A descriptive study of racial and ethnic differences of drug overdoses and naloxone administration in Pennsylvania

Early detection and prediction of non-fatal drug-related incidents and fatal overdose outbreaks using the Farrington algorithm

AIMS

The aim of this study was to assess the validity of undertaking time-series analyses on both fatal and non-fatal drug overdose outcomes for the surveillance of emerging drug threats, and to determine the validity of analyzing non-fatal indicators to support the early detection of fatal overdose outbreaks.

DESIGN, SETTING AND PARTICIPANTS

Time-series analyses using county-level data containing fatal overdoses and non-fatal overdose counts were collected at monthly intervals between 2015 and 2021 in California and Florida, USA. To analyze these data, we used the Farrington algorithm (FA), a method used to detect aberrations in time-series data such that an abnormal increase in counts relative to previous observations would result in an alert. The FA's performance was compared with a bench-mark approach, using the standard deviation as an aberration detection threshold. We evaluated whether monthly alerts in non-fatal overdose can aid in identifying fatal drug overdose outbreaks, defined as a statistically significant increase in the 6-month overdose death rate. We also conducted analyses across regions, i.e. clusters of counties.

MEASUREMENTS

Measurements were taken during emergency department and emergency medical service visits.

FINDINGS

Both methods yielded a similar proportion of alerts across scenarios for non-fatal overdoses, while the bench-mark method yielded more alerts for fatal overdoses. For both methods, the correlations between surveillance evaluations were relatively poor in the detection of aberrations (typically < 35%) but were high between evaluations yielding no alerts (typically > 75%). For ongoing fatal overdose outbreaks, a strategy based on the detection of alerts at the county level from either method yielded a sensitivity of 66% for both California and Florida. At the regional level, the equivalent analyses had sensitivities of 81% for California and 77% for Florida.

CONCLUSION

Aberration detection methods can support the early detection of fatal drug overdose outbreaks, particularly when methodologies are applied in combination rather than individual methods separately.

Naloxone Administration and Survival in Overdoses Involving Opioids and Stimulants: An Analysis of Law Enforcement Data from 63 Pennsylvania Counties

Background

In consideration of rising deaths from opioid-stimulant-involved overdoses in the United States, this study explored rates of naloxone administration and survival in opioid overdoses with versus without stimulants co-involved.

Methods

The study used data from the Pennsylvania Overdose Information Network, focusing on 26,635 suspected opioid-involved overdose events recorded by law enforcement and other first responders in 63 Pennsylvania counties from January 2018 to July 2024. Relative frequencies and chi-square tests were first used to compare suspected opioid overdoses with, versus without, stimulants (cocaine or methamphetamine) co-involved. Next, mediation analyses tested naloxone administration as a mediator of the association between stimulant co-involvement (in opioid overdoses) and survival.

Results

Naloxone was reportedly administered in 72.2% of the opioid-no-cocaine overdoses, compared to 55.1% of the opioid-cocaine-involved overdoses, and 72.1% of the opioid-no-methamphetamine overdoses vs. 52.4% of the opioid-methamphetamine-involved overdoses. With respect to survival rates, 18.0% of the opioid-no-cocaine overdoses ended in death, compared to 41.3% of the opioid-cocaine overdoses; 18.1% of the opioid-no-methamphetamine overdoses ended in death, versus 42.9% of the opioid-methamphetamine overdoses. In mediation analyses (adjusted for demographics, county, year, and other drug co-involvement), naloxone administration mediated 38.7% (95% Confidence Interval [CI], 31.3%-46.0%) of the association between cocaine co-involvement and survival and 39.2% (95% CI, 31.3%-47.1%) of the association between methamphetamine co-involvement and survival.

Conclusions

Among suspected opioid overdose events recorded in the Pennsylvania Overdose Information Network, stimulant co-involvement was associated with lower naloxone administration and higher fatality, with naloxone partially mediating the association between stimulant co-involvement and death.

