Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study

BACKGROUND

Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use. We sought to determine whether the opening of an SIF in Vancouver, BC, Canada, was associated with a reduction in overdose mortality.

METHODS

We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city.

FINDINGS

Of 290 decedents, 229 (79·0%) were male, and the median age at death was 40 years (IQR 32-48 years). A third (89, 30·7%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35·0% after the opening of the SIF, from 253·8 to 165·1 deaths per 100,000 person-years (p=0·048). By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9·3%, from 7·6 to 6·9 deaths per 100,000 person-years (p=0·490). There was a significant interaction of rate differences across strata (p=0·049).

INTERPRETATION

SIFs should be considered where injection drug use is prevalent, particularly in areas with high densities of overdose.

FUNDING

Vancouver Coastal Health, Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.

Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study

OBJECTIVE

To examine the relation between plasma HIV-1 RNA concentrations in the community and HIV incidence among injecting drug users.

DESIGN

Prospective cohort study.

SETTING

Inner city community in Vancouver, Canada.

PARTICIPANTS

Injecting drug users, with and without HIV, followed up every six months between 1 May 1996 and 30 June 2007.

MAIN OUTCOME MEASURES

Estimated community plasma HIV-1 RNA in the six months before each HIV negative participant's follow-up visit. Associated HIV incidence.

RESULTS

Among 622 injecting drug users with HIV, 12 435 measurements of plasma HIV-1 RNA were obtained. Among 1429 injecting drug users without HIV, there were 155 HIV seroconversions, resulting in an incidence density of 2.49 (95% confidence interval 2.09 to 2.88) per 100 person years. In a Cox model that adjusted for unsafe sexual behaviours and sharing used syringes, the estimated community plasma HIV-1 RNA concentration remained independently associated with the time to HIV seroconversion (hazard ratio 3.32 (1.82 to 6.08, P<0.001), per log(10) increase). When the follow-up period was limited to observations after 1 January 1988 (when the median plasma HIV RNA concentration was <20 000 copies/ml), the median viral load was no longer statistically associated with HIV incidence (1.70 (0.79 to 3.67, P=0.175), per log(10) increase).

CONCLUSIONS

A longitudinal measure of community plasma HIV-1 RNA concentration was correlated with the community HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviours and sharing used syringes. If these findings are confirmed, they could help to inform both HIV prevention and treatment interventions.

Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System

This analysis examines the association of death from overdose among individuals released from the Rhode Island correctional system after implementation of a comprehensive program of medications for addiction therapy.

Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States

Importance

Treatment with methadone or buprenorphine is the current standard of care for opioid use disorder. Given the paucity of research identifying which patients will respond best to which medication, both medications should be accessible to all patients so that patients can determine which works best for them. However, given differences in the historical contexts of their initial implementation, access to each of these medications may vary along racial/ethnic lines.

Objective

To examine the extent to which capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation.

Design, Setting, and Participants

This cross-sectional study included all counties and county-equivalent divisions in the US in 2016. Data on racial/ethnic population distribution were derived from the American Community Survey, and data on locations of facilities providing methadone and buprenorphine were obtained from Substance Abuse and Mental Health Services Administration databases. Data were analyzed from August 22, 2018, to September 11, 2019.

Exposures

Two county-level measures of racial/ethnic segregation, including dissimilarity (representing the proportion of African American or Hispanic/Latino residents who would need to move census tracts to achieve a uniform spatial distribution of the population by race/ethnicity) and interaction (representing the probability that an African American or Hispanic/Latino resident will interact with a white resident and vice versa, assuming random mixing across census tracts).

Main Outcomes and Measures

County-level capacity to provide methadone or buprenorphine, defined as the number of facilities providing a medication per 100 000 population.

Results

Among 3142 US counties, there were 1698 facilities providing methadone (0.6 facilities per 100 000 population) and 18 868 facilities providing buprenorphine (5.9 facilities per 100 000 population). Each 1% decrease in probability of interaction of an African American resident with a white resident was associated with 0.6 more facilities providing methadone per 100 000 population. Similarly, each 1% decrease in probability of interaction of a Hispanic/Latino resident with a white resident was associated with 0.3 more facilities providing methadone per 100 000 population. Each 1% decrease in the probability of interaction of a white resident with an African American resident was associated with 8.17 more facilities providing buprenorphine per 100 000 population. Similarly, each 1% decrease in the probability of interaction of a white resident with a Hispanic/Latino resident was associated with 1.61 more facilities providing buprenorphine per 100 000 population.

