Association between law enforcement seizures of illicit drugs and drug overdose deaths involving cocaine and methamphetamine, Ohio, 2014-2019

Law enforcement fentanyl seizures and overdose mortality in US counties, 2013-2020

BACKGROUND

The spread of illicitly manufactured fentanyl is driving steep increases in US overdose deaths. Fentanyl seizures are correlated with state-level opioid-related mortality; however, more granular seizure surveillance information has the potential to better inform overdose prevention and harm reduction efforts.

METHODS

Using data on fentanyl pill and powder seizures from High Intensity Drug Trafficking Areas (HIDTA), we tested associations between seizure prevalence and overdose mortality, from 2013 to 2020. The primary exposure-seizure burden-was constructed by identifying counties having high (above the median) prevalence of pill, powder, or combined pill/powder seizure burden per 100,000 population. Poisson models accounted for county demographic, law enforcement and time trends.

RESULTS

During the timeframe, there were 13,842 fentanyl seizures in 606 US counties. In adjusted models, counties with a high burden of pill or powder fentanyl seizures, or both (combined pills/powder) exhibited higher total overdose mortality than non-high burden counties (pills adjusted prevalence ratio [aPR]: 1.10 [95 % confidence interval [CI]: 1.08, 1.12]; powder aPR 1.12 [CI: 1.11, 1.13]; combined pills/powder aPR: 1.27 [CI: 1.25, 1.29]). A similar pattern of associations with fentanyl seizure burden was noted for overdose deaths involving synthetic opioids (pills [aPR]: 0.99 [CI: 0.96, 1.02]; powder aPR 1.29 [CI: 1.27, 1.30]; combined pills/powder aPR 1.55 [CI: 1.52, 1.58]).

CONCLUSIONS

Law enforcement data on fentanyl seizures predicts drug overdose mortality at the county-level. Integrating these data with more traditional epidemiologic surveillance approaches has the potential to inform community overdose response efforts.

Estimating changes in overdose death rates from increasing methamphetamine supply in Ohio: Evidence from crime lab data

Background

We investigate the relationship between the supply of methamphetamine and overdose death risk in Ohio. Ohio and the overall US have experienced a marked increase in overdose deaths from methamphetamine combined with fentanyl over the last decade. The increasing use of methamphetamine may be increasing the risk of overdose death. However, if people are using it to substitute away from more dangerous synthetic opioids, it may reduce the overall risk of overdose death.

Methods

Ohio's Bureau of Criminal Investigation's crime lab data include a detailed list of the content of drug samples from law enforcement seizures, which are used as a proxy for drug supply. We use linear regressions to estimate the relationship between the proportion of methamphetamine in lab samples and unintentional drug overdose death rates from January 2015 through September 2021.

Results

Relatively more methamphetamine in crime lab data in a county-month has either no statistically significant relationship with overdose death rates (in small and medium population counties) or a negative and statistically significant relationship with overdose death rates (in large population counties). Past overdose death rates do not predict future increases in methamphetamine in crime lab data.

Conclusions

The results are consistent with a relatively higher supply of methamphetamine reducing the general risk of overdose death, possibly due to substitution away from more dangerous synthetic opioids. However, the supply of methamphetamine appears unrelated to the past illicit drug risk environment. The non-lethal and yet serious health effects of MA use were not explored and, thus, even if the presence of MA reduces the population-level overdose mortality rate, the rise of other adverse health effects may counteract any public health benefits of fewer deaths.

National and regional trends in fentanyl seizures in the United States, 2017-2023

BACKGROUND

Rates of synthetic opioid-related deaths over time and across regions have been compared within the US, but other indicator data could help inform prevention and harm reduction as well. We compared regional trends in fentanyl seizures to examine potential shifts in illicit fentanyl availability.

METHODS

Annual trends in fentanyl seizures were examined using data from High Intensity Drug Trafficking Areas for the US overall and by region from 2017 through 2023. Multiple measures included the number of seizures, the number of powder seizures, the number of pill seizures, the total weight of seizures, the number of pills seized, and the percentage of the number of pill seizures relative to the number of total seizures.

