Media reports of heroin overdose spates: Public health messages, moral panics or risk advertisements?

Overdosevarslingssystemer – en kartleggingsoversikt med maskinlæring

Bakgrunn: Helsedirektoratet ønsker å vurdere muligheten for å etablere et nasjonalt overdosevarslingssystem (OVS) for å kunne varsle brukere om økt overdosefare. OVS som system forstås her som et sett med sammenhengende elementer som fungerer som en helhet, der hensikten er tidlig oppdagelse av økt overdoserisiko kombinert med rask varsling til de som står i fare for overdoser. Metode: Vi utførte en kartleggingsoversikt over forskning om varslingssystemer for økt overdosefare. Mål 1 var å kartlegge eksisterende forskning om effekten av et OVS (antall brukere nådd, antall overdoser, varslingshurtighet). Mål 2 var å kartlegge eksisterende forskning som kunne belyse brukeres erfaringer med slike systemer. Resultater: Vi brukte flere maskinlæringsfunksjoner for å identifisere og vurdere totalt 4102 referanser fra litteratursøk gjennomført i mars/april 2022, hvorav 11 studier oppfylte inklusjonskriteriene. Effekt av OVS på antall overdoser var ikke mulig å skille fra eksisterende overdoseforebyggende tiltak. OVS’er varslet skadereduksjonsgrupper eller erfaringskonsulenter så tidlig som fire timer etter innmeldt/oppdaget fare. Antall brukere varslet ble i stor grad ikke rapportert, antageligvis fordi data om dette ikke ble innsamlet. Fra syv kvalitative studier ble mønstre i hovedfunn sett på tvers, som omhandlet preferanser for språkbruk og innhold, hvor varslinger burde komme fra, og prinsippene bak dem. Konklusjon: Vi identifiserte lite empirisk forskning om eksisterende OVS’er, særlig relatert til effekt av slike systemer. Uten tilstrekkelig forskningsgrunnlag om effekt må vi være forsiktige med å trekke konklusjoner om hvilke typer OVS’er som bør og ikke bør innføres i Norge. Opprettelse av et OVS trenger ikke nødvendigvis innebære etablering av en ny infrastruktur, men heller være snakk om at to godt utviklede, eksisterende systemer – systemer for overvåking og skadereduksjonstiltak – kan kobles sammen.

Perceptions about fentanyl-adulterated heroin and overdose risk reduction behaviors among persons seeking treatment for heroin use

BACKGROUND

Fentanyl-adulterated heroin supply chains are increasing risks for fatal overdose in the U.S.

OBJECTIVE

The current study examined the use of overdose risk reduction behaviors among persons seeking treatment for heroin use and whether perceptions about the presence of fentanyl in one's heroin are associated with overdose risk reduction behaviors.

METHOD

We recruited persons with opioid use disorder entering a managed withdrawal program. We used multiple linear regression to estimate the adjusted associations of participant characteristics and perception of fentanyl exposure with the frequency of engaging in each of five overdose reduction behaviors.

RESULTS

Participants (n = 239; 75.3% male, 81.2% White, 67% injectors) estimated that 69.2% of the heroin they use contains fentanyl, and 94.6% knew that fentanyl increases overdose risk. Approximately 30% of respondents reported usually or always making sure others are around when they use heroin, carrying naloxone, taking "tester" doses of heroin or intentionally using in reduced amounts. While a majority of the sample reported never carrying naloxone or taking tester doses, and 70.2% reported never making sure that others around them carry naloxone, 84.5% had implemented one or more behavior at least rarely. Past month injection drug use was associated with making sure others are around, but perceptions about fentanyl in one's heroin were not associated with use of harm reduction behaviors.

CONCLUSIONS

In this sample of people who use heroin, although overdose risk reduction behaviors were not usually used, a majority had tried at least one behavior. That perceived exposure to fentanyl-adulterated heroin was not associated with the use of such behaviors provides important implications for public health education and intervention programming.

Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence

BACKGROUND

Exposure to potent synthetic opioids such as illicitly manufactured fentanyl (IMF) has fueled the escalating overdose crisis in the USA, particularly in the east coast. Drug checking services, which allow people who use drugs (PWUD) to learn about the contents of their drugs, remain limited and even criminalized in many states. Further, there is a persistent belief that PWUD are not willing or able to change their behaviors despite being aware of their potential exposure to fentanyl through drug use.

METHODS

We conducted a multi-site cross-sectional study among PWUD to assess what behaviors, if any, were employed in the case of suspected fentanyl exposure, and the correlates of engaging in harm reduction behaviors (HRB). PWUD (N = 334) were recruited in Boston (n = 80), Providence (n = 79), and in Baltimore (n = 175). At the time of the survey, no legal drug checking services were available in these cities.

RESULTS

The majority of PWUD (84%) expressed concern about fentanyl. Among those who suspected fentanyl exposure prior to using their drugs (n = 196), 39% reported employing HRB including using less of the drug (12%) or abstaining altogether (10%), using more slowly (5%), and doing a tester shot (5%). In adjusted logistic regression models, the odds (aOR) of practicing HRB after suspecting fentanyl exposure were increased among PWUD who were non-White (aOR 2.1; p = 0.004) and older (aOR 1.52 per decade of age; p < 0.001). Daily injection (aOR 0.50; p < 0.001), using drugs in public (aOR 0.58; p = 0.001), using drugs alone (aOR 0.68; p < 0.001), and experiencing multiple recent overdoses (aOR 0.55; p < 0.001) were associated with decreased odds of practicing HRB.

CONCLUSIONS

These data illustrate that PWUD employ a number of practices to reduce overdose risk in a context of unknown drug purity and content. Results may also guide efforts to identify early adopters of drug checking services and engage them in peer-outreach to target the most socially and structurally vulnerable PWUD, who are not reporting behavior change, with harm reduction messaging.

Trusting the source: The potential role of drug dealers in reducing drug-related harms via drug checking

OBJECTIVES

Drug checking technologies (DCTs) have been implemented as a response to the ongoing opioid overdose epidemic. We examined the level of trust people who use drugs (PWUD) have in their drug dealers as well as their perspectives on the potential for drug dealers to use DCTs to provide knowledge of drug contents to their customers.

METHODS

We conducted one-to-one qualitative semi-structured interviews with 20 PWUD in Vancouver, Canada's Downtown Eastside. Participants were purposively recruited from ongoing cohort studies of PWUD and were required to currently be using stimulants and/or opioids.

RESULTS

Most participants discussed having a high level of trust for their drug dealers based on length of relationships, drug supply consistencies, and communication. Given this, participants did not identify drug checking as a priority. However, participants discussed a lower level of trust when buying drugs from an unfamiliar source. Participants also discussed how DCTs would provide knowledge to drug dealers about drug contents and how communicating test results to customers could be a risk reduction measure. Participants described privacy concerns that drug dealers might experience as well as the lack of concern that some drug dealers have about their drug supply.

CONCLUSIONS

Future drug checking programming should consider ways to engage drug dealers to test their supplies and develop communication strategies to more accurately inform PWUD of drug contents and avert risks associated with using them. Additionally, drug policies that address the effects of criminalization should be considered to lessen potential barriers to DCT use by drug dealers.

Action-focused, plain language communication for overdose prevention: A qualitative analysis of Rhode Island's overdose surveillance and information dashboard

BACKGROUND

In 2015, the state of Rhode Island reported the fifth highest drug overdose mortality rate in the United States. In response to this crisis, Rhode Island created a statewide, publicly accessible drug surveillance and information system, www.PreventOverdoseRI.org (PORI). Alongside near real-time overdose surveillance data, PORI provides plain language materials and resources regarding overdose prevention, recognition and response. We sought to determine how people who use drugs (PWUD) perceive and utilize overdose prevention material, and to evaluate PORI's action-based, plain language content.

METHODS

We conducted 21 semi-structured qualitative interviews with PWUD from February-June 2017 in the state of Rhode Island. Data were audio-recorded, transcribed, coded in NVivo (Version 11), and key themes were developed.

