Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98

A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times

BACKGROUND AND AIMS

Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation.

DESIGN

Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System.

SETTING

This study was conducted Australia-wide.

CASES

There were 610 cases of fatal heroin-related drug toxicity.

MEASUREMENTS

Information was collected on characteristics, manner of death, toxicology and autopsy results.

FINDINGS

The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood.

CONCLUSIONS

The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.

Effects of a Two-Month Exercise Training Program on Concurrent Non-Opiate Substance Use in Opioid-Dependent Patients during Substitution Treatment

BACKGROUND

This randomized controlled trial aimed to evaluate the effects of a two-month exercise intervention on the concurrent non-opiate substance use (alcohol, cocaine, cannabis, and benzodiazepines) in opioid users during their medication treatment.

METHODS

Ninety opioid users (41 females) in methadone and buprenorphine medication treatment were randomly divided into four groups: (a) buprenorphine experimental (BEX; n = 26, aged 41.9 ± 6.1 yrs); (b) buprenorphine control (BCON; n = 25, aged 41.9 ± 5.6 yrs); (c) methadone experimental (MEX; n = 20, aged 46.7 ± 6.6 yrs); and (d) methadone control (MCON; n = 19, aged 46.1 ± 7.5 yrs). The experimental groups (BEX and MEX) followed an aerobic exercise training program on a treadmill for 20 min at 70% HRmax, 3 days/week for 8 weeks. Socio-demographic, anthropometric, and clinical characteristics, as well as non-opioid drug use in days and quantity per week, were assessed before and after the intervention period.

RESULTS

Following the exercise training, the weekly non-opioid substance consumption (days) decreased (p < 0.05) in both exercise groups and was lower in BEX compared to MEX, while no differences were observed (p > 0.05) between the control groups (BCON vs. MCON) or compared to their baseline levels. Similarly, the daily amount of non-opiate substance intake was reduced (p < 0.05) post-training in BEX and MEX, whereas it did not differ (p > 0.05) in BCON and MCON compared to the baseline.

CONCLUSIONS

The two-month exercise intervention reduced the non-opioid drug use in both the methadone and buprenorphine substitution groups compared to the controls, suggesting that aerobic exercise training may be an effective strategy for treating patients with OUDs.

Adverse health outcomes among people who inject drugs who engaged in recent sex work: findings from a national survey

OBJECTIVES

This study explores trends in sex work among people who inject drugs (PWID) by gender and the relationship between sex work and adverse health outcomes including overdose, injection-site, and blood-borne virus (BBV) infections.

STUDY DESIGN

The Unlinked Anonymous Monitoring Survey of PWID is an annual cross-sectional survey that monitors BBV prevalence and behaviours, including transactional sex, among PWID recruited through specialist services in England, Wales, and Northern Ireland.

METHODS

Trends in sex work among PWID (2011-2021) were described. Data were analysed to assess differences between PWID who engaged in sex work in the past year (sex workers [SWs]) and those who did not (non-SWs) by gender (Pearson Chi2 tests) (2018-2021). Associations between sex work in the past year and adverse health outcomes were investigated using logistic regression.

RESULTS

Between 2011 and 2021, sex work among PWID remained stable, with 31% of women and 6.3% of men who inject, reporting having ever engaged in sex work, and 14% of women and 2.2% of men engaging in sex work in the past year. Between 2018 and 2021, SWs had greater odds of reporting symptoms of an injection-site infection (adjusted odds ratio (aOR): 1.68 [95% confidence interval {CI}: 1.31-2.16], P < 0.001) and reporting overdose (aOR: 2.21 [CI: 1.74-2.80], P < 0.001) than non-SWs had in the past year. Among men, SWs had 243% greater odds of having HIV than non-SWs (aOR: 3.43 [CI: 1.03-11.33], P = 0.043).

CONCLUSIONS

Our findings highlight disproportionate vulnerability and intersection of overlapping risk factors experienced by PWID SWs and a need for tailored interventions which are inclusive and low-threshold.

Trend Analysis of Deaths With Unintentional Poisoning and Years of Life Lost in the South of Iran: 2004-2019

BACKGROUND

This study was conducted to determine the mortality rate and the years of life lost (YLL) due to unintentional poisoning in Fars province in the south of Iran. Study Design: A cross-sectional study.

METHODS

In this study, data from all of the deaths due to unintentional poisoning in the south of Iran between 2004 and 2019 was extracted from the population-based Electronic Death Registry System (EDRS). The Joinpoint Regression method was used to examine the trend of the crude mortality rate, the age-standardized mortality rate (ASMR), and the YLL rate.

RESULTS

During the 16-year study period (2004-2019), 1466 deaths due to poisoning occurred in Fars province. Of this number, 75.2% (1103 cases) were in men, and 37.5% (550 cases) were in the age group of 15-29 years. The total YLL due to poisoning during the 16-year study period were 25149 and 8392 in men and women, respectively. According to the joinpoint regression analysis, the 16-year trend of YLL rate due to premature mortality was stable. Moreover, the annual percent change (APC) was -0.7% (95% CI: -4.0 to 2.7, P=0.677) for males and - 0.3% (95% CI: -3.8 to 3.3, P=0.862) for females.

CONCLUSION

The trend of crude mortality rate, ASMR and YLL due to unintentional poisonings was stable. Considering the high rate of mortality and YLL due to unintentional poisoning in the age group of 15-29 years, it is essential to take necessary actions in this age group.

Using Social Media to Examine Themes Surrounding Fentanyl Misuse and Risk Indicators

Background: Opioid misuse is a crisis in the United States, and synthetic opioids such as fentanyl pose risks for overdose and mortality. Individuals who misuse substances commonly seek information and support online due to stigma and legal concerns, and this online networking may provide insight for substance misuse prevention and treatment. We aimed to characterize topics in substance-misuse related discourse among members of an online fentanyl community. Method: We investigated posts on a fentanyl-specific forum on the platform Reddit to identify emergent substance misuse-related themes potentially indicative of heightened risk for overdose and other adverse health outcomes. We analyzed 27 posts and 338 comments with a qualitative codebook established using a subset of user posts via inductive and deductive methods. Posts and comments were independently reviewed by two coders with a third coder resolving discrepancies. The top 200 subreddits with the most activity by r/fentanyl members were also inductively analyzed to understand interests of r/fentanyl users. Results: Functional/quality of life impairments due to substance misuse (29%) was the most commonly occurring theme, followed by polysubstance use (27%) and tolerance/dependence/withdrawal (20%). Additional themes included drug identification with photos, substances cut with other drugs, injection drugs, and past overdoses. Media-focused subreddits and other drug focused communities were among the communities most often followed by r/fentanyl users. Conclusion: Themes closely align with DSM-V substance use disorder symptoms for fentanyl and other substances. High involvement in media-focused subreddits and other substance-misuse-related communities suggests digital platforms as acceptable for overdose prevention and recovery support interventions.

