decade and BZD misuse contributes to thousands of emergency department (ED) visits annually, with the highest rates in adolescents and young adults. Because there are gaps in understanding BZD poisoning in youth and whether differences occur by sex, we aimed to characterize BZD poisoning ED visits in young people by sex.

METHODS

BZD poisoning visits were identified in the Nationwide Emergency Department Sample, among adolescents (12-17 years) and young adults (18-29 years). Stratified by sex and age, we described ED visits for BZD poisonings in 2016, including poisoning intent, concurrent substances involved, and co-occurring mental health disorder diagnoses. With logistic regression we examined the association between intent and concurrent substance.

RESULTS

There were approximately 38,000 BZD poisoning ED visits by young people nationwide with annual population rates per 10,000 of 2.9=adolescents and 5.8=young adults. Depression was diagnosed in 40 % of female and 23 % of male BZD visits (p < 0.01). Over half of BZD poisonings in females and a third in males were intentional (p < 0.01). Male BZD visits were more likely to involve opioids or cannabis and less likely to involve antidepressants than females (p-values<0.01). In males and females, BZD poisonings concurrent with antidepressants and other psychotropic medications were more likely to be intentional than unintentional (OR range:2.1-6.3).

CONCLUSIONS

The high proportion of BZD poisonings that are intentional and include mental health disorder diagnoses, especially among young females, underscore the importance of ED mental health and suicide risk assessment with appropriate follow-up referral.

The Fast Track intervention's impact on behaviors of despair in adolescence and young adulthood

How to mitigate the dramatic increase in the number of self-inflicted deaths from suicide, alcohol-related liver disease, and drug overdose among young adults has become a critical public health question. A promising area of study looks at interventions designed to address risk factors for the behaviors that precede these -often denoted-"deaths of despair." This paper examines whether a childhood intervention can have persistent positive effects by reducing adolescent and young adulthood (age 25) behaviors that precede these deaths, including suicidal ideation, suicide attempts, hazardous drinking, and opioid use. These analyses test the impact and mechanisms of action of Fast Track (FT), a comprehensive childhood intervention designed to decrease aggression and delinquency in at-risk kindergarteners. We find that random assignment to FT significantly decreases the probability of exhibiting any behavior of despair in adolescence and young adulthood. In addition, the intervention decreases the probability of suicidal ideation and hazardous drinking in adolescence and young adulthood as well as opioid use in young adulthood. Additional analyses indicate that FT's improvements to children's interpersonal (e.g., prosocial behavior, authority acceptance), intrapersonal (e.g., emotional recognition and regulation, social problem solving), and academic skills in elementary and middle school partially mediate the intervention effect on adolescent and young adult behaviors of despair and self-destruction. FT's improvements to interpersonal skills emerge as the strongest indirect pathway to reduce these harmful behaviors. This study provides evidence that childhood interventions designed to improve these skills can decrease the behaviors associated with premature mortality.

How Do Drug-Death-Bereaved Parents Adjust to Life Without the Deceased? A Qualitative Study

Knowledge about how bereaved persons grieve can enhance quality in providing the support and potential services that they need. We aimed to identify ways in which drug-death-bereaved Norwegian parents go on with their lives and what inhibits or promotes adaptation during their grieving. Reflexive thematic analysis was used to analyze 14 semistructured in-depth interviews. We generated three themes: (I) processing grief emotions, (II) proactive coping, and (III) giving and receiving support and assistance. Processing guilt rumination, reflections on blame and a burden of grief emotions characterized grieving early on. Using cognitive strategies and functional-support-giving were found to be the most frequently used strategies. Oscillation between processing stressors and reorientation to the world promoted adjustment to ongoing life. We discuss characteristics of parents who struggle to reorient and outline important implications for policy and practice.

Association of Violence Against Female Sex Workers Who Use Drugs With Nonfatal Drug Overdose in Kazakhstan

IMPORTANCE

Female sex workers (FSWs) who use drugs face increased risk of intimate partner violence (IPV) and nonpartner violence (NPV). The association between violence and drug overdose is unknown.

OBJECTIVE

To examine the association between IPV, NPV, and nonfatal drug overdose among FSWs who use drugs in Kazakhstan.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 400 adult FSWs in Kazakhstan who reported illicit drug use in the past year, exchanged sex for money or drugs, and reported having unprotected sex in the past 90 days. Baseline data were collected from February 2015 to May 2017 from Project Nova, an HIV prevention study among FSWs who use drugs in Kazakhstan. Data analysis was conducted from April 2019 to March 2020.

EXPOSURES

Lifetime and recent (past 90 day) experiences of physical, sexual, and psychological IPV and NPV using the Revised Conflict Tactics Scale. Subtypes of violence were identified using exploratory factor analysis.

MAIN OUTCOMES AND MEASURES

Lifetime and recent incidence of nonfatal overdose; sociodemographic characteristics as well as lifetime and recent sex work and drug use behaviors were also collected.

RESULTS

The 400 participants had a mean (SD) age of 34.1 (8.4) years. Most experienced food insecurity (358 [89.5%]) and homelessness (232 [58.0%]) in the past 90 days; one-third (130 [32.5%]) reported a history of incarceration. Most (359 [89.7%]) experienced some form of violence; 150 (37.5%) reported a lifetime nonfatal overdose, of whom 27 (18.0%) reported nonfatal overdose in the past 90 days. Lifetime severe physical violence (adjusted odds ratio [aOR], 1.27; 95% CI, 1.02-1.59; P = .03), engagement in sex work for more than 10 years (aOR, 2.54; 95% CI, 1.50-4.28; P < .001), and a history of incarceration (aOR, 4.34; 95% CI, 2.58-7.32; P < .001) were associated with greater odds of nonfatal overdose. Engaging in sex work for more than 10 years (aOR, 3.97; 95% CI, 1.36-11.61; P = .01) and a history of incarceration (aOR, 3.63; 95% CI, 1.39-9.48; P = .008) were associated with greater odds of recent nonfatal overdose.

CONCLUSIONS AND RELEVANCE

In this study, violence against FSWs who use drugs in Kazakhstan was associated with increased odds of nonfatal overdose. Harm reduction programs for women should consider including services to address gender-based violence and the needs of women after incarceration.

