Fentanyl and Drug Overdose: Perceptions of Fentanyl Risk, Overdose Risk Behaviors, and Opportunities for Intervention among People who use Opioids in Baltimore, USA

Layperson knowledge on naloxone and medications for opioid use disorder in an urban population: a cross sectional survey study

BACKGROUND AND OBJECTIVES

There has been little research in an urban population regarding knowledge of harm reduction measures and treatment options. The objective of our study was to evaluate knowledge and perceptions of harm reduction measures and types of treatment available for opioid use disorder among patients and family in an urban emergency department (ED) waiting room.

METHODS

We conducted a single center, cross-sectional survey study that occurred between September 2021 and August 2022. A convenience sample of patients and family members that were above 18 and English speaking were recruited by research assistants. Participants were assessed on knowledge and preferences around drug treatment options and harm reduction. Data were summarized using descriptive statistics and compared using the Freeman-Halton/Kruskall-Wallis/Mann-Whitney U tests. p-Values were reported at the 0.05 significance level.

RESULTS

We collected 200 responses. Of these, 104 people had a connection to someone with a substance use disorder (SUD) and 50 had an SUD. Of those who had a connection to someone with SUD, 63 had heard of naloxone (60.6%, CI: [50.5, 69.9]). Fewer than 60% of respondents in each group had heard of Medications for Opioid Use Disorder (MOUD) (p = 0.46) and fewer than 50% thought that among people who use drugs that they knew would be interested in receiving treatment (p = 0.10).

DISCUSSION AND CONCLUSIONS

Our study found that among people who came to an urban emergency department, there was a lack of awareness of harm reduction and MOUD. Interventions should be put into place to educate on the importance of MOUD and harm reduction.

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland

BACKGROUND

Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs.

METHODS

People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services.

RESULTS

The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors).

CONCLUSIONS

Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Three noteworthy idiosyncrasies related to Canada's opioid-death crisis, and implications for public health-oriented interventions

Canada has been experiencing a prolonged public health-crisis of high rates of overdose deaths caused by exceptionally potent/toxic, illicit opioid use. While many key features of this drug death epidemic are well-documented, several idiosyncratic aspects with relevance for public health-oriented interventions are not adequately recognised. These include: (i) the discrepant opioid patterns pan-Canada, with large majorities of opioid deaths caused by illicit fentanyl drugs in Western, but not Eastern regions where prescription-type opioid prevail; (ii) the environments of overdose deaths, where vast majorities occur in 'residential' or other shelter-type settings, presenting barriers for emergency interventions rather than health protection; and (iii) shifting drug use modes, where now majorities of overdose deaths are associated with drug 'inhalation' (instead of 'injection') in contexts of potent/toxic drug supply. We briefly describe these factors and related implications for intervention programming towards an improved response to the drug death-crisis.

Multinational appraisal of the epidemiological distribution of opioid fatalities: a systematic review and meta-analysis

Background

The global or multinational scientific evidence on the distribution of opioid fatality is unknown. Hence, the current study collects epidemiological characteristics to shed light on the ongoing global or multinational opioid crisis and to promote the development of public health prevention/management strategies.

Method

All documents on PRISMA standards were retrieved via electronic databases.

Results

Among the 47 articles relevant to our studies, which depict a total population size of 10,191 individuals, the prevalence of opioid fatal overdose was 15,022 (14.74%). Among the 47 articles, 14 of them reported the gender of the participants, with 22,125 (15.79%) male individuals and 7,235 (5.17%) female individuals, and the age distribution of the participants that was most affected by the overdose was as follows: 29,272 (31.13%) belonged to the 18-34-year-old age group and 25,316 (26.92%) belonged to the less than 18-year-old age group. Eighteen studies qualified for the meta-analysis of the multinational prevalence of fatal opioid overdose, depicting an overall pooled prevalence estimate of 19.66%, with 95% CIs (0.13-0.29), I2 = 99.76% determined using the random-effects model, and Q statistic of 7198.77 (p < 0.0001). The Egger test models of publication bias revealed an insubstantial level of bias (p = 0.015). The subgroup analysis of the study design (cohort or other) revealed that others have the highest prevalence estimate of 34.37, 95% CIs (0.1600-0.5901), I2 = 97.04%, and a sample size of less than 1,000 shows the highest prevalence of 34.66, 95% CIs (0.2039-0.5234), I2 = 97.82%, compared to that of more than 1,000 with a prevalence of 12.28, 95% CIs (0.0675-0.2131), I2 = 99.85%. The meta-regression analysis revealed that sample size (less-than or greater-than 1,000), (p = 0.0098; R2 = 3.83%) is significantly associated with the observed heterogeneity.