Conclusions and Relevance

These findings suggest that the racial/ethnic composition of a community was associated with which medications residents would likely be able to access when seeking treatment for opioid use disorder. Reforms to existing regulations governing the provisions of these medications are needed to ensure that both medications are equally accessible to all.

Highly active antiretroviral therapy and survival in HIV-infected injection drug users

CONTEXT

Highly active antiretroviral therapy (HAART) is often withheld from injection drug users (IDUs) infected with the human immunodeficiency virus (HIV) based on the belief that their unstable lifestyles may predetermine a markedly inferior outcome with HAART. However, long-term evaluations of HIV treatment outcomes among IDUs in comparison with other risk groups are not available.

OBJECTIVE

To compare survival rates among HIV-infected patients initiating HAART with and without a history of injection drug use.

DESIGN, SETTING, AND PATIENTS

Population-based, prospective cohort study (HAART Observational Medical Evaluation and Research [HOMER]) of 3116 antiretroviral-naive HIV-infected patients in a province-wide HIV/AIDS treatment program in British Columbia, Canada. Of the 3116 patients, 915 were IDUs (29.4%), 579 were female (18.6%), and the median age was 39.4 years (interquartile range, 33.3-46.4 years). Treatment with HAART was initiated between August 1, 1996, and June 30, 2006. The median duration of follow-up was 5.3 years (interquartile range, 2.8-8.3 years) for IDUs and 4.3 years (interquartile range, 2.0-7.6 years) for non-IDUs. Patients were followed up until June 30, 2007. Data were analyzed between November 1, 2007, and May 26, 2008.

MAIN OUTCOME MEASURE

All-cause mortality.

RESULTS

Overall, 622 individuals died (20.0%) during the study period (232 IDUs and 390 non-IDUs), for a crude mortality rate of 20.0% (95% confidence interval [CI], 18.4%-21.5%). At 84 months after the initiation of HAART, the product limit estimate of the cumulative all-cause mortality rate was similar between the 915 IDUs (26.5%; 95% CI, 23.2%-29.8%) and 2201 non-IDUs (21.6%; 95% CI, 16.9%-26.2%) (Wilcoxon P = .47). In multivariate time-updated Cox regression, the hazard ratio of mortality was similar between IDUs and non-IDUs (1.09; 95% CI, 0.92-1.29).

CONCLUSION

In this study population, injection drug use was not associated with decreased survival among HIV-infected patients initiating HAART.

Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study

BACKGROUND

Illicit fentanyl use has become wide spread in the US, causing high rates of overdose deaths among people who use drugs. This study describes patterns and perceptions of fentanyl exposure among opioid users in Rhode Island.

METHODS

A mixed methods study was conducted via questionnaire with a convenience sample of 149 individuals using illicit opioids or misusing prescription opioids in Rhode Island between January and November 2016. Of these, 121 knew of fentanyl and reported known or suspected exposure to fentanyl in the past year. Semi-structured interviews were conducted with the first 47 participants.

RESULTS

Study participants were predominantly male (64%) and white (61%). Demographic variables were similar across sample strata. Heroin was the most frequently reported drug of choice (72%). Self-reported exposure to illicit fentanyl in the past year was common (50.4%, n=61). In multivariate models, regular (at least weekly) heroin use was independently associated with known or suspected fentanyl exposure in the past year (adjusted prevalence ratio (APR)=4.07, 95% CI: 1.24-13.3, p=0.020). In interviews, users described fentanyl as unpleasant, potentially deadly, and to be avoided. Participants reporting fentanyl exposure routinely experienced or encountered non-fatal overdose. Heroin users reported limited ability to identify fentanyl in their drugs. Harm reduction strategies used to protect themselves from fentanyl exposure and overdose, included test hits, seeking prescription opioids in lieu of heroin, and seeking treatment with combination buprenorphine/naloxone. Participants were often unsuccessful in accessing structured treatment programs.