RESULTS

Participants viewed online health promotion and harm reduction materials as a useful approach for overdose prevention. Information displayed as accessible, action-driven statements was seen as most desirable for learning and dissemination. After viewing overdose prevention material, participants reported feeling better prepared for responding to an accidental overdose and motivated to share the infographics and website to other people either at risk for or likely to witness an overdose.

CONCLUSION

Action-focused, plain language approaches for overdose prevention materials can be of particular use for public health campaigns addressing opioid overdose crises. Overdose prevention health campaigns should incorporate evidence-based testing to ensure that outreach material is grounded in plain language techniques.

Prevalence of Heavy Alcohol Use Among People Receiving Methadone Following Change to Methadose

BACKGROUND

A recent switch in methadone formulation from methadone (1 mg/mL) to Methadose (10 mg/mL) in British Columbia (BC), Canada, was associated with increased reports of opioid withdrawal and increases in illicit opioid use. Impacts on other forms of drug use have not been assessed. Since alcohol use is common among people receiving Medication-Assisted Treatment (MAT), we assessed if switch was associated with increased prevalence of heavy alcohol use.

METHODS

Drawing on data from two open prospective cohort studies of people who inject drugs in Vancouver, BC, generalized estimating equations (GEE) model examined relationship between methadone formulation change and heavy alcohol use, defined by National Institute for Alcohol Abuse and Alcoholism (NIAAA). A sub-analysis examined relationship with heavier drinking defined as at least eight drinks per day on average in last six months.

RESULTS

Between June 2013 and May 2015, a total of 787 participants on methadone were eligible for the present analysis, of which 123 (15.6%) reported heavy drinking at least once in last six months. In an unadjusted GEE model, Methadose use was not significantly associated with an increased likelihood of heavy drinking [Odds Ratio (OR) = 1.03; 95% Confidence interval (CI) = 0.87-1.21]. Methadose use was not significantly associated with an increased likelihood of drinking at least eight drinks daily on average (OR = 1.09, 95% CI = 0.72-1.65).

CONCLUSIONS

Despite reported changes in opioid use patterns coinciding with the change, there appeared to be no effect of the methadone formulation change on heavy drinking in this setting.

Drug quality assessment practices and communication of drug alerts among people who use drugs

BACKGROUND

Regional health bodies in British Columbia (BC) issue drug alerts to the public when health risks associated with drug quality are identified, such as increased illicit drug deaths, overdoses or other harms. There is a lack of evidence-based guidelines for producing timely, effective public health alerts to mitigate these harms. This study sought to understand (1) the practices used by people who use drugs (PWUD) to assess the quality of street drugs and reduce harms from adulterants and (2) how drug alerts could be better communicated to PWUD.

METHODS

Guided by interpretive and descriptive methodology, this study consisted of brief questionnaires and in-depth focus groups with 32 PWUD.

RESULTS

Findings suggest the most effective and trusted information about drug quality was primarily from: (a) trusted, reputable dealers or (b) peer-based social networks. Most PWUD thought information received through health service providers was not timely and did not discuss drug quality with them. A number of concrete guidelines were suggested by participants to improve the effectiveness of drug alert modes and methods of communication in the community, including the use of language on drug alert postings that implies harm, indicates what drug effects to look for, and suggests appropriate responses to overdose, such as the use of naloxone. Participants also emphasized the need to date posters and remove them in a timely manner so as to not desensitize the community to such alerts.

CONCLUSION

Since it is difficult to control adulteration practices in an unregulated drug market, this study suggests methods of effectively producing and communicating drug alerts among PWUD to mitigate harms associated with drug use.

'It's more about the heroin': injection drug users' response to an overdose warning campaign in a Canadian setting

AIMS

To assess heroin injectors' perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses.

DESIGN

Semi-structured qualitative interviews.

SETTING

Vancouver, Canada.

PARTICIPANTS

Eighteen active heroin injectors.

MEASUREMENTS

Semi-structured interview guide focussing on heroin injectors' perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations.

FINDINGS

Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages.

CONCLUSIONS

Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.