RESULTS

The percentage of seizures in pill form in the US increased from 10.3 % in 2017 to 49.0 % in 2023 (adjusted annual percentage change [AAPC]=25.2, 95 % CI: 17.6, 33.2), with 115.6 million individual pills seized in 2023. Pill weight related to total seizure weight also increased from 0.4 % to 54.5 % (AAPC=112.6, 95 % CI: 78.6, 153.2). In 2023, the plurality of seizures was in the West, in seven out of eight of our measures, with 77.8 % of seizures in the West being in pill form. Although the Midwest had lower prevalence of seizures than the West, there were notable increases in the Midwest in the number of pill seizures (AAPC=142.2, 95 % CI: 91.9, 205.8) and number of pills seized (AAPC=421.0, 95 % CI: 272.7, 628.4). Total weight of fentanyl seized increased the most in the West (AAPC=84.6, 95 % CI: 72.3, 97.8).

CONCLUSIONS

The number and size of fentanyl seizures is increasing in the US, with the majority of seizures, especially in pill form, in the West. Continued monitoring of regional shifts in the fentanyl supply can help inform targeted prevention and public health response.

National and regional trends in seizures of shrooms (psilocybin) in the United States, 2017-2022

BACKGROUND

Psilocybin, the principle psychoactive component in "shrooms", is regaining acceptance in therapeutic settings, leading to media coverage of medical benefits associated with use. Possession is also becoming increasingly decriminalized throughout the United States. There is a lack of data on prevalence of shroom use, but trends in law enforcement seizure data can provide one indicator of shroom availability in US communities. We determined whether seizures of shrooms have shifted between 2017 and 2022.

METHODS

This study examined national and regional trends in counts and total weight of shroom seizures reported to High Intensity Drug Trafficking Areas in the US between 2017 and 2022 (N=4526).

RESULTS

There were 402 seizures in 2017 compared to 1396 in 2022 with the plurality occurring in the Midwest (36.0%), followed by the West (33.5%). Between 2017 Quarter 1 (Q1) and 2022 Quarter 4 (Q4), the number of seizures increased by 368.9% (AQPC=7.0; 95 CI: 5.9-8.1) and there were significant increases in all four regions. In terms of weight, 226.0kg was seized in 2017 vs. 844.0kg in 2022, and the greatest total weight in seizures was in the West (1864.2kg, 42.6%), followed by the South (1831.9kg, 41.8%). Between 2017 Q1 and 2022 Q4, the total weight seized in the US increased by 2749.7% (AQPC=6.2, 95% CI: 0.3-12.4) and there were significant increases in all four regions.

CONCLUSIONS

Seizures of shrooms have increased, suggesting that availability may be escalating; thus, increases in prevention efforts and harm reduction education are warranted.

"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America

BACKGROUND

Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs.

METHODS

From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs.

RESULTS

Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust.

CONCLUSION

While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Drug supply measures and drug overdose mortality in the era of fentanyl and stimulants

Background

Illicitly-manufactured fentanyl and stimulants have replaced prescription opioids as the primary contributors to fatal overdoses in the United States (US), yet the street supply of these substances is challenging to quantify. Building on the foundation of prior research on law enforcement drug reports, the present study compares publicly available forensic laboratory drug report measures to identify which measures account for the most variation in drug overdose mortality between states, within states over time, and in various demographic groups.

Methods

Drug reports from the National Forensic Laboratory Information System and drug overdose mortality rates from the Centers for Disease Control and Prevention were examined for all US states and the District of Columbia, 2013-2021 (459 state-years). State- and year- fixed effects models regressed drug overdose mortality rates (in the overall population and subpopulations by sex, age, and race/ethnicity) on various drug report measures, including rates per population and proportional shares of drug reports positive for fentanyl/fentanyl-related compounds, heroin, cocaine, methamphetamine, and xylazine.

