Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98

(Re)conceptualizing “Polydrug Use”: Capturing the Complexity of Combining Substances

The use of multiple psychoactive substances is a widespread phenomenon among people who use drugs. Yet the concept of polydrug use is poorly defined in the social sciences. As a result, theoretical and empirical knowledge of polydrug use is underdeveloped; approaches to measuring polydrug use are inconsistent; and understandings of the cultural meanings of combining substances are limited. This article draws on a collaborative synthesis of three qualitative case studies of polydrug use from four countries: Australia and France, Finland, and Ireland. All three studies explored the practice of substance combination, or “combos” using the lens of intentionality, functionality, and social setting. In addition, the studies shared a common concern with teasing out the rationale for substance combining, and the controls used to balance pleasures with risks, beyond the simple physiological or sensory effects of substances. Our analysis leads us to recommend that a standard definition of polydrug use be adopted for future social science research—that is, the ingestion of two or more substances in combination, at the same time or in temporal proximity, so that the effects of different substances overlap. For analytical purposes, we suggest two subcategories: simultaneous and sequential intake. Moreover, we contend that it is the intention, meaning, and socio-structural context underpinning the use of substance combinations that is central to understanding polydrug use. Consequently, we suggest an adaptation of Zinberg’s seminal concept to one of “drug combo, set, and setting” to incorporate an analysis of the effects of using substances together, or in sequence within a short time frame.

Conditioned taste avoidance induced by the combination of heroin and cocaine: Implications for the use of speedball

Speedball (heroin + cocaine) is a prevalent drug combination among intravenous drug users. Although its use is generally discussed to be a function of changes in the rewarding effects of either or both drugs, changes in the aversive effects of either drug may also be impacted (weakened) by the combination. To address this latter possibility and its potential role in the use of speedball, the present studies examined the interaction of cocaine and heroin in taste avoidance conditioning. In Experiment 1, male Sprague-Dawley rats were given access to a novel saccharin solution and then injected with either vehicle or heroin (3.2 mg/kg, IP) followed immediately by various doses of cocaine (10, 18 or 32 mg/kg, SC). At the two lowest doses of cocaine, only animals injected with the drug combination (H + C) displayed a taste avoidance relative to control subjects (taste avoidance was induced with both the combination and the high dose of cocaine). At no dose did animals injected with the combination of heroin and cocaine drink more than animals injected with cocaine alone. In Experiment 2, male Sprague-Dawley rats were similarly treated but injected with vehicle or cocaine (10 mg/kg) followed by injections of various doses of heroin (1.8, 3.2, 5.6 or 10 mg/kg). At the three highest doses of heroin, only animals injected with the drug combination (C + H) displayed significant avoidance relative to control subjects (no avoidance was evident with the combination of cocaine and the low dose of heroin). At no dose did animals injected with the combination of cocaine and heroin drink more than animals injected with heroin alone. Together, these results suggest that the aversive effects of heroin and cocaine are not attenuated by co-administration by cocaine and heroin, respectively. The importance of this for the use of speedball was discussed.

History of regular nonmedical sedative and/or alcohol use differentiates substance-use patterns and consequences among chronic heroin users

BACKGROUND

Concurrent use of sedating substances (e.g. alcohol or benzodiazepines) with opioids is associated with increased negative consequences of opioid use; however, few studies have attempted to differentiate effects of using sedating substances on heroin-use outcomes. This study examines differences between heroin users who use alcohol or misuse sedatives regularly and those who do not.

METHODS

Substance-use data were collected from 367 non-treatment seeking, chronic heroin-using, 18-to-55 year-old participants. We created 4 groups based on self-reported lifetime history of regular (at least weekly) substance use: heroin only (n = 95), heroin and sedatives (n = 21), heroin and alcohol (n = 151), and heroin, sedative, and alcohol (n = 100). Chi-square analyses and ANOVAs with Bonferroni post hoc tests were used to explore differences between these groups.

RESULTS

Heroin users who denied lifetime alcohol or nonmedical sedative use regularly endorsed fewer consequences associated with any substance they had used. Total adverse consequences of heroin use (e.g. health problems) were significantly higher among those who misused sedatives regularly, irrespective of alcohol use history (F(3,361) = 10.21; p < .001). Regular alcohol use did not independently impact heroin consequences but was associated with increased use of other substances.

CONCLUSIONS

Although polysubstance use is normative among heroin users, the risks depend on the substances used. Regular sedative use is associated with increased heroin consequences whereas regular alcohol use is not. This study refines the investigation of polysubstance use and highlights subgroup differences depending on types of substances used regularly. This knowledge is critical for understanding substance-use motivations and creating avenues for harm reduction.

A gender-based analysis of nonmedical prescription opioid use among people who use illicit drugs

BACKGROUND

Research investigating the unique impacts associated with engaging in nonmedical prescription opioid use (NMPOU) among males and females who also use illicit drugs is needed.

METHODS

Data were collected between 2013 and 2017 from two linked prospective cohort studies in Vancouver: the At-Risk Youth Study and Vancouver Injection Drug Users Study. Generalized estimating equations were used to identify factors associated with engaging in NMPOU among females and males separately.

RESULTS

Among 1459 participants, 534 were female (37%). Similar proportions of females (46%) and males (48%) engaged in NMPOU at their first visit during the study period. In multivariable analyses, factors associated with NMPOU among both males and females included heroin use, overdose, drug dealing, and difficulty accessing health and social services. Among females, those who engaged in NMPOU were more likely to report Caucasian or white ethnicity, cocaine use, crystal methamphetamine use, and sex work; among males, those who engaged in NMPOU were older, reported crack use and engaged in binge drug use (all p < 0.05).

CONCLUSION

The prevalence of NMPOU was similar among males and females who use illicit drugs in Vancouver, and NMPOU was independently associated with markers of vulnerability among both genders. Findings highlight the need for a comprehensive public health approach to address NMPOU that integrates overdose prevention and reversal services, employment opportunities, and better access to services for both women and men.

Combining Alcohol with Benzodiazepines or Psychostimulants. Metaphoric Meanings and the Concept of Control in the Online Talk of Polydrug Use

The co-administration of different substances is a widespread practice in the context of hard drug use. Among others, alcohol combined with certain substances produces potentially dangerous interactions. This article explores how people who combine alcohol with benzodiazepines or psychostimulants perceive these practices and how they share their perceptions in Finnish and Swedish online discussions. This is carried out by analyzing discussants' use of metaphoric expressions. We found that the metaphors given to the use of these substance combinations reflect their pharmacological characteristics. Through that, the metaphors and meanings were different depending on the substance alcohol was combined with. Moreover, we found that, in the realities the metaphors create, the control of use was differently conceptualized. The different aspects of control could be divided into three categories that, however, were not related to any specific substances but overarched all metaphors: 1) controlling pharmacological risks, 2) controlling social appearance and 3) ignoring control. As our findings bring out, often the actual health dangers and risks of the studied substance combinations were bypassed, and the control was rather understood either as a form of socially appropriate behavior or wholly ignored.

Opioid-related hospitalizations in Pennsylvania: A latent class analysis

BACKGROUND

Opioid abuse is associated with substantial morbidity and often results in hospitalization. Despite this, patient-level factors associated with opioid-related hospitalizations are not well understood.