Conclusion

Research-based findings of fatal opioid overdose are grossly lacking in middle- and low-income nations. We established that there is a need for opioid fatality surveillance systems in developing nations.

Characterizing prescription opioid, heroin, and fentanyl initiation trajectories: A qualitative study

We understand the current crisis of overdose deaths to be driven by widespread opioid use, characterized by distinct 'waves' of drug use. The first wave was driven by prescription opioids, the second by heroin, and the third by illicit, non-pharmaceutical fentanyl and fentanyl analogues (henceforth, fentanyl). The purpose of this study is to describe opioid initiation within each of the three waves from the perspective of people who use illicit opioids, with a focus on emerging pathways into fentanyl use. The authors recruited sixty people reporting past-30-day illicit opioid use in Dayton, Ohio. Participants completed a brief survey and a semi-structured in-depth qualitative interview, conducted from March to November 2020 with a total of 13 in-person and 47 virtual interviews. The qualitative interviews were transcribed in their entirety and analyzed thematically using NVivo 12. We noted supply-side changes as influencing trajectories in all three waves. However, we also noted differences in the experiences of prescription opioid and heroin initiation, with these trajectories influenced by pharmacological effects, pain management, curiosity, intergenerational use, pricing, and peers. In comparison, most participants were unaware that they were initiating fentanyl, and many reported overdosing with their first use of fentanyl. We identified a trajectory into fentanyl with limited to no prior heroin use among a few participants. The increased risk of overdose with initiation into fentanyl use further emphasizes the need for an expansion of naloxone distribution and the implementation of more comprehensive measures, such as overdose prevention centers, drug testing, and a safer supply. Further research on the dynamics of the ongoing overdose death crisis in the era of fentanyl and the 4th wave of the overdose crisis is critical in developing responsive prevention and intervention strategies.

Severe and Fatal Fentanyl Poisonings from Transdermal Systems after On-Skin and Ingestion Application

In recent years, the administration of fentanyl (FNTL) implicitly in transdermal drug delivery systems (TDDS) has vastly increased in chronic pain treatment. Non-medical and uncontrolled use of FNTL in TFDS (transdermal fentanyl delivery systems) may reveal toxic effects by the route of exposure, dermal or alternative, by ingestion of patches, and drug release in the stomach. The purpose of this study was to present three different cases of FNTL poisonings, two of which resulted in death due to TFDS abuse. The first case is a 66-year-old woman treated for accidental FTNL poisoning resulting in acute respiratory distress syndrome. Two remaining cases are a 31-year-old woman and a 25-year-old man who died as a result of FNTL overdose after on-skin and ingestion application of the drug patches. During the hospitalization of the 66-year-old patient, in blood samples, FNTL was confirmed at a concentration of 10.0 ng/mL. Tests run on blood taken from the corpses of 25- and 31-year-old patients exhibited FNTL presence in concentrations of 29.1 ng/mL and 38.7 ng/mL, respectively. The various routes of administration and ultimately toxic effects are important to present because, in TDDS, fentanyl can be a reason for severe to fatal poisoning, as shown by the three cases above.

Social media engagement in the maritime industry during the pandemic

The maritime sectors are suffering severe disruptions as a result of COVID-19. Maritime companies have turned to social media to interact with partners and clear up confusion. However, not every social media post receives the same engagement levels especially during a pandemic. For a more holistic analysis of social media engagement during a pandemic, the Protection Motivation Theory and classical theories such as user gratification and media richness theories were included. The research uses hierarchical regression analysis on information gathered from Facebook posts about COVID-19 made by eighteen different companies from four distinct maritime sectors. It was found that the rate of stakeholder engagement is highly influenced by informational, relational, and entertaining content as well as content that fosters self-efficacy, severity, and vulnerability. Additionally, the stakeholder engagement rate is greatly influenced by posts with greater vividness and fluency, which are characterized by providing external links. This is the first study to look into why stakeholders interact with posts linked to COVID-19 on social media. The findings will help maritime organisations use social media as a management and communication instrument.

"I don't want to die": a qualitative study of coping strategies to prevent fentanyl-related overdose deaths among people who inject drugs and its implications for harm reduction policies

BACKGROUND

Fentanyl and fentanyl-related analogues are the main drivers of overdose death in the USA, particularly among people who inject drugs (PWID). Despite the fact that non-Hispanic whites exhibit higher population rates of synthetic opioid mortality, overdose deaths have increased among African American and Latinos in urban areas. Yet little attention has been paid to the introduction of fentanyl among rural PWID in Puerto Rico.