Results

For drug overdose death rates in the overall population and nearly all subpopulations examined by sex, race/ethnicity, and age, the model including all drug report proportional measures represented the best-performing model (as identified via the lowest Akaike Information Criterion and highest within R-squared value), followed by the model including only the fentanyl/fentanyl-related compounds proportion.

Conclusions

Findings support the utility of publicly available drug report composition measures, particularly the proportion of fentanyl/fentanyl-related compounds, as predictors of drug overdose mortality in the US and in various subpopulations.

A case study for local data surveillance in opioid overdose fatalities in Cuyahoga County, OH 2016-2020

Introduction

Fentanyl and fentanyl analogs have increased the overdose mortality rates in the United States, significantly impacting states like Ohio. We examined carfentanil overdose deaths, other contributing Cause of Death (COD) drugs, and drug seizure trends from 2016 to 2020 in Northeast Ohio.

Materials and methods

We studied death investigation data from the Cuyahoga County, Ohio Medical Examiner's Office (CCMEO) of all fatal accidental opioid overdoses as well as drug seizure data from Cuyahoga County Regional Forensic Science Laboratory (CCRFSL). We also compared decedents' race, gender, age, residential locality, drugs contributing to the COD in opioid cases, and for carfentanil, fentanyl, and cocaine seizures in Cuyahoga County from 2016 to 2020 (N = 2948).

Results

Decedents' had an average of three different drugs contributing to their COD. A bimodal carfentanil spike was observed in fatal accidental overdoses in Cuyahoga County for the years 2017 and 2019. Decedents in urban residency, who were Non-Hispanic, White and younger, significantly predicted the presence of carfentanil contributing to the COD. In 2020, decedents who were Black and older were significantly associated with cocaine contributing to the COD. Carfentanil and carfentanil-related overdoses were significantly correlated.

Discussion

The pervasiveness of illicitly manufactured fentanyl and fentanyl analog (e.g., carfentanil) mixtures with other drugs are changing the demographics of persons who fatally overdose in Cuyahoga County, OH. Significant trending shifts can also be observed for the presence of carfentanil in decedent and seizure county data.

Conclusions

Local data of drug-related overdose deaths and drug seizures from a medical examiner's office and affiliated forensic laboratory lab can be used for timely public health surveillance, and informing prevention, and intervention at the county level.

Associations between opioid overdose deaths and drugs confiscated by law enforcement and submitted to crime laboratories for analysis, United States, 2014-2019: an observational study

Background

The overdose epidemic in the United States (US) continues to generate unprecedented levels of mortality. There is urgent need for a national data system capable of yielding high-quality, timely, and actionable information on existing and emerging drugs. Public health researchers have started using law enforcement forensic laboratory data to obtain surveillance information on illicit drugs. This study is the first to use drug reports from the entire US to examine correlations between a changing drug supply and increasing opioid-involved overdose deaths (OOD) on a national scale.

Methods

This study is observational and investigates associations between law enforcement drug reports and OOD for the US from 2014 to 2019. OOD data are from the Centers for Disease Control and Prevention's National Vital Statistics System restricted-use multiple cause of death files. The US Drug Enforcement Administration's National Forensic Laboratory Information System (NFLIS) contains forensic laboratory-tested drug exhibit information for the entire US (NFLIS-Drug). Counts of forensic laboratory reports and OOD were aggregated for each state by month, quarter, and year. A difference-in-differences framework was used to estimate contemporaneous and lagged associations.

Findings

Between 2014 and 2019 in the US, 249,522 OOD were reported, with the annual number nearly doubling from 28,723 to 50,179. OOD involving illicitly manufactured fentanyls (IMF) also increased substantially during this period, from 19.4% to 72.9%. In addition, 3,817,438 forensic laboratory reports in the US that were reported to NFLIS-Drug contained an opioid, stimulant, or benzodiazepine. Reports of fentanyl and fentanyl-related compounds (FFRC) had the strongest association with OOD. Each additional FFRC exhibit was associated with a 2.97% (95% CI: 1.7%, 4.1%) increase in OOD per 100,000 persons per quarter.