METHODS

We used the Pennsylvania Health Care Cost Containment Council dataset (2000-2014) to identify opioid-related hospitalizations using primary and/or secondary ICD-9-CM hospital discharge codes for opioid use disorder (OUD), opioid poisoning, and heroin poisoning. Latent class analyses (LCA) of patient-level factors including sociodemographic characteristics, pregnancy, alcohol, tobacco, other substance use, and psychiatric disorders were used to identify common patterns within hospitalizations.

RESULTS

Among 28,538,499 hospitalizations, 430,569 (1.5%) were opioid-related. LCA identified five latent class (LC) patient groups associated with opioid-related hospitalizations: pregnant women with OUD (LC1); women over 65 with opioid overdose (LC2); OUD, polysubstance use and co-occurring psychiatric disorders (LC3); patients with opioid overdose without co-occurring polysubstance use (LC4); and African American patients with OUD and co-occurring cocaine use (LC5). LC3 was the largest latent class (58.2%) with annual hospitalizations doubling over time.

DISCUSSION

Among patients with opioid-related discharges, we identified five subpopulations among this sample. These findings suggest increased outpatient OUD treatment, mental health service support for patients with co-occurring psychiatric disorders and polysubstance use to prevent overdose and hospitalization.

Psychiatric symptoms and recent overdose among people who use heroin or other opioids: Results from a secondary analysis of an intervention study

Background

Drug overdose (OD) is the leading cause of accidental death in the United States and most of these deaths involve opioids. Despite research linking opioid abuse to mental illness, and evidence suggesting a large portion of opioid OD deaths are suicides, OD prevention strategies scarcely take into account mental health risk factors.

Methods

We examined a sample of heroin or other opioid users enrolled in an intervention study to determine the prevalence of overdose, the prevalence of suicide attempts in overdose, and whether those with higher levels of psychiatric symptomatology would be more likely to experience a recent OD compared to other opioid users. By performing bivariate analyses and multivariate logistic regression models that controlled for poly drug use, criminal justice status, age, race, gender, and education, we evaluated the association of severe depression, severe anxiety, posttraumatic stress disorder (PTSD) and, psychosis and past three-month OD.

Results

Just over 12% (45/368) of recent opioid users reported a recent overdose. Four of these recent overdose victims reported that the overdose was a suicide attempt. Multiple logistic regression analysis revealed that severe depression (odds ratio 2.46; 95% CI: 1.24, 4.89), PTSD (odds ratio: 2.77; 95% CI: 1.37–5.60) and psychosis (odds ratio 2.39; 95% CI: 1.10–5.15) were significantly associated with elevated odds for OD.

Conclusions

Findings suggest systematic mental health symptom screening and connection to mental health treatment for opioid users—especially those identified with OD—may be critical for OD prevention.

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A sample of recent opioid users in an intervention study was examined

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Over 10% of the study sample of recent opioid users reported a recent overdose

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Almost 9% of recent overdose victims reported that the overdose was a suicide attempt

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Depressive symptoms, PTSD, and psychosis were associated with recent overdose

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OD risk assessment tools should include validated mental health screening

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.

Expectations about alcohol, cocaine, and benzodiazepine abstinence following inpatient heroin withdrawal management

BACKGROUND AND OBJECTIVES

Polysubstance use is associated with relapse and poor treatment outcomes among people dependent on heroin. Despite the high prevalence of polysubstance use among patients detoxifying from heroin, little is known about patients' expectations to abstain or use non-opiate substances. The current study examined factors associated with expectations about abstaining from alcohol, cocaine, and benzodiazepines (BZDs) following heroin withdrawal management.

METHODS

Between May and December of 2015, we surveyed 417 patients (71.9% male, 31.7 [±8.39] mean years old) initiating short-term inpatient heroin withdrawal management who reported alcohol, cocaine, or BZD use in the past 30 days. We used logistic regression to evaluate the adjusted associations of background characteristics with expectations about using each substance following discharge.

RESULTS

Approximately half of respondents reported past month alcohol (52%), cocaine (47.0%), or BZD (47.0%) use, and 25.9% reported using all three substances. Approximately half of those reporting drinking, 6.6% reporting cocaine use, and 27% of reporting BZD use expected to abstain from using that substance following heroin withdrawal. Prior opioid withdrawal was associated with a lower likelihood of expecting to stop using alcohol and BZDs, and more days of BZD use was associated with a greater likelihood of expecting to abstain from BZDs following discharge.

CONCLUSION

Persons with opioid use disorder often do not expect to stop using other substances following withdrawal management, with very few planning cocaine cessation.

SCIENTIFIC SIGNIFICANCE

Inpatient heroin withdrawal programs need to address and educate patients about how polysubstance use complicates recovery from heroin use. (Am J Addict 2019;28:36-42).

Provider reasons for discontinuing long-term opioid therapy following aberrant urine drug tests differ based on the type of substance identified

OBJECTIVE

Urine drug testing (UDT) is increasingly performed as a means of identifying aberrant behavior that may be grounds for discontinuation of long-term opioid therapy (LTOT). Little is known, however, about the ways in which positive UDT results may differentially inform decisions to discontinue LTOT based on the type of substance for which the UDT screened positive. The aim of this study was to examine the likelihood of clinician-initiated discontinuation of LTOT attributed to positive UDT results across three discrete categories of substances: (1) cannabis, (2) alcohol or illicit substances (excluding cannabis), and (3) controlled prescription medications that were not prescribed.

DESIGN

This retrospective study utilized the US Department of Veterans Affairs (VA) Health Care System. Corporate Data Warehouse to assemble a sample of 600 patients with substance use disorders and matched controls who were discontinued from LTOT in 2012. Comprehensive manual medical record review identified UDT results in the year prior to discontinuation and reason(s) for discontinuation.

PATIENTS, PARTICIPANTS

Patients with one or more UDTs positive for a single substance (N = 185) comprised the study sample.

MAIN OUTCOME MEASURE(S)

Likelihood of clinician-initiated discontinuation attributed to a positive UDT across the three categories.

RESULTS

Patients with one or more UDTs positive for cannabis were more likely to be discontinued from opioid therapy as a result of the positive UDT compared to those with one or more UDTs positive for nonprescribed prescription medication (adjusted odds ratio [OR] = 18.05, 95% CI = 7.29-44.66). Similarly, patients with UDTs positive for alcohol or illicit substances were more likely to be discontinued for the positive UDTs relative to patients who tested positive for nonprescribed prescription medications (adjusted OR = 13.10, 95% CI = 4.81-35.68). No difference in UDT-related discontinuation decisions was evident between patients with UDTs positive for alcohol/illicit substances versus cannabis (adjusted OR = 1.47, 95% CI = 0.57-3.77).

CONCLUSIONS

High odds of UDT-related discontinuation were found in patients who tested positive for cannabis, alcohol, or illicit substances, relative to nonprescribed prescription medications.

Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD

Background

The opioid crisis remains a major public health issue in the US and beyond. Despite rapid rises in fentanyl-related mortality nationally, little is known about the role of fentanyl in the occurrence of non-fatal overdose among people who use drugs. We examined the prevalence of non-fatal overdose and perceived fentanyl exposure among syringe services program (SSP) clients and modeled the correlates of non-fatal overdose.

Methods

Data were drawn from a cross-sectional survey of 203 SSP clients in Baltimore, MD recruited in 2016. Logistic regression models were used to identify the correlates of experiencing non-fatal overdose in the past 12 months.