METHODS

We conducted N = 38 in-depth interviews with PWID in rural Puerto Rico to document participants' experiences of injection drug use after the arrival of fentanyl and the strategies they implemented to manage overdose death risks.

RESULTS

Participants suggest that the arrival of fentanyl in large scale happened after Hurricane Maria in 2017; this coincided with a dramatic increase in overdose episodes and deaths. Fear of overdose deaths motivated some participants to substitute intravenous drug use for other forms of substance use or to seek MOUD. PWID that continued injection use resorted to conducting "hit tests," avoiding injecting alone, using naloxone, and employing fentanyl testing strips.

CONCLUSIONS

While overdose deaths would have been higher without participants' willingness to adopt harm-reduction strategies, this paper illustrates the limits of these policies to address the current epidemic of fentanyl-related overdose deaths among this population. More studies are needed to understand how health disparities shape overdose risks for minority populations. However, major policy changes, in particular the revision of the harmful role of the War on Drugs and the termination of failed neoliberal economic policies that contribute to deaths of despair, should be addressed if we are to make a dent in this epidemic.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The salience of social context, opioid antagonist use, and prior opioid exposure as determinants of fatal and non-fatal opioid overdoses

This study examines the salience of social context for opioid overdoses in Boston from 2014 to 2019. Longitudinal negative binomial models with random effects indicated that higher levels of concentrated disadvantage, residential instability, and illicit drug activity increased annual block group counts of opioid overdoses. Logistic hierarchical and cross-classified random effects models indicated that the use of Narcan and greater exposure to drugs through previous opioid overdose and contextual lillicit drug crime activity reduced the odds of fatal opioid overdose relative to non-fatal opioid overdose. The findings suggest that the accurate tracking of both fatal and non-fatal overdoses, and a consideration of the broader social context, can facilitate effective public health resource allocation to reduce opioid overdoses.

A Dose of Truth: A Qualitative Assessment of Reactions to Messages about Fentanyl for People Who Use Drugs

Background: Fentanyl-related overdoses are occurring at alarming rates and developing campaigns to increase awareness about fentanyl and harm-reduction strategies is critical. A Dose of Truth is an educational campaign aiming to increase knowledge about the threat of fentanyl and risk of exposure among people who use drugs (PWUD). The current study tests preliminary concepts and messages for the campaign. Methods: Twenty-one one-on-one interviews were conducted with young adults ages 18-35 who use drugs. Participants discussed knowledge of fentanyl and perceived risk of exposure, and provided feedback on four concepts. Thematic analysis of transcripts generated insights about promising approaches and topics. Results: Findings demonstrated that fentanyl awareness is growing among PWUD, but they perceive low risk of exposure because they trust a source. Messaging that challenged that trust, by highlighting that contaminated drug supplies are increasingly widespread, made personal risk salient. Additionally, messaging conveyed through a personal narrative that encouraged carrying naloxone to protect friends was perceived as personally relevant. Conclusions: While opioid- and fentanyl-related campaigns exist, few have used an evidence-based process to guide campaign development. Addressing gaps in knowledge and developing messages that are personally relevant are foundational steps in creating effective campaigns on fentanyl and other substances.

Prevalence and correlates of using opioids alone among individuals in a residential treatment program in Michigan: implications for overdose mortality prevention

BACKGROUND

Avoiding use of opioids while alone reduces overdose fatality risk; however, drug use-related stigma may be a barrier to consistently using opioids in the presence of others.

METHODS

We described the frequency of using opioids while alone among 241 people reporting daily heroin use or non-prescribed use of opioid analgesic medications (OAMs) in the month before attending a substance use disorder treatment program in the Midwestern USA. We investigated drug use-related stigma as a correlate of using opioids while alone frequently (very often vs. less frequently or never) and examined overdose risk behaviors associated with using opioids while alone frequently, adjusted for sociodemographic and clinical characteristics.

RESULTS

The sample was a median age of 30 years, 34% female, 79% white, and nearly all (91%) had experienced an overdose. Approximately 63% had used OAMs and 70% used heroin while alone very often in the month before treatment. High levels of anticipated stigma were associated with using either opioid while alone very often (adjusted PR: 1.20, 95% CI: 1.04-1.38). Drinking alcohol and taking sedatives within two hours of OAMs very often (vs. less often or never) and using OAMs in a new setting very often (vs. less often or never) were associated with using OAMs while alone very often. Taking sedatives within two hours of using heroin and using heroin in a new setting very often (vs. less often or never) were associated with using heroin while alone very often.