From Bumps to Binges: Overview of Deaths Associated with Cocaine in England, Wales and Northern Ireland (2000-2019)

The UK, as the "cocaine capital of Europe," currently accounts for ∼75% of all cocaine-related hospital admissions in Europe. This study aims to analyze the trends in cocaine-related deaths in England, Wales and Northern Ireland over 20 years (2000-2019). Cases reported to the National Programme on Substance Abuse Deaths (NPSAD) occurring between 2000 and 2019 where cocaine was detected at post-mortem (PM) were extracted for analysis. A total of 5,339 cases were retrieved, with an increase in the rate of reporting over time. Cocaine was deemed a cause of death and quantified in PM blood samples along with its major metabolite benzoylecgonine in 685 cases. Of these 685 cases, 25% (n = 170/685) occurred following acute use, 22% (n = 154/685) following chronic/binge use, 40% (n = 271/685) in combination with morphine, 4% (n = 29/685) in drug packer/swallower circumstances and 9% (n = 61/685) in a suicide context. Cardiac complications were evident in 22% of cases (n = 154/685). The average concentration of cocaine detected in cardiac cases (900 ng/mL) was considerably lower than that detected in cases where acute (19,100 ng/mL) or chronic/binge (6,200 ng/mL) dosing was evident. This is the first cocaine-related mortality study in these geographical areas. Deaths following cocaine use continue to rise despite its Class A drug listing in the UK. While underlying and external risk factors including polydrug use, cardiac complications and mental health can all contribute to the incidence of fatal drug toxicity following cocaine use, this study demonstrates that the risk of a cocaine overdose cannot be attributed to a specific blood concentration range.

Characteristics and context of fentanyl test strip use among syringe service clients in southern Wisconsin

BACKGROUND

Fentanyl adulteration of illicit drugs is a major driver of opioid-involved overdose in the USA. Fentanyl test strips are increasingly used by people who use drugs to check for fentanyl. However, little is known about factors that influence test strip use in this population.

METHODS

In this mixed-methods study employing semi-structured open-ended interviews (n = 29) and a structured survey (n = 341), we examined characteristics associated with test strip use, characteristics of test strip use, and situational, logistical and psychosocial factors influencing test strip use. Respondents were recruited from a syringe service program in southern Wisconsin. Bivariate tests of association and multivariable logistic regression examined the relationship between respondent characteristics and test strip use. Summary statistics were used to describe how situational, logistical and psychosocial factors impact test strip use.

RESULTS

Most respondents were male (59.6%), non-Hispanic white (77.4%), young (mean 35.7 years), reported heroin as their primary drug (70.7%), injection as their primary route (87.9%), and use ≥ 3 times daily (78.6%). In multivariable models, site, race and ethnicity, drug of choice, and seeking fentanyl were associated with test strip use. Among test strip users, 36.5% use them most of the time or more and 80.6% get positive results half the time or more. Among individuals reporting heroin, fentanyl, methamphetamine, or cocaine or crack cocaine at least once per month, 99.1%, 56.8%, 42.2%, and 55.7% reported testing these drugs, respectively. Test strip use is supported by information from suppliers, regular transportation, diverse distribution locations, recommendations from harm reduction staff, and having a safe or private place to use.

CONCLUSIONS

We found that individuals who use fentanyl test strips are more often non-Hispanic white, use heroin, and seek drugs with fentanyl relative to individuals without test strip use. Findings confirm high fentanyl penetration in the Wisconsin drug supply. Low rates of stimulant testing suggest inadequate awareness of fentanyl penetration. Findings support outreach to key populations, increased diversity of distributing locations, efforts to correct misperceptions about drug wasting, emphasis on pre-consumption testing, and the importance of adjunct behaviors to prevent overdose given high rates of intentional fentanyl use.

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.

Risks and overdose responses: Participant characteristics from the first seven years of a national take-home naloxone program

BACKGROUND

In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use.

METHODS

This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included.

RESULTS

In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%).

CONCLUSION

People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.

Evidence of Pre-mortem Opioid Use among Fentanyl Overdose Decedents in a Safety Net Healthcare System

The rapid increase in fentanyl overdose deaths, particularly those also attributed to stimulants, has led to concerns about unintentional fentanyl exposure. Utilizing vital and medical record data, we identified overdose decedents from 2018 to 2021 in San Francisco who received care in the safety net system in the 3 years preceding death. Among 506 decedents, medical record evidence of pre-mortem opioid use was present for 48% of stimulant-only, 56% of stimulant-fentanyl, 65% of fentanyl-only, and 82% of non-fentanyl opioid decedents (p<0.001). Among stimulant-fentanyl decedents, an increase in 10 years of age (adjusted odds ratio (aOR) 0.74 [95% CI:0.59-0.94]) and race other than White or Black (aOR 0.36 [95% CI:0.15-0.87]) had lower odds of evidence of pre-mortem opioid use. While not conclusive, these findings raise the possibility that a significant proportion of fentanyl overdose decedents in San Francisco may have not intended to consume an opioid on the occasion of their death.

Prevalence and associates of non-fatal overdose among people who inject drugs in Saveh, Iran

Background

As a public health issue, non-fatal overdose (NFOD) is highly prevalent among people who inject drugs (PWID). This can lead to an elevated risk of future overdose, causing various harms including possible death. It is essential to improve knowledge concerning this problem and its associated risk factors to inform overdose prevention and assistance programs. The primary aim of the present study was to determine the prevalence of NFOD and associated risk factors among PWID in Saveh, Iran.

Methods

In the present cross-sectional study, 272 PWID living in Saveh, Iran were interviewed face-to-face using a structured survey. Data concerning socio-demographics, substance use, risky behaviors, and services utilization data were collected. The outcome variable (i.e., NFOD) was assessed by answering “Yes” to the question: “In the past three months, have you ever overdosed (at least once) by accident?”

Results

The prevalence of NFOD among PWID in the past three months was 54%. The characteristics and behaviors that were associated with an increased risk of experiencing NFOD in the past three months were being of older age (AOR = 5.2, p < 0.05), drug use initiation under the age of 22 years (AOR = 7.8, p < 0.05), being an alcohol user (AOR = 3.0, p < 0.05), and being a simultaneous multiple drug user (AOR = 5.8, p < 0.05). Also, more recent initiates to injecting (< 2 years) had an increased risk of experiencing a non-fatal overdose in the past three months. Findings also indicated that those who (i) attended a needle and syringe program (AOR: 0.3, p < 0.05), (ii) were visited by a general practitioner (AOR: 0.03, p < 0.05), and (iii) received a psychosocial intervention (AOR: 0.1, p < 0.05) were 0.3, 0.03 and 0.1 times less likely to report non-fatal overdosing than other participants, respectively.

Conclusions

The results indicate that intervention and prevention initiatives seeking to reduce NFOD among PWID should not only be focused on the primary drug used but also the use of alcohol and polysubstance use. Specific and tailored psychological interventions combined with pharmacotherapy may be highly beneficial for PWID who experience more severe types of substance use, including alcohol use disorders and/or polysubstance abuse.