Results

The majority (65%) was male, 52% were black, 41% were white, and 37% were homeless. Almost all (97%) used heroin, 64% injected heroin with cocaine (i.e., speedball), and many used other types of drugs. Half (53%) perceived fentanyl presence in their drugs either half, most or all of the time. Lifetime and past 12 month prevalence of non-fatal overdose were 58 and 31%, respectively. Independent correlates of non-fatal overdose in the past 12 months were perceiving fentanyl in drugs more than half the time (aOR = 2.79; 95% CI = 1.00–4.68), speedball injection (aOR = 2.80, 95% CI = 1.26–6.23), non-prescription buprenorphine use (aOR = 6.37; 95% CI = 2.86–14.17), and homelessness (aOR = 3.07; 95% CI = 1.28–7.39).

Conclusions

These data demonstrate that SSP clients are at high-risk of overdose, some of which is likely attributable to fentanyl exposure. Addressing the rising fentanyl epidemic will require comprehensive and innovative strategies that attend to drug use patterns and structural factors such as homelessness.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Alcohol use disorder and associated physical health complications and treatment amongst individuals with and without opioid dependence: A case-control study

BACKGROUND

Dependence upon one substance may increase vulnerability for dependence on other substances. This study aimed to i) examine the association between opioid dependence and alcohol use and dependence; and ii) identify demographic, mental health, substance use, and alcohol-related withdrawal, physical health complications, and treatment correlates of comorbid alcohol and opioid dependence versus the former only.

METHODS

In this case-control study, 1475 participants with opioid dependence recruited from opioid substitution therapy (OST) clinics and 516 non-opioid dependent matched participants completed a structured interview covering psychiatric history, substance dependence, child maltreatment, and history of alcohol use. Analyses were mainly concentrated on cases (n = 696) and controls (n = 194) reporting lifetime alcohol dependence.

RESULTS

Cases with opioid dependence had higher rates of lifetime alcohol dependence than controls. Binary logistic regression analyses showed comorbid cases reported greater socio-economic disadvantage, poorer psychiatric history, greater incidence of dependence on other substances, earlier onset of regular drinking and alcohol dependence, and greater severity of alcohol dependence (relative to controls with alcohol dependence only). Comorbid cases were also more likely to report endorsement of certain DSM-IV criteria (i.e., legal problems due to alcohol and desire/inability to cut down use), specific withdrawal symptoms (e.g., tachycardia, hallucinations), using other substances to relieve withdrawal symptoms, and experiencing liver disease/jaundice. Rates of lifetime treatment engagement were low overall.

CONCLUSIONS

Though strongly associated with alcohol dependence and alcohol-related harms, people with a history of opioid dependence have complex social and clinical backgrounds, which appear to be important factors associated with higher levels of alcohol dependence.

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.

Quantity fluctuations of illicitly used opioids and overdose risk

BACKGROUND

Reduced opioid tolerance is believed to be associated with overdose risk, although this relationship has primarily been examined in the context of gaps and frequency of opioid use. We sought to assess how changes in the quantity of opioids used, as opposed to periods of abstinence or overall frequency of use, relate to overdose risk.

METHODS

Among repeated visits of participants of a behavioral intervention trial from 2014 to 2016, we used multivariable logistic regression models fit with generalized estimating equations to examine the relationship between the percentage of opioid use days on which individuals used more or less than the quantity they used on average (i.e., quantity volatility) and the occurrence of opioid overdose.

RESULTS

Our sample included 290 four-month reporting periods among 63 participants (67% male). Opioid overdose events were reported by 28 (44%) participants during 48 (17%) reporting periods. Our measure of quantity volatility had a median of 20% (IQR 0.0-50.0). In multivariable analysis, using a quantity different than the quantity used on average on more than 20% of all opioid use days in the reporting period was significantly associated with odds of any opioid overdose (Adjusted OR = 3.55, 95%CI = 1.55-8.13, p = 0.003), controlling for confounders.

CONCLUSION

Quantity volatility of illicitly used opioids was positively associated with overdose risk and may contribute to the complex system of overlapping factors that influence overdose risk. Future observational research among opioid users should collect detailed opioid use data, including quantity used over time, to clarify the patterns that most elevate overdose risk.

Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain

Objective

More than 100 million adults in the United States experience chronic pain, and prescription opioids are the third most widely prescribed class of medications. Current opioid overdose prevention efforts almost exclusively target illicit opioid users, and little is known about the experience of overdose among patients being treated for chronic pain (CP) with a prescription opioid.

Methods

Patients experiencing CP for three or more months and receiving a prescription opioid for pain management (N = 502) completed a self-report survey that asked questions about opioid overdose history, past 30-day risk factors, and knowledge of opioid overdose, overdose risk, and naloxone.

Results

Approximately one in five CP participants reported experiencing a lifetime overdose. CP participants reported engaging in several behaviors associated with overdose risk and were unlikely to have been trained to administer naloxone. Fewer than 50% of participants answered any knowledge item correctly. The likelihood of having experienced an overdose increased as the scores on the SOAPP-R and DSM-5 opioid use disorder checklist increased, and a SOAPP-R score of 7 or higher or meeting DSM-5 mild opioid use disorder criteria were significantly associated with reporting a lifetime overdose (85% and 84% of participants who experienced an overdose, respectively).

Conclusions

Opioid overdose occurs at a high rate among CP participants, and this group is relatively uninformed about risk factors for overdose. Established SOAPP-R and DSM thresholds provide an opportunity to identify participants at elevated risk for having experienced an opioid overdose. These data support development of additional concentrated efforts to prevent overdose among chronic pain patients.

The relationship between drug use settings, roles in the drug economy, and witnessing a drug overdose in Baltimore, Maryland

BACKGROUND

There has been a dramatic increase in drug overdose deaths in the United States. In the current study, the authors examined factors associated with witnessing a drug overdose.

METHODS

A sample of 450 substance users in Baltimore, Maryland, were recruited for a behavioral intervention and were administered a survey. Multinomial logistic regression models were used to compare participants who never witnessed a drug overdose with those who witnessed one in the prior 6 months and those who witnessed an overdose over 6 months ago.

RESULTS

Most (58%) participants were male, 40% experienced homelessness in the prior 6 months, 63% reported a history of heroin injecting, 84% had snorted heroin, 75% reported witnessing a drug overdose, and 38% experienced an overdose. In multinomial logistic regression models, witnessing an overdose in the past 6 months was associated with number of different types of places where drugs were used (adjusted odds ratio [aOR] = 1.34), history of experiencing an overdose (aOR = 1.80), injecting heroin and/or speedball (aOR = 1.78), and snorting heroin (aOR = 1.54). Witnessing an overdose more than 6 months ago was associated with number of different places where drugs were used (aOR = 1.25), history of experiencing an overdose (aOR = 1.61), snorting heroin (aOR = 1.42), and injecting heroin or speedball (aOR = 1.47).

CONCLUSIONS

These data suggest that people who engage in more public and frequent drug use, and hence are more likely to witness an overdose, should be targeted for interventions to prevent and treat drug overdose.

Cross-sectional cause of death comparisons for stimulant and opioid mortality in San Francisco, 2005-2015

BACKGROUND

Opioids and stimulants (e.g., cocaine or methamphetamine/amphetamine [MAMP]) are major contributors to acute substance toxicity deaths. Causes of stimulant death have received little attention. We sought to characterize and compare causes of death and significant contributing conditions among persons who died from acute opioid, cocaine, or MAMP toxicity.

METHODS

We identified all opioid, cocaine, or MAMP deaths in San Francisco from 2005 to 2015 through the California Electronic Death Reporting System. Multivariable logistic regression analyses were used to estimate associations between acute substance toxicity deaths (opioid versus stimulant; cocaine versus MAMP), additional reported causes of death, and significant contributing conditions most often linked to opioid and stimulant use.