CONCLUSION

Anticipated stigma, polysubstance use, and use in a new setting were associated with using opioids while alone. These findings highlight a need for enhanced overdose harm reduction options, such as overdose detection services that can initiate an overdose response if needed. Addressing stigmatizing behaviors in communities may reduce anticipated stigma and support engagement and trust in these services.

Knowledge, attitudes, and behaviors related to the fentanyl-adulterated drug supply among people who use drugs in Oregon

INTRODUCTION

Nonpharmaceutical fentanyl has reconfigured the U.S. illicit drug market, contributing to a drastic increase in overdose drug deaths. While illicit fentanyl has subsumed the drug supply in the Northeast and Midwest, it has more recently reached the West. For this study, we explored knowledge, attitudes, and behaviors among people who use drugs in Oregon in the context of the emergence of fentanyl in the drug supply.

METHODS

We conducted in-depth interviews by phone with 34 people who use drugs in Oregon from May to June 2021. We used thematic analysis to analyze transcripts and construct themes.

RESULTS

People who use drugs knew about fentanyl, expressed doubt that fentanyl could be found in methamphetamine; believed those who were younger or less experienced were at higher risk for harm; and received information about fentanyl from drug dealers, syringe service programs, or peers (other people who use drugs). Preference for fentanyl's presence in drugs like heroin or methamphetamine was mixed. Some felt that their preference was irrelevant since fentanyl was unavoidable. Participants reported engaging in harm reduction practices, including communicating about fentanyl with dealers and peers, testing for fentanyl, using smaller quantities of drugs, switching from injecting to smoking, and using naloxone.

CONCLUSION

People who use drugs are responding to the rise of fentanyl on the West Coast and are concerned about the increasing uncertainty and hazards of the drug supply. They are willing and motivated to adopt harm reduction behaviors. Harm reduction promotion from syringe service programs and public health agencies is essential to reduce injury and death from nonpharmaceutical fentanyl.

High-Precision Automatic Identification of Fentanyl-Related Drugs by Terahertz Spectroscopy with Molecular Dynamics Simulation and Spectral Similarity Mapping

Fentanyl is a potent opioid analgesic with high bioavailability. It is the leading cause of drug addiction and overdose death. To better control the abuse of fentanyl and its derivatives, it is crucial to develop rapid and sensitive detection methods. However, fentanyl-related substrates undergo similar molecular structures resulting in similar properties, which are difficult to be identified by conventional spectroscopic methods. In this work, a method for the automatic identification of 8 fentanyl-related substances with similar spectral characteristics was developed using terahertz (THz) spectroscopy coupled with density functional theory (DFT) and spectral similarity mapping (SSM). To characterize the THz fingerprints of these fentanyl-related samples more accurately, the method of baseline estimation and denoising with sparsity was performed before revealing the unique molecular dynamics of each substance by DFT. The SSM method was proposed to identify these fentanyl analogs based on weighted spectral cosine–cross similarity and fingerprint discrete Fréchet distance, generating a matching list by stepwise searching the entire spectral database. The top matched list returned the identification results of the target fentanyl analogs with accuracies of 94.48~99.33%. Results from this work provide algorithms’ increased reliability, which serves as an artificial intelligence-based tool for high-precision fentanyl analysis in real-world samples.

Drug use behaviors, trauma, and emotional affect following the overdose of a social network member: A qualitative investigation

BACKGROUND

Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network.

METHODS

We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes.

RESULTS

We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living.

CONCLUSIONS

Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.

“It's my frenemy”: A qualitative exploration of knowledge and perceptions of fentanyl use during the COVID-19 pandemic in people who use drugs at a syringe services program in Philadelphia, PA

Background

Exacerbated by the COVID-19 pandemic and the proliferation of fentanyl and fentanyl analogs, overdose deaths have surged in the United States, making it important to understand how individuals who use drugs experience and perceive the risks of fentanyl use and how it has changed during the COVID-19 pandemic.

Methods

Twenty clients from a Philadelphia syringe services program completed a questionnaire and in-depth interview about their fentanyl experiences from January to March 2021. These interviews were transcribed and analyzed using thematic analysis methods.

Results

Sixty percent of participants were female and racial/ethnic minority. Participants indicated they believed fentanyl use accounted for most Philadelphia opioid-related overdoses and understood that fentanyl was different from other opioids. Fentanyl use was characterized as “all-consuming” by taking over lives and inescapable. While most perceived their risk of fentanyl overdose as high, there was low interest in and reported use of harm reduction strategies such as fentanyl test strips. The COVID-19 pandemic was noted to have negative effects on fentanyl availability, use and overdose risk, as well as mental health effects that increase drug use.

