The global health and equity imperative for safe consumption facilities

A qualitative assessment of tablet injectable opioid agonist therapy (TiOAT) in rural and smaller urban British Columbia, Canada: Motivations and initial impacts

BACKGROUND

The evolving and unpredictable unregulated drug market has driven an unprecedented overdose crisis that requires effective intervention. Growing evidence suggests that novel opioid agonist treatments, such as tablet injectable opioid agonist therapy (TiOAT), have potential to prevent overdoses and other drug-related harms. More evidence is needed to characterize their utility in achieving these outcomes. The current article is an analysis of two TiOAT programs implemented in British Columbia, Canada, to assess impact on health and well-being, including overdose risk. Moreover, we explored participants' enrollment goals and if they were achieved.

METHODS

The study employed qualitative methods to evaluate the TiOAT program in two sites between October 2021 and April 2022. We developed a semi-structured interview tool to guide in depth interviews. All interviews (n = 32) took place on teleconference software or in person. Thematic analysis allowed for the emergence of themes associated with TiOAT participation.

RESULTS

Participants discussed various motivations for enrolling in TiOAT, which included gaining financial stability, reducing or eliminating drug use, addressing withdrawal symptoms, wanting to work, and improving social circumstances. An assessment of initial programmatic impacts revealed that many participant-identified motivators were achieved. Participants also reported fewer or no overdoses since starting TiOAT, and many reported switching from injecting to smoking drugs. Some challenges included adequate dosing as evidenced by ongoing withdrawal and pain. Some participants requested additional opioids, such as diacetylmorphine, to aid in reducing illicit drug use.

CONCLUSION

Participants described how TiOAT helped them to achieve many of their goals. Suggested programmatic improvements include enhanced patient-provider co-design with respect to dosing to address ongoing withdrawal and pain. As the unpredictability the unregulated drug market worsens, novel options, such as TiOAT, ought to be implemented broadly to reduce overdose events and improve quality of life for people who use drugs.

Nursing Students' Use of Harm Reduction in the Clinical Setting

BACKGROUND

The use and awareness of harm reduction education strategies are missing from nursing care of people with substance use disorder (SUD).

PURPOSE

To determine whether targeted training improved nursing students' application of harm reduction education in the clinical setting.

METHODS

This was an experimental 2-group repeated-measures survey study. Nursing students in a baccalaureate program received targeted training for 3 semesters. Training included presentations by people with lived experience, an addiction-trained physician, and a role-play exercise. Students received harm reduction education and reported on the application of this education.

RESULTS

Students in the traditional track cared for more people with SUD than students in the accelerated track. Referral for treatment was the most common education provided, and information related to injection drug use was the least commonly taught education.

CONCLUSIONS

Targeted training increased the number of harm reduction options nursing students presented to people with SUD in the clinical setting.

Increases in drug overdose deaths in Norway and the United States during the COVID-19 pandemic

INTRODUCTION

Little international comparative work exists describing pandemic-related spikes in overdose and related implications for drug and public health policy. We compared increases in overdose deaths during the pandemic in Norway and the United States, two countries in the top 10 for per-capita overdose mortality, yet with very different approaches to the pandemic, healthcare and drug policy.

METHODS

We examined monthly overdoses in 2020 versus baseline rates (the monthly average across 2017-2019). We compared excess overdose mortality to shifts in human mobility and social interaction, measured using cellphone-based mobility data, an indicator of the societal response to the pandemic.

RESULTS

Both the US and Norway saw large magnitude exacerbations in overdose mortality during the pandemic-related lockdowns, reaching 46.8% and 57.0% above baseline, respectively. Maximum increases occurred 2-3 months after peak reductions in mobility, suggesting lagged mechanisms. While overdose mortality returned to baseline relatively quickly in Norway, rates remained elevated in the US to the end of 2020.

CONCLUSIONS

Spikes in overdose mortality in both contexts may relate to disruptions in healthcare access and the drug supply becoming more potent. Norway's quicker return to baseline may reflect more robust access to harm reduction and addiction-related healthcare services. Nevertheless, it is notable that even in Norway - with universal access to high-quality services, low COVID-19 rates, and a highly effective public health infrastructure - a greater than 50% spike in overdose deaths was still seen at the onset of lockdown measures. This may have important implications for future pandemic and disaster planning.