Perspectives of clients and providers on factors influencing opioid agonist treatment uptake among HIV-positive people who use drugs in Indonesia, Ukraine, and Vietnam: HPTN 074 study

BACKGROUND

Opioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID.

METHODS

As a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns.

RESULTS

Despite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators.

CONCLUSION

These results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Socioeconomic marginalization and opioid-related overdose: A systematic review

BACKGROUND

Socioeconomic marginalization (SEM) is an important but under-explored determinant of opioid overdose with important implications for health equity and associated public policy initiatives. This systematic review synthesizes evidence on the role of SEM in both fatal and non-fatal overdose among people who use opioids.

METHODS

Studies published between January 1, 2000 and March 31, 2018 were identified through searching electronic databases, citations, and by contacting experts. The titles, abstracts, citation information, and descriptor terms of citations were screened by two team members. Data were synthesized using the lumping technique.

RESULTS

A total of 37 studies met inclusion criteria and were included in the review, with 34 of 37 finding a significant association between at least one socioeconomic factor and overdose. The included studies contained variables related to eight socioeconomic factors: criminal justice system involvement, income, employment, social support, health insurance, housing/homelessness, education, and composite measures of socio-economic status. Most studies found associations in the hypothesized direction, whereby increased SEM was associated with a higher rate or increased likelihood of the overdose outcome measured. The review revealed an underdeveloped evidence base.

CONCLUSIONS

Nearly all reviewed studies found a connection between a socioeconomic variable and overdose, but more research is needed with an explicit focus on SEM, using robust and nuanced measures that capture multiple dimensions of disadvantage, and collect data over time to better inform decision making around opioid overdose.

Repeat Self-Harm Following Hospital-Presenting Intentional Drug Overdose among Young People-A National Registry Study

Background: The incidence of hospital-presenting self-harm peaks among young people, who most often engage in intentional drug overdose (IDO). The risk of self-harm repetition is high among young people and switching methods between self-harm episodes is common. However, little is known about their patterns of repetition and switching following IDO. This study aimed to investigate repeat self-harm and method-switching following hospital-presenting IDO among young people. Methods: Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 10–24 years during 2009–2018 were examined. Cox proportional hazards regression models with associated hazard ratios (HRs), survival curves and Poisson regression models with risk ratios (RRs), were used to examine risk factors for repetition and method-switching. Results: During 2009–2018, 16,800 young people presented following IDO. Within 12 months, 2136 young people repeated self-harm. Factors associated with repetition included being male (HR = 1.13, 95% CI: 1.03–1.24), aged 10–17 years (HR = 1.29, 95% CI: 1.18–1.41), consuming ≥ 50 tablets (HR = 1.27, 95% CI: 1.07–1.49) and taking benzodiazepines (HR = 1.67, 95% CI: 1.40–1.98) or antidepressants (HR = 1.36, 95% CI: 1.18–1.56). The cumulative risk for switching method was 2.4% (95% CI: 2.2–2.7). Method-switching was most likely to occur for males (RR = 1.36; 95% CI: 1.09–1.69) and for those who took illegal drugs (RR = 1.63; 95% CI: 1.19–2.25). Conclusion: Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.

Knowledge of Good Samaritan Laws and Beliefs About Arrests Among Persons Who Inject Drugs a Year After Policy Change in Baltimore, Maryland

OBJECTIVES

Delivering and receiving prompt medical care during an overdose are imperative to ensure survival. Good Samaritan laws encourage people to call 911 during an overdose by providing immunity from selected drug arrests (eg, low-level possession). However, it is unclear whether persons who inject drugs (PWID) are aware of and understand these laws and their implications. We examined awareness among PWID of the 2015 Good Samaritan law in Maryland and their beliefs about whether they could be arrested for calling 911 or having an overdose.

METHODS

We surveyed 298 PWID in Baltimore, Maryland. We estimated the proportion who knew what the Good Samaritan law addressed and who believed they could be arrested for calling 911 or overdosing. We used a multivariate model to assess the association between harm-reduction services and knowledge of the Good Samaritan law or beliefs about getting arrested for calling 911 or overdosing.

RESULTS

Of PWID, 56 of 298 (18.8%) knew what the Good Samaritan law addressed, 43 of 267 (16.1%) believed they could be arrested for calling 911, and 32 of 272 (11.8%) believed they could be arrested for having an overdose. After adjusting for demographic characteristics, accessing the syringe services program was associated with accurate knowledge and the belief that PWID could be arrested for calling 911; however, training in overdose reversal was not associated.

CONCLUSIONS

Most PWID were unaware of the Good Samaritan law; this lack of awareness is a barrier to preventing overdose deaths. Educating PWID about Good Samaritan laws is essential, and such education should include police to ensure that law enforcement is congruent with Good Samaritan laws and does not perpetuate mistrust between police and PWID.

Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness

IMPORTANCE

Individuals with a history of homelessness are at increased risk for drug or alcohol overdose, although the proportion who have had recent nonfatal overdose is unknown. Understanding risk factors associated with nonfatal overdose could guide efforts to prevent fatal overdose.

OBJECTIVES

To determine the prevalence of recent overdose and the individual contributions of drugs and alcohol to overdose and to identify characteristics associated with overdose among veterans who have experienced homelessness.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was conducted from November 15, 2017, to October 1, 2018, via mailed surveys with telephone follow-up for nonrespondents. Eligible participants were selected from the records of 26 US Department of Veterans Affairs medical centers and included veterans who had received primary care at 1 of these Veterans Affairs medical centers and had a history of experiencing homelessness according to administrative data. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020.

MAIN OUTCOMES AND MEASURES

Self-report of overdose (such that emergent medical care was obtained) in the previous 3 years and substances used during the most recent overdose. All percentages are weighted according to propensity to respond to the survey, modeled from clinical characteristics obtained in electronic health records.