Conclusions

The divide between perceived risk and uptake of protective strategies could be driven by diminished self-efficacy as it relates to acting on and engaging with resources available at the syringe services program and represents a potential intervention target for harm reduction intervention uptake. But the COVID-19 pandemic has exacerbated risks due to fentanyl use, making an effective, accessible, and well-timed intervention important to address the disconnect between perceived overdose risk and use of preventive behaviors.

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply

Background

Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl’s dramatic increase in the recreational drug supply over the past decade.

Methods

We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes.

Results

PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers.

Conclusion

PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00659-9.

Spatial and neighborhood-level correlates of lay naloxone reversal events and service availability

BACKGROUND

The opioid epidemic in the United States continues to surge, reaching record deaths from opioid and fentanyl overdoses in 2020. This study analyzes spatial and neighborhood correlates of free naloxone distribution sites as well as overdose and naloxone reversal events in Baltimore, Maryland, which has one of the highest overdose rates in the country.

METHODS

Using data from a randomized clinical trial on HIV prevention among people using substances in Baltimore, Maryland, as well as demographic data from the US Census Bureau, we conducted: (1) exploratory spatial visualizations of census tracts' minimum distance to naloxone distribution sites, (2) univariable Wilcoxon rank-sum tests to compare census tracts on demographic metrics, and (3) bivariable and multivariable negative binomial regression models to assess associations between census tract characteristics and naloxone reversal events.

RESULTS

Valid geographic data were provided for 518 overdose events involving either fentanyl or heroin in this study. Of these, 190 (37%) attempted naloxone reversal events were reported. Exploratory spatial visualization techniques suggest that most distribution sites are appropriately located near populations at high risk of overdose, but study findings also identify areas where drug use and overdoses occur that are located farther from distribution sites. In multivariable analyses, naloxone administration was significantly and inversely associated with distance to the nearest distribution site (incidence rate ratio (IRR)=0.72 per 1000m increase, 95% CI 0.59-0.89, p=0.002).

CONCLUSION

Study findings emphasize the correlation between proximity to naloxone sites and utilization of resources, highlighting that physical proximity to harm reduction resources may contribute to uptake. Results further underscore that research on service accessibility and utilization must consider the spatial distribution of health services.

Trends in seizures of powders and pills containing illicit fentanyl in the United States, 2018 through 2021

BACKGROUND

Prevalence of fentanyl-laced counterfeit prescription pills has been increasing in the US, possibly placing a wider population at risk for unintentional exposure. We aimed to determine whether there have been shifts in the number of fentanyl seizures and in the form of fentanyl seized in the US.

METHODS

We examined quarterly national seizure data from High Intensity Drug Trafficking Areas to determine the number of drug seizures in the US containing fentanyl from January 2018 through December 2021. Generalized additive models were used to estimate trends in the number and weight of pill and powder seizures containing fentanyl.

RESULTS

There was an increase both in the number of fentanyl-containing powder seizures (from 424 in 2018 Quarter 1 [Q1] to 1539 in 2021 Quarter 4 [Q4], β = 0.94, p < 0.001) and in the number of pill seizures (from 68 to 635, β = 0.96, p < 0.01). The proportion of pills to total seizures more than doubled from 13.8% in 2018 Q1 to 29.2% in 2021 Q4 (β = 0.92, p < 0.001). Weight of powder fentanyl seizures increased from 298.2 kg in 2018 Q1 to 2416.0 kg in 2021 Q4 (β = 1.12, p = 0.01); the number of pills seized increased from 42,202 in 2018 Q1 to 2,089,186 in 2021 Q4 (β = 0.90, p < 0.001).

CONCLUSIONS

Seizures of drugs containing fentanyl have been increasing in the US. Given that over a quarter of fentanyl seizures are now in pill form, people who obtain counterfeit pills such as those disguised as oxycodone or alprazolam are at risk for unintentional exposure to fentanyl.

"It's probably going to save my life;" attitudes towards treatment among people incarcerated in the era of fentanyl

INTRODUCTION

In recent years, there has been a dramatic increase in overdose deaths involving illicitly manufactured fentanyl. The risk of death due to fentanyl exposure is far higher for people without adequate tolerance, such as those being released from incarceration. However, little is known about knowledge and perceptions of fentanyl among people who are incarcerated.

METHODS

We conducted 40 semi-structured qualitative interviews with people who were incarcerated at the Rhode Island Department of Corrections (RIDOC). We explored the impressions of, preferences for and experiences with fentanyl among these people. Analysis employed a general, inductive approach using NVivo 12.