Fentanyl harm reduction strategies among Latinx communities in the United States: a scoping review

PURPOSE

Fueled by the prescription opioid overdose crisis and increased influx of illicitly manufactured fentanyl, fentanyl overdoses continue to be a public health crisis that has cost the US economy over $1 trillion in reduced productivity, health care, family assistance, criminal justice, and accounted for over 74,000 deaths in 2023. A recent demographic shift in the opioid crisis has led to a rise in overdose deaths among the Latinx population. Harm reduction interventions, including the use of naloxone and fentanyl test strips, have been shown to be effective measures at reducing the number of opioid overdose deaths. The aim of this scoping review is to summarize naloxone and fentanyl test strip interventions and public health policies targeted to Latinx communities.

METHODS

PubMed, CINHAL, Web of Science, Embase, and PsycINFO research databases using the keywords "fentanyl," "Latinx," "Harm Reduction," "Naloxone," and "Fentanyl Test Strips'' to identify studies published between January 1, 2013 and December 31, 2023. Endnote and Covidence software were used to catalog and manage citations for review of studies. Subsequently, studies that met inclusion criteria were then summarized using resulting themes.

RESULTS

Twenty-seven articles met the inclusion criteria and were further abstracted for the scoping review. Of these articles, 77.7% (n = 21) included a naloxone intervention, while only 11.1% (n = 3) included a fentanyl test strip intervention. Furthermore, 30.1% (n = 8) of these studies were Latinx targeted, and 7.7% (n = 2) of the studies were adapted for Latinx populations. Four themes, including an overall lack of knowledge and awareness, a lack of access to harm reduction or opioid overdose prevention resources, an overall lack of culturally adapted and/or targeted interventions, and restrictive and punitive policies that limit the effectiveness of protective factors were highlighted in this scoping review.

CONCLUSION

Limited published research exists on the use of emerging harm reduction behaviors, such as the use of naloxone and fentanyl test strips as community intervention strategies to prevent opioid overdose deaths. Even fewer publications exist on the targeting and cultural adaptation of harm reduction interventions responsive to Latinx communities, especially those using theoretical approaches or frameworks to support these interventions. Future research is needed to assess the unique needs of Latinx populations and to develop culturally responsive programs to prevent opioid-related overdose deaths among this population.

Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model

ISSUES

To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors.

APPROACH

Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors.

KEY FINDINGS

Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder.

IMPLICATIONS

There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement.

CONCLUSION

There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.

Naloxone use by Aotearoa New Zealand emergency medical services, 2017-2021

OBJECTIVE

Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future.

METHODS

A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017-2021) and Wellington Free Ambulance (2018-2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described.

RESULTS

There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population-years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min.

CONCLUSIONS

A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care.

Daily opioid and stimulant co-use and nonfatal overdoses in the context of social disadvantage: Findings on marginalized populations

OBJECTIVE

Opioids and stimulants are increasingly implicated in overdose deaths, particularly among minoritized groups. We examined daily opioid and cocaine co-use, nonfatal overdoses, and naloxone carrying among minoritized people who inject drugs (PWID).

METHODS

The study derived data from 499 PWID in Baltimore City, MD, recruited using street-based outreach between 2016 and 2019. Participants reported overdoses; sociodemographic characteristics; and use of nonmedical prescription opioids, heroin, cocaine, and naloxone.

RESULTS

Among the participants, the mean age was 46, 34 % were female, 64 % self-identified as Black, and 53 % experienced recent homelessness. Black PWID, compared to White PWID, were as likely to use opioids and cocaine daily but were 61 % less likely to have naloxone. After controlling for sociodemographic characteristics, women (aOR:1.88, 95%CI: 1.14, 3.11), persons experiencing homelessness (aOR:3.07, 95%CI: 1.79, 5.24), and those who experienced a recent overdose (aOR:2.14, 95%CI: 1.29, 3.58) were significantly more likely to use opioids and any form of cocaine every day. In a subanalysis of only female PWID, females engaged in sex work (aOR:2.27, 95%CI: 1.02, 5.07) and females experiencing recent homelessness (aOR:5.82, 95%CI: 2.50, 13.52) were significantly more likely to use opioids and cocaine daily. Furthermore, females (aOR:1.69, 95%CI:1.03, 2.77), persons experiencing homelessness (aOR:1.94, 95%CI:1.16, 3.24), and those with higher educational attainment (aOR:2.06, 95%CI:1.09, 3.91) were more likely to often/always carry naloxone, while Black PWID were less likely to have naloxone (aOR:0.39, 95%CI:0.22, 0.69).