RESULTS

A total of 5766 veterans completed the survey (completion rate, 40.2%), and data on overdose were available for 5694 veterans. After adjusting for the propensity to respond to the survey, the mean (SD) age was 56.4 (18.3) years; 5100 veterans (91.6%) were men, 2225 veterans (38.1%) were black, and 2345 veterans (40.7%) were white. A total of 379 veterans (7.4%) reported any overdose during the past 3 years; 228 veterans (4.6%) reported overdose involving drugs, including 83 veterans (1.7%) who reported overdose involving opioids. Overdose involving alcohol was reported by 192 veterans (3.7%). In multivariable analyses, white race (odds ratio, 2.44 [95% CI, 2.00-2.98]), self-reporting a drug problem (odds ratio, 1.66 [95% CI, 1.39-1.98]) or alcohol problem (odds ratio, 2.54 [95% CI, 2.16-2.99]), and having witnessed someone else overdose (odds ratio, 2.34 [95% CI, 1.98-2.76]) were associated with increased risk of overdose.

CONCLUSIONS AND RELEVANCE

These findings suggest that nonfatal overdose is relatively common among veterans who have experienced homelessness. While overdose involving alcohol was more common than any specific drug, 1.7% of veterans reported overdose involving opioids. Improving access to addiction treatment for veterans who are experiencing homelessness or who are recently housed, especially for those who have experienced or witnessed overdose, could help to protect this population.

LSD Overdoses: Three Case Reports

OBJECTIVE

In academic settings around the world, there is a resurgence of interest in using psychedelic substances for the treatment of addictions, posttraumatic stress disorder, depression, anxiety, and other diagnoses. This case series describes the medical consequences of accidental overdoses in three individuals.

METHOD

Case series of information were gathered from interviews, health records, case notes, and collateral reports.

RESULTS

The first case report documents significant improvements in mood symptoms, including reductions in mania with psychotic features, following an accidental lysergic acid diethylamide (LSD) overdose, changes that have been sustained for almost 20 years. The second case documents how an accidental overdose of LSD early in the first trimester of pregnancy did not negatively affect the course of the pregnancy or have any obvious teratogenic or other negative developmental effects on the child. The third report indicates that intranasal ingestion of 550 times the normal recreational dosage of LSD was not fatal and had positive effects on pain levels and subsequent morphine withdrawal.

CONCLUSIONS

There appear to be unpredictable, positive sequelae that ranged from improvements in mental illness symptoms to reduction in physical pain and morphine withdrawal symptoms. Also, an LSD overdose while in early pregnancy did not appear to cause harm to the fetus.

Drug overdose among women in intimate relationships: The role of partner violence, adversity and relationship dependencies

BACKGROUND

This study examines the relationship between experiencing intimate partner violence (IPV), exposure to prior childhood adversity, lifetime adverse experiences, drug-related relationship dependencies with intimate partners and overdose, hospitalization for drug use, friends and family members who overdosed and witnessing overdose.

METHODOLOGY

This paper included a sample of 201 women who use drugs in heterosexual relationships with criminal justice-involved men in New York City. We included measures of experiencing overdose, hospitalization for drug use, witnessing overdose, and having friends and family who overdosed. Intimate partner violence consisted of either 1) none/verbal only, 2) moderate and 3) severe abuse. Dichotomous indicators of drug-related relationship dependencies included financial support, drug procurement, splitting and pooling drugs. A scale measured cumulative exposure to childhood adversity and lifetime exposures to adverse events. This paper hypothesized that experiencing moderate and severe IPV, drug-related dependencies and exposure to prior childhood and lifetime adversity would be associated with a greater risk of experiencing overdose, hospitalization for drug use, witnessing overdose and having friends and family members who overdosed. Generalized linear modeling with robust variance estimated relative risk ratios that accounted for potential bias in confidence intervals and adjusted for race, ethnicity, education and marital status.

RESULTS

We found experiencing moderate or severe IPV was associated with ever being hospitalized for drug use and having a family member who experienced overdose. Experiencing moderate IPV was associated with increased risk of witnessing overdose, Partner drug dependencies were associated with overdose, ever being hospitalized for drug use, witnessing overdose, and having a family member or friend who experienced overdose. Childhood and lifetime adversity exposures were significantly associated with increased risk of overdose, ever being hospitalized for drug use, ever witnessing overdose and having a friend and family member who overdosed.

CONCLUSION

Findings underscore the intersection of experiencing IPV and drug-related relationship dependencies, childhood adversity and lifetime adversity in shaping experiences of and witnessing overdose among women who use drugs. They highlight the urgent need to address IPV, adversity experiences and drug-related relationship dependencies in overdose prevention for women who use drugs.

Defining a recovery-oriented cascade of care for opioid use disorder: A community-driven, statewide cross-sectional assessment

BACKGROUND

In light of the accelerating and rapidly evolving overdose crisis in the United States (US), new strategies are needed to address the epidemic and to efficiently engage and retain individuals in care for opioid use disorder (OUD). Moreover, there is an increasing need for novel approaches to using health data to identify gaps in the cascade of care for persons with OUD.

METHODS AND FINDINGS

Between June 2018 and May 2019, we engaged a diverse stakeholder group (including directors of statewide health and social service agencies) to develop a statewide, patient-centered cascade of care for OUD for Rhode Island, a small state in New England, a region highly impacted by the opioid crisis. Through an iterative process, we modified the cascade of care defined by Williams et al. for use in Rhode Island using key national survey data and statewide health claims datasets to create a cross-sectional summary of 5 stages in the cascade. Approximately 47,000 Rhode Islanders (5.2%) were estimated to be at risk for OUD (stage 0) in 2016. At the same time, 26,000 Rhode Islanders had a medical claim related to an OUD diagnosis, accounting for 55% of the population at risk (stage 1); 27% of the stage 0 population, 12,700 people, showed evidence of initiation of medication for OUD (MOUD, stage 2), and 18%, or 8,300 people, had evidence of retention on MOUD (stage 3). Imputation from a national survey estimated that 4,200 Rhode Islanders were in recovery from OUD as of 2016, representing 9% of the total population at risk. Limitations included use of self-report data to arrive at estimates of the number of individuals at risk for OUD and using a national estimate to identify the number of individuals in recovery due to a lack of available state data sources.