RESULTS

We found that a majority of the participants were familiar with fentanyl, sought to avoid it and utilized harm reduction techniques when using drugs and taking treatment with medication for opioid use disorder (MOUD) to reduce their risk of overdose.

DISCUSSION

Our findings suggest that broad access to MOUD, especially for incarcerated people, is increasingly necessary in the era of fentanyl, both to aid people seeking recovery due to the increased overdose risk of drug use and to reduce overdose morbidity for people who use drugs.

Effect of an Unsanctioned Safe Consumption Site in the United States on Syringe Sharing, Rushed Injections, and Isolated Injection Drug Use: A Longitudinal Cohort Analysis

BACKGROUND

HIV and other medical complications of drug use, including overdose, are rising among people who inject drugs in the United States (US). Risk of complications and mortality increase with injection behaviors such as syringe sharing, rushing injections, and injecting in isolated places. Studies suggest safe consumption sites (SCS) reduce high-risk injection behaviors by offering sterile syringes and a safe, supervised space to consume drugs, although this has yet to be evaluated in the US.

SETTING

An unsanctioned SCS in an undisclosed US location.

METHODS

From 2018 to 2019, we recruited people who inject drugs using targeted sampling methods (N = 494) and conducted interviews at baseline, 6-, and 12-months. We sought to determine associations of past-month SCS use with past-month receptive syringe sharing, rushed injections, and injections in isolated places. We analyzed data using inverse probability of treatment weighted Poisson regression models. Generalized estimating equations accounted for repeated measures.

RESULTS

Fifty-two (11%) participants had past-month SCS use. Participants with past-month SCS use had decreased rates of receptive syringe sharing (Incident rate ratio [IRR] 0.17, 95% CI: 0.03 to 1.02) and injecting in an isolated location (IRR 0.77, 95% CI: 0.54 to 1.27) compared with those without past-month SCS use, although results were not statistically conclusive. Rate of rushed injections was only slightly lower (IRR 0.94, 95% CI: 0.70 to 1.30).

CONCLUSION

SCS may show benefit in reducing high-risk injection practices, and legal sanctioning of an SCS may offer further advantages. SCS implementation should be considered to help reduce the spread of HIV, overdose mortality, and prevent other medical complications of injection drug use.

Rationalities of Space and Drug-Related Harms: Accounts of People Who Inject Drugs in Nigeria

BACKGROUND

Studies have examined how people who inject drugs (PWID) navigate public spaces for drug consumption, but little is known about consumption of drugs in private apartments. This study explores social, structural and physical environment factors influencing injecting practices and the rationalities shaping how PWID make decisions about where to consume drugs.

METHODS

The study is based on qualitative data from 41 in-depth interviews conducted with both homeless and housed PWID recruited through snowball sampling in Uyo, Nigeria. Thematic analysis, framed by the theoretical constructs of structural and everyday violence, and situated rationality theories, was undertaken on transcripts.

RESULTS

Analysis revealed different socio-spatial rationalities underlying decisions about where to use drugs: avoidance of police arrest, convenience and relaxation, avoidance of drug sharing, avoidance of drug-scene violence, and stigma and shame. These factors show the impacts of social, structural and physical environment factors on the lived experiences of PWID. Injecting in private apartments potentially offset the risk of stigma, police arrest and violence linked to public injecting, but increase the risk of overdose and sharing of drugs and needle-syringes based on social relations of trust.

CONCLUSIONS

Findings show that PWID chose between competing risks when deciding on where to inject drugs. Interventions should consider the situated contexts of risk, and adapt harm reduction measures to the risk profile of different populations of PWID.

Injecting Alone: Practices and Preferences among People Who Inject Drugs in New York City

Injecting alone is a suspected risk factor for opioid overdose death among people who inject drugs (PWID). Better understanding of PWID's injecting practices and preferences could guide pragmatic harm reduction and overdose prevention interventions. We investigated injection practices and preferences among PWID attending syringe services programs (SSPs). We surveyed 108 PWID with opioid use disorder from 3 New York City SSPs between November 2020 and August 2021 to ascertain harm reduction service preferences. This secondary analysis examined injection behavior preferences, reasons for these preferences, and self-reported non-fatal lifetime overdoses. Slightly more participants preferred injecting alone (56%) than with someone present (44%), but most in both groups inject alone most of the time (97% vs 52%, p &lt; 0.01). Commonly reported reasons for preferring to inject alone were privacy (82%) and not wanting to be judged (78%), whereas many preferred to inject with others to have someone present in case of overdose (92%), for camaraderie (69%), and to share drugs (65%). Those preferring to inject alone (vs. with someone present) self-reported higher mean number of lifetime overdoses (3.1 vs 2.6), but differences were not statistically significant. In conclusion, most participants injected alone regardless of preference. While not associated with prior non-fatal overdose, injection preference likely carries risk for future overdose. Participants preferred injecting alone to avoid shame or injecting with others in case of overdose, which can inform public health interventions that support both preferences. Reducing stigma while facilitating rapid overdose response can mitigate the risk of fatal overdose.