CONCLUSIONS

These findings highlight the need for targeted naloxone distribution and other harm-reduction interventions among minoritized groups in urban areas.

Age-specific disparities in fatal drug overdoses highest among older black adults and American Indian/Alaska native individuals of all ages in the United States, 2015-2020

INTRODUCTION

Increasing disparities within and between racial/ethnic groups in overdose deaths underscore the need to identify drivers and patterns to optimize overdose prevention strategies. We assess age-specific mortality rates (ASMR) in drug overdose deaths by race/ethnicity in 2015-2019 and 2020.

METHODS

Data were from the CDC Wonder, and included information for N = 411,451 deceased individuals in the United States (2015-2020) with a drug overdose-attributed cause of death (ICD-10 codes: X40-X44, X60-X64, X85, Y10-Y14). We compiled overdose death counts by age, race/ethnicity, and population estimates to derive ASMRs, mortality rate ratios (MRR), and cohort effects.

RESULTS

The ASMRs for Non-Hispanic Black adults (2015-2019) followed a different pattern than other racial/ethnic groups-low ASMRs among young individuals and peaking between 55-64 years-a pattern exacerbated in 2020. Younger Non-Hispanic Black individuals had lower MRRs than young Non-Hispanic White individuals, yet, older Non-Hispanic Black adults had much higher MRRs than older Non-Hispanic White adults (45-54yrs:126%, 55-64yrs:197%; 65-74yrs:314%; 75-84:148%) in 2020. American Indian/Alaska Native adults had higher MRRs than Non-Hispanic White adults in death counts compiled from pre-pandemic years (2015-2019); however, MRRs increased in 2020 (15-24yrs:134%, 25-34yrs:132%, 35-44yrs:124%, 45-54yrs:134%, 55-64yrs:118%). Cohort analyses suggested a bimodal distribution of increasing fatal overdose rates among Non-Hispanic Black individuals aged 15-24 and 65-74.

CONCLUSIONS AND RELEVANCE

Overdose fatalities unprecedently impact older Non-Hispanic Black adults and American Indian/Alaska Native populations of all ages, deviating from the pattern found for Non-Hispanic White individuals. Findings highlight the need for targeted naloxone and low-threshold buprenorphine programs to reduce racial disparities.

Variability in Opioid-Related Drug Overdoses, Social Distancing, and Area-Level Deprivation during the COVID-19 Pandemic: a Bayesian Spatiotemporal Analysis

Monitoring the spatial and temporal course of opioid-related drug overdose mortality is a key public health determinant. Despite previous studies exploring the evolution of drug-related fatalities following the stay-at-home mandates during the COVID-19 pandemic, little is known about the spatiotemporal dynamics that mitigation efforts had on overdose deaths. The purpose of this study was to describe the spatial and temporal dynamics of overdose death relative risk using a 4-week interval over a span of 5 months following the implementation of the COVID-19 lockdown in the city of Chicago, IL. A Bayesian space-time model was used to produce posterior risk estimates and exceedance probabilities of opioid-related overdose deaths controlling for measures of area-level deprivation and stay-at-home mandates. We found that area-level temporal risk and inequalities in drug overdose mortality increased significantly in the initial months of the pandemic. We further found that a change in the area-level deprivation from the first to the fourth quintile increased the relative risk of a drug overdose risk by 44.5%. The social distancing index measuring the proportion of persons who stayed at home in each census block group was not associated with drug overdose mortality. We conclude by highlighting the importance of contextualizing the spatial and temporal risk in overdose mortality for implementing effective and safe harm reduction strategies during a global pandemic.

Naloxone administration among opioid-involved overdose deaths in 38 United States jurisdictions in the State Unintentional Drug Overdose Reporting System, 2019

BACKGROUND

The majority of drug overdose deaths in the United States involve opioids, and synthetic opioid-involved overdose death rates are increasing. Naloxone is a key prevention strategy yet estimates of its administration are limited.