CONCLUSIONS

Our findings indicate that cross-sectional summaries of the cascade of care for OUD can be used as a health policy tool to identify gaps in care, inform data-driven policy decisions, set benchmarks for quality, and improve health outcomes for persons with OUD. There exists a significant opportunity to increase engagement prior to the initiation of OUD treatment (i.e., identification of OUD symptoms via routine screening or acute presentation) and improve retention and remission from OUD symptoms through improved community-supported processes of recovery. To do this more precisely, states should work to systematically collect data to populate their own cascade of care as a health policy tool to enhance system-level interventions and maximize engagement in care.

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.

Data-informed targets for suicide prevention: a small-area analysis of high-risk suicide regions in Australia

PURPOSE

To investigate small-area variation in risks associated with suicide deaths across four regional communities in New South Wales, Australia, and to determine whether these areas have unique demographic and socioeconomic risk profiles that could inform targeted means restriction suicide prevention efforts.

METHODS

Archival data on suicide mortality for all deaths in New South Wales, Australia, over the period 2006-2015 were geospatially attributed to four high-risk priority regions. Deaths in the four regions were compared to each other, and to NSW, on demographic factors, indicators of economic deprivation, and suicide means.

RESULTS

Priority means restriction targets were identified for all sites. In Murrumbidgee, suicide deaths were significantly more likely to involve firearms and older males (p < 0.001). The Central Coast had a greater proportion of overdose deaths (p < 0.001), which were associated with being female and unemployed. Suicide deaths in Newcastle were associated with being younger (p = 0.001) and involving 'jumping from a height' (p < 0.001), while economic deprivation was a major risk for suicide death in Illawarra Shoalhaven (p < 0.001).

CONCLUSIONS

Local regions were significantly differentiated from each other, and from the State, in terms of priority populations and means of suicide, demonstrating the need for locally based, targeted interventions. There were, however, also some risk constancies across all sites (males, hanging, economic deprivation), suggesting that prevention initiatives should, optimally, be delivered within multilevel models that target risk commonalities and provide tailored initiatives that address risk specific to a region.

Access to means of lethal overdose among psychiatric patients with co-morbid physical health problems: Analysis of national suicide case series data from the United Kingdom

BACKGROUND

Many physical health problems are associated with elevated suicide risk whilst also providing access to means of overdose. We aimed to investigate whether psychiatric patients with physical co-morbidities who die by suicide were more likely than those without co-morbidities to self-poison with non-psychotropic medications.

METHODS

We analysed data on 14,648 psychiatric patients who died by suicide in England & Wales during 2004-2015, as recorded by the National Confidential Inquiry into Suicide and Safety in Mental Health. Using logistic regression models adjusted for age, gender, ethnicity, and primary drug dependence/misuse we compared patients diagnosed with physical co-morbidities versus those without to assess whether a greater proportion of the former had died by overdose, and medication prescribed to treat such disorders (e.g. opioids, insulin).

RESULTS

24% (n = 3525) were recorded as having physical co-morbidity. A greater proportion of these individuals died by self-poisoning than those without physical co-morbidity (37% vs. 20%, p < .001; adjusted OR 2.47; 95% CI 2.26-2.70), and they were more likely to have used medications for a physical health disorder in overdose (50% vs. 34%; adjusted OR 2.10; 95% CI 1.80-2.46), particularly opioids (30% vs. 22%; p < .001), paracetamol/opioid compounds (11% vs. 7%, p < .001) and insulin (4% vs. 1%, p < .001).

LIMITATIONS

Use of survey data may have resulted in under-reporting of physical health problems and/or overdose medications.

CONCLUSIONS

Overdose, rather than hanging, is the leading cause of suicide among psychiatric patients with physical co-morbidities, particularly using non-psychotropic medications. There is potential for means restriction in preventing suicide among these patients.

Patterns of polysubstance use and overdose among people who inject drugs in Baltimore, Maryland: A latent class analysis

BACKGROUND

Opioid-related overdose rates continue to climb. However, little research has examined the reach of overdose education and naloxone trainings among people who inject drugs (PWID). Understanding gaps in coverage is essential to improving the public health response to the ongoing crisis.

METHODS

We surveyed 298 PWID in Baltimore City, MD. We conducted a latent class analysis of drug use indicators and tested for differences by class in past month overdose, having received overdose training, and currently having naloxone.

RESULTS

Three classes emerged: cocaine/heroin injection (40.2%), heroin only injection (32.2%), and multi-drug/multi-route use (27.6%). The prevalence of past month overdose differed marginally by class (p = 0.06), with the multi-drug/multi-route use class having the highest prevalence (22.5%) and the heroin only class having the lowest (4.6%). The prevalence of previous overdose training differed significantly by class (p = 0.02), with the heroin/cocaine class (76.5%) having more training than the other two classes. Training was least common amongst the multi-drug/multi-route class (60.3%), though not statistically different from the heroin only class (63.0%). Classes did not differ significantly in current naloxone possession, although the multi-drug/multi-route class exhibited the lowest prevalence of naloxone possession (37.2%).

CONCLUSIONS

People who inject multiple substances are at high risk for overdose and are also the least likely to receive overdose trainings. The current service landscape does not adequately reach individuals with high levels of structural vulnerability and high levels of drug use and homelessness. Actively including this subgroup into harm reduction efforts are essential for preventing overdose fatalities.

Trusting the source: The potential role of drug dealers in reducing drug-related harms via drug checking

OBJECTIVES

Drug checking technologies (DCTs) have been implemented as a response to the ongoing opioid overdose epidemic. We examined the level of trust people who use drugs (PWUD) have in their drug dealers as well as their perspectives on the potential for drug dealers to use DCTs to provide knowledge of drug contents to their customers.

METHODS

We conducted one-to-one qualitative semi-structured interviews with 20 PWUD in Vancouver, Canada's Downtown Eastside. Participants were purposively recruited from ongoing cohort studies of PWUD and were required to currently be using stimulants and/or opioids.