Impact of a Homeless Encampment Closure on Crime Complaints in the Bronx, New York City, 2017: Implications for Municipal Policy

Purpose

As part of COVID-19 control policy, the Centers for Disease Control and Prevention has advised local jurisdictions to permit the formation of homeless encampments to prevent community disease spread. This new federal public health guidance is in conflict with existing police policies in many jurisdictions to raze or evict homeless encampments upon discovery. However, no empirical research on homeless encampment policy actions exists.

Methods

This study utilized interrupted time series to estimate the impact of the 2017 closure of "the Hole"-a longstanding encampment of homeless people who use drugs in the Bronx, New York City-on crime complaints. Daily crime complaints originating from public spaces within 1 mile of the encampment were captured during the 30-day periods before and after closure.

Results

Closure was associated with no short-term changesin complaints [IRR=1.01; 95% CI (0.81-1.27)], with daily complaints remaining at baseline levels during the post-closure period [IRR 0.99; 95% CI (0.98-1.00)].

Discussion

Findings preliminarily suggest that the presence of a homeless encampment may not have been associated with increased levels of crime in the neighborhood where it was located. Future research is necessary to understand the health and social impacts of homeless encampments and inform municipal policymakers.

Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019

BACKGROUND

People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities.

METHODS

We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019.

RESULTS

The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05).

CONCLUSION

We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.

"It's like 'liquid handcuffs": The effects of take-home dosing policies on Methadone Maintenance Treatment (MMT) patients' lives

BACKGROUND

Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing risk of overdose, arrest, and transmission of blood-borne viruses like HIV and HCV among people that use opioids. Yet, MMT's use of restrictive take-home dose policies that force most patients to attend their clinic on a daily, or near-daily, basis may be unpopular with many patients and lead to low rates of treatment uptake and retention. In response, this article examines how clinics' take-home dosing policies have affected patients' experiences of treatment and lives in general.

METHODS

This article is based on semi-structured, qualitative interviews with a variety of stakeholders in MMT. Interviews explored: reasons for engaging with, or not engaging with MMT; how MMT is conceptualized by patients and treatment providers (e.g., as harm reduction or route to abstinence and/or recovery); experiences with MMT; perception of barriers to MMT (e.g., organizational/regulatory, social) and how MMT might be improved to support peoples' substance use treatment needs and goals.

RESULTS

Nearly all of the patients with past or present MMT use were highly critical of the limited access to take-home doses and consequent need for daily or near daily clinic attendance. Participants described how the use of restrictive take-home dose policies negatively impacted their ability to meet day-to-day responsibilities and also cited the need for daily attendance as a reason for quitting or avoiding OAT. Responses also demonstrate how such policies contribute to an environment of cruelty and stigma within many clinics that exposes this already-stigmatized population to additional trauma.

CONCLUSIONS

Take-home dose policies in MMT are not working for a substantial number of patients and are reasonably seen by participants as degrading and dehumanizing. Revision of MMT regulations and policies regarding take home doses are essential to improve patient satisfaction and the quality and effectiveness of MMT as a key evidence-based treatment and harm reduction strategy.

Correlations between Changes in Medical Opioid Dispensing and Contributions of Fentanyl to Opioid-Related Overdose Fatalities: Exploratory Analyses from Canada

Canada is experiencing an epidemic of opioid-related mortality, with increasing yet heterogeneous fatality patterns from illicit/synthetic (e.g., fentanyl) opioids. The present study examined whether differential provincial reductions in medical opioid dispensing following restrictive regulations (post-2010) were associated with differential contributions of fentanyl to opioid mortality. Annual provincial opioid dispensing totals in defined daily doses/1000 population/day, and change rates in opioid dispensing for the 10 provinces for (1) 2011-2018 and (2) "peak-year" to 2018 were derived from a pan-Canadian pharmacy-based dispensing panel. Provincial contribution rates of fentanyl to opioid-related mortality (2016-2019) were averaged. Correlation values (Pearson's R) between provincial changes in opioid dispensing and the relative fentanyl contributions to mortality were computed for the two scenarios. The correlation between province-based changes in opioid dispensing (2011-2018) and the relative contribution of fentanyl to total opioid deaths (2016-2019) was -0.70 (t = 2.75; df = 8; p = 0.03); the corresponding correlation for opioid dispensing changes ("peak-year" to 2018) was -0.59 (t = -2.06; df = 8; p = 0.07). Provincial reductions in medical opioid dispensing indicated (near-)significant correlations with fentanyl contribution rates to opioid-related death totals. Differential reductions in pharmaceutical opioid availability may have created supply voids for nonmedical use, substituted with synthetic/toxic (e.g., fentanyl) opioids and leading to accelerated opioid mortality. Implications of these possible unintended adverse consequences warrant consideration for public health policy.