A Scientometric Visualization Analysis for Molecular Mechanisms of Substance Abuse and Its Neurotoxicity From 1997 to 2021

Substance abuse has become a global problem due to drug-induced addiction and neurotoxicity, which causes a huge physical, social, and financial burden. Various kinds of drugs can hijack the users’/abusers’ behavior and associated neurocircuitry. To summarize recent scientific advances on drug abuse, we reviewed relevant publications to analyze research progress and such trends through bibliometric ways. Based on retrieval strategies, a total of 681 scientific records published from 1997 to 2021 were screened and included in the Web of Science (WoS) database. Further scientometric analysis revealed that annual publication output increased across this period, with the United States of America (USA) contributing a significant number of reasons. Research has focused on neurotransmitter, oxidative stress, mitochondrial system injury, and other neurotoxic mechanisms. Neuroimmune, neurotoxic targets, and new psychoactive substances have been hot topics in recent years, which deserve continued research in the future. Specific research on molecular mechanisms has progressed across this period, with an emphasis on the root cause of toxicity and molecular targets for therapy. Moreover, collaborations of international multi-disciplinary research teams have been efficient and need to be encouraged for addiction research and the development of appropriate therapeutic processes.

Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin

BACKGROUND

Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality.

METHODS

We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted.

RESULTS

Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone.

CONCLUSIONS

Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.

Postmortem forensic toxicology cases: A retrospective review from Milan, Italy

We are presenting a study on 136 cases performed in a 2-year period (2018-2019) at the Bureau of Legal Medicine of the University of Milan for which toxicological analyses were requested and we are making a detailed interpretation of clinical records and discussing toxicological results from each case included in the study. Total number of autopsies was 1323 and in 10.3% of the cases, toxicological analyses were requested to obtain further information. Analyses were assessed with High-Performance Liquid Chromatography-Mass Spectrometry system and Gas Chromatography-Mass Spectrometry analyses. Additionally, Blood Alcohol Concentration and detection of volatile substances were obtained with Head Space-Gas Chromatography-Mass Spectrometry system. From these analyses, 101 cases out of 136 provided positive results (74.3%). Main substances detected were cocaine, diazepam, morphine, and ethanol. The most representative profiles of individuals that emerged from this study were: a Caucasian male, age 41-50, that died for cocaine acute intoxication or was killed; a Caucasian male or female with a range-of-age of 31-50 deceased for simple suicide caused by acute intoxication or by complex suicide caused by acute intoxication and suffocation; and finally, a Caucasian male with a range-of-age 21-40 that died in a car accident without any toxicological evidence. From the results, acute intoxication at the time of death was confirmed in 54 cases and in 57 cases the toxicological analyses helped in the determination of the cause and manner of death. From this study, the importance of toxicological data among forensic sciences is confirmed.

A Forensic Diagnostic Algorithm for Drug-Related Deaths: A Case Series

The best evidence provided in the literature worldwide suggests the importance of harmonizing the investigation in drug-related fatalities. In this study, the application of a multidisciplinary approach in eight cases of drug-related deaths is presented. Although death scene findings could be highly suggestive of drug intoxication, external examination and toxicological screening test alone are insufficient. There are several variables, and it is not always easy to give the proper interpretation of the drug detection. A complete autopsy is necessary to correctly complete organ and tissues sampling for further histological and toxicological studies and obtain body fluids. The use of peripheral blood is recommended to avoid artifacts. The collection of many specimens is warranted to get more responses. The sampling aims to provide a picture of the distribution of the substance in the body. The sample and the selection of the drugs and the matrices to investigate are case-dependent. The presented diagnostic algorithm provides the coroner with all the elements to investigate drug-related deaths and cooperate with toxicologists. Toxicological forensic diagnosis is still extremely heterogeneous in regional and national contexts. Funding for method development, research, networking, facilities, and technologies improvement is mandatory to standardize the toxicological investigation.

HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland

Drug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors among PWID in Baltimore City (BC) and Anne Arundel Country (AAC), Maryland. PWID (N = 283) were recruited to the study through targeted sampling at street-based locations in BC and AAC from July 2018 to March 2020. Receptive syringe sharing (RSS) [adjusted odds ratio (AOR): 2.8, 95% confidence interval (CI): 1.2–6.3] and daily injecting (AOR: 1.9, 95% CI: 1.0–3.6) were associated with injecting fentanyl and cocaine together. Fentanyl availability and COVID-19 bring new HIV prevention challenges, particularly among those who inject fentanyl with cocaine, highlighting the importance to expand and sustain harm reduction, prevention, and treatment services for PWID to reduce HIV and overdose burden.

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis

OBJECTIVES

To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland.

METHODS

We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths that occurred from 2016 to 2018 (N = 6566) using latent class analysis and regression.

RESULTS

Drug overdose deaths were concentrated in 2 of 24 counties in Maryland (Baltimore City and County). Fentanyl was involved in 71% of all drug overdose deaths, and the majority (76%) of these deaths included multiple substances. Three latent classes emerged: (1) fentanyl/heroin/cocaine (64%); (2) fentanyl/alcohol (18%); and (3) prescription drugs including opioids, benzodiazepines and antidepressants (18.0%). The fentanyl/heroin/cocaine class members were significantly younger (<30 years), female and White compared to the fentanyl/alcohol class, but more male and non-White than the prescription drugs class (all P < 0.05). Deaths in Baltimore City/County were more likely than in other locations to involve fentanyl/alcohol (P < 0.05).

CONCLUSIONS

The majority of fentanyl-involved overdose deaths in Maryland involved multiple substances, and several demographic and geographic differences in these patterns emerged. Geographically-targeted interventions that are tailored to reduce the harms associated with polysubstance use (including cocaine, alcohol, and prescription drugs) for different demographic groups are warranted.

Detecting risk level in individuals misusing fentanyl utilizing posts from an online community on Reddit

INTRODUCTION

Opioid misuse is a public health crisis in the US, and misuse of synthetic opioids such as fentanyl have driven the most recent waves of opioid-related deaths. Because those who misuse fentanyl are often a hidden and high-risk group, innovative methods for identifying individuals at risk for fentanyl misuse are needed. Machine learning has been used in the past to investigate discussions surrounding substance use on Reddit, and this study leverages similar techniques to identify risky content from discussions of fentanyl on this platform.

METHODS

A codebook was developed by clinical domain experts with 12 categories indicative of fentanyl misuse risk, and this was used to manually label 391 Reddit posts and comments. Using this data, we built machine learning classification models to identify fentanyl risk.

RESULTS

Our machine learning risk model was able to detect posts or comments labeled as risky by our clinical experts with 76% accuracy and 76% sensitivity. Furthermore, we provide a vocabulary of community-specific, colloquial words for fentanyl and its analogues.