RESULTS

Most participants discussed having a high level of trust for their drug dealers based on length of relationships, drug supply consistencies, and communication. Given this, participants did not identify drug checking as a priority. However, participants discussed a lower level of trust when buying drugs from an unfamiliar source. Participants also discussed how DCTs would provide knowledge to drug dealers about drug contents and how communicating test results to customers could be a risk reduction measure. Participants described privacy concerns that drug dealers might experience as well as the lack of concern that some drug dealers have about their drug supply.

CONCLUSIONS

Future drug checking programming should consider ways to engage drug dealers to test their supplies and develop communication strategies to more accurately inform PWUD of drug contents and avert risks associated with using them. Additionally, drug policies that address the effects of criminalization should be considered to lessen potential barriers to DCT use by drug dealers.

The relationship between parental heavy drinking and non-fatal overdose among people who inject drugs in Vancouver, Canada

BACKGROUND

Despite the acute drug-related and behavioural risk factors for experiencing a drug overdose, few remote childhood experiences have been examined as risk factors for subsequent later life overdose risk. Parental heavy drinking has been associated with some later life negative outcomes, but little is known regarding the impact on drug overdoses, especially among people who inject drugs. Given the current overdose crisis in North America, we sought to evaluate the impact of parental heavy drinking on later life non-fatal overdose among people who inject drugs in Vancouver, Canada.

METHODS

Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2012 and May 2016. We employed multivariable generalized estimating equations to examine the relationship between parental heavy drinking and non-fatal overdose in the past six months.

RESULTS

Among 327 eligible participants, 111 (33.9%) reported parental heavy drinking and 95 (29.1%) reported a non-fatal overdose at least once during the study period. In a multivariable analysis, experiencing parental heavy drinking remained independently associated with non-fatal overdose (adjusted odds ratio: 1.69; 95% confidence interval: 1.07-2.66) after adjustment for a range of socio-demographic and drug using confounders.

CONCLUSIONS

These findings suggest long-term negative impacts of parental heavy drinking, on subsequent risk taking or other mechanisms associated with overdose. Current overdose prevention efforts may benefit from the evaluation of life course vulnerabilities that may be amenable to earlier interventions.

Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study

BACKGROUND

In 2016, drug overdose deaths exceeded 64,000 in the United States, driven by a sixfold increase in deaths attributable to illicitly manufactured fentanyl. Rapid fentanyl test strips (FTS), used to detect fentanyl in illicit drugs, may help inform people who use drugs about their risk of fentanyl exposure prior to consumption. This qualitative study assessed perceptions of FTS among young adults.

METHODS

From May to September 2017, we recruited a convenience sample of 93 young adults in Rhode Island (age 18-35 years) with self-reported drug use in the past 30 days to participate in a pilot study aimed at better understanding perspectives of using take-home FTS for personal use. Participants completed a baseline quantitative survey, then completed a training to learn how to use the FTS. Participants then received ten FTS for personal use and were asked to return 2-4 weeks later to complete a brief quantitative and structured qualitative interview. Interviews were transcribed, coded, and double coded in NVivo (Version 11).

RESULTS

Of the 81 (87%) participants who returned for follow-up, the majority (n = 62, 77%) used at least one FTS, and of those, a majority found them to be useful and straightforward to use. Positive FTS results led some participants to alter their drug use behaviors, including discarding their drug supply, using with someone else, and keeping naloxone nearby. Participants also reported giving FTS to friends who they felt were at high risk for fentanyl exposure.

CONCLUSION

These findings provide important perspectives on the use of FTS among young adults who use drugs. Given the high level of acceptability and behavioral changes reported by study participants, FTS may be a useful harm reduction intervention to reduce fentanyl overdose risk among this population.

TRIAL REGISTRATION

The study protocol is registered with the US National Library of Medicine, Identifier NCT03373825, 12/24/2017, registered retrospectively. https://clinicaltrials.gov/ct2/show/NCT03373825?id=NCT03373825&rank=1.

Changes in Pharmacists' Perceptions After a Training in Opioid Misuse and Accidental Overdose Prevention

INTRODUCTION

Continuing education is needed for health professionals to take an active role in reversing the opioid crisis. This report describes the results of training to promote behavioral change by altering pharmacists' perceptions toward opioid misuse through the provision of content-related education.

METHODS

A free 3-hour opioid misuse and overdose prevention training program was developed and delivered to 43 community pharmacists. The training consisted of five modules addressing the disease of addiction, risks associated with opioids and accidental overdose, the role of naloxone, opioid dispensing and consultation pearls, and effective ways to communicate with patients about opioids. A paired analysis was performed from a 12-item survey delivered before and after the training program to assess changes in pharmacists' perception.

RESULTS

Five items showed a statistically significant (P < .05) change in perceptions after the training. Significant changes were reported for opioid addiction being outside the control of the affected person, the role of family history in prescription drug abuse, the value of counseling to support patients at risk of prescription opioid abuse, the value of screening tools, and the importance of viewing things from the patient's perspective. Correlation analysis identified that pharmacists' views on their role in the fight against the opioid epidemic and their agreement in the value to screen for opioid misuse were most closely related to the desire for behavioral change.

DISCUSSION

A training program influenced pharmacists' attitudes and perceptions about targeted behaviors and associated with the value of screening for opioid misuse or overdose risk and counseling patients about the benefits and risks of opioids.

Drug overdose and child maltreatment across the United States' rural-urban continuum

This national study of US counties (n = 2963) investigated whether county-level drug overdose mortality is associated with maltreatment report rates, and whether the relationship between overdose mortality and maltreatment reports is moderated by a county's rural, non-metro or metro status. Data included county-level 2015 maltreatment reports from the National Child Abuse and Neglect Data System, modeled drug-overdose mortality from the Centers for Disease Control, United States Department of Agriculture Rural-Urban Continuum Codes, US Census demographic data and crime reports from the Federal Bureau of Investigation. All data were linked across counties. Zero-inflated negative binomial (ZINB) regression was used for county-level analysis. As hypothesized, results from the ZINB model showed a significant and positive relationship between drug overdose mortality and child maltreatment report rates (χ = 101.26, p < .0001). This relationship was moderated by position on the rural-urban continuum (χ=8.76, p = .01). For metro counties, there was a 1.9% increase in maltreatment report rate for each additional increment of overdose deaths (IRR=1.019, CI=[1.010, 1.028]). For non-metro counties, the rate of increase was 1.8% higher than for metro counties (IRR=1.018, CI=[1.006, 1.030]); for rural counties, the rate of increase was 1.2% higher than for metro counties (IRR=1.012, CI=[0.999, 1.026]). Additional research is needed to determine why the relationship between drug overdose mortality and maltreatment reports is stronger in non-metro and rural communities. One potential driver requiring additional inquiry is that access to mental and physical health care and substance use treatment may be more limited outside of metropolitan counties.