RESULTS

From 2005-2015, there were 1252 opioid deaths and 749 stimulant deaths. Cocaine accounted for most stimulant deaths. Decedents with cardiac or cerebral hemorrhage deaths had higher adjusted odds of death due to acute stimulant toxicity versus acute opioid toxicity (aOR = 4.79, 95%CI = 2.88-7.96, p < 0.01; aOR = 58.58, 95%CI = 21.06-162.91, p < 0.01, respectively); no statistically significant associations were found for cocaine compared to MAMP deaths. Significant contributing cardiac conditions were associated with higher adjusted odds of stimulant compared to opioid (aOR = 1.46, 95%CI = 1.19-1.79, p < 0.01) and cocaine compared to MAMP death (aOR = 1.66, 95%CI = 1.13-2.45, p = .01).

CONCLUSIONS

Stimulant compared to opioid deaths tended to involve cardiac or cerebrovascular causes of death, and cocaine deaths were more likely than MAMP deaths to involve significant contributing cardiac conditions. Mounting evidence suggests that stimulant use be considered a cardio/cerebrovascular risk factor and clinical care be adjusted to address this heightened risk.

Polydrug Use and Heterogeneity in HIV Risk Among People Who Inject Drugs in Estonia and Russia: A Latent Class Analysis

Non-medical drug injection is a major risk factor for HIV infection in Russia and Estonia. Multiple drug use (polydrug) has further been associated with increased harms. We compared HIV, injecting and sexual risk associated with polydrug use among people who injected drugs (PWID) in 2012–2013 in Kohtla-Järve (Estonia, n = 591) and St Petersburg (Russia, n = 811). Using latent class analysis, we identified five (poly)drug classes, the largest consisting of single-drug injectors among whom an opioid was the sole drug injected (56% of PWID). The four remaining polydrug classes included polydrug-polyroute injectors who injected and used opiates and stimulants (9%), opiate-stimulant poly-injectors who injected amphetamine-type-stimulants with a primary opiate (7%) and opiate-opioid poly-injectors who injected opioids and opiates (16%). Non-injection stimulant co-users were injectors who also used non-injection stimulants (12%). In multivariable multinomial regressions, all four polydrug classes were associated with greater injection risks than single-drug injection, while opiate-stimulant and opiate-opioid poly-injection were also associated with having multiple sex partners. Riskier behaviours among polydrug-injectors suggest increased potential for transmission of blood-borne and sexually-transmitted infections. In addition to needles/syringes provision, services tailored to PWID drug and risk profiles, could consider drug-appropriate treatment and sexual risk reduction strategies to curb HIV transmission.

Opioid Overdose Experience, Risk Behaviors, and Knowledge in Drug Users from a Rural versus an Urban Setting

BACKGROUND

Opioid use is highly prevalent in the United States and there has been an increased incidence in the rate of opioid-related overdose. While evidence suggests there are substantial differences in opioid use among rural versus urban settings, the rate of overdose and corresponding frequency of opioid overdose risk behaviors and overdose knowledge between rural and urban settings have not been examined.

METHODS

Individuals with opioid use disorder from rural (N=98) and urban (N=247) settings completed a self-report survey regarding their lifetime history of overdose and overdose risk behaviors. Participants also completed the Brief Opioid Overdose Knowledge (BOOK) questionnaire, a 12-item self-report measure of opioid overdose knowledge.

RESULTS

Overall, 35.6% of participants had experienced an overdose, and prevalence of overdose was significantly higher (p<.01) among rural (45.9%) vs. urban (31.6%) participants, though fewer rural participants reported past 30-day risk behaviors. There were few differences observed between the subset of rural and urban participants who had experienced an overdose, and fewer rural participants with a history of overdose reported past 30-day risk behaviors. Both rural and urban participants performed poorly on the BOOK, though the percent of correct responses was lowest among rural participants with a history of overdose.

CONCLUSION

Results demonstrate higher rates of overdose among rural opioid users, though rural participants were less likely to report recent risk behaviors. Results also suggest that knowledge regarding key factors related to opioid overdose is severely lacking, particularly among rural opioid users, which could be a potential target for future intervention efforts.

Methamphetamine self-administration reduces alcohol consumption and preference in alcohol-preferring P rats

Subclinical levels of polysubstance use are a prevalent and understudied phenomenon. Alcohol is a substance commonly co‐used with other substances of other drug classes. These studies sought to determine the consumption effects of combining alcohol drinking and methamphetamine (MA) self‐administration. Male alcohol‐preferring P rats had continuous access to a two‐bottle alcohol drinking procedure in the home cage. Control rats remained alcohol naïve. Rats were also surgically implanted with intra‐jugular catheters and trained to self‐administer saline (control) or MA in daily 2‐hour sessions. We first measured the acquisition and maintenance of MA intake in alcohol‐consuming or control rats. MA intake was initially enhanced by alcohol consumption on a fixed ratio 1 schedule of reinforcement, but this effect did not prevail as the difficulty of the schedule (FR5 and progressive ratio) was increased. We next measured both alcohol consumption and preference before, during and after MA (or saline) self‐administration. MA self‐administration significantly reduced alcohol intake and preference ratios, a robust effect that persisted across several experimental variations. Interestingly, alcohol consumption rebounded following the cessation of MA self‐administration. The effects of MA self‐administration were specific to alcohol intake because it did not alter total fluid consumption or consumption of sucrose. MA self‐administration did not impact blood‐alcohol concentrations or alcohol‐induced loss of righting reflex suggesting no effect of MA intake on the alcohol metabolism or sensitivity. Together, the results suggest that MA intake disrupts alcohol consumption and preferences but not the reverse in alcohol‐preferring P rats.

Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis

BACKGROUND

Drug overdose is a public health crisis in the United States, due in part to the unintended consequences of increases in prescribing of opioid analgesics. Many clinicians evaluate risk markers for opioid-related harms when prescribing opioids for chronic pain; however, more data on predictive risk markers are needed. Risk markers are attributes (modifiable and non-modifiable) that are associated with increased probability of an outcome. This review aims to identify risk markers associated with fatal and non-fatal prescription drug overdose by synthesizing findings in the existing peer-reviewed and grey literature. Eligible cohort, case-control, cross-sectional, and case-cohort studies were reviewed and data were extracted for qualitative and quantitative synthesis.

FINDINGS

Summary odds ratios (SOR) were estimated from 29 studies for six risk markers: sex, age, race, psychiatric disorders, substance use disorder (SUD), and urban/rural residence. Heterogeneity was assessed and effect estimates were stratified by study characteristics. Of the six risk markers identified, SUD had the strongest association with drug overdose death (SOR = 5.24, 95% confidence interval (CI) = 3.53 - 7.76), followed by psychiatric disorders (SOR = 3.94, 95% CI = 3.09 - 5.01), white race (SOR = 2.28, 95% CI = 1.93 - 2.70), the 35-44 year age group relative to the 25-34 year reference group (SOR = 1.52, 95% CI = 1.31 - 1.76), and male sex (SOR = 1.33, 95% CI = 1.17 - 1.51).

CONCLUSIONS

This review highlights fatal and non-fatal prescription drug risk markers most frequently assessed in peer-reviewed and grey literature. There is a need to better understand modifiable risk markers and underlying reasons for drug misuse in order to inform interventions that may prevent future drug overdoses.