DISCUSSION

This study uses an interdisciplinary approach leveraging machine learning techniques and clinical domain expertise to automatically detect risky discourse, which may elicit and benefit from timely intervention. Moreover, our vocabulary of online terms for fentanyl and its analogues expands our understanding of online "street" nomenclature for opiates. Through an improved understanding of substance misuse risk factors, these findings allow for identification of risk concepts among those misusing fentanyl to inform outreach and intervention strategies tailored to this at-risk group.

Co-exposure of cocaine and cannabinoids and its association with select biological, behavioural and health outcomes: A systematic scoping review of multi-disciplinary studies

Cocaine use entails severe health- and social-related harms globally. Treatment options for cocaine dependence are highly limited. Benefits of cannabinoids for addiction have been documented, making it opportune to examine existing data on the possible outcomes associated with cannabinoids and cocaine co-use. We conducted a systematic scoping review following the PRISMA guidelines of peer-reviewed, English-language studies published from 2000 to 2021 in four databases (Medline, Web-of-Science, CINAHL Plus, and PsycInfo), assessing the co-exposure of cannabis/cannabinoids with cocaine on behavioural, biological or health outcomes. Both quantitative and qualitative, as well as humans and pre-clinical animals' studies (n=46) were included. Pre-clinical studies (n=19) showed mostly protective effects of cannabidiol (CBD) administration on animal models of addiction (e.g., cocaine-craving, -relapse, and -withdrawal) and cocaine-toxicity. Tetrahydrocannabinol (THC) had more inconsistent results, with both protective and counter-protective effects. Human studies (n=27) were more heterogeneous and assessed natural ongoing cannabis and cocaine use or dependence. Quantitative-based studies showed mostly enhanced harms in several outcomes (e.g., cocaine use, mental health); two available clinical trials found no effect upon CBD administration on cocaine-related treatment outcomes. Qualitative data-based studies reported cannabis use as a substitute for or to alleviate harms of crack-cocaine use. While pre-clinical studies suggest a potential of cannabinoids, especially CBD, to treat cocaine addiction, the few trials conducted in humans found no benefits. Cannabis co-use by cocaine users commonly presents a risk factor, entailing enhanced harms for users. More rigorous, controlled trials are still necessary to investigate cannabinoids' potential considering pre-clinical findings and reported benefits from specific drug users.

The uptake of foil from needle and syringe provision services and its role in smoking or snorting heroin among people who inject drugs in Scotland

BACKGROUND

In the UK, legislation was implemented in 2014 allowing needle and syringe provision (NSP) services to offer foil to people who inject drugs (PWID) to encourage smoking rather than injecting. This paper aims to examine the association between foil uptake and smoking or snorting heroin among PWID. This is the first large scale national study to examine foil uptake and smoking or snorting heroin among PWID post legislative change.

METHOD

Data from 1453 PWID interviewed via Scotland's Needle Exchange Surveillance Initiative in 2017-2018 were analysed using multivariate logistic regression.

RESULTS

Overall, 36% of PWID had obtained foil from NSP services in the past six months. The odds of smoking or snorting heroin were higher among those who had obtained foil (Adjusted Odds Ratio (AOR) 3.79 (95% CI 2.98-4.82) p<0.001) compared to those who had not. Smoking or snorting heroin was associated with lower odds of injecting four or more times daily (AOR 0.60 (95% CI 0.40-0.90) p = 0.012) and injecting into the groin or neck (AOR 0.57 (95% CI 0.46-0.71) p<0.001) but increased odds of having had a skin and soft tissue infection (SSTI) (AOR 1.49 (95% CI 1.17-1.89) p = 0.001) and having experienced an overdose (AOR 1.58 (95% CI 1.18-2.10) p = 0.002) both in the past year.

CONCLUSION

The promotion of smoking drugs via foil provision from NSP services may contribute to the package of harm reduction measures for PWID alongside the provision of injecting equipment. We found that those in receipt of foil were more likely to smoke or snort heroin, and that smoking or snorting heroin was associated with a lower likelihood of some risky injecting behaviours, namely frequent injecting and injecting into the groin or neck. But it remains uncertain if the provision of foil can lead to a reduction in health harms, such as SSTI and overdose. Future research is needed to understand PWID motivations for smoking drugs, obtaining foil from NSP services, and its uses particularly among polydrug users.

A vicious cycle of neuropathological, cognitive and behavioural sequelae of repeated opioid overdose

In the midst of an escalating U.S. opioid crisis, the immediate focus of public health interventions is on fatal overdose prevention. Few studies, however, have sought to examine the long-term health consequences of exposure to repeated nonfatal opioid overdose. We reviewed recent literature to examine three corresponding downstream health outcomes of repeated overdose: a) neurodegenerative processes; b) cognition and memory; and c) overdose risk behaviours. We found a remarkable congruency among available biochemical and cognitive data on how nonfatal overdose precipitates various pathological feedforward and feedback loops that affect people who use opioids for years to come. We found however that downstream behavioural implications of neurodegenerative and cognitive sequelae are less studied despite being most proximal to an overdose. Findings point to a vicious cycle of nonfatal overdose leading to neurodegeneration - closely resembling Alzheimer Disease - that results in cognitive decline that in turn leads to potentially reduced adherence to safe drug use behaviours. The collected evidence not only brings into the focus the long-term health consequences of nonfatal overdose from the perspectives of biology, neuroscience, and public health, but also creates new cross-disciplinary context and awareness in the research and public health community that should benefit people at risk.

Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis

The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.

Valuation system connectivity is correlated with poly-drug use in young adults

Poly-drug consumption contributes to fatal overdose in more than half of all poly-drug users. Analyzing decision-making networks may give insight into the motivations behind poly-drug use. We correlated average functional connectivity of the valuation system (VS), executive control system (ECS) and valuation-control complex (VCC) in a large population sample (n = 992) with drug use behaviour. VS connectivity is correlated with sedative use, ECS connectivity is separately correlated with hallucinogens and opiates. Network connectivity is also correlated with drug use via two-way interactions with other substances including alcohol and tobacco. These preliminary findings can contribute to our understanding of the common combinations of substance co-use and associated neural patterns.

Socioeconomic stability is associated with lower injection frequency among people with distinct trajectories of injection drug use

BACKGROUND

Little is known about how socioeconomic circumstances relate to injection frequencies among people who inject drugs (PWID) with diverse trajectories of injection. We aimed to characterize trajectories of injection drug use in a community-based sample of PWID over 7.5 years and to investigate the extent to which two modifiable factors reflecting socioeconomic stability-stable housing and stable income-relate to injection frequencies across distinct trajectories.

METHODS

HEPCO is an open, prospective cohort study of PWID living in Montréal with repeated follow-up at three-month or one-year intervals. Self-reported data on injection frequency, housing and income are collected at each visit. Injection frequency was defined as the number of injection days (0-30), reported for each of the past three months. Using group-based trajectory modeling, we first estimated average trajectories of injection frequency. Then, we estimated the trajectory group-specific average shift upward or downward associated with periods of stable housing and stable income relative to periods when these conditions were unstable.

