Sociodemographic and geographic disparities in excess fatal drug overdoses during the COVID-19 pandemic in California: A population-based study

Appalachia - Bridging the Opioid Epidemic Amid the Fentanyl Crisis

Although the opioid epidemic and fentanyl crisis are nationwide problems of immense proportions, calming the storm raging across the isolating geo-economic framework of Appalachia demonstrates the need for courageous, culturally effective programs that have the power to address and overcome the grave situation of addiction in this region. In the Appalachian region, unjust social structures are embedded in the communities' socio-economic conditions. As this reality poses even greater barriers to addressing the opioid epidemic in these communities, the restoration of social relationships within a community becomes vital to the development of a broader approach to social functioning and human flourishing. Faith traditions and faith communities can play an important role in helping to establish and support such social cohesion through attention to the individual, social, and spiritual needs of the community. This essay explores the complex problem of the opioid epidemic compounded by the fentanyl crisis. It considers the importance of public health research within the regional geo-economic framework of Appalachia to (a) inform policies that improve health inequities and promote social cohesion, (b) develop social solutions with a spiritual dimension, and (c) reveal remedies capable of informing moral norms in support of building a more just society. Reflecting on the virtue of solidarity, this essay also highlights the witness of the Catholic Church's response to the suffering experienced within the communities and the societies within the Appalachian mountains. While there may be considerable interest in viewing this article as a research document, foundationally, this essay utilizes a literary narrative approach through a Catholic lens to inform ethical deliberations, reasoning, and practice while supporting ethical reflection and consideration of the responses raised. Further, the reader is strongly encouraged to reference the comprehensive footnote system provided for extension and verification of the data presented.

Evolution of an epidemic: Understanding the opioid epidemic in the United States and the impact of the COVID-19 pandemic on opioid-related mortality

We conduct this research with a two-fold aim: providing a quantitative analysis of the opioid epidemic in the United States (U.S.), and exploring the impact of the COVID-19 pandemic on opioid-related mortality. The duration and persistence of the opioid epidemic lends itself to the need for an overarching analysis with extensive scope. Additionally, studying the ramifications of these concurrent severe public health crises is vital for informing policies to avoid preventable mortality. Using data from CDC WONDER, we consider opioid-related deaths grouped by Census Region spanning January 1999 to October 2022 inclusive, and later add on a demographic component with gender-stratification. Through the lens of key events in the opioid epidemic, we build an interrupted time series model to reveal statistically significant drivers of opioid-related mortality. We then employ a counterfactual to approximate trends in the absence of COVID-19, and estimate excess opioid-related deaths (defined as observed opioid-related deaths minus projected opioid-related deaths) associated with the pandemic. According to our model, the proliferation of fentanyl contributed to sustained increases in opioid-related death rates across three of the four U.S. census regions, corroborating existing knowledge in the field. Critically, each region has an immediate increase to its opioid-related monthly death rate of at least 0.31 deaths per 100,000 persons at the start of the pandemic, highlighting the nationwide knock-on effects of COVID-19. There are consistent positive deviations from the expected monthly opioid-related death rate and a sizable burden from cumulative excess opioid-related deaths, surpassing 60,000 additional deaths nationally from March 2020 to October 2022, ∼70% of which were male. These results suggest that robust, multi-faceted measures are even more important in light of the COVID-19 pandemic to prevent overdoses and educate users on the risks associated with potent synthetic opioids such as fentanyl.

The Role of Cooperative Extension in Delivering Training and Technical Assistance to Support Evidence-Based Behavioral Health Practices in Rural Communities

The opioid epidemic in the United States continues to disproportionately affect those in rural, compared to urban, areas due to a variety of treatment and recovery barriers. One mechanism to increase capacity of rural-serving providers is through delivery of training and technical assistance (TTA) for evidence-based programs by leveraging the Cooperative Extension System. Guided by the Interactive Systems Framework, the current study evaluates TTA delivered by the Northwest Rural Opioid Technical Assistance Collabroative to opioid prevention, treatment, and recovery providers on short- (satisfaction, anticipated benefit), medium-, (behavioral intention to change current practice), and long-term goals (changes toward adoption of evidence-based practices). We also evaluated differences in short- and medium-term goals by intensity of TTA event and rurality of provider. Surveys of 351 providers who received TTA indicated high levels of satisfaction with TTA events attended, expressed strong agreement that they would benefit from the event, intended to make a professional practice change, and preparation toward implementing changes. Compared to urban-based providers, rural providers reported higher intention to use TTA information to change current practice. We conclude with a review of remaining gaps in the research to practice pipeline and recommendations for moving forward.