Polydrug use and its association with drug treatment outcomes among primary heroin, methamphetamine, and cocaine users

BACKGROUND

Polydrug use may challenge effective treatment for substance use disorders. We evaluate whether secondary substance use modifies the association between treatment and primary drug use among primary heroin, cocaine and methamphetamine (MA) users.

METHODS

Data were obtained from prospective cohort studies on people who use illicit drugs (PWUD) in California, USA. Using repeated monthly data on self-reported secondary substance use (heroin, cocaine, MA, alcohol or marijuana; ≥1day in a month), primary drug use (≥1day in a month), and treatment participation, collected via timeline follow-back, we fitted generalized linear mixed multiple regression models controlling for potential confounders to examine the interactions between treatment and secondary substance use on the odds of primary heroin, cocaine and MA use, respectively.

RESULTS

Included in our study were 587 primary heroin, 444 primary MA, and 501 primary cocaine users, with a median of 32.4, 13.3 and 18.9 years of follow-up, respectively. In the absence of secondary substance use, treatment was strongly associated with decreased odds of primary drug use (adjusted odds ratios (aORs): 0.25, 95% CI: 0.24, 0.27, 0.07 (0.06, 0.08), and 0.07 (0.07, 0.09)) for primary heroin, MA, and cocaine users, respectively. Secondary substance use of any kind moderated these associations (0.82 (0.78, 0.87), 0.25 (0.21, 0.30) and 0.53 (0.45, 0.61), respectively), and these findings were consistent for each type of secondary substance considered. Moreover, we observed different associations in terms of direction and magnitude between secondary substance use and primary drug use during off-treatment periods across substance types.

CONCLUSION

This study demonstrates secondary substance use moderates the temporal associations between treatment and primary drug use among primary heroin, MA and cocaine users. Disparate patterns of polydrug use require careful measurement and analysis to inform targeted treatment for polydrug users.

Behavioral intervention to reduce opioid overdose among high-risk persons with opioid use disorder: A pilot randomized controlled trial

OBJECTIVE

The United States is amidst an opioid epidemic, including synthetic opioids that may result in rapid death, leaving minimal opportunity for bystander rescue. We pilot tested a behavioral intervention to reduce the occurrence of opioid overdose among opioid dependent persons at high-risk for subsequent overdose.

MATERIALS AND METHODS

We conducted a single-blinded randomized-controlled trial of a repeated dose motivational interviewing intervention (REBOOT) to reduce overdose versus treatment as usual, defined as information and referrals, over 16 months at the San Francisco Department of Public Health from 2014-2016. Participants were 18-65 years of age, had opioid use disorder by Structured Clinical Interview, active opioid use, opioid overdose within 5 years, and prior receipt of naloxone kits. The intervention was administered at months 0, 4, 8, and 12, preceded by the assessment which was also administered at month 16. Dual primary outcomes were any overdose event and number of events, collected by computer-assisted personal interview, as well as any fatal overdose events per vital records.

RESULTS

A total of 78 persons were screened and 63 enrolled. Mean age was 43 years, 67% were born male, 65% White, 17% African-American, and 14% Latino. Ninety-two percent of visits and 93% of counseling sessions were completed. At baseline, 33.3% of participants had experienced an overdose in the past four months, with a similar mean number of overdoses in both arms (p = 0.95); 29% overdosed during follow-up. By intention-to-treat, participants assigned to REBOOT were less likely to experience any overdose (incidence rate ratio [IRR] 0.62 [95%CI 0.41-0.92, p = 0.019) and experienced fewer overdose events (IRR 0.46, 95%CI 0.24-0.90, p = 0.023), findings that were robust to sensitivity analyses. There were no differences between arms in days of opioid use, substance use treatment, or naloxone carriage.

CONCLUSIONS

REBOOT reduced the occurrence of any opioid overdose and the number of overdoses.

TRIAL REGISTRATION

clinicaltrials.gov NCT02093559.

Perceived Treatment Need and Latent Transitions in Heroin and Methamphetamine Polydrug Use among People who Inject Drugs in Tijuana, Mexico

People who inject drugs (PWID) in Tijuana, Mexico, use heroin and/or methamphetamine. While polydrug use is associated with HIV risk behavior, less is known about the stability of polydrug use patterns over time and how polydrug use is related to perceived treatment need. Within a cohort of PWID in Tijuana (N = 735) we sought to (1) characterize subgroups of polydrug and polyroute use from baseline to six months; (2) determine the probabilities of transitioning between subgroups; and (3) examine whether self-reported need for help for drug use modified these transition probabilities. Latent transition analysis (LTA) identified four latent statuses: heroin-only injection (38% at both baseline and follow-up); co-injection of heroin with methamphetamine (3% baseline, 15% follow-up); injection of heroin and methamphetamine (37% baseline, 32% follow-up); and polydrug and polyroute users who injected heroin and both smoked and injected methamphetamine (22% baseline, 14% follow-up). Heroin-only injectors had the highest probability of remaining in the same latent status at follow-up. The majority reported great or urgent need for treatment (51%) and these PWID had greater odds of transitioning to a higher-risk status at follow-up, emphasizing the need for evidence-based drug treatment options for PWID.

The willingness of people who inject drugs in Boston to use a supervised injection facility

BACKGROUND

In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness.

METHODS

A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%).

RESULTS

Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9-15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8-14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2-21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6-14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9-18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2-14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2-14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2-10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3-8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2-8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2-7.4; P = .02).

CONCLUSIONS

Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.

Increases from 2002 to 2015 in prescription opioid overdose deaths in combination with other substances

BACKGROUND

Prescription opioid (PO) overdose deaths increased sharply over the last decade. Changes in PO deaths in combination with other psychoactive substances may provide a partial explanation.

METHODS

PO deaths from the National Multiple-Cause-of-Death Files for 2002-03 (N=15,973) and 2014-15 (N=41,491) were analyzed. We calculated (1) changes in proportions of deaths in combination with benzodiazepines, antidepressants, heroin, alcohol, cocaine between the two periods, and (2) proportions of increase in deaths attributable to each substance among PO and synthetic opioids other than methadone (SO-M) deaths, by age, gender, race/ethnicity.

RESULTS

Between 2002-03 and 2014-15, PO deaths increased 2.6 times; SO-M deaths 5.6 times, especially for ages 18-34, males, African-Americans. For PO deaths, most frequent combinations at both periods were with benzodiazepines; for SO-M, benzodiazepines, antidepressants in 2002-03, heroin, benzodiazepines in 2014-15. The largest increases occurred in combination with heroin among all PO (4.6% to 15.4%, change ratio=3.3[95%CI=3.1-3.6]), but especially SO-M deaths (1.2% to 24.5%, change ratio=21.3[95%CI=15.0-30.3]). Deaths involving cocaine decreased among PO, increased among SO-M deaths. One-fifth of increased PO or SO-M deaths were attributable to any of the five substances. Increased PO deaths were equally attributable to benzodiazepines and heroin; deaths attributable to heroin were higher among ages 18-49, males, and non-Hispanic whites. Increased SO-M deaths were attributable mostly to heroin among all groups.

CONCLUSIONS

Increased PO overdose deaths over the last decade may be partially explained by increased deaths in combination with other psychoactive substances. Use of other substances should be considered in efforts toward reducing prescription opioid overdoses.