RESULTS

Based on 19,527 injection frequency observations accrued by 529 participants followed over 2011-2019 (18.3% female, median age: 41), we identified five trajectories of injection frequency: three characterized by sustained injection at different frequencies (28% infrequent; 19% fluctuating; 19% frequent), one by a gradual decline (12%), and another by cessation (28%). Periods of stable housing and stable income were each independently associated with a lower injection frequency, on average, in all five trajectory groups (2.2-7.5 fewer injection days/month, depending on the factor and trajectory group).

CONCLUSION

Trajectories of injection drug use frequency were diverse and long-lasting for many PWID. Despite this diversity, socioeconomic stability was consistently associated with a lower injection frequency, emphasizing the close relationship between access to fundamental necessities and injection patterns in all PWID, irrespective of whether they are on a path to cessation or sustained injecting.

Correlation study between anatomopathological data and levels of blood morphine concentrations in heroin-related deaths

Heroin-related mortality is a complex phenomenon involving several factors that make an individual more susceptible to opioid toxicity. Among these, pre-existing pathological conditions play an important role. The current paper reviewed 51 autopsied cases performed over the last 30 years, each subject ("frequent heroin user") having taken heroin intravenously alone before death. For each case, total blood morphine concentration determined by gas chromatography-mass spectrometry (GC-MS) was obtained from the archives. For histopathological evaluation we examined microscopic sections of the heart, lung, brain, liver and kidney, and for each organ a score table with a numerical value from 1 to 5, as an indicator of increasing severity, was drawn up. Finally, we created a scoring system based on the Injury Severity Score (ISS), generated by the sum of the squares of the three highest organ scores. We investigated the relationship between total blood morphine value (mg/l) and pathological score by inserting the two variables in a linear regression model: Score = a + b·Morphinemia (p-value <0.001). The results demonstrated a statistically significant correlation between the two variables: individuals with low total blood morphine values tended to have a higher pathological score. Our study provides useful assessment tools for forensic practice, confirming the need to combine two important disciplines in drug death investigation: forensic pathology and toxicology.

Prevalence and correlates of simultaneous, multiple substance injection (co-injection) among people who inject drugs in Melbourne, Australia

AIMS

To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co-injection) among a community-recruited cohort of people who inject drugs.

DESIGN

Cross-sectional study.

SETTING

Melbourne, Australia.

PARTICIPANTS

A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted.

MEASUREMENTS

We constructed two statistical models: a logistic regression model analysing correlates of co-injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin-diphenhydramine co-injection only, co-injection of other substances and no co-injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non-fatal overdose.

FINDINGS

One-third [n = 226, 31%; 95% confidence interval (CI): 28-34%] of participants reported co-injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin-diphenhydramine (n = 121, 54%; 95% CI = 48-60%) and heroin-methamphetamine (n = 121, 54%; 95% CI = 48-60%). In logistic regression analyses, reporting co-injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18-2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31-3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin-diphenhydramine co-injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80-13.56, P < 0.001] and overdose (requiring an ambulance) in the past 12 months (aRRR = 2.81, 95% CI = 1.17-6.72, P = 0.021) compared with participants reporting no co-injection or co-injection of other substances.

CONCLUSIONS

A substantial proportion of people who inject drugs report co-injection of multiple substances, which is associated with a range of socio-demographic, drug use and health service use risk factors.

Association of Opioid Use Disorder Treatment With Alcohol-Related Acute Events

IMPORTANCE

Persons with opioid use disorder (OUD) and co-occurring alcohol use disorder (AUD) are understudied and undertreated. It is unknown whether the use of medications to treat OUD is associated with reduced risk of alcohol-related morbidity.

OBJECTIVE

To determine whether the use of OUD medications is associated with decreased risk for alcohol-related falls, injuries, and poisonings in persons with OUD with and without co-occurring AUD.

DESIGN, SETTING, AND PARTICIPANTS

This recurrent-event, case-control, cohort study used prescription claims from IBM MarketScan insurance databases from January 1, 2006, to December 31, 2016. The sample included persons aged 12 to 64 years in the US with an OUD diagnosis and taking OUD medication who had at least 1 alcohol-related admission. The unit of observation was person-day. Data analysis was performed from June 26 through September 28, 2020.

EXPOSURES

Days of active OUD medication prescriptions, with either agonist (ie, buprenorphine or methadone) or antagonist (ie, oral or extended-release naltrexone) treatments compared with days without OUD prescriptions.

MAIN OUTCOMES AND MEASURES

The primary outcome was admission for any acute alcohol-related event defined by International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Conditional logistic regression was used to compare OUD medication use between days with and without an alcohol-related event. Stratified analyses were conducted between patients with OUD with and without a recent AUD diagnostic code.

RESULTS

There were 8 424 214 person-days of observation time among 13 335 participants who received OUD medications and experienced an alcohol-related admission (mean [SD] age, 33.1 [13.1] years; 5884 female participants [44.1%]). Agonist treatments (buprenorphine and methadone) were associated with reductions in the odds of any alcohol-related acute event compared with nontreatment days, with a 43% reduction for buprenorphine (odds ratio [OR], 0.57; 95% CI, 0.52-0.61) and a 66% reduction for methadone (OR, 0.34; 95% CI, 0.26-0.45). The antagonist treatment naltrexone was associated with reductions in alcohol-related acute events compared with nonmedication days, with a 37% reduction for extended-release naltrexone (OR, 0.63; 95% CI, 0.52-0.76) and a 16% reduction for oral naltrexone (OR, 0.84; 95% CI, 0.76-0.93). Naltrexone use was more prevalent among patients with OUD with recent AUD claims than their peers without AUD claims.

CONCLUSIONS AND RELEVANCE

These findings suggest that OUD medication is associated with fewer admissions for alcohol-related acute events in patients with OUD with co-occurring AUD.

Fentanyl and fentanyl analogs in the illicit stimulant supply: Results from U.S. drug seizure data, 2011-2016

BACKGROUND

U.S. research examining the illicit drug supply remains rare even though the information could help reduce overdoses. Relatively little is known regarding how often opioids are found in stimulants and whether temporal and geographic trends exist. We examined trends in fentanyl-cocaine and fentanyl-methamphetamine combinations in the national illicit drug supply.

METHODS

We analysed serial cross-sectional data from the National Forensic Laboratory Information System (NFLIS) collected between January 2011 and December 2016. We restricted the analysis to cocaine (N = 1,389,968) and methamphetamine (n = 1,407,474) samples and calculated proportions containing fentanyl (including 23 related analogs) over time.

RESULTS

The combined presence of fentanyl and cocaine steadily increased nationally between 2012-2016 (p = 0.01), and the number of such samples tripled from 2015 to 2016 (n = 423 to n = 1,325). Similarly, the combined presence of fentanyl and methamphetamine increased 179 % from 2015 to 2016 (n = 82-n = 272). Patterns varied widely by state; in 2016, fentanyl-cocaine samples were most common in New Hampshire (7.2 %), Connecticut (5.4 %), Ohio (2.6 %) and Massachusetts (2.1 %), whereas fentanyl-methamphetamine samples were most often in New Hampshire (6.1 %), Massachusetts (5.6 %), Vermont (2.4 %) and Maine (1.2 %).