Prescription-, Illicit-, and Self-Harm Opioid Overdose Cases Treated in Hospital

OBJECTIVE

Research suggests unintentional overdose on prescription drugs and intentional self-harm cases differ fundamentally from unintentional illicit drug overdoses, but there are few data on opioid overdose per se.

METHOD

We analyzed consecutive opioid overdose patients age 13 and over (N = 435) treated by a toxicology consult service to compare three poisoning groups: unintentional illicit drug (illicit, n = 128), unintentional prescription drug (prescription, n = 217), and intentional self-harm (self-harm, n = 90). The groups were compared on key characteristics of the poisoning events (severity, co-ingestion of non-opioid) and the hospital-based treatments required to manage the poisonings (use of antidote, provision of pharmacological support). Logistic regressions yielded incident rate ratios (IRRs) and 95% confidence intervals (CI) adjusted for age and sex.

RESULTS

Compared to the illicit group, the prescription group was more likely to co-ingest a non-opioid drug (IRR [95% CI] = 1.594 [1.077, 2.358], p = .020. Compared to illicit cases, self-harm cases were more likely to co-ingest a non-opioid drug (IRR = 3.181 [1.620, 6.245], p = .001) and had a lower poisoning severity score (IRR = 0.750 [0.564, 0.997], p = .048). There were no statistically significant differences between the self-harm and prescription groups.

CONCLUSIONS

The similarities between the self-harm and prescription poisoning groups suggest that they may benefit from common interventions including appropriate restriction on prescription of opioids and other medications that may be misused (e.g., sedative-hypnotic/muscle relaxants). The characteristics of the illicit poisoning group (use of heroin; more severe overdose events) suggest the need for initiation of intensive substance use treatment interventions during hospitalization.

"Feeling confident and equipped": Evaluating the acceptability and efficacy of an overdose response and naloxone administration intervention to service industry employees in New York City

BACKGROUND

The problem of injection drug use in public bathrooms has been documented from the perspectives of people who inject drugs and service industry employees (SIEs). Previous studies suggest that SIEs are unaware of how to respond to opioid overdoses, yet there are no behavioral interventions designed for SIEs to address their specific needs. In response to this gap in the field, we constructed, implemented, and evaluated a three-module behavioral intervention for SIEs grounded in the Information-Motivation-Behavioral skills model. This paper focuses on the evaluation of one module, namely, the intervention component addressing overdose response and naloxone administration (ORNA).

METHODS

Participants were SIEs (N = 18 from two separate business establishments) recruited using convenience sampling. The study utilized a pre-/post-test concurrent nested mixed method design and collected quantitative and qualitative data including an evaluation of the intervention module. The primary outcomes were opioid overdose-related knowledge and attitudes. Acceptability was also assessed.

RESULTS

SIEs demonstrated significant improvements (p <  0.01, Cohen's d = 1.45) in opioid overdose-related knowledge as well as more positive opioid overdose-related attitudes (p< 0.01, Cohen's d = 2.45) following the intervention. Participants also reported high levels of acceptability of the module and suggestions for improvement (i.e., more role-playing).

CONCLUSIONS

This study highlights the acceptability and evidence of efficacy of the ORNA module, as well as the utility of training SIEs in ORNA. The expansion of this training to other SIEs and public employees (librarians, etc.) who manage public bathrooms warrants further investigation.

Being "hooked up" during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York City

Illicitly manufactured fentanyl (IMF), a category of synthetic opioids 50-100 times more potent than morphine, is increasingly being added to heroin and other drugs in the United States (US). Persons who use drugs (PWUD) are frequently unaware of the presence of fentanyl in drugs. Use of heroin and other drugs containing fentanyl has been linked to sharp increases in opioid mortality. In New York City (NYC), opioid-related mortality increased from 8.2 per 100,000 residents in 2010 to 19.9 per 100,000 residents in 2016; and, in 2016, fentanyl accounted for 44% of NYC overdose deaths. Little is known about how PWUD are adapting to the increase in fentanyl and overdose mortality. This study explores PWUDs' adaptations to drug using practices due to fentanyl. In-depth qualitative interviews were conducted with 55 PWUD at three NYC syringe services programs (SSP) about perceptions of fentanyl, overdose experiences and adaptations of drug using practices. PWUD utilized test shots, a consistent drug dealer, fentanyl test strips, naloxone, getting high with or near others and reducing drug use to protect from overdose. Consistent application of these methods was often negated by structural level factors such as stigma, poverty and homelessness. To address these, multi-level overdose prevention approaches should be implemented in order to reduce the continuing increase in opioid mortality.

Medications for Alcohol and Opioid Use Disorders and Risk of Suicidal Behavior, Accidental Overdoses, and Crime

OBJECTIVE

The authors examined associations between medications for alcohol and opioid use disorders (acamprosate, naltrexone, methadone, and buprenorphine) and suicidal behavior, accidental overdoses, and crime.

METHOD

In this total population cohort study, 21,281 individuals who received treatment with at least one of the four medications between 2005 and 2013 were identified. Data on medication use and outcomes were collected from Swedish population-based registers. A within-individual design (using stratified Cox proportional hazards regression models) was used to compare rates of suicidal behavior, accidental overdoses, and crime for the same individuals during the period when they were receiving the medication compared with the period when they were not.