CONCLUSION

Among illicit opioid users in Rhode Island, known or suspected fentanyl exposure is common, yet demand for fentanyl is low. Fentanyl-contaminated drugs are generating user interest in effective risk mitigation strategies, including treatment. Responses to the fentanyl epidemic should be informed by the perceptions and experiences of local users. The rapid scale-up of buprenorphine/naloxone provision may slow the rate of fentanyl-involved overdose deaths.

Nonmedical Prescription Opioid Use in Childhood and Early Adolescence Predicts Transitions to Heroin Use in Young Adulthood: A National Study

OBJECTIVES

To examine the relationship between nonmedical use of prescription opioids and heroin initiation from childhood to young adulthood, and to test whether certain ages, racial/ethnic, and income groups were at higher risk for this transition.

STUDY DESIGN

Among a nationally representative sample of US adolescents assessed in the 2004-2011 National Surveys on Drug Use and Health cross-sectional surveys (n = 223,534 respondents aged 12-21 years), discrete-time hazard models were used to estimate the age-specific hazards of heroin initiation associated with prior history of nonmedical use of prescription opioids. Interactions were estimated between prior history of nonmedical use of prescription opioids and age of nonmedical use of prescription opioid initiation, race/ethnicity, and income.

RESULTS

A prior history of nonmedical use of prescription opioids was strongly associated with heroin initiation (hazard ratio 13.12, 95% CI 10.73, 16.04). Those initiating nonmedical use of prescription opioids at ages 10-12 years had the highest risk of transitioning to heroin use; the association did not vary by race/ethnicity or income group.

CONCLUSIONS

Prior use of nonmedical use of prescription opioids is a strong predictor of heroin use onset in adolescence and young adulthood, regardless of the user's race/ethnicity or income group. Primary prevention of nonmedical use of prescription opioids in late childhood may prevent the onset of more severe types of drug use such as heroin at later ages. Moreover, because the peak period of heroin initiation occurs at ages 17-18 years, secondary efforts to prevent heroin use may be most effective if they focus on young adolescents who already initiated nonmedical use of prescription opioids.

Health outcomes associated with methamphetamine use among young people: a systematic review

OBJECTIVES

Methamphetamine (MA) use among young people is of significant social, economic and public health concern to affected communities and policy makers. While responses have focused upon various perceived severe harms of MA use, effective public health interventions require a strong scientific evidence base.

METHODS

We conducted a systematic review to identify scientific studies investigating health outcomes associated with MA use among young people aged 10-24 years. The International Classification of Diseases (ICD-10) was used to categorize outcomes and determine the level of evidence for each series of harms.

RESULTS

We identified 47 eligible studies for review. Consistent associations were observed between MA use and several mental health outcomes, including depression, suicidal ideation and psychosis. Suicide and overdose appear to be significant sources of morbidity and mortality among young MA users. Evidence for a strong association between MA use and increased risk of human immunodeficiency virus (HIV) and other sexually transmitted infections is equivocal. Finally, we identified only weak evidence of an association between MA use and dental diseases among young people.

CONCLUSIONS

Available evidence indicates a consistent relationship between MA use and mental health outcomes (e.g. depression, psychosis) and an increased risk of mortality due to suicide and overdose. We found insufficient evidence of an association between MA use and other previously cited harms, including infectious diseases and dental outcomes. As such, future research of higher methodological quality is required to further investigate possible associations. Current interventions should focus attention upon MA-related health outcomes for which sound scientific evidence is available.

Formalizing the role of agent-based modeling in causal inference and epidemiology

Calls for the adoption of complex systems approaches, including agent-based modeling, in the field of epidemiology have largely centered on the potential for such methods to examine complex disease etiologies, which are characterized by feedback behavior, interference, threshold dynamics, and multiple interacting causal effects. However, considerable theoretical and practical issues impede the capacity of agent-based methods to examine and evaluate causal effects and thus illuminate new areas for intervention. We build on this work by describing how agent-based models can be used to simulate counterfactual outcomes in the presence of complexity. We show that these models are of particular utility when the hypothesized causal mechanisms exhibit a high degree of interdependence between multiple causal effects and when interference (i.e., one person's exposure affects the outcome of others) is present and of intrinsic scientific interest. Although not without challenges, agent-based modeling (and complex systems methods broadly) represent a promising novel approach to identify and evaluate complex causal effects, and they are thus well suited to complement other modern epidemiologic methods of etiologic inquiry.