CONCLUSIONS

Although relatively uncommon, the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occuring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast. Given these trends, strengthening community-based drug checking programs and surveillance within the public health infrastructure could help promote timely responses to novel threats posed by rapid shifts in the drug supply that may lead to inadvertent exposures.

Cerebral vasculitis associated with drug abuse

PURPOSE OF REVIEW

To review understand the epidemiology, background, neuropharmacology, and histopathology of literature verified cases, and likely etiopathogenic mechanisms.

RECENT FINDINGS

There are only a handful of histologically confirmed patients in the literature with cerebral vasculitis because of drug abuse.

SUMMARY

There is little justification for invasive laboratory investigation given the ready availability of highly accurate vascular neuroimaging techniques to dictate management, which usually rests upon avoidance of further exposure and minimizing the secondary neurotoxic effects of the abused substances and polypharmacy use.

Does a hypoxic injury from a non-fatal overdose lead to an Alzheimer Disease?

Long term consequence of non-fatal overdose in people who use opioids are not well understood. The intermittent exposure to non-fatal overdose leads to a tauopathy that is often accompanied by abrogated neuroprotective response, abnormal amyloid processing and other pathologies. The scope and limitations of available literature are discussed including neuropathologies associated with opioid and overdose exposures, contributing comorbidities and proteinopathies. Contrasting postmortem data of overdose victims with animal models of opioid neuropathologies and hypoxic injury paints a picture distinct from other proteinopathies as well as effects of moderate opioid exposure. Furthermore the reported biochemical changes and potential targets for therapeutic intervention were mapped pointing to underlying imbalance between tau kinases and phosphatases that is characteristic of Alzheimer Disease.

An Undergraduate Student-Led Neuroscience Outreach Program Shows Promise in Shifting Teen Attitudes About Drugs

Drug Outreach, Promoting Awareness (DOPA) is an undergraduate outreach program for local high school students designed to convey the neurobiological basis, risks, and addictive potential of commonly abused drugs. Here we describe DOPA and evaluate the program, including its impact on high school student attitudes about drug harm risk and addiction. Undergraduate neuroscience students versed in the neurobiology, physiology, and policy of drugs are trained in active learning methods, enabling them to create engaging and interactive classroom-based educational materials. Survey results showed that participation in DOPA increased high school student perceptions of the addictive potential and harm risk of drugs, which studies have shown to be inversely correlated with drug-taking. High school students also responded positively to the interactive nature of the program. These findings demonstrate how extensively trained undergraduates who are close peers to high school students can effectively lead science outreach initiatives and shift adolescent attitudes about drugs.

Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework

Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies.

CONTEXT

Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction.

METHODS

In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally.

FINDINGS

De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction.

CONCLUSIONS

Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.

Changes in substance use in relation to opioid agonist therapy among people who use drugs in a Canadian setting

BACKGROUND

Although previous studies have shown that opioid agonist therapy (OAT) is linked to reductions in illicit opioid use, less is known about how OAT impacts the use of other psychoactive substances. We aimed to examine the changes in use of different substances by comparing patterns before and after initiating OAT.

METHODS

Data for this study was derived from three ongoing prospective cohorts involving people who use drugs in Vancouver, Canada from 1996 to 2018. We assessed use patterns for heroin, illicit prescription opioid, cocaine, crack cocaine, crystal methamphetamine, cannabis, daily alcohol use, and benzodiazepines. Segmented regression was conducted to compare the trends of substance use between pre-treatment and post-treatment periods.

RESULTS

The study included 1107 participants. After OAT engagement, we observed an immediate decline in the proportion as well as a decreasing trend for heroin (Adjusted Odds Ratio (AOR): 0.80, 95% confidence interval (CI): 0.77, 0.83), illicit prescription opioid (AOR: 0.87, 95% CI: 0.83, 0.90), and benzodiazepines (AOR: 0.73, 95 % CI: 0.67, 0.80). There was no significant difference comparing the pre-treatment and post-treatment trends for cocaine, crack cocaine, crystal methamphetamine, and cannabis. However, higher growth slope was noted during the post-treatment period for daily alcohol use (P = 0.016).

CONCLUSIONS

We observed significant reduction in illicit opioids use following OAT initiation, but not for stimulant and cannabis. The increasing problematic use of alcohol may pose challenges to the safety and effectiveness of OAT. Development of comprehensive and tailored treatment strategies is needed for poly-substance users accessing OAT.

Links between suicidal intent, polysubstance use, and medical treatment after non-fatal opioid overdose

BACKGROUND

Suicidal thinking during non-fatal overdose may elevate risk for future completed suicide or intentional overdose. Long-term outcomes following an intentional non-fatal overdose may be improved through specific intervention and prevention responses beyond those designed for unintentional overdoses, yet little research has assessed suicidal intent during overdoses or defined characteristics that differentiate these events from unintentional overdoses.

METHODS

Patients with a history of opioid overdose (n = 274) receiving residential addiction treatment in the Midwestern United States completed self-report surveys to classify their most recent opioid overdose as unintentional, actively suicidal (wanted to die), or passively suicidal (didn't care about the risks). We characterized correlates of intent using descriptive statistics and prevalence ratios. We also examined how intent related to thoughts of self-harm at the time of addiction treatment.

RESULTS

Of opioid overdoses, 51 % involved suicidal intent (44 % passive and 7 % active). Active suicidal intent was positively associated with hospitalization. Active/passive intent (vs. no intent, aPR: 2.2, 95 % CI: 1.4-3.5) and use of ≥5 substances (vs. 1 substance, aPR: 3.6, 95 % CI: 1.2-10.6) at the last opioid overdose were associated with having thoughts of self-harm or suicide in the 2 weeks before survey completion in adjusted models. Participants who reported active/passive intent more commonly used cocaine or crack (27 %) with opioids during their last overdose relative to unintentional overdoses (16 %).

CONCLUSIONS

Over half of opioid overdoses among individuals in addiction treatment involved some degree of suicidal thinking. Identifying patients most at risk will facilitate better targeting of suicide prevention and monitoring services.

Characterizing profiles of polysubstance use among high school students in Baltimore, Maryland: A latent class analysis

BACKGROUND

Adolescent drug use has long term health consequences, like substance use disorders and psychiatric illnesses. Proximal health risks, especially for overdose, are amplified when multiple substances are combined. Existing literature on polysubstance use among adolescents has largely focused on alcohol, tobacco, and marijuana, but has largely excluded other drugs like opioids. Understanding how adolescents combine illicit drugs is essential for intervening to prevent poor health outcomes.