METHODS

We analyzed 2019 data from 37 states and the District of Columbia in CDC's State Unintentional Drug Overdose Reporting System to estimate the percentage of decedents, by sociodemographic subgroup, who experienced a fatal opioid-involved overdose and had no evidence of naloxone administration.

RESULTS

A total of 77.3% of 33,084 opioid-involved overdose deaths had no evidence of naloxone administration. Statistically significant subgroup differences were observed for all sociodemographic groups examined except housing status. The highest percentages of decedents lacking evidence of naloxone administration were those with highest educational attainment (doctorate or professional degree, 87.0%), oldest (55-64 years, 83.4%; ≥65 years, 87.3%) and youngest ages (<15 years, 87.5%), and single marital status (84.5%). The lowest percentages of no evidence of naloxone administration were observed for non-Hispanic American Indian/Alaskan Native persons (66.2%) and those ages 15-24 years (70.8%).

CONCLUSIONS

More than three-quarters of opioid-involved overdose deaths had no evidence of naloxone administration, underscoring the need to ensure sufficient naloxone access and capacity for utilization. While fatal overdose data cannot fully characterize sociodemographic disparities in naloxone administration, naloxone education and access efforts can be informed by apparent inequities. Public health partners can assist persons who use drugs (PWUD) by maintaining naloxone supply and amplifying messages about the high risk of using drugs alone among PWUD and their social networks.

Assessing open science and citizen science in addictions and substance use research: A scoping review

BACKGROUND

The EU promotes 'Open Science' as a public good. Complementary to its implementation is Citizen Science, which redefines the relationship between the scientific community, civic society and the individual. Open Science and Citizen Science poses challenges for the substance use and addictions research community but may provide positive opportunities for future European addiction research. This paper explores both current barriers and potential facilitators for the implementation of Open Science and Citizen Science in substance use and addictions research.

METHODOLOGY

A scoping review was used to examine barriers and facilitators identified in the substance use and addiction research literature for the adoption of Open Science and Citizen Science.

RESULTS

'Technical' facilitators included the pre-registration of study protocols; publication of open-source datasets; open peer review and online tools. 'Motivational' facilitators included enhanced reputation; embracing co-creation; engaged citizenship and gamification. 'Economic' facilitators included the use of free tools and balanced remuneration of crowdworkers. 'Political' facilitators included better informed debates through the 'triple helix' approach and trust-generating transparency. 'Legal' facilitators included epidemiologically informed law enforcement; better policy surveillance and the validation of other datasets. 'Ethical' facilitators included the 'democratisation of science' and opportunities to explore new concepts of ethics in addiction research.

CONCLUSION

Open Science and Citizen Science in substance use and addictions research may provide a range of benefits in relation to the democratisation of science; transparency; efficiency and the reliability/validity of data. However, its implementation raises a range of research integrity and ethical issues that need be considered. These include issues related to participant recruitment; privacy; confidentiality; security; cost and industry involvement. Progressive journal policies to support Open Science practices; a shift in researcher norms; the use of free tools and the greater availability of methodological and ethical standards are likely to increase adoption in the field.

Racial differences in overdose training, naloxone possession, and naloxone administration among clients and nonclients of a syringe services program

OBJECTIVE

To evaluate racial (Black/White) differences in overdose response training and take-home naloxone (THN) possession and administration among clients and nonclients of the Baltimore syringe service program (SSP).

METHODS

The study derived data from a cross-sectional survey of 263 (183 SSP clients, 80 nonclients) people who inject drugs (PWID). The study recruited SSP clients using targeted sampling and recruited nonclients through peer referral from April to November 2016.

RESULTS

In our sample, 61% of the participants were Black, 42% were between the ages of 18 and 44, and 70% were males. SSP clients, regardless of race, were more likely to have received overdose response training than Black nonclients (Black clients AOR: 3.85, 95% CI: 1.88, 7.92; White clients AOR: 2.73, 95% CI: 1.29, 5.75). The study found no significant differences in overdose response training between Black and White nonclients. SSP clients and White nonclients were more likely to possess THN than Black nonclients (Black clients: AOR: 4.21, 95% CI: 2.00, 8.87; White clients: AOR: 3.54, 95% CI: 1.56, 8.04; White nonclients AOR: 4.49, 95% CI: 1.50,13.47).