Use of rapid fentanyl test strips among young adults who use drugs

BACKGROUND

The overdose epidemic has been exacerbated by a dramatic increase in deaths involving illicitly manufactured fentanyl (IMF). Drug checking is a novel strategy to identify IMF in illicit drugs. We examined the uptake and acceptability of rapid fentanyl test strips among young adults.

METHODS

From May to September 2017, we recruited 93 young adults in Rhode Island who reported injecting drugs or using heroin, cocaine, or illicitly obtained prescription pills in the past 30 days. Participants were asked to test either their urine after drug use (post-consumption) or a drug sample prior to use (pre-consumption) using rapid fentanyl test strips. After a questionnaire and a brief training, participants received ten strips for their personal use and were asked to return for a one-month follow-up visit, which assessed the uptake and acceptability of the rapid strips tests and the behavioral outcomes associated with receipt of a positive test.

RESULTS

Of the 81 (87%) participants who returned for follow-up and who had complete data, the mean age was 27, 45 (56%) were male, and 37 (46%) were non-white. A total of 62 participants (77%) reported using at least one test strip. Of these, 31 (50%) received at least one positive result. A positive result was associated with older age, homelessness, heroin use, injection drug use, ever witnessing an overdose, and concern about overdose or drugs being laced with fentanyl (all p < 0.05). Receiving a positive result was significantly associated with reporting a positive change in overdose risk behavior between baseline and follow-up (p ≤  0.01). Among all participants, 79 (98%) reported confidence in their ability to use the test strips and 77 (95%) wanted to use them in the future.

CONCLUSIONS

Young adults reported high uptake and acceptability of fentanyl test strips to detect IMF in illicit drugs.

Homelessness and unstable housing associated with an increased risk of HIV and STI transmission among street-involved youth

The role that environmental factors play in driving HIV and STI transmission risk among street-involved youth has not been well examined. We examined factors associated with number of sex partners using quasi-Poisson regression and consistent condom use using logistic regression among participants enroled in the At Risk Youth Study (ARYS). Among 529 participants, 253 (47.8%) reported multiple partners while only 127 (24.0%) reported consistent condom use in the past 6 months. Homelessness was inversely associated with consistent condom use (adjusted odds ratio [aOR]=0.47, p=0.008), while unstable housing was positively associated with greater numbers of sex partners (adjusted incidence rate ratio [aIRR]=1.44, p=0.010). These findings indicate the need for interventions which modify environmental factors that drive risk among young street-involved populations.

Association of Pharmaceutical Industry Marketing of Opioid Products With Mortality From Opioid-Related Overdoses

IMPORTANCE

Prescription opioids are involved in 40% of all deaths from opioid overdose in the United States and are commonly the first opioids encountered by individuals with opioid use disorder. It is unclear whether the pharmaceutical industry marketing of opioids to physicians is associated with mortality from overdoses.

OBJECTIVE

To identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across US counties.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, county-level analysis of industry marketing information used data from the Centers for Medicare & Medicaid Services Open Payments database linked with data from the Centers for Disease Control and Prevention on opioid prescribing and mortality from overdoses. All US counties were included, with data on overdoses from August 1, 2014, to December 31, 2016, linked to marketing data from August 1, 2013, to December 31, 2015, using a 1-year lag. Statistical analyses were conducted between February 1 and June 1, 2018.

MAIN OUTCOMES AND MEASURES

County-level mortality from prescription opioid overdoses, total cost of marketing of opioid products to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors.

RESULTS

Between August 1, 2013, and December 31, 2015, there were 434 754 payments totaling $39.7 million in nonresearch-based opioid marketing distributed to 67 507 physicians across 2208 US counties. After adjustment for county-level sociodemographic factors, mortality from opioid overdoses increased with each 1-SD increase in marketing value in dollars per capita (adjusted relative risk, 1.09; 95% CI, 1.05-1.12), number of payments to physicians per capita (adjusted relative risk, 1.18; 95% CI, 1.14-1.21, and number of physicians receiving marketing per capita (adjusted relative risk, 1.12; 95% CI, 1.08-1.16). Opioid prescribing rates also increased with marketing and partially mediated the association between marketing and mortality.