Illicit drug use is increasing among non-medical users of prescription drugs-Results from population-based surveys 2002-2014

BACKGROUND

Non-medical use of prescription drugs (NMUPD) is known to be associated with illicit drug use, but less is known about how illicit drug use has changed in NMUPD. We examined (1) the changes in illicit drug use among Finnish non-medical users of prescription drugs during the 2000s and (2) whether the trends of illicit drug use differ by non-medical use of prescription drugs in the general population.

METHODS

Data were derived from population-based (aged 15-69) Drug Surveys conducted in Finland in 2002, 2006, 2010 and 2014. The response rates varied between 63% and 48%. NMUPD during the last year was measured (n=252). Past-year illicit drug use among non-medical users of prescription drugs and the reference population not reporting NMUPD (n=10,967) was compared. Logistic regression was used to estimate the p-values for trends.

RESULTS

Illicit drug use has increased notably among Finnish non-medical users of prescription drugs (from 21% to 70%, p for trend<0.001). This was not explained by the respondents' gender, age, employment status or alcohol use. Among the reference population, illicit drug use also increased statistically significantly, but much more moderately (from 2.5% to 5.4%). The difference between the trends was confirmed by an interaction test (p=0.022).

CONCLUSIONS

NMUPD seems to be increasingly merging with illicit drug use. This indicates an increasing prevalence of polydrug use among non-medical users of prescription drugs, which may bring about more severe harms and worse health outcomes for users and more challenges in regard to treatment.

Potential Risks of Ecological Momentary Assessment Among Persons Who Inject Drugs

BACKGROUND

Ecological momentary assessment (EMA)-which often involves brief surveys delivered via mobile technology-has transformed our understanding of the individual and contextual micro-processes associated with legal and illicit drug use. However, little empirical research has focused on participant's perspective on the probability and magnitude of potential risks in EMA studies.

OBJECTIVES

To garner participant perspectives on potential risks common to EMA studies of illicit drug use.

METHODS

We interviewed 38 persons who inject drugs living in San Diego (CA) and Philadelphia (PA), United States. They completed simulations of an EMA tool and then underwent a semi-structured interview that systematically explored domains of risk considered within the proposed revisions to the Federal Policy for the Protection of Human Subjects or the "Common Rule." Interviews were transcribed verbatim and coded systematically to explore psychological, physical, social, legal, and informational risks from participation.

RESULTS

Participants perceived most risks to be minimal. Some indicated that repetitive questioning about mood or drug use could cause psychological (i.e., anxiety) or behavioral risks (i.e., drug use relapse). Ironically, the questions that were viewed as risky were considered motivational to engage in healthy behaviors. The most cited risks were legal and social risks stemming from participant concerns about data collection and security.

IMPORTANCE

Improving our understanding of these issues is an essential first step to protect human participants in future EMA research. We provide a brief set of recommendations that can aid in the design and ethics review of the future EMA protocol with substance using populations.

The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland

BACKGROUND

Overdose is a major cause of death among PWID, and for opioid overdoses naloxone administration can reduce harm. However, globally there is limited national level data on the extent of non-fatal overdose and naloxone uptake. The first national level data on the extent of self-reported overdose and self-reported receipt of naloxone among UK PWID, providing a baseline to monitor the impact of the recent policy change regarding naloxone availability, is presented.

METHODS

Data on self-reported overdose and receipt of naloxone during the preceding year for 2013-2014 from a national survey of PWID was analysed. Participants who reported injecting during the preceding year were included.

RESULTS

Participants (3850) were predominantly male (75%); mean age was 36 years. The most commonly injected drugs were: heroin (91%), crack (45%) and amphetamine (29%). 15% (591) reported overdosing during the preceding year. There were no differences in the proportion reporting overdose by age or gender, but overdose was more common among those who: injected multiple drugs; recently ceased addiction treatment; injected with used needles/syringes; ever had transactional sex; had used a sexual health clinic or emergency department and lived in Wales or Northern Ireland. Among those reporting an overdose during the preceding year, a third reported two to four overdoses and 7.5% five or more overdoses; half reported receiving naloxone. Those reporting naloxone receipt in the preceding year were more likely to: live in Wales or Northern Ireland; ever received used needles/syringes; ever been imprisoned; and less likely to have injected two drug types.

CONCLUSION

These data provide a baseline for monitoring the impact of the 2015 UK policy change to improve take-home naloxone access. Interventions tackling overdose should promote naloxone awareness and access, and target those who; are poly-drug injectors, have ceased treatment, share needles/syringes and whose drug use links to sexual activity.

Randomized controlled trial of a computerized opioid overdose education intervention

BACKGROUND

Opioid overdose (OD) has become a significant public health problem in need of effective interventions. The majority of existing educational interventions target provision of naloxone and are conducted in-person; these elements present logistical barriers that may limit wide-spread implementation. This study developed and evaluated an easily disseminated opioid OD educational intervention and compared computerized versus pamphlet delivery METHODS: Participants (N=76) undergoing opioid detoxification were randomly assigned to receive OD education via a Pamphlet (N=25), Computer (N=24), or Computer+Mastery (N=27) with identical content for all delivery modalities. Primary outcomes were changes from pre- to post-intervention in knowledge of opioid effects, opioid OD symptoms, and recommended opioid OD responses, as well as intervention acceptability. Also assessed at 1 and 3-month follow-ups were retention of knowledge and change in reported OD risk behaviors.

RESULTS

Knowledge increased following all three intervention-delivery modalities with few between-group differences observed in knowledge gain or acceptability ratings. Largest gains were in the domain of opioid OD response (from 41.8% to 73.8% mean correct responses; p<0.001). Knowledge was well sustained at the 1 and 3-month follow-ups among completers, where a significant reduction was seen in the critical behavioral risk factor of using opioids while alone.

CONCLUSION

Opioid overdose education delivered by computer or written pamphlet produced sustained increases in knowledge and reduction in a key behavioral risk factor.

RESULTS

Results support further evaluation of this educational intervention that can be used alone or to complement naloxone-training programs.

The risks of opioid treatment: Perspectives of primary care practitioners and patients from safety-net clinics

BACKGROUND

Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy.

METHODS

We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology.

RESULTS

(1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences of opioids, except for addiction. (3) Both patients and PCPs were concerned about PCPs' medicolegal risks related to opioid prescribing. (4) Patients reported feeling stigmatized by policies aimed at reducing opioid misuse.

CONCLUSION

We identified differences in how clinicians and patients perceive opioid risk. To improve the informed consent process for opioid therapy, patients and PCPs need to have a shared understanding of the risks of opioids and engage in discussions that promote patient autonomy and safety. As clinics implement opioid prescribing policies, clinicians must develop effective communication strategies in order to educate patients about opioid risks and decrease patients' experiences of stigma and discrimination.

Examining Fatal Opioid Overdoses in Marion County, Indiana

Drug-related overdoses are now the leading injury-related death in the USA, and many of these deaths are associated with illicit opioids and prescription opiate pain medication. This study uses multiple sources of data to examine accidental opioid overdoses across 6 years, 2010 through 2015, in Marion County, IN, an urban jurisdiction in the USA. The primary sources of data are toxicology reports from the county coroner, which reveal that during this period, the most commonly detected opioid substance was heroin. During the study period, 918 deaths involved an opiod, and there were significant increases in accidental overdose deaths involving both heroin and fentanyl. In order to disentangle the nature and source of opioid overdose deaths, we also examine data from Indiana's prescription drug monitoring program and the law enforcement forensic services agency. Results suggest that there have been decreases in the number of opiate prescriptions dispensed and increases in law enforcement detection of both heroin and fentanyl. Consistent with recent literature, we suggest that increased regulation of prescription opiates reduced the likelihood of overdoses from these substances, but might have also had an iatrogenic effect of increasing deaths from heroin and fentanyl. We discuss several policy implications and recommendations for Indiana.

