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Erath TG, LaCroix R, O'Keefe E, Higgins ST, Rawson RA. Substance use patterns, sociodemographics, and health profiles of harm reduction service recipients in Burlington, Vermont. Harm Reduct J 2024; 21:76. [PMID: 38580997 PMCID: PMC10998322 DOI: 10.1186/s12954-024-00995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/31/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision. METHODS Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test. RESULTS Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits). CONCLUSIONS Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.
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Affiliation(s)
- Tyler G Erath
- Vermont Center on Behavior and Health, Burlington, VT, USA.
- Department of Psychiatry, University of Vermont, University Health Center, 1 S. Prospect St., Burlington, VT, 05401, USA.
| | | | - Erin O'Keefe
- Howard Center Safe Recovery, Burlington, VT, USA
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, Burlington, VT, USA
- Department of Psychiatry, University of Vermont, University Health Center, 1 S. Prospect St., Burlington, VT, 05401, USA
- Center on Rural Addictions, University of Vermont, Burlington, VT, USA
| | - Richard A Rawson
- Vermont Center on Behavior and Health, Burlington, VT, USA
- Department of Psychiatry, University of Vermont, University Health Center, 1 S. Prospect St., Burlington, VT, 05401, USA
- Center on Rural Addictions, University of Vermont, Burlington, VT, USA
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Bazazi AR, Low P, Gomez BO, Snyder H, Hom JK, Soran CS, Zevin B, Mason M, Graterol J, Coffin PO. Overdose from Unintentional Fentanyl Use when Intending to Use a Non-opioid Substance: An Analysis of Medically Attended Opioid Overdose Events. J Urban Health 2024; 101:245-251. [PMID: 38568466 PMCID: PMC11052958 DOI: 10.1007/s11524-024-00852-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/28/2024]
Abstract
Fentanyl-mixed and substituted heroin is well-documented, but less is known about unintentional fentanyl use among people using stimulants. To determine the prevalence of and racial and ethnic disparities in unintentional fentanyl use among people experiencing a medically attended opioid overdose, we reviewed 448 suspected non-fatal overdose cases attended by a community paramedic overdose response team in San Francisco from June to September 2022. We applied a case definition for opioid overdose to paramedic records and abstracted data on intended substance use prior to overdose. Among events meeting case criteria with data on intended substance use, intentional opioid use was reported by 57.3%, 98.0% of whom intended to use fentanyl. No intentional opioid use was reported by 42.7%, with most intending to use stimulants (72.6%), including methamphetamine and cocaine. No intentional opioid use was reported by 58.5% of Black, 52.4% of Latinx, and 28.8% of White individuals (p = 0.021), and by 57.6% of women and 39.5% of men (p = 0.061). These findings suggest that unintentional fentanyl use among people without opioid tolerance may cause a significant proportion of opioid overdoses in San Francisco. While intentional fentanyl use might be underreported, the magnitude of self-reported unintentional use merits further investigation to confirm this phenomenon, explore mechanisms of use and disparities by race and ethnicity, and deploy targeted overdose prevention interventions.
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Affiliation(s)
- Alexander R Bazazi
- Division of Substance Abuse and Addiction Medicine at San Francisco General Hospital, Department of Psychiatry and Behavioral Sciences, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA.
| | - Patrick Low
- Division of Substance Abuse and Addiction Medicine at San Francisco General Hospital, Department of Psychiatry and Behavioral Sciences, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Bryson O Gomez
- Division of Substance Abuse and Addiction Medicine at San Francisco General Hospital, Department of Psychiatry and Behavioral Sciences, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Hannah Snyder
- Department of Family and Community Medicine, University of California San Francisco, 995 Potrero Ave, San Francisco, CA, 94110, USA
| | - Jeffrey K Hom
- Population Behavioral Health, Behavioral Health Services Division, San Francisco Department of Public Health, 101 Grove St, San Francisco, CA, 94102, USA
| | - Christine S Soran
- Division of Substance Abuse and Addiction Medicine at San Francisco General Hospital, Department of Psychiatry and Behavioral Sciences, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Barry Zevin
- Street Medicine and Shelter Health, San Francisco Department of Public Health, 555 Stevenson St, San Francisco, CA, 94105, USA
| | - Michael Mason
- Community Paramedicine Division, San Francisco Fire Department, 698 2nd St, San Francisco, CA, 94107, USA
| | - Joseph Graterol
- Community Paramedicine Division, San Francisco Fire Department, 698 2nd St, San Francisco, CA, 94107, USA
| | - Phillip O Coffin
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Center On Substance Use and Health, San Francisco Department of Public Health, 101 Grove St, San Francisco, CA, 94102, USA
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Coffin PO, Suen LW. Methamphetamine Toxicities and Clinical Management. NEJM EVIDENCE 2023; 2:EVIDra2300160. [PMID: 38320504 DOI: 10.1056/evidra2300160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Methamphetamine Toxicities and Clinical ManagementMethamphetamine increases the release and blocks the uptake of norepinephrine, serotonin, and dopamine. This article reviews the morbidity and mortality associated with methamphetamine use and discusses prevention and treatment strategies.