Behavior change after fentanyl testing at a safe consumption space for women in Northern Mexico: A pilot study

BACKGROUND

Fentanyl has led to an increased number of overdose deaths in North America. Testing substances for fentanyl may be a harm reduction strategy to prevent overdose. Little is known about behavior change after fentanyl testing and the attitudes around fentanyl knowledge and testing along the US-Mexico border in the context of a safe consumption site.

METHODS

This was a pilot quantitative and qualitative study with 30 women who use drugs at an unsanctioned safe consumption site in Mexicali, Mexico. Women participated in a quantitative survey, a semi-structured interview, and fentanyl testing of substances. Injection behavior was observed after fentanyl testing results were provided. Qualitative data were collected to explore the meanings participants attributed to fentanyl and fentanyl testing.

RESULTS

Half of the substances tested positive for fentanyl (n=15, 50%), and all of them were in samples of black tar heroin. Among those participants who tested positive for fentanyl, 7 (47%) subsequently used less of the intended substance, 1 did not use the intended substance, and 7 (47%) did not change their behavior (i.e., used as originally intended). In qualitative interviews, a predominant theme was a description of fentanyl as dangerous and deadly and fentanyl testing as being helpful for modifying drug use behaviors. However, participants recognized that there could be no change in behavior following a positive fentanyl test in the context of not being able to find substances free of fentanyl.

CONCLUSION

We observed mixed results related to behavior change after women's intended substance for use tested positive for fentanyl. Fentanyl testing was acceptable to women, but behavior change was hampered by the inability to find substances free of fentanyl. Further research is needed to maximize the potential of fentanyl testing as a harm reduction tool especially in the context of a changing drug supply.

The introduction of fentanyl on the US-Mexico border: An ethnographic account triangulated with drug checking data from Tijuana

BACKGROUND

Illicitly-manufactured fentanyls (fentanyl) have changed the risk environment of people who use drugs (PWUD). In California and many western US states, the opioid overdose rate spiked from 2016 to 2021, driven largely by fentanyl. Mexican border cities act as transit through-points for the illicit drug supply and similar evolving health risks are likely to be present. Nevertheless, due to data gaps in surveillance infrastructure, little is known about fentanyl prevalence in Mexico.

METHODS

We employ intensive ethnographic participant-observation among PWUD, as well as key informants including harm reduction professionals, EMTs, and physicians on the front lines in Tijuana, Mexico. We triangulate interview data and direct observations of consumption practices with n=652 immunoassay-based fentanyl tests of drug paraphernalia from mobile harm reduction clinics in various points throughout the city.

RESULTS

PWUD informants described a sharp increase in the psychoactive potency and availability of powder heroin-referred to as "china white"-and concomitant increases in frequency of overdose, soft tissue infection, and polysubstance methamphetamine use. Fentanyl positivity was found among 52.8% (95%CI: 48.9-56.6%) of syringes collected at harm reduction spaces, and varied strongly across sites, from 2.7% (0.0-5.7%) to 76.5% (68.2-84.7%), implying strong market heterogeneity. Controlling for location of collection, syringe-based fentanyl positivity increased by 21.7% (10.1-42.3%) during eight months of testing. Key informants confirm numerous increased public health risks from fentanyl and describe the absence of a systematic or evidence-based governmental response; naloxone remains difficult to access and recent austerity measures have cut funding for harm reduction in Mexico.

CONCLUSIONS

Fentanyl, linked to powder heroin, is changing the risk environment of PWUD on the US-Mexico border. Improved surveillance is needed to track the evolving street drug supply in Mexico and related health impacts for vulnerable populations. Structural factors limiting access to naloxone, harm reduction, substance use treatment, and healthcare, and minimal overdose surveillance, must be improved to provide an effective systemic response.

Impact of an overdose reversal program in the context of a safe consumption site in Northern Mexico

Background

Drug overdoses are prevalent in low- and middle-income countries but are scarcely reported in the literature. We report on an opioid overdose reversal and naloxone distribution program that was instituted at the first safe consumption site in Latin America.

Methods

A cross-sectional analysis of witnessed drug overdoses and naloxone distribution between 1 June 2019 and 31 May 2021 in Mexicali, Mexico. Case report forms were entered in an electronic database. Trends in overdose and naloxone distribution were described. Comparisons were made before and after the COVID-19 pandemic was declared in the city. Maps were created to represent the geographic distribution of overdose in the city.