A Hazard Analysis of Risk Factors of Mortality in Individuals Who Inject Drugs in Denver CO

Despite multiple risk factors for mortality among People Who Inject Drugs (PWID), more research is warranted that examines sub-populations within PWID. Mortality data from PWID participating in longitudinal HIV prevention research in Denver were obtained from The Colorado Department of Public Health and Environment. Risk factors for both all-cause and acute-toxicity related mortality were analyzed using Cox proportional hazards regression. Two-thousand seven individuals were interviewed at baseline. Eighty-six individuals died during the time frame of the study, 58 of which were due to acute-toxicity. Disabled (HR = 3.3, p < 0.001), gay/lesbian-identified (HR = 2.6, p = 0.03), white race/ethnicity (HR = 2.4, p = 0.003), and use of a shared cooker (HR = 2.1, p = 0.01) were important adjusted risk factors. These suggest that drug and HIV interventions should utilize techniques that can address the needs of marginalized populations in addition to HIV drug risk behaviors.

Latent classes of polydrug and polyroute use and associations with human immunodeficiency virus risk behaviours and overdose among people who inject drugs in Tijuana, Baja California, Mexico

INTRODUCTION AND AIMS

Patterns of polydrug use among people who inject drugs (PWID) may be differentially associated with overdose and unique human immunodeficiency virus (HIV) risk factors. Subgroups of PWID in Tijuana, Mexico, were identified based on substances used, route of administration, frequency of use and co-injection indicators.

DESIGN AND METHODS

Participants were PWID residing in Tijuana age ≥18 years sampled from 2011 to 2012 who reported injecting an illicit substance in the past month (n = 735). Latent class analysis identified discrete classes of polydrug use characterised by 11 indicators of past 6 months substance use. Multinomial logistic regression examined class membership association with HIV risk behaviours, overdose and other covariates using an automated three-step procedure in mplus to account for classification error.

RESULTS

Participants were classified into five subgroups. Two polydrug and polyroute classes were defined by use of multiple substances through several routes of administration and were primarily distinguished from each other by cocaine use (class 1: 5%) or no cocaine use (class 2: 29%). The other classes consisted primarily of injectors: cocaine, methamphetamine and heroin injection (class 3: 4%); methamphetamine and heroin injection (class 4: 10%); and heroin injection (class 5: 52%). Compared with the heroin-only injection class, memberships in the two polydrug and polyroute use classes were independently associated with both HIV injection and sexual risk behaviours.

DISCUSSION AND CONCLUSIONS

Substance use patterns among PWID in Tijuana are highly heterogeneous, and polydrug and polyroute users are a high-risk subgroup who may require more tailored prevention and treatment interventions. [Meacham MC, Roesch SC, Strathdee SA, Lindsay S, Gonzalez-Zuniga P, Gaines TL. Latent classes of polydrug and polyroute use and associations with human immunodeficiency virus risk behaviours and overdose among people who inject drugs in Tijuana, Baja California, Mexico. Drug Alcohol Rev 2018;37:128-136].

Health service utilisation attributable to methamphetamine use in Australia: Patterns, predictors and national impact

AIM AND BACKGROUND

We estimated health service utilisation attributable to methamphetamine use, its national impact and examined other predictors of health service utilisation among dependent methamphetamine users.

METHOD

Past year rates of health service utilisation (number of attendances for general hospitals, psychiatric hospitals, emergency departments, general practitioners, psychiatrists, counsellors or psychologists, and dentists) were estimated for three levels of methamphetamine use (no use, < weekly, ≥ weekly) using panel data from a longitudinal cohort of 484 dependent methamphetamine users from Sydney and Brisbane, Australia. Marginal rates for methamphetamine use were multiplied by 2013 prevalence estimates from the National Drug Strategy Household Survey. Covariates included other substance use, demographics, mental disorders and drug treatment.

FINDINGS

Health service use was high. More frequent methamphetamine use was associated with more frequent presentations to emergency departments (incidence rate ratios 1.3-2.1) and psychiatric hospitals (incidence rate ratios 5.3-8.3) and fewer presentations to general practitioners, dentists and counsellors. We estimate methamphetamine use accounted for between 28 400 and 80 900 additional psychiatric hospital admissions and 29 700 and 151 800 additional emergency department presentations in 2013. More frequent presentations to these services were also associated with alcohol and opioid use, comorbid mental health disorders, unemployment, unstable housing, attending drug treatment, low income and lower education.

CONCLUSIONS

Frequent methamphetamine use has a significant impact on emergency medical and psychiatric services. Better provision of non-acute health care services to address the multiple health and social needs of dependent methamphetamine users may reduce the burden on these acute care services. [McKetin R, Degenhardt L, Shanahan M, Baker AL, Lee NK, Lubman DI. Health service utilisation attributable to methamphetamine use in Australia: patterns, predictors and national impact. Drug Alcohol Rev 2017;00:000-000].

Substance use and treatment outcomes among Spanish-speaking Latino/as from four acculturation types

The purpose of this study was to examine the association of acculturation with substance use treatment outcomes in a sample of treatment-seeking Latino/as (N = 405). The study used data from a multisite randomized controlled trial of a culturally adapted version of Motivational Enhancement Therapy delivered in Spanish. Berry, Kim, Minde, and Mok's (1987) acculturation model was used to divide the sample into 4 types (integrated, assimilated, separated, marginalized), based on Bicultural Involvement Questionnaire scores. One-way analyses of variance, chi-squared tests, and repeated-measures regression were used to examine baseline acculturation, posttreatment outcomes, and follow-up outcomes. All participants were of Latino/a background, and 88.4% of the sample was male. Participants with greater acculturation to American culture (i.e., integrated and assimilated acculturation types) reported more substance use and associated problems at baseline, χ²(3) = 20.5, p < .001, with the integrated type reporting the highest percentage of substance use disorder symptoms and problems (67.6%). No significant differences in substance use were detected among acculturation types posttreatment or at follow-up. Although the integrated and assimilated acculturation types were associated at baseline with more substance use and associated problems, all acculturation types seemed to benefit at posttreatment from an evidence-based culturally adapted treatment. (PsycINFO Database Record

Assessing the accuracy of opioid overdose and poisoning codes in diagnostic information from electronic health records, claims data, and death records

PURPOSE

The purpose of this study is to assess positive predictive value (PPV), relative to medical chart review, of International Classification of Diseases (ICD)-9/10 diagnostic codes for identifying opioid overdoses and poisonings.

METHODS

Data were obtained from Kaiser Permanente Northwest and Northern California. Diagnostic data from electronic health records, submitted claims, and state death records from Oregon, Washington, and California were linked. Individual opioid-related poisoning codes (e.g., 965.xx and X42), and adverse effects of opioids codes (e.g., E935.xx) combined with diagnoses possibly indicative of overdoses (e.g., respiratory depression), were evaluated by comparison with chart audits.

RESULTS

Opioid adverse effects codes had low PPV to detect overdoses (13.4%) as assessed in 127 charts and were not pursued. Instead, opioid poisoning codes were assessed in 2100 individuals who had those codes present in electronic health records in the period between the years 2008 and 2012. Of these, 10/2100 had no available information and 241/2100 were excluded potentially as anesthesia-related. Among the 1849 remaining individuals with opioid poisoning codes, 1495 events were accurately identified as opioid overdoses; 69 were miscodes or misidentified, and 285 were opioid adverse effects, not overdoses. Thus, PPV was 81%. Opioid adverse effects or overdoses were accurately identified in 1780 of 1849 events (96.3%).