Impact of the COVID-19 Pandemic on Functions of Nursing Professionals in the Care of Opioid Use Disorder: Systematic Review

BACKGROUND

Nursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health aspects of major diseases, including OUDs. There are limited data on the major ways in which the COVID-19 pandemic has affected the functions of nursing professionals in the care of OUDs.

METHOD

This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and examined published data for trends in OUD care during the first 2 years of the COVID-19 pandemic, focusing on nursing functions. The National Library of Medicine PubMed database and the EMBASE database were examined for peer-reviewed studies with primary data published between January 1, 2020, and December 31, 2021.

REVIEW FINDINGS AND CONCLUSIONS

Rapid changes were observed in numerous aspects of OUDs during the early pandemic stage, as well as its care by nursing and other health professionals. These changes include increased overdoses (primarily from synthetic opioids such as fentanyl) and emergency department visits. These trends varied considerably across U.S. jurisdictions, underscoring the importance of region-specific examinations for public health policy and intervention. Out of necessity, healthcare systems and nursing professionals adapted to the challenges of OUD care in the pandemic. These adaptations included increases in telehealth services, increases in take-home doses of methadone or buprenorphine/naloxone, and expansion of layperson training in the use of naloxone for overdose reversal. It is likely that some of these adaptations will result in long-term changes in standards of care practices for OUDs by nursing professionals.

Social vulnerability predictors of drug poisoning mortality: A machine learning analysis in the United States

BACKGROUND AND OBJECTIVES

Drug poisoning is a leading cause of unintentional deaths in the United States. Despite the growing literature, there are a few recent analyses of a wide range of community-level social vulnerability features contributing to drug poisoning mortality. Current studies on this topic face three limitations: often studying a limited subset of vulnerability features, focusing on small sample sizes, or solely including local data. To address this gap, we conducted a national-level analysis to study the impacts of several social vulnerability features in predicting drug mortality rates in the United States.

METHODS

We used machine learning to investigate the role of 16 social vulnerability features in predicting drug mortality rates for US counties in 2014, 2016, and 2018-the most recent available data. We estimated each vulnerability feature's gain relative contribution in predicting drug poisoning mortality.

RESULTS

Among all social vulnerability features, the percentage of noninstitutionalized persons with a disability is the most influential predictor, with a gain relative contribution of 18.6%, followed by population density and the percentage of minority residents (13.3% and 13%, respectively). Percentages of households with no available vehicles, mobile homes, and persons without a high school diploma are the following features with gain relative contributions of 6.3%, 5.8%, and 5.1%, respectively.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

We identified social vulnerability features that are most predictive of drug poisoning mortality. Public health interventions and policies targeting vulnerable communities may increase the resilience of these communities and mitigate the overdose death and drug misuse crisis.

Substance Use and the Nervous System

OBJECTIVE

This article informs and updates the practicing neurologist on the current landscape of known neurologic injuries linked to the use of illicit drugs, focusing on emerging agents.

LATEST DEVELOPMENTS

Synthetic opioids such as fentanyl and similar derivatives have exploded in prevalence, becoming the leading cause of overdose fatalities. The higher potency of synthetic opioids compared with semisynthetic and nonsynthetic opiates poses an increased risk for unintentional overdose when found as an adulterant in other illicit drug supplies such as heroin. Conversely, misinformation about the risk of symptomatic exposure to fentanyl through casual contact with the skin and ambient air has led to misdirected fear and stigma that threatens to impede valid harm-reduction measures for fentanyl users at risk of actual overdose. Finally, during the COVID-19 pandemic, overdose rates and deaths continued to climb, especially among those who use opioids and methamphetamine.

ESSENTIAL POINTS

A variety of potential neurologic effects and injuries can occur with illicit drug use owing to the diverse properties and mechanisms of action of the various classes. Many high-risk agents are not detected on standard drug screens, including so-called designer drugs, and the practicing neurologist is best served by recognizing the clinical features of the traditional toxidrome and other potential idiosyncratic effects of various illicit agents.

Prevalence of hepatitis C virus among fatal drug overdoses in Tennessee: an analysis using 2019-2020 Tennessee State Unintentional Drug Overdose Reporting System Data

PURPOSE

Given the nature of the co-occurring epidemics of hepatitis C virus (HCV) and fatal stimulant overdose, we sought to assess the prevalence of HCV among opioid and stimulant-positive overdoses.