Results

During the study period 1,534 doses of naloxone were distributed throughout the community. In addition, there were 464 overdoses reported during this period, of which 4 were fatal. There was a 30% increase in reported overdoses from the period before the COVID-19 pandemic to the period after the pandemic was declared (p = 0.03). Most common substance reported included heroin (93%), sedatives (21%), methamphetamine (16%) and fentanyl (14%). Naloxone was given in 96% of cases (median 1 dose, IQR 1-2 doses) and emergency services were called in 20% of cases.

Conclusions

An opioid overdose reversal program in Mexicali, Mexico was able to distribute naloxone and register drug overdoses between 2019 and 2021 as a harm reduction strategy. This adds to the growing body of literature on the impact of community-based programs on preventing fatal overdoses and the potential for implementation in low-resource settings.

Racial/Ethnic, Social, and Geographic Trends in Overdose-Associated Cardiac Arrests Observed by US Emergency Medical Services During the COVID-19 Pandemic

IMPORTANCE

Provisional records from the US Centers for Disease Control and Prevention (CDC) through July 2020 indicate that overdose deaths spiked during the early months of the COVID-19 pandemic, yet more recent trends are not available, and the data are not disaggregated by month of occurrence, race/ethnicity, or other social categories. In contrast, data from emergency medical services (EMS) provide a source of information nearly in real time that may be useful for rapid and more granular surveillance of overdose mortality.

OBJECTIVE

To describe racial/ethnic, social, and geographic trends in EMS-observed overdose-associated cardiac arrests during the COVID-19 pandemic through December 2020 and assess the concordance with CDC-reported provisional total overdose mortality through May 2020.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included more than 11 000 EMS agencies in 49 US states that participate in the National EMS Information System and 83.7 million EMS activations in which patient contact was made.

EXPOSURES

Year and month of occurrence of overdose-associated cardiac arrest; patient race/ethnicity; census region and division; county-level urbanicity; and zip code-level racial/ethnic composition, poverty, and educational attainment.

MAIN OUTCOMES AND MEASURES

Overdose-associated cardiac arrests per 100 000 EMS activations with patient contact in 2020 were compared with a baseline of values from 2018 and 2019. Aggregate numbers of overdose-associated cardiac arrests and percentage increases were compared with provisional total mortality in CDC records from rolling 12-month windows with end months spanning January 2018 through July 2020.

RESULTS

Among 33.4 million EMS activations in 2020, 16.8 million (50.2%) involved female patients and 16.3 million (48.8%) involved non-Hispanic White individuals. Overdose-associated cardiac arrests were elevated by 42.1% nationally in 2020 (42.3 per 100 000 EMS activations at baseline vs 60.1 per 100 000 EMS activations in 2020). The highest percentage increases were seen among Latinx individuals (49.7%; 38.8 per 100 000 activations at baseline vs 58.1 per 100 000 activations in 2020) and Black or African American individuals (50.3%; 21.5 per 100 000 activations at baseline vs 32.3 per 100 000 activations in 2020), people living in more impoverished neighborhoods (46.4%; 42.0 per 100 000 activations at baseline vs 61.5 per 100 000 activations in 2020), and the Pacific states (63.8%; 33.1 per 100 000 activations at baseline vs 54.2 per 100 000 activations in 2020), despite lower rates at baseline for these groups. The EMS records were available 6 to 12 months ahead of CDC mortality figures and showed a high concordance (r = 0.98) for months in which both data sets were available. If the historical association between EMS-observed and total overdose mortality holds true, an expected total of approximately 90 632 (95% CI, 85 737-95 525) overdose deaths may eventually be reported by the CDC for 2020.

CONCLUSIONS AND RELEVANCE

In this cohort study, records from EMS agencies provided an effective manner to rapidly surveil shifts in US overdose mortality. Unprecedented overdose deaths during the pandemic necessitate investments in overdose prevention as an essential aspect of the COVID-19 response and postpandemic recovery. This is particularly urgent for more socioeconomically disadvantaged and racial/ethnic minority communities subjected to the compounded burden of disproportionate COVID-19 mortality and rising overdose deaths.