CONCLUSIONS AND RELEVANCE

In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses. Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted.

Sexual Minority Health Disparities in Adult Men and Women in the United States: National Health and Nutrition Examination Survey, 2001-2010

OBJECTIVES

We used nationally representative data to investigate health disparities associated with sexual minority status among adults in the United States.

METHODS

We analyzed data from 11,114 adults who participated in the 2001 to 2010 waves of the National Health and Nutrition Examination Survey. Using multiple logistic regressions, we examined the prevalence of HIV, sexually transmitted infections, mental health problems, cigarette smoking, and alcohol and illicit drug use in sexual minorities and heterosexual adults.

RESULTS

After adjusting for sociodemographic characteristics, sexual minority men had greater odds of mental health problems, testing positive for HIV and herpes simplex virus type 2 and self-reported gonorrhea and chlamydia. Sexual minority women had greater odds of mental health problems, testing positive for hepatitis C, smoking, heavy drinking, and illicit drug use.

CONCLUSIONS

Numerous health disparities continue to face sexual minority men and women in the United States. Notably, health disparities persisted beyond the role of sociodemographic factors, including access to insurance and primary care, suggesting that further research is warranted to identify the determinants of health inequity for sexual minorities.

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.

High willingness to use rapid fentanyl test strips among young adults who use drugs

BACKGROUND

Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since 2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid test strips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), may help inform people about their exposure risk. The purpose of this study was to determine whether young adults who use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. We hypothesized that those who had ever overdosed would be more willing to use the test strips.

METHODS

We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September 2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. The survey assessed participant's socio-demographic and behavioral characteristics, overdose risk, as well as suspected fentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine. Participants were then trained to use the test strips and were given ten to take home.

RESULTS

Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male, and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%) of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%) participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly all participants (n = 88, 95%) reported that they planned to use the test strips.

CONCLUSIONS

More than 90% of participants reported willingness to use rapid test strips regardless of having ever overdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young people who use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.

Acceptability of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore, Boston and Providence

BACKGROUND

North America is experiencing a rising trend of opioid overdose exacerbated primarily in recent years through adulteration of the heroin supply with fentanyl and its analogues. The east coast of the United States has been particularly hard hit by the epidemic. In three east coast states of Maryland, Massachusetts and Rhode Island, fentanyl has been detected in over half of all overdoses with available toxicology screens. To determine the acceptability of drug checking involving fentanyl test strips (FTS) or other technologies among those at high risk for overdose, we assessed correlates of intention to utilize such services and logistical preferences among people who use drugs (PWUD).

METHODS

Through FORECAST (the Fentanyl Overdose REduction Checking Analysis STudy), street-based PWUD (N = 334) were recruited in Baltimore, Maryland, Boston, Massachusetts, and Providence, Rhode Island. Questionnaires 7were administered from June to October 2017 and ascertained drug use, overdose history, fentanyl knowledge, and drug checking intent and logistical preferences. Pearson's χ² and logistic regression determined factors associated with drug checking intent.

RESULTS

Overall, 84% were concerned about fentanyl, 63% had ever overdosed, and 42% had ever witnessed a fatal overdose. Ninety percent felt drug checking would help them prevent an overdose, the majority of those interested would utilize drug checking at least daily (54%). Factors independently associated with intent to use drug checking included: older age (aOR: 1.5, 95% CI: 1.3-1.8); homelessness (aOR: 0.6, 95% CI: 0.5-0.7); being non-white (aOR: 2.0, 95% CI: 1.0-4.0); witnessing ≥1 fatal overdose (aOR: 1.6, 95% CI:1.1-2.3); and suspected recent fentanyl exposure (aOR: 1.8, 95% CI: 1.1-3.1).

CONCLUSIONS

The majority of PWUD endorsed drug checking for overdose prevention, with intent amplified by having witnessed a fatal overdose and recent fentanyl exposure. Drug checking should be part of a comprehensive approach to address the risks associated with the proliferation of fentanyl.

Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing

This database analysis examines the extent to which pharmaceutical industry marketing of opioid products to physicians during 2014 was associated with opioid prescribing during 2015.

Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study

AIMS

To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care.

DESIGN

Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use.

SETTING

Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC.

PARTICIPANTS

A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012.