METHODS

We conducted a cross-sectional study to examine the prevalence of HCV among fatal drug overdoses in Tennessee using 2019-2020 data from the State Unintentional Drug Overdose Reporting System. We defined history of HCV using surveillance data and autopsy reports. Descriptive statistics were calculated for circumstances of overdose deaths for different categories of opioid and stimulant positivity on toxicology.

RESULTS

Between 2019 and 2020, 3570 unintentional or undetermined drug overdose deaths occurred in Tennessee with an available autopsy. History of HCV was found in 24.6% of deaths. When assessing different involvement between stimulants and opioids, the highest prevalence of HCV was found for deaths where methamphetamine and opioids were present in toxicology (35.4%). Scene evidence of injection drug use occurred more frequently among decedents with a history of HCV (P < .0001).

CONCLUSIONS

This analysis while descriptive highlights the importance of linking datasets to enhance infectious disease and drug overdose surveillance. Partnership between communicable disease and drug overdose surveillance teams should continue to identify relationships between disease and drug overdose and strengthen the evidence to tailor crucial treatment and prevention activities.

Changes in suicide in California from 2017 to 2021: a population-based study

BACKGROUND

Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years.

METHODS

We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages.

RESULTS

Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas.

CONCLUSIONS

The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.

A counterfactual analysis of opioid-involved deaths during the COVID-19 pandemic using a spatiotemporal random forest modeling approach

The global pandemic of SARS-CoV-2 (COVID-19) has been linked to adversely impacting individuals with opioid use disorder in the United States. This study focuses on analyzing opioid-involved mortality in the context of COVID-19 in the U.S. from a geospatial perspective. We investigated spatiotemporal patterns of opioid-involved deaths during 2020 and compared the spatiotemporal pattern of these deaths with patterns for the previous three years (2017-2019) to understand changes in the context of the COVID-19 pandemic. A counterfactual analysis framework together with a space-time random forest (STRF) model were used to estimate the increase in opioid-involved deaths related to the pandemic. To gain further insight into the relationship between opioid deaths and COVID-19-related factors, we built a space-time random forest model for the City of Chicago, that experienced a steep increase in opioid-related deaths during 2020. High ranking indicators identified by the model such as the number of positive COVID-19 cases adjusted by population and the change in stay-at-home dwell time during the pandemic were used to generate a vulnerability index for opioid overdoses during the COVID-19 pandemic in Chicago.

Characteristics of fatal drug overdoses among college age decedents in Tennessee, 2019-2020

Purpose

College age persons experienced unique disruptions to their regular lives during the COVID-19 pandemic, sometimes resulting in negative coping mechanisms. We examined changes in the number of and characteristics of college age fatal drug overdoses before and during the early COVID-19 pandemic.

Methods

We conducted a statewide cross-sectional study to determine the changes in the number and characteristics of college age fatal drug overdose decedents before and during the COVID-19 pandemic using 2019-2020 data from the Tennessee State Unintentional Drug Overdose Reporting System. We defined college age as 18-24 years. Frequencies and rates were generated to compare demographics, circumstances, and toxicology between 2019 and 2020.

Results

From 2019 to 2020, 336 college age persons experienced an unintentional or undetermined fatal drug overdose in Tennessee. Characteristics of college age decedents: mean age 21.7 years, 68.5% males, and 71.4% White. Rates of fatal overdoses among college age persons increased 50.0% overall, 150.1% for female decedents, and 141.7% for Black decedents. Fewer people were treated for substance use disorder or mental health conditions (p = 0.0243) in 2020.

Conclusion

This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts to curtail the overdose epidemic among college age persons in Tennessee.

The effects of the COVID-19 pandemic on drug and poison–related deaths in Gold Coast, Australia

Introduction

COVID-19 is postulated to impact drug- and poison-related deaths. America has reported an increased in drug-related deaths, whereas Australia has reported a decline. Regional studies are scant and may not mirror national data. Characterising drug and poison–related deaths during COVID-19 at a regional level would inform local interventions and policies on the current and future pandemics.

Methods

A 4-year retrospective study from January 1, 2018, to December 31, 2019 (pre-COVID-19 pandemic) and from January 1, 2020, to December 31, 2021 (COVID-19 pandemic) of all drug and poison–related deaths admitted to the Gold Coast University Hospital under Coronial investigation.

Results

Drug and poison–related deaths increased in both the proportion and absolute numbers before and during the COVID-19 pandemic. There was no statistical difference in age, sex, location of death, manner of death and classification of drugs and poison implicated.

Conclusions

Although there is an increase in drug and poison–related deaths, the overall demographic and pattern have not changed. Further studies to account for the variation may enable implementation of targeted public health interventions to address the burden of related deaths in regional settings in the context of future pandemics.

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.