Interpretation

Adding to the emerging consensus, protracted growth in IMF supply was more strongly associated with OOD than all other illicit drugs reported to NFLIS-Drug over the study time period. Findings demonstrate NFLIS-Drug data usefulness for research that require proxy indicators for the illicit drugs supply. A concerted effort between public health and public safety to make NFLIS-Drug more timely could strengthen its utility as a national, public health, drug surveillance system.

Funding

Sangeetha Arctic Slope Mission Services, LLC, ASMS Contract No. ASM5-00017.

Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021

Objectives. To test the hypothesis that law enforcement efforts to disrupt local drug markets by seizing opioids or stimulants are associated with increased spatiotemporal clustering of overdose events in the surrounding geographic area. Methods. We performed a retrospective (January 1, 2020 to December 31, 2021), population-based cohort study using administrative data from Marion County, Indiana. We compared frequency and characteristics of drug (i.e., opioids and stimulants) seizures with changes in fatal overdose, emergency medical services nonfatal overdose calls for service, and naloxone administration in the geographic area and time following the seizures. Results. Within 7, 14, and 21 days, opioid-related law enforcement drug seizures were significantly associated with increased spatiotemporal clustering of overdoses within radii of 100, 250, and 500 meters. For example, the observed number of fatal overdoses was two-fold higher than expected under the null distribution within 7 days and 500 meters following opioid-related seizures. To a lesser extent, stimulant-related drug seizures were associated with increased spatiotemporal clustering overdose. Conclusions. Supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy. (Am J Public Health. 2023;113(7):750-758. https://doi.org/10.2105/AJPH.2023.307291).

"All carrots and no stick": Perceived impacts, changes in practices, and attitudes among law enforcement following drug decriminalization in Oregon State, USA

BACKGROUND

By passing Ballot Measure 110 (BM 110), Oregon became the first U.S. state to decriminalize noncommercial possession of drugs that are illegal under the Controlled Substances Act. This study examined the perceived impacts of BM 110 on law enforcement and Oregon communities.

METHODS

Our team visited four geographically distinct Oregon counties in August 2022 (two urban, two rural). The qualitative study involved conducting 34 hour-long interviews with law enforcement, other criminal legal system personnel, and representatives from emergency medical services/fire and substance use treatment and harm reduction agencies. Interviewees were asked about their perceptions of BM 110's effects on law enforcement, their communities, and agencies.

RESULTS

Law enforcement interviewees viewed BM 110 as a failure; they perceived it resulted in an erosion of their authority. They expressed frustration that they could not use drug possession as a "tool" for investigations to pursue and build cases, establish probable cause, and impose what they believed necessary for social order. Law enforcement personnel in all four counties indicated they routinely seized drugs and drug paraphernalia during encounters with people using drugs, even when that was the only offense being committed. Police lacked knowledge that BM 110 included support for harm reduction services, housing assistance, and employment support. Law enforcement personnel had different opinions and practices regarding issuing Class E violations; those who did not issue them viewed them as a waste of time because they are not entry points into the criminal legal system.

CONCLUSION

This study provides insights into drug decriminalization in Oregon. This examination is critical for informing BM 110's continued implementation as Oregon proceeds with increased treatment and support service provision. Our findings have important implications regarding other states' design and implementation of drug policy alternatives, including ones that remove law enforcement's role in addressing drug use.

Antecedents of fatal overdose in an adult cohort identified through administrative record linkage in Indiana, 2015-2022

BACKGROUND

The United States continues to experience unprecedented rates of overdose mortality and need to identify effective policies or practices that can be implemented. This study aims to measure the prevalence, frequency, timing, and rate of touchpoints that occurred prior to a fatal overdose where communities might intervene.