MEASUREMENTS

The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use.

FINDINGS

Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35].

CONCLUSIONS

New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.

Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis

The burden of HIV/AIDS and other transmissible diseases is higher in prison and jail settings than in the non-incarcerated communities that surround them. In this comprehensive review, we discuss available literature on the topic of clinical management of people infected with HIV, hepatitis B and C viruses, and tuberculosis in incarcerated settings in addition to co-occurrence of one or more of these infections. Methods such as screening practices and provision of treatment during detainment periods are reviewed to identify the effect of community-based treatment when returning inmates into the general population. Where data are available, we describe differences in the provision of medical care in the prison and jail settings of low-income and middle-income countries compared with high-income countries. Structural barriers impede the optimal delivery of clinical care for prisoners, and substance use, mental illness, and infectious disease further complicate the delivery of care. For prison health care to reach the standards of community-based health care, political will and financial investment are required from governmental, medical, and humanitarian organisations worldwide. In this review, we highlight challenges, gaps in knowledge, and priorities for future research to improve health-care in institutions for prisoners.

Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically

BACKGROUND

The rate of overdose deaths caused by fentanyl-contaminated heroin (FCH) use is increasing rapidly in the United States. We examined risk factors for exposure to FCH and experiences with FCH use among young adult non-medical prescription opioids (NMPO) users.

METHODS

We analyzed data from the Rhode Island Young Adult Prescription Drug Study (RAPiDS), which enrolled young adults aged 18 to 29 reporting prior 30day NMPO use between January 2015 and February 2016. Participants completed questionnaires ascertaining drug use patterns and risk behaviors, including FCH exposure. Logistic regression was used to assess factors associated with known or suspected FCH exposure.

RESULTS

Of 199 participants, the median age was 25 (IQR: 22, 27), 130 (65.3%) were male, and 122 (61.3%) were of White, non-Hispanic race/ethnicity. In total, 22 (11%) reported known or suspected FCH exposure in the prior six months. Several drug use patterns and risk behaviors were associated with FCH exposure, including: regular heroin and cocaine use; diverted pharmaceutical fentanyl use in the prior six months; NMPO use to avoid withdrawal symptoms; longer duration of NMPO use; regular injection drug use; and prior overdose (all p<0.001). Among participants who reported FCH exposure, 59% were unaware that their heroin was contaminated with fentanyl prior to last use, 59% reported that FCH provides a better high, and all recognized that fentanyl increases overdose risk.

CONCLUSIONS

Exposure to fentanyl-contaminated heroin is an emerging trend among young adult NMPO users in Rhode Island. Overdose prevention programs addressing FCH use are urgently needed.

The epidemiology of substance use disorders in US Veterans: A systematic review and analysis of assessment methods

BACKGROUND

Substance use disorders (SUDs), which encompass alcohol and drug use disorders (AUDs, DUDs), constitute a major public health challenge among US veterans. SUDs are among the most common and costly of all health conditions among veterans.

OBJECTIVES

This study sought to examine the epidemiology of SUDs among US veterans, compare the prevalence of SUDs in studies using diagnostic and administrative criteria assessment methods, and summarize trends in the prevalence of SUDs reported in studies sampling US veterans over time.

METHODS

Comprehensive electronic database searches were conducted. A total of 3,490 studies were identified. We analyzed studies sampling US veterans and reporting prevalence, distribution, and examining AUDs and DUDs.

RESULTS

Of the studies identified, 72 met inclusion criteria. The studies were published between 1995 and 2013. Studies using diagnostic criteria reported higher prevalence of AUDs (32% vs. 10%) and DUDs (20% vs. 5%) than administrative criteria, respectively. Regardless of assessment method, both the lifetime and past year prevalence of AUDs in studies sampling US veterans has declined gradually over time.

CONCLUSION

The prevalence of SUDs reported in studies sampling US veterans are affected by assessment method. Given the significant public health problems of SUDs among US veterans, improved guidelines for clinical screening using validated diagnostic criteria to assess AUDs and DUDs in US veteran populations are needed.

SCIENTIFIC SIGNIFICANCE

These findings may inform VA and other healthcare systems in prevention, diagnosis, and intervention for SUDs among US veterans.