CONCLUSION

SSP clients were more likely to receive overdose response training than their nonclient peers who they referred to the study, illustrating the utility of SSPs in reaching PWID at high risk of overdose. We also observed that Black PWID, who did not access services at the SSP, were the least likely to possess THN, suggesting the need to employ outreach targeting Black PWID who do not access this central harm reduction intervention.

The naloxone delivery cascade: Identifying disparities in access to naloxone among people who inject drugs in Los Angeles and San Francisco, CA

BACKGROUND

Opioid overdoses are a leading cause of injury death in the United States. Providing people who inject drugs (PWID) with naloxone is essential to preventing deaths. However, research regarding gaps in naloxone delivery is limited.

METHODS

We interviewed 536 PWID in San Francisco and Los Angeles, California from 2017 to 2018. We described naloxone engagement and re-engagement cascades, and identified factors associated with receiving naloxone in the past six months and currently owning naloxone.

RESULTS

The engagement cascade showed 72 % of PWID ever received naloxone, 49 % received it in the past six months, and 35 % currently owned naloxone. The re-engagement cascade showed, among PWID who received naloxone in the past six months, 74 % used and/or lost naloxone, and 67 % refilled naloxone. In multivariable analyses, identifying as Latinx (aRR = 0.53; 95 % CI: 0.39, 0.72) and Black (aRR = 0.73; 95 % CI: 0.57, 0.94) vs White were negatively associated with receiving naloxone in the past six months, while using opioids 1-29 times (aRR = 1.35; 95 % CI: 1.04, 1.75) and 30+ times (aRR = 1.52; 95 % CI: 1.17, 1.99) vs zero times in the past 30 days and witnessing an overdose in the past six months (aRR = 1.69; 95 % CI: 1.37, 2.08) were positively associated with receiving naloxone in the past six months. In multivariable analyses, being unhoused vs housed (aRR = 0.82; 95 % CI: 0.68, 0.99) was negatively associated with currently owning naloxone.

CONCLUSIONS

Our study adds to the literature by developing naloxone engagement and re-engagement cascades to identify disparities. Naloxone scale-up should engage populations facing inequitable access, including people of color and those experiencing homelessness.

Opioid-related overdose mortality in the era of fentanyl: Monitoring a shifting epidemic by person, place, and time

BACKGROUND

With the emergence of illicit fentanyl, fentanyl-involved overdose rates increased from 2013 to 2017 in the United States (US). We describe US trends in opioid-related overdose mortality rates by race, age, urbanicity, and opioid type before and after the emergence of fentanyl.

METHODS

Using the Centers for Disease Control and Prevention's WONDER database, we estimated crude and age-standardized opioid-related overdose mortality rates at the intersections of race (non-Hispanic [NH] Black and white), age (<55 and ≥55 years), sex (male and female) and urbanicity (urban and rural residence) from 2005 to 2017. We compare relative changes in mortality from 2013 to 17, and describe changes in the contributions of fentanyl, heroin, and other opioids to opioid-related overdose mortality.

RESULTS

From 2013 to 2017, the overall opioid overdose mortality rate was consistently higher in NH white Americans, however, the rate increase was greater among NH Black (174 %) compared to NH white (85 %) Americans. The steepest increases occurred in the overdose rates between 2013 and 2017 among younger (aged <55 years) urban NH Black Americans (178 % increase). Among older (≥55 years) adults, only urban NH Black Americans had an increase in overdose-related mortality rate (87 % increase). Urban NH Black Americans also experienced the greatest increase in the percent of fentanyl-involved deaths (65 % in younger, 61 % in older).

CONCLUSIONS

In the era of increased availability of illicitly manufactured fentanyl (2013-2017), there has been a disproportionate increase in opioid-related overdose deaths among urban NH Black Americans. Interventions for urban NH Black Americans are urgently needed to halt the increase in overdose deaths.