METHODS

In collaboration with Indiana state government, we conducted record-linkage of statewide administrative datasets to vital records (January 1, 2015, through August 26, 2022) to identify touchpoints (jail booking, prison release, prescription medication dispensation, emergency department visits, and emergency medical services). We examined touchpoints within 12-months prior to a fatal overdose among an adult cohort and explored variation over time and by demographic characteristics.

RESULTS

Over the 92-month study period there were 13,882 overdose deaths (89.3% accidental poisonings, X40-X44) in our adult cohort that were record-linked to multiple administrative datasets and revealed nearly two-thirds (64.7%; n=8980) experienced an emergency department visit, the most prevalent touchpoint followed by prescription medication dispensation, emergency medical services responses, jail booking, and prison release. However, with approximately 1 out of every 100 returning citizens dying from drug overdose within 12-months of release, prison release had the highest touchpoint rate followed by emergency medical services responses, jail booking, emergency department visits, and prescription medication dispensation.

CONCLUSION

Record-linking administrative data from routine practice to vital records from overdose mortality is a viable means of identifying where resources should be situated to reduce fatal overdose, with potential to evaluate the effectiveness of overdose prevention efforts.

Supply-side predictors of fatal drug overdose in the Washington/Baltimore HIDTA region: 2016-2020

BACKGROUND

Rising rates of fentanyl- and polydrug-involved drug overdose deaths have prompted inquiry into the role of drug supply in fatal overdose outcomes in the United States. To date, however, there have been few empirical investigations of drug enforcement strategies on fatal overdose rates, despite knowledge that both drug use and supply are often geographically distributed. To address this limitation, we examined measures of drug enforcement as predictors of next-year fatal overdose rates in the Washington/Baltimore High Intensity Drug Trafficking Area (W/B HIDTA).

METHODS

We conducted mixed-effects models to examine the role of drug seizures and disruption in drug trafficking organizations (DTOs) and money laundering organizations (MLOs) on fatal overdose rates over a 5-year period (2016-2020) across 45 local jurisdictions in the W/B HIDTA region. Outcomes included any, opioid-involved, and fentanyl-involved fatal overdose.

RESULTS

Adjusting for covariates, both the total number of drug seizures and amount of cocaine seized (in dosage units per capita) positively predicted next-year opioid- and fentanyl-involved fatal overdose rates. Disruption to DTO and MLO operations did not significantly predict next-year fatal overdose rates for any outcome.

CONCLUSION

Supply-side enforcement activities alone may have limited impact on reducing fatal overdose rates, but may serve as important markers to identify communities at high risk of fatal overdose and facilitate targeted intervention. Our findings underscore the importance of comprehensive law enforcement approaches that extend beyond drug enforcement to integrate prevention, linkage to treatment, and harm reduction strategies as needed to address the overdose epidemic.

Legality of drug checking equipment in the United States: A systematic legal analysis

BACKGROUND

Fentanyl and fentanyl analogs are increasingly prevalent in the nation's illicit drug supply. While fentanyl-related deaths were previously confined largely to states east of the Mississippi, they are now increasing rapidly throughout much of the United States. Contaminants other than fentanyl are also present in illicitly obtained drugs. Using drug checking equipment to determine the contaminants that may be present in these drugs is a promising avenue for reducing overdose-related harm.

METHODS

Systematic legal review in which three trained legal researchers collected, reviewed, and coded all US state laws that specify whether the possession and distribution of drug checking equipment is generally legal, whether is it legal in the context of syringe services programs, and, where possession or distribution of drug checking equipment is not clearly legal, the potential penalties for violation.

RESULTS

We find that it is clearly legal to possess some or all drug checking equipment in 22 states, and clearly legal to distribute it to adults in 19 states. In 14 states where distribution of drug checking equipment is not clearly legal generally, it is legal when that equipment is obtained from a syringe services program. Potential penalties for violations range from small civil fines to multi-year jail sentences.

CONCLUSIONS

There are currently great variations between states regarding the legality of drug checking equipment. Clarifying, modifying, or repealing drug paraphernalia laws would likely improve access to these promising technologies, potentially reducing overdose deaths.