METHODS

We aimed to explore patterns of lifetime polysubstance use among adolescents in Baltimore City. We used data on 9th-12th graders recruited to participate in the 2017 local Baltimore Youth Risk Behavior Survey who reported any lifetime drug use (n = 387; 60 % female, 77 % non-Hispanic Black). We then conducted a latent class analysis using 10 indicators of lifetime drug and alcohol use. After selecting the class model, we tested for associations between the class profiles and race, sex, school grade, and lifetime injection drug use.

RESULTS

We identified three profiles of lifetime polysubstance use in our sample: alcohol and marijuana (68.6 % of sample), polysubstance (22.0 %), and alcohol/pain medication/inhalant use (9.4 %). Members of the polysubstance use class were more likely to be male and to report injection drug use.

CONCLUSIONS

Understanding broader patterns of drug use beyond alcohol, tobacco and marijuana among adolescents is a crucial step towards preventing adverse drug and health-related outcomes later in life. More research is needed to characterize the full health impact of youth polysubstance use patterns and related risk behaviors like injection drug use.

Temporal changes in non-fatal opioid overdose patterns among people who use drugs in a Canadian setting

Background and Aims: Little is known about how the expansion of opioid agonist therapy (OAT) and emergence of fentanyl in the illicit drug supply in North America has influenced non-fatal opioid overdose (NFOD) risk. Therefore, we sought to identify patterns of substance use and addiction treatment engagement (i.e., OAT, other inpatient or outpatient treatment) prior to NFOD, as well as the trends and correlates of each pattern among people who use drugs (PWUD) in Vancouver, Canada. Methods: Data were derived from participants in three prospective cohorts of PWUD in Vancouver in 2009-2016. Observations from participants reporting opioid-related NFOD in the previous six months were included. A latent class analysis was used to identify classes based on substances used at the time of last NFOD and addiction treatment engagement in the month prior to the last NFOD. Multivariable generalized estimating equations estimated the correlates of each class membership. Results: In total, 889 observations from 570 participants were included. Four distinct classes were identified: (1) polysubstance use (PSU) and addiction treatment engagement; (2) PSU without treatment engagement; (3) exposure to unknown substances, mostly without treatment engagement; and (4) primary heroin users without treatment engagement. The class of exposure to unknown substances appeared in 2015 and became the dominant group (76.9%) in 2016. In multivariable analyses, the odds of membership in the class of primary heroin users decreased over time (adjusted odds ratio [AOR]: 0.74, 95% confidence interval [CI]: 0.68-0.81). Conclusions: Changing profiles of PWUD reporting opioid-related NFOD were seen over time. Notably, there was a sudden increase in reports of overdose following exposure to unknown substances since 2015, the majority of whom reported no recent addiction treatment engagement. Further study into patterns of substance use and strategies to improve addiction treatment engagement is needed to improve and focus overdose prevention efforts.

Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose?

BACKGROUND

Unintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period.

METHODS

Participants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use.

RESULTS

Almost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis.

DISCUSSION

The findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed.

Discrepancies in Written Versus Calculated Durations in Opioid Prescriptions: Pre-Post Study

BACKGROUND

The United States is in the midst of an opioid epidemic. Long-term use of opioid medications is associated with an increased risk of dependence. The US Centers for Disease Control and Prevention makes specific recommendations regarding opioid prescribing, including that prescription quantities should not exceed the intended duration of treatment.

OBJECTIVE

The purpose of this study was to determine if opioid prescription quantities written at our institution exceed intended duration of treatment and whether enhancements to our electronic health record system improved any discrepancies.

METHODS

We examined the opioid prescriptions written at our institution for a 22-month period. We examined the duration of treatment documented in the prescription itself and calculated a duration based on the quantity of tablets and doses per day. We determined whether requiring documentation of the prescription duration affected these outcomes.

RESULTS

We reviewed 72,314 opioid prescriptions, of which 16.96% had a calculated duration that was greater than what was documented in the prescription. Making the duration a required field significantly reduced this discrepancy (17.95% vs 16.21%, P<.001) but did not eliminate it.

CONCLUSIONS

Health information technology vendors should develop tools that, by default, accurately represent prescription durations and/or modify doses and quantities dispensed based on provider-entered durations. This would potentially reduce unintended prolonged opioid use and reduce the potential for long-term dependence.

Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness

IMPORTANCE

Individuals with a history of homelessness are at increased risk for drug or alcohol overdose, although the proportion who have had recent nonfatal overdose is unknown. Understanding risk factors associated with nonfatal overdose could guide efforts to prevent fatal overdose.

OBJECTIVES

To determine the prevalence of recent overdose and the individual contributions of drugs and alcohol to overdose and to identify characteristics associated with overdose among veterans who have experienced homelessness.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was conducted from November 15, 2017, to October 1, 2018, via mailed surveys with telephone follow-up for nonrespondents. Eligible participants were selected from the records of 26 US Department of Veterans Affairs medical centers and included veterans who had received primary care at 1 of these Veterans Affairs medical centers and had a history of experiencing homelessness according to administrative data. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020.

MAIN OUTCOMES AND MEASURES

Self-report of overdose (such that emergent medical care was obtained) in the previous 3 years and substances used during the most recent overdose. All percentages are weighted according to propensity to respond to the survey, modeled from clinical characteristics obtained in electronic health records.

RESULTS

A total of 5766 veterans completed the survey (completion rate, 40.2%), and data on overdose were available for 5694 veterans. After adjusting for the propensity to respond to the survey, the mean (SD) age was 56.4 (18.3) years; 5100 veterans (91.6%) were men, 2225 veterans (38.1%) were black, and 2345 veterans (40.7%) were white. A total of 379 veterans (7.4%) reported any overdose during the past 3 years; 228 veterans (4.6%) reported overdose involving drugs, including 83 veterans (1.7%) who reported overdose involving opioids. Overdose involving alcohol was reported by 192 veterans (3.7%). In multivariable analyses, white race (odds ratio, 2.44 [95% CI, 2.00-2.98]), self-reporting a drug problem (odds ratio, 1.66 [95% CI, 1.39-1.98]) or alcohol problem (odds ratio, 2.54 [95% CI, 2.16-2.99]), and having witnessed someone else overdose (odds ratio, 2.34 [95% CI, 1.98-2.76]) were associated with increased risk of overdose.

CONCLUSIONS AND RELEVANCE

These findings suggest that nonfatal overdose is relatively common among veterans who have experienced homelessness. While overdose involving alcohol was more common than any specific drug, 1.7% of veterans reported overdose involving opioids. Improving access to addiction treatment for veterans who are experiencing homelessness or who are recently housed, especially for those who have experienced or witnessed overdose, could help to protect this population.

Motivations for crystal methamphetamine-opioid co-injection/co-use amongst community-recruited people who inject drugs: a qualitative study

Aims

We report on motivations for crystal methamphetamine-opioid co-use/co-injection through narratives of people who inject drugs during a period of increased crystal methamphetamine use reporting in Australia.

Methods

Fourteen in-depth interviews were undertaken with selected participants (12 male, 2 female) from the Melbourne Injecting Drug User Cohort Study, including those in and out of opioid substitution therapy (OST).