RESULTS

No significant associations with any of the primary outcomes were found for acamprosate. For naltrexone, there was a reduction in the hazard ratio for accidental overdoses during periods when individuals received treatment compared with periods when they did not (hazard ratio=0.82, 95% CI=0.70, 0.96). Buprenorphine was associated with reduced arrest rates for all crime categories (i.e., violent, nonviolent, and substance-related) as well as reduction in accidental overdoses (hazard ratio=0.75, 95% CI=0.60, 0.93). For methadone, there were significant reductions in the rate of suicidal behaviors (hazard ratio=0.60, 95% CI=0.40-0.88) as well as reductions in all crime categories. However, there was an increased risk for accidental overdoses among individuals taking methadone (hazard ratio=1.25, 95% CI=1.13, 1.38).

CONCLUSIONS

Medications currently used to treat alcohol and opioid use disorders also appear to reduce suicidality and crime during treatment.

Grief in a biography of losses: Meaning-making in hard drug users' grief narratives on drug-related death

The focus in grief theories has been increasingly shifting toward questions of meaning. In this study, we draw on the meaning-reconstruction model of grief for studying the unique case of hard drug users who have experienced a drug-related death. The social context of hard drug use, as well as the death and grief circumstances, is problematic and stigmatized. Grief narratives of 10 respondents were analyzed according to the principles of grounded theory. We identified four main themes: (1) the inhibition of emotion by drugs leading to fragmented grief reactions, (2) social exclusion and notions of disenfranchized grief, (3) the acceptance of death, and (4) meaningfulness in a "biography of losses." Connecting these results with the literature on meaning, we find that meaning-making is a multidimensional and layered process, where some layers result in meanings made while others do not. Finally, this study emphasizes the importance of social and emotional aspects of grieving, as well as the ambiguity of the notion of successful meaning-making in relation to grief.

Characterizing peer roles in an overdose crisis: Preferences for peer workers in overdose response programs in emergency shelters

OBJECTIVES

A growing body of research points to increasing peer involvement in programs for people who use drugs, although this work has focused primarily on naloxone education and distribution. This study extends this work by examining the roles of peers in leading a novel overdose response program within emergency shelters.

METHODS

Semi-structured qualitative interviews were conducted with 24 people who use drugs, recruited from two emergency shelters, as well as ethnographic observation in these settings. Interviews were transcribed and analyzed thematically with attention to peer roles.

RESULTS

Four themes emerged from the data. First, participants discussed the development of peer support through relationship building and trust. Second, participants described a level of safety using drugs in front of peer workers due to their shared lived experience. Third, peer workers were described as favorable compared to non-peer staff because of nominal power dynamics and past negative experiences with non-peer staff. Last, given the context of the overdose crisis, peer worker roles were often routinized informally across the social networks of residents, which fostered a collective obligation to respond to overdoses.

CONCLUSIONS

Findings indicate that participants regarded peer workers as providing a range of unique benefits. They emphasized the critical role of both social networks and informal roles in optimizing overdose responses. The scaling up of peer programming in distinct risk environments such as emergency shelters through both formal and informal roles has potential to help improve overdose prevention efforts, including in settings not well served by conventional public health programming.

Assessment of barrier severity and willingness to enter opioid agonist treatment among people who inject drugs in Ukraine

BACKGROUND

Opioid agonist therapies (OAT) in Ukraine were first introduced in 2004 not as addiction treatment, but for HIV prevention. Numerous obstacles have thwarted OAT scale-up, including individual constraints and structural barriers.

METHODS

A cross-sectional survey of 1613 opioid dependent people who inject drugs (PWID) were recruited in 2014-2015 using stratified sampling in Kyiv, Odesa, Mykolayiv, Dnipro and Lviv. Analysis was restricted to a subset of 811 PWID who never received OAT. Barriers to OAT were assessed based on reasons why study participants were reluctant to enroll into OAT. A Rasch model from the Item Response Theory was applied to 24 potential barriers, used to score their severity and estimate a latent composite measure for each person's willingness and ability to participate in OAT.

RESULTS

The Rasch model confirmed the cumulative nature of barriers with concerns over treatment efficacy, safety and tolerability being more prevalent than barriers related to logistical constraints, opportunity costs and social stigma. If barriers related to treatment perception and logistics were eliminated, the average barrier number would decrease from 10 to 2.2. Participants were more likely to have a higher resistance to OAT entry if they experienced fewer overdoses, did not attain higher education, were not previously incarcerated and if their peers did not have a higher level of resistance to OAT.

CONCLUSIONS

Understanding the interdependence of various barriers and attitudes toward OAT can improve the rate of OAT expansion and ameliorate entry into substance abuse treatment programs in Ukraine.

Not just heroin: Extensive polysubstance use among US high school seniors who currently use heroin

BACKGROUND

Heroin-related deaths are on the rise in the US and a large portion of heroin overdoses involve co-use of other drugs such as benzodiazepines. A better understanding of heroin polysubstance use patterns could help discern better prevention measures.

METHODS

Data were examined from past-month ("current") heroin users from a nationally representative sample of high school seniors in the Monitoring the Future study (2010-2016, n = 327). We examined how past-month use and frequency of use of various drugs relate to frequency of current heroin use using chi-square and multivariable ordinal logistic regression.

RESULTS

Prevalence of any past-month use of various other drugs (and past-month use 10+ times) tends to increase as the frequency of heroin use increases; however, other drug use tends to decline among those reporting the use of heroin 40+ times in the past month. In multivariable models controlling for demographic characteristics, most levels of alcohol use were associated with decreased odds of higher-frequency heroin use (ps<.05). Nonmedical opioid (aOR = 5.84, p = .037) and tranquilizer (aOR = 14.63, p = .045) use 40+ times in the past month were associated with increased odds of higher-frequency heroin use.

CONCLUSIONS

High school seniors who use heroin also use multiple other drugs. Increases in the frequency of heroin use are associated with shifts in the nature and frequency of polysubstance use, with a higher frequency of heroin use associated with the highest percentage and frequency of use of depressants (nonmedical opioid and benzodiazepine use), compounding the risk of overdose. Prevention measures should consider polysubstance use patterns among heroin-using adolescents.

Student pharmacist perceptions of participation in hands-on naloxone counseling

BACKGROUND AND PURPOSE

Opioid overdose is a leading cause of death across the United States. Rho Chi Pharmacy Honor Society students at the University of Kentucky initiated a project to provide fellow students a volunteer opportunity to educate at-risk patients about naloxone using a physician-approved protocol. The goal was to improve student counseling skills by allowing them to apply knowledge learned during didactic and simulated training.