Injection drug use among street-involved youth in a Canadian setting

Background

Street-involved youth contend with an array of health and social challenges, including elevated rates of blood-borne infections and mortality. In addition, there has been growing concern regarding high-risk drug use among street-involved youth, in particular injection drug use. We undertook this study to examine the prevalence of injection drug use and associated risks among street-involved youth in Vancouver, Canada.

Methods

From September 2005 to November 2007, baseline data were collected for the At-Risk Youth Study (ARYS), a prospective cohort of street-recruited youth aged 14 to 26 in Vancouver, Canada. Using multiple logistic regression, we compared youth with and without a history of injection.

Results

The sample included 560 youth among whom the median age was 21.9 years, 179 (32%) were female, and 230 (41.1%) reported prior injection drug use. Factors associated with injection drug use in multivariate analyses included age ≥ 22 years (adjusted odds ratio [AOR] = 1.18, 95% CI: 1.10–1.28); sex work involvement (AOR = 2.17, 95% CI: 1.35–3.50); non-fatal overdose (AOR = 2.10, 95% CI: 1.38–3.20); and hepatitis C (HCV) infection (AOR = 22.61, 95% CI: 7.78–65.70).

Conclusion

These findings highlight an alarmingly high prevalence of injection drug use among street-involved youth and demonstrate its association with an array of risks and harms, including sex work involvement, overdose, and HCV infection. These findings point to the need for a broad set of policies and interventions to prevent the initiation of injection drug use and address the risks faced by street-involved youth who are actively injecting.

Association of Prescribed Opioids With Increased Risk of Community-Acquired Pneumonia Among Patients With and Without HIV

IMPORTANCE

Some opioids are known immunosuppressants; however, the association of prescribed opioids with clinically relevant immune-related outcomes is understudied, especially among people living with HIV.

OBJECTIVE

To assess the association of prescribed opioids with community-acquired pneumonia (CAP) by opioid properties and HIV status.

DESIGN, SETTING, AND PARTICIPANTS

This nested case-control study used data from patients in the Veterans Aging Cohort Study (VACS) from January 1, 2000, through December 31, 2012. Participants in VACS included patients living with and without HIV who received care in Veterans Health Administration (VA) medical centers across the United States. Patients with CAP requiring hospitalization (n = 4246) were matched 1:5 with control individuals without CAP (n = 21 146) by age, sex, race/ethnicity, length of observation, and HIV status. Data were analyzed from March 15, 2017, through August 8, 2018.

EXPOSURES

Prescribed opioid exposure during the 12 months before the index date was characterized by a composite variable based on timing (none, past, or current); low (<20 mg), medium (20-50 mg), or high (>50 mg) median morphine equivalent daily dose; and opioid immunosuppressive properties (yes vs unknown or no).

MAIN OUTCOME AND MEASURE

CAP requiring hospitalization based on VA and Centers for Medicare & Medicaid data.

RESULTS

Among the 25 392 VACS participants (98.9% male; mean [SD] age, 55 [10] years), current medium doses of opioids with unknown or no immunosuppressive properties (adjusted odds ratio [AOR], 1.35; 95% CI, 1.13-1.62) and immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and current high doses of opioids with unknown or no immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and immunosuppressive properties (AOR, 3.18; 95% CI, 2.44-4.14) were associated with the greatest CAP risk compared with no prescribed opioids or any past prescribed opioid with no immunosuppressive (AOR, 1.24; 95% CI, 1.09-1.40) and immunosuppressive properties (AOR, 1.42; 95% CI, 1.21-1.67), especially with current receipt of immunosuppressive opioids. In stratified analyses, CAP risk was consistently greater among people living with HIV with current prescribed opioids, especially when prescribed immunosuppressive opioids (eg, AORs for current immunosuppressive opioids with medium dose, 1.76 [95% CI, 1.20-2.57] vs 2.33 [95% CI, 1.60-3.40]).

CONCLUSIONS AND RELEVANCE

Prescribed opioids, especially higher-dose and immunosuppressive opioids, are associated with increased CAP risk among persons with and without HIV.

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs

BACKGROUND

The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs.

OBJECTIVE

The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis.

DESIGN

Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns.

PARTICIPANTS

We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island.

APPROACH

Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels.

KEY RESULTS

Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction.

CONCLUSIONS

Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.