Results

The main motivations for co-use reported by participants were as follows: (1) that heroin could be used to reduce the negative side effects of heavy crystal methamphetamine use, particularly during the ‘comedown’ phase; (2) that small quantities of crystal methamphetamine used with heroin could prolong the intoxication effect of heroin, and hence the time before opioid withdrawal; (3) that co-injection of crystal methamphetamine and heroin produced a more desirable intoxication effect than using either substance on its own and; (4) that crystal methamphetamine provided a substitute ‘high’ for heroin after commencing OST treatment.

Conclusions

Co-use of methamphetamine and opioids has been used by people who inject drugs to facilitate intoxication, sometimes as the result of ineffective opioid substitution therapy (OST) treatment and perceived lack of pleasure after stabilisation on OST treatment.

Multivariate spatiotemporal modeling of drug- and alcohol-poisoning deaths in New York City, 2009-2014

Drug- and alcohol-poisoning deaths remain current public health problems. Studies to date have typically focused on individual-level predictors of drug overdose deaths, and there remains a limited understanding of the spatiotemporal patterns and predictors of the joint outcomes. We use a hierarchical Bayesian spatiotemporal multivariate Poisson regression model on data from (N = 167) ZIP-codes between 2009 and 2014 in New York City to examine the spatiotemporal patterns of the joint occurrence of drug (opioids) and alcohol-poisoning deaths, and the covariates associated with each outcome. Results indicate that rates of both outcomes were highly positively correlated across ZIP-codes (cross-correlation: 0.57, 95% credible interval (CrI): 0.29, 0.77). ZIP-codes with a higher prevalence of heavy drinking had higher alcohol-poisoning deaths (relative risk (RR):1.63, 95% CrI: 1.26, 2.05) and drug-poisoning deaths (RR: 1.29, 95% CrI: 1.03, 1.59). These spatial patterns may guide public health planners to target specific areas to address these co-occurring epidemics.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

Polysubstance use in rural West Virginia: Associations between latent classes of drug use, overdose, and take-home naloxone

BACKGROUND

Rural communities in the United States have been disproportionately affected by the opioid crisis. Little research has explored the relationship between polysubstance use and overdose experiences among people who inject drugs (PWID) in rural communities. We sought to identify classes of polysubstance drug use among rural PWID and evaluate the associations between polysubstance drug use classes, recent overdose experiences, and receipt of take-home naloxone (THN).

METHODS

We surveyed 420 PWID (June-July 2018) who had injected drugs in the previous 6 months in Cabell County, West Virginia. Participants were recruited from the local syringe services program and through street-based recruitment. We conducted a latent class analysis using 9 measures of injection and non-injection drug use and tested for associations with having experienced an overdose in the past 6 months and having received THN in the past 6 months.

RESULTS

We identified four substance use classes in our sample: polydrug/polyroute use (35.0% of the sample), polyroute stimulant/injection opioid use (33.3%), polyroute stimulant use (20.3%), and injection opioid use (11.3%). Overall, 42.6% of the sample had experienced an overdose in the past 6 months. The classes differed in terms of overdose (χ=91.53, p<0.001), with the polydrug/polyroute use class having the highest probability of overdose and the polyroute stimulants class having the lowest. Only 46.5% of participants had received THN, and probabilities differed between classes (χ=21.93, p<0.001). The polyroute stimulants/injection opioid use and polydrug/polyroute use classes had the highest levels of THN receipt while the polyroute stimulants use class had the least.

CONCLUSION

Among rural PWID in West Virginia, polysubstance use was prevalent and associated with overdose and THN acquisition. These analyses demonstrate the importance of scaling up naloxone distribution in rural settings. Overdose prevention initiatives are reaching persons at high risk of overdose, but expansion of services is needed.

Racial differences in overdose events and polydrug detection in Indianapolis, Indiana

BACKGROUND

We examine racial disparities in drug overdose death rates by analyzing trends in fatal and nonfatal overdose outcomes in a large metropolitan area (Indianapolis, Indiana).

METHODS

Death certificate and toxicology records for accidental drug overdose deaths from 2011 to 2018 were linked with emergency medical services (EMS) data. Bivariate comparisons examined differences in toxicology findings at the time of death as well as prior EMS events both overall and by indicator of non-fatal overdose.

RESULTS

From 2011-2018, 2204 residents (29.4 per 100,000) died of drug overdose, 18.6% were Black (N = 410, 19.5 per 100,000) and 78.5% White (N = 1730, 35.2 per 100,000). In the year prior to death, 33.5% (N = 656) of decedents had an EMS event, 12.1% (N = 237) had an overdose event, and 9.4% (N = 185) had naloxone administered. Overdose complaint and naloxone administration were more likely to occur among White than Black patients. White decedents were more likely than Black decedents to have had naloxone administered in the year prior to death (10.1% vs. 6.8%, χ² = 4.0, p < .05, Cramer's V=.05). Toxicology data illustrate changing polydrug combinations, with Black decedents more likely to test positive for fentanyl-cocaine polydrug use in recent years.

CONCLUSIONS

Recent racial disparities in overdose deaths are driven by a combination of fentanyl and cocaine, which disproportionally impacts African American drug users, but may be addressed through expanded harm reduction and community outreach services. Additionally, there is a need to assess the role of differing practices in overdose emergency service provision as a contributing factor to disparities.

Predictors of Overdose Death Among High-Risk Emergency Department Patients With Substance-Related Encounters: A Data Linkage Cohort Study

STUDY OBJECTIVE

Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters.

METHODS

This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories.

RESULTS

A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05).

CONCLUSION

These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.

Mortality and causes of death among people suspected of driving under the influence and testing positive for multiple substances

Aims: Understanding the mortality of drug users using multiple substances is helpful in preventing the harmful effects of polydrug use. We examined overall and cause-specific mortality and differences in mortality based on social background among people suspected of driving under the influence and testing positive for multiple substances (DUIMS) compared with the general Finnish population. Methods: Register data from 785 DUIMS during 2003-2006 were studied, with a reference population (n = 25,381) drawn from the general Finnish population. The effect of DUIMS on all-cause and cause-specific mortality was estimated using a Poisson regression model. Results: DUIMS had an increased risk of death compared with the general population (MRR 5.3, 95% CI 4.2-6.6). The most common causes of death in DUIMS were poisonings (37.9%) and suicides (13.6%), whereas in the reference population these were cardiovascular diseases (30.8%) and cancer (26.6%). The cause-specific risk of death among DUIMS was higher in all observed causes of death, except for cancer. The effect of DUIMS on mortality was modified by age, employment status and marital status; DUIMS was associated with an elevated risk of death especially in younger age groups and in singles. Conclusions: DUIMS indicates higher mortality, and DUIMS' profiles in causes of death differ from the general population. Elevated risk for, for instance, suicidal, accidental and violent death among those using multiple substances highlights the need to also pay attention to causes of death other than poisoning/overdose.