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Affiliation(s)
- Phillip O Coffin
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco
- Department of Medicine, University of California San Francisco, San Francisco
| | - Leslie W Suen
- Department of Medicine, University of California San Francisco, San Francisco
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Wagner KD, Fiuty P, Page K, Tracy EC, Nocera M, Miller CW, Tarhuni LJ, Dasgupta N. Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking services. Drug Alcohol Depend 2023; 252:110985. [PMID: 37826988 PMCID: PMC10688611 DOI: 10.1016/j.drugalcdep.2023.110985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Overdose deaths involving stimulants and opioids simultaneously have raised the specter of widespread contamination of the stimulant supply with fentanyl. METHODS We quantified prevalence of fentanyl in street methamphetamine and cocaine, stratified by crystalline texture, analyzing samples sent voluntarily to a public mail-in drug checking service (May 2021-June 2023). Samples from 77 harm reduction programs and clinics originated in 25 US states. Sample donors reported expected drug and physical descriptions. Substances were identified by gas chromatography-mass spectrometry. Negative binomial models were used to calculate fentanyl prevalence, adjusting for potential confounders related to sample selection. We also examined if xylazine changed donors' accuracy of detecting fentanyl. RESULTS We analyzed 718 lab-confirmed samples of methamphetamine (64%) and cocaine (36%). The adjusted prevalence of fentanyl was 12.5% (95% CI: 2.2%, 22.9%) in powder methamphetamine and 14.8% (2.3%, 27.2%) in powder cocaine, with notable geographic variation. Crystalline forms of both methamphetamine (Chisq=57, p<0.001) and cocaine (Chisq=18, p<0.001) were less likely to contain fentanyl: less than 1% of crystal methamphetamine (2/276) and no crack cocaine (0/53). Heroin was present in 6.6% of powder cocaine samples. Xylazine reduced donors' ability to detect fentanyl, with correct classification dropping from 92% to 42%. CONCLUSIONS Fentanyl was detected primarily in powder forms of methamphetamine and cocaine. Recommended interventions include expanding community-based drug checking, naloxone and fentanyl test strip distribution for people who use stimulants , and supervised drug consumption sites. New strategies to dampen variability in street drug composition are needed to reduce inadvertent fentanyl exposure.
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Affiliation(s)
- Karla D Wagner
- Department of Health Behavior, Policy, and Administration Sciences, School of Public Health, University of Nevada, Reno, NV 89557, USA.
| | | | - Kimberly Page
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA.
| | - Erin C Tracy
- Injury Prevention Research Center, University of North Carolina, CB 7505, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599, USA.
| | - Maryalice Nocera
- Injury Prevention Research Center, University of North Carolina, CB 7505, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599, USA.
| | - Colin W Miller
- Injury Prevention Research Center, University of North Carolina, CB 7505, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599, USA.
| | - Lina J Tarhuni
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA; Department of Pharmacy, University of Washington, Seattle, WA 98195, USA.
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina, CB 7505, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599, USA.
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Tilhou AS, Zaborek J, Baltes A, Salisbury-Afshar E, Malicki J, Brown R. Differences in drug use behaviors that impact overdose risk among individuals who do and do not use fentanyl test strips for drug checking. Harm Reduct J 2023; 20:41. [PMID: 36978170 PMCID: PMC10053743 DOI: 10.1186/s12954-023-00767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Abstract
Background
Opioid-involved overdose continues to rise, largely explained by fentanyl adulteration of the illicit opioid supply. Fentanyl test strips are a novel drug checking tool that can be used by people who use drugs to detect the presence of fentanyl in drug products. However, it is unclear whether fentanyl test strip use can prompt behavior changes that impact risk of overdose.