CONCLUSIONS

Opioid poisoning codes have a predictive value of 81% to identify opioid overdoses, suggesting ICD opioid poisoning codes can be used to monitor overdose rates and evaluate interventions to reduce overdose. Further research to assess sensitivity, specificity, and negative predictive value are ongoing. Copyright © 2017 John Wiley & Sons, Ltd.

Measuring Concurrent Polydrug Use in General Populations: A Critical Assessment

BACKGROUND/AIMS

Polydrug use is a complicated phenomenon that is measured in a wide variety of different ways. Using Finland as an example, we aimed to demonstrate how the prevalence and prevalence trends of concurrent polydrug use (CPU) varied in the general population based on the different measurements used.

METHODS

Population-based Drug Surveys conducted every 4 years during 1998-2014 were used. CPU was measured with different measurements: strict, medial and loose definition of CPU, which were based on different combinations of alcohol, illicit drugs, pharmaceutical drugs and cigarettes used during the last 12 months/30 days. Logistic regression was used to estimate the p values for assessing trends.

RESULTS

Depending on the measurements used, the prevalence of CPU in 2014 varied between 2.0 and 18.7%. Different definitions also produced contradictory trends of CPU: there was a modest increase in prevalence if it was measured with a medial (p < 0.001) or strict (p = 0.054) definition, but when measured with the loose definition (only measure that included smoking), there was a decrease in prevalence (p < 0.001).

CONCLUSIONS

The prevalence of CPU varies greatly depending on the measurement used, as does the course of the prevalence trends. The concept of simultaneous polydrug use may capture the phenomenon better compared to the concept of CPU.

Mortality in HIV-Infected Alcohol and Drug Users in St. Petersburg, Russia

In Russia, up to half of premature deaths are attributed to hazardous drinking. The respective roles of alcohol and drug use in premature death among people with HIV in Russia have not been described. Criminalization and stigmatization of substance use in Russia may also contribute to mortality. We explored whether alcohol, drug use and risk environment factors are associated with short-term mortality in HIV-infected Russians who use substances. Secondary analyses were conducted using prospective data collected at baseline, 6 and 12-months from HIV-infected people who use substances recruited between 2007-2010 from addiction and HIV care settings in a single urban setting of St. Petersburg, Russia. We used Cox proportional hazards models to explore associations between 30-day alcohol hazardous drinking, injection drug use, polysubstance use and environmental risk exposures (i.e. past incarceration, police involvement, selling sex, and HIV stigma) with mortality. Among 700 participants, 59% were male and the mean age was 30 years. There were 40 deaths after a median follow-up of 12 months (crude mortality rate 5.9 per 100 person-years). In adjusted analyses, 30-day NIAAA hazardous drinking was significantly associated with mortality compared to no drinking [adjusted Hazard Ratio (aHR) 2.60, 95% Confidence Interval (CI): 1.24-5.44] but moderate drinking was not (aHR 0.95, 95% CI: 0.35-2.59). No other factors were significantly associated with mortality. The high rates of short-term mortality and the strong association with hazardous drinking suggest a need to integrate evidence-based alcohol interventions into treatment strategies for HIV-infected Russians.

Traumatic brain injury and alcohol/substance abuse: A Bayesian meta-analysis comparing the outcomes of people with and without a history of abuse

Alcohol and substance (drugs and/or alcohol) abuse are major risk factors for traumatic brain injury (TBI); however, it remains unclear whether outcomes differ for those with and without a history of preinjury abuse. A meta-analysis was performed to examine this issue. The PubMed, Embase, and PsycINFO databases were searched for research that compared the neuroradiological, cognitive, or psychological outcomes of adults with and without a documented history of alcohol and/or substance abuse who sustained nonpenetrating TBIs. Data from 22 studies were analyzed using a random-effects model: Hedges's g effect sizes measured the mean difference in outcomes of individuals with/without a history of preinjury abuse, and Bayes factors assessed the probability that the outcomes differed. Patients with a history of alcohol and/or substance abuse had poorer neuroradiological outcomes, including reduced hippocampal (g = -0.82) and gray matter volumes (g = -0.46 to -0.82), and enlarged cerebral ventricles (g = -0.73 to -0.80). There were limited differences in cognitive outcomes: Executive functioning (g = -0.51) and memory (g = -0.39 to -0.43) were moderately affected, but attention and reasoning were not. The findings for fine motor ability, construction, perception, general cognition, and language were inconclusive. Postinjury substance and alcohol use (g = -0.97 to -1.07) and emotional functioning (g = -0.29 to -0.44) were worse in those with a history of alcohol and/or substance abuse (psychological outcomes). This study highlighted the type and extent of post-TBI differences between persons with and without a history of alcohol or substance abuse, many of which may hamper recovery. However, variation in the criteria for premorbid abuse, limited information regarding the history of abuse, and an absence of preinjury baseline data prevented an assessment of whether the differences predated the TBI, occurred as a result of ongoing alcohol/substance abuse, or reflected the cumulative impact of alcohol/substance abuse and TBI.

Heroin overdose

BACKGROUND AND AIMS

This narrative review aims to provide a brief history of the development of the heroin overdose field by discussing a selection of major 'classics' from the latter part of the 20th century.

METHODS

Papers considered landmarks were selected from 1972, 1977, 1983, 1984 and 1999.

RESULTS

Findings of earlier works suggest much of what later research was to demonstrate. These include arguing that overdoses occurred primarily among tolerant older users, that most 'overdose' deaths involved low morphine concentrations, that most overdoses involve polypharmacy, that drug purity has only a moderate influence on overdose rates and that instant death following heroin administration is rare.

CONCLUSIONS

Landmark studies of heroin overdose from the 1970s, 1980s and 1990s laid the foundations for subsequent overdose research, mainly by identifying the major demographic characteristics of overdose cases, risk factors, survival times and behaviours at overdose events.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Examining Risk for Frequent Cocaine Use: Focus on an African American Treatment Population

BACKGROUND

Cocaine use and its consequences are disproportionately higher and more severe among African Americans compared to other ethnic/racial groups.

OBJECTIVES

The aims of this study were to examine a risk model specific for African American users and assess whether risk varies as a function of sex.

METHODS

270 African American adults in a residential drug treatment facility completed measurements assessing first and past year crack/cocaine use frequency, childhood trauma, and stress reactivity. Multiple linear regression analysis was used to examine the unique effect of each predictor variable on past year crack/cocaine frequency. Sex was included as a moderator variable in the regression analysis.

RESULTS

All predictor variables were positively correlated with past year crack/cocaine use. However, sex differences were also observed: females reported higher rates of childhood emotional abuse, childhood sexual abuse, and stress reactivity-as well as past year crack use and cocaine use-than males. Regression analyses were performed with sex, first year use, and stress reactivity emerging as the only significant predictors for frequency of crack and cocaine use among all study participants. Moreover, sex differences were observed in the influence of first year crack use frequency on past year crack use frequency, such that the effect was stronger for males than for females. Conclusion/Importance: This study offers a clearer understanding of the risk factors for crack and cocaine abuse specific to African Americans, as well as sex specific pathways to risk, providing useful implications for future prevention and treatment efforts.