COVID-19 and the Drug Overdose Crisis: Uncovering the Deadliest Months in the United States, January‒July 2020

Objectives. To determine the magnitude of increases in monthly drug-related overdose mortality during the COVID-19 pandemic in the United States. Methods. We leveraged provisional records from the Centers for Disease Control and Prevention provided as rolling 12-month sums, which are helpful for smoothing, yet may mask pandemic-related spikes in overdose mortality. We cross-referenced these rolling aggregates with previous monthly data to estimate monthly drug-related overdose mortality for January through July 2020. We quantified historical errors stemming from reporting delays and estimated empirically derived 95% prediction intervals (PIs). Results. We found that 9192 (95% PI = 8988, 9397) people died from drug overdose in May 2020-making it the deadliest month on record-representing a 57.7% (95% PI = 54.2%, 61.2%) increase over May 2019. Most states saw large-magnitude increases, with the highest in West Virginia, Kentucky, and Tennessee. We observed low concordance between rolling 12-month aggregates and monthly pandemic-related shocks. Conclusions. Unprecedented increases in overdose mortality occurred during the pandemic, highlighting the value of presenting monthly values alongside smoothed aggregates for detecting shocks. Public Health Implications. Drastic exacerbations of the US overdose crisis warrant renewed investments in overdose surveillance and prevention during the pandemic response and postpandemic recovery efforts.

Risk of non-fatal overdose and polysubstance use in a longitudinal study with people who inject drugs in Tijuana, Mexico

INTRODUCTION

Among people who inject drugs (PWID), polysubstance use has been associated with fatal and non-fatal overdose (NFOD). However, the risk of overdose due to the cumulative number of various recently used drug types remains unexplored. We estimated the risk of NFOD for different polysubstance use categories among PWID in Tijuana, Mexico.

METHODS

Data came from 661 participants followed for 2 years in Proyecto El Cuete-IV, an ongoing prospective cohort of PWID. A multivariable Cox model was used to assess the cumulative impact of polysubstance use on the time to NFOD. We used the Cochran-Armitage test to evaluate a dose-response relationship between number of polysubstance use categories and NFOD.

RESULTS

We observed 115 NFOD among 1029.2 person-years of follow-up (incidence rate: 11.2 per 100 person-years; 95% confidence interval [CI] 9.3-13.3). Relative to those who used one drug class, the adjusted hazard ratio of NFOD for individuals reporting using two drug classes was 1.11 (95% CI 0.69-1.79), three drug classes was 2.00 (95% CI 1.16-3.44) and for those reporting three compared to two was 1.79 (95% CI 1.09-2.97). A significant Cochran-Armitage trend test (P < 0.001) suggested a dose-response relationship.

DISCUSSION AND CONCLUSIONS

Polysubstance use was associated with increased risk of NFOD with a dose-response relationship over 2 years. We identified a subgroup of PWID at high risk of NFOD who reported concurrent use of opioids, stimulants and benzodiazepines. Prioritising tailored harm reduction and overdose prevention interventions for PWID who use multiple substances in Tijuana is needed.

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011-2018

BACKGROUND

People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID.

METHODS

Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age.

RESULTS

Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective.

CONCLUSION

In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.

Attitudes towards safe consumption sites among police and people with lived experience in Tijuana, Mexico: initial report from the field

Introduction. Mexico northern border has high levels of heroin use. For more than 10 years, the country has implemented several harm reduction interventions to reduce the risks associated with drug use. New strategies such as Safe Consumption Sites (SCS) must be considered as a next step to service vulnerable populations and increase their health outcomes. Objective. This report seeks to measure and compare attitudes on a potential SCS intervention in Tijuana among police and people with lived experience (PLE) in heroin use in the city. Method. Two parallel studies on police practices and everyday experiences of heroin users in Tijuana were able to ask similar questions about attitudes toward SCS and its implementation in the city. They conducted quantitative interviews with 771 active police officers and 200 PLE while in rehabilitation services. Results. Both groups showed a high personal support for SCS of nearly 82% and a perceived implementation success around 80%. Officers reported 58.9% peer support for SCS while PLE 79%. Around 76% of both groups agreed that a SCS would help to improve their personal health. Finally, 86.2% of the officers would refer people to a SCS while 62.5% of PLE would use the service. Discussion and conclusions. The strong positive attitudes from police officers and PLE towards SCS in the city of Tijuana reported in both studies indicate the possibility of a successful implementation of a SCS. This intervention would represent an innovative way to protect PLE from police harassment and victimization, helping reduce HIV and HCV risk behaviors while improving community health.

"Another Person Was Going to Do It": The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region

Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.