EDUCATIONAL ACTIVITY AND SETTING

Third and fourth year pharmacy students at the University of Kentucky voluntarily provided opioid overdose and naloxone counseling to patients at the health department and other locations. Students who counseled at the health department were asked to complete an Institutional Review Board (IRB)-approved, anonymous, electronic survey at the end to gauge their perceptions of the experience.

FINDINGS

Thirty-five of forty-five participating students responded to the survey, indicating a 78% response rate. The results suggested that student comfort with naloxone counseling increased after real-world counseling, compared with their perceived comfort levels entering the experience. The majority of the respondents (77%, n = 27) reported a change in their personal views on drug addiction and the associated patient population. Ninety-one percent (n = 32) of students plan to pursue certification to dispense naloxone as part of their future pharmacy practice. Most (94%, n = 33) perceived the counseling experience as practical application of their didactic education.

DISCUSSION AND CONCLUSIONS

As opioid addiction and accidental overdose plagues the nation, pharmacists are prepared to lead the battle against this disease. Pharmacy education and hands-on opportunities provide students with the practical knowledge and skills necessary to have impact on their patients and the opioid epidemic.

Vortioxetine overdose in a suicidal attempt: A case report

RATIONALE

Vortioxetine is a new multimodal antidepressant approved by the Food and Drug Administration for the treatment of Major Depressive Disorder and recently introduced in Europe. While antidepressant properties of vortioxetine and its tolerability have been demonstrated by preclinical and clinical studies data on the safety of vortioxetine after overdose are still lacking.

PATIENT CONCERNS

A 50-year-old Caucasian man presenting a severe depressive episode that in a suicide attempt he took vortioxetine at 250 mg.

DIAGNOSES

Suicide attempt by vortioxetine in a patient affected by Major Depressive Disorder.

INTERVENTIONS

General evaluations and gastric lavage with 2 L of water plus 50 g of activated charcoal was performed. After 12 hours of clinical stability, the patient was discharged from the emergency department and considering the suicidal ideation he was admitted to the inpatients psychiatric department.

OUTCOMES

After vortioxetine overdose the patient displayed no clinical signs or symptoms resulting from the exposure suggesting a good safety in overdose.

LESSON

Overdose safety of different antidepressant drugs is a matter of great considering that overdose in individuals affected by Major Depressive Disorder frequently involves prescribed antidepressants. Previous studies showed wide variation in the relative toxicity of different antidepressant drugs with higher toxicity for tricyclic antidepressants, followed by venlafaxine bupropion and mirtazapine and lower for selective serotonin reuptake inhibitors. By now there is limited clinical trial experience regarding human overdose with vortioxetine and the maximum single dose tested was 75 mg in men associated with increased rates of nausea, dizziness, diarrhea, abdominal discomfort, generalized pruritus, somnolence, and flushing. Even if there is still limited available evidence and further investigation is needed to better understand the potential risk of vortioxetine overdose; from our case, it seems that vortioxetine overdose at 250 mg (12 times the common daily dose) showed no signs or symptoms resulting from the exposure suggesting a good safety in overdose.

A Simulated Case of Acute Salicylate Toxicity From an Intentional Overdose

INTRODUCTION

Salicylate poisoning is a serious toxicologic problem with a complex pathophysiology that requires prompt diagnosis and action for a favorable outcome. A simulated experience in the evaluation and management of an aspirin-overdose patient allows learners to construct a differential diagnosis from an array of symptoms and signs, analyze a mixed acid-base disturbance, and explore the multistep management of this disorder.

METHODS

This simulation exercise was designed for second-year medical students. At the start of the session, teams received a 10-minute introduction to the activity. Upon entering a room in a simulated Emergency Department, teams had 15 minutes to complete a focused history and physical exam of the patient, interpret arterial blood gas and basic metabolic panel data, and administer treatment based on key findings and a presumptive diagnosis. The scenario was followed by a 90-minute facilitated debriefing session. An alternative 45-minute debriefing guideline is also included.

RESULTS

Students voluntarily completed a 13-question, 5-point Likert-scale survey about the educational exercise immediately following the session. They evaluated the preparatory materials and briefing, the simulation scenario, the usefulness of the debriefing, and their confidence in their understanding of salicylate poisoning following the session. Students reported a favorable response to the overall experience and the debriefing, as well as an increase in confidence following the session.

DISCUSSION

This simulation exercise was successful in exposing students to the clinical presentation of salicylate toxicity and giving them the opportunity to apply and synthesize basic science knowledge during the scenario.

A Conceptual Framework for Understanding Unintended Prolonged Opioid Use

An urgent need exists to better understand the transition from short-term opioid use to unintended prolonged opioid use (UPOU). The purpose of this work is to propose a conceptual framework for understanding UPOU that posits the influence of 3 principal domains that include the characteristics of (1) individual patients, (2) the practice environment, and (3) opioid prescribers. Although no standardized method exists for developing a conceptual framework, the process often involves identifying corroborative evidence, leveraging expert opinion to identify factors for inclusion in the framework, and developing a graphic depiction of the relationships between the various factors and the clinical problem of interest. Key patient characteristics potentially associated with UPOU include (1) medical and mental health conditions; (2) pain etiology; (3) individual affective, behavioral, and neurophysiologic reactions to pain and opioids; and (4) sociodemographic factors. Also, UPOU could be influenced by structural and health care policy factors: (1) the practice environment, including the roles of prescribing clinicians, adoption of relevant practice guidelines, and clinician incentives or disincentives, and (2) the regulatory environment. Finally, characteristics inherent to clinicians that could influence prescribing practices include (1) training in pain management and opioid use; (2) personal attitudes, knowledge, and beliefs regarding the risks and benefits of opioids; and (3) professionalism. As the gatekeeper to opioid access, the behavior of prescribing clinicians directly mediates UPOU, with the 3 domains interacting to determine this behavior. This proposed conceptual framework could guide future research on the topic and allow plausible hypothesis-based interventions to reduce UPOU.