Methods
In this mixed-methods study involving a structured survey (n = 341) of syringe service program clients in southern Wisconsin, we examined the association between fentanyl test strip use and overdose risk behaviors in scenarios where the presence of fentanyl is confirmed and unknown. Individual items were transformed into summary scales representing the performance of riskier and safer behaviors. Linear regression examined the association of behaviors with FTS use. Models are adjusted for study site, race/ethnicity, age, gender, drug of choice, indicator of polysubstance use, times used per day, and lifetime overdose count.
Results
In response to survey questions before prompting about fentanyl risk, people who used fentanyl test strips reported an increased number of safer (p = 0.001) as well as riskier behaviors (p = 0.018) relative to people who did not use fentanyl test strips. The same held true in situations when fentanyl adulteration was suspected, though fentanyl test strip use lost significance in the fully adjusted model examining safer behaviors (safer: p = 0.143; riskier: p = 0.004). Among people who use fentanyl test strips, in unadjusted models, a positive test result was associated with more safer behaviors and fewer riskier behaviors, but these associations became nonsignificant in fully adjusted models (safer: p = 0.998; riskier: p = 0.171). Loss of significance was largely due to the addition of either polysubstance use or age to the model.
Conclusions
Fentanyl test strip use is associated with behaviors that may impact overdose risk, including safer and riskier behaviors. Specifically, a positive test result may promote more risk reducing behaviors and fewer risk enhancing behaviors than a negative test result. Results suggest that while FTS may promote safer drug use behaviors, outreach and education should emphasize the need for multiple harm reduction techniques in all scenarios.
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Tilhou AS, Birstler J, Baltes A, Salisbury-Afshar E, Malicki J, Chen G, Brown R. Characteristics and context of fentanyl test strip use among syringe service clients in southern Wisconsin. Harm Reduct J 2022; 19:142. [PMID: 36522777 PMCID: PMC9753354 DOI: 10.1186/s12954-022-00720-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/19/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fentanyl adulteration of illicit drugs is a major driver of opioid-involved overdose in the USA. Fentanyl test strips are increasingly used by people who use drugs to check for fentanyl. However, little is known about factors that influence test strip use in this population. METHODS In this mixed-methods study employing semi-structured open-ended interviews (n = 29) and a structured survey (n = 341), we examined characteristics associated with test strip use, characteristics of test strip use, and situational, logistical and psychosocial factors influencing test strip use. Respondents were recruited from a syringe service program in southern Wisconsin. Bivariate tests of association and multivariable logistic regression examined the relationship between respondent characteristics and test strip use. Summary statistics were used to describe how situational, logistical and psychosocial factors impact test strip use. RESULTS Most respondents were male (59.6%), non-Hispanic white (77.4%), young (mean 35.7 years), reported heroin as their primary drug (70.7%), injection as their primary route (87.9%), and use ≥ 3 times daily (78.6%). In multivariable models, site, race and ethnicity, drug of choice, and seeking fentanyl were associated with test strip use. Among test strip users, 36.5% use them most of the time or more and 80.6% get positive results half the time or more. Among individuals reporting heroin, fentanyl, methamphetamine, or cocaine or crack cocaine at least once per month, 99.1%, 56.8%, 42.2%, and 55.7% reported testing these drugs, respectively. Test strip use is supported by information from suppliers, regular transportation, diverse distribution locations, recommendations from harm reduction staff, and having a safe or private place to use. CONCLUSIONS We found that individuals who use fentanyl test strips are more often non-Hispanic white, use heroin, and seek drugs with fentanyl relative to individuals without test strip use. Findings confirm high fentanyl penetration in the Wisconsin drug supply. Low rates of stimulant testing suggest inadequate awareness of fentanyl penetration. Findings support outreach to key populations, increased diversity of distributing locations, efforts to correct misperceptions about drug wasting, emphasis on pre-consumption testing, and the importance of adjunct behaviors to prevent overdose given high rates of intentional fentanyl use.
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Affiliation(s)
- Alyssa Shell Tilhou
- grid.189504.10000 0004 1936 7558Department of Family Medicine, Boston University/Boston Medical Center, 771 Albany St., Dowling 5 South, Rm 5507A, Boston, MA 02118 USA
| | - Jen Birstler
- grid.14003.360000 0001 2167 3675Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Amelia Baltes
- grid.14003.360000 0001 2167 3675Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Elizabeth Salisbury-Afshar
- grid.14003.360000 0001 2167 3675Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Julia Malicki
- grid.14003.360000 0001 2167 3675Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Guanhua Chen
- grid.14003.360000 0001 2167 3675Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Randall Brown
- grid.14003.360000 0001 2167 3675Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
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