Understanding opioid overdose risk and response preparedness among people who use cocaine and other drugs: Mixed-methods findings from a large, multi-city study

BACKGROUND

Fatal overdoses involving cocaine (powdered or crack) and fentanyl have increased nationally and in Massachusetts. It is unclear how overdose risk and preparedness to respond to an overdose differs by patterns of cocaine and opioid use. Methods: From 2017 to 2019, we conducted a nine-community mixed-methods study of Massachusetts residents who use drugs. Using survey data from 465 participants with past-month cocaine and/or opioid use, we examined global differences (p < 0.05) in overdose risk and response preparedness by patterns of cocaine and opioid use. Qualitative interviews (n = 172) contextualized survey findings. Results: The majority of the sample (66%) used cocaine and opioids in the past month; 18.9% used opioids alone; 9.2% used cocaine and had no opioid use history; and 6.2% used cocaine and had an opioid use history. Relative to those with a current/past history of opioid use, significantly fewer of those with no opioid use history were aware of fentanyl in the drug supply, carried naloxone, and had received naloxone training. Qualitative interviews documented how people who use cocaine and have no history of opioid use are largely unprepared to recognize and respond to an overdose. Conclusions: Public health efforts are needed to increase fentanyl awareness and overdose prevention preparedness among people primarily using cocaine.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Age-based preferences for risk communication in the fentanyl era: 'A lot of people keep seeing other people die and that's not enough for them'

AIMS

To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age.

DESIGN

A single-site qualitative in-depth interview study.

SETTING

Boston, MA, United States.

PARTICIPANTS

The sample included 21 people (10 women, 11 men) who were either 18-25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings.

MEASUREMENTS

Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content.

FINDINGS

We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl's lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages.

CONCLUSIONS

Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers' ability to provide compassionate harm reduction communication.

Trends in overdose experiences and prevention behaviors among people who use opioids in Baltimore, MD, 2017-2019

BACKGROUND

Little is known about trends in overdose behaviors. This study explored non-fatal overdose and engagement in overdose prevention behaviors and compared these trends to city-wide overdose fatality rates from 2017 to 2019 in Baltimore, MD.

METHODS

The analysis included people who used opioids (PWUO; N = 502) recruited through a community-based study. Enrollment date was used to categorize participants into annual quarters. Logistic regression models examined change in overdose experiences and prevention behaviors with time. Baltimore's fatal overdoses were also mapped over the study period to assess overlaps in trends.

RESULTS

The majority of the sample were male(68 %), Black(61 %), reported past 6 months homelessness(56 %), and were on average 45 years old. Most had witnessed(61 %), and 28 % had personally experienced an overdose in the past 6 months. Witnessing overdose marginally increased(aβ = 0.182;p = 0.058) while experiencing overdose did not significantly change by enrollment quarter. Most participants had or had been prescribed naloxone(72 %), and one fifth(22 %) regularly carried naloxone, with both access to(aβ = 0,408;p = 0.002) and carrying naloxone(aβ = 0.302;p = 0.006) increasing over time. Overdose communication remained stable, with 63 % of participants reporting discussing overdose sometimes/often. Among participants who injected (n = 376), regularly injecting alone decreased(aβ=-0.207;p = 0.055), and reporting others often/always having naloxone with them when injecting increased over time(aβ = 0.573;p < 0.001).

CONCLUSIONS

Witnessed overdose marginally increased from 2017 to 2019, aligning with city trends of fatal overdose. Overdose prevention behaviors significantly increased over time. Despite reporting having naloxone or a naloxone prescription, most PWUO did not regularly carry naloxone, and many used alone. Social network diffusion interventions may be a strategy to promote normative overdose prevention behaviors.

Case report: Increasing the frequency of intramuscular naltrexone administration in a high risk patient with opioid use disorder

Background: As the United States faces a national opioid crisis, opioid overdose deaths have significantly risen over the past decade. Patients with opioid use disorder, particularly those who use high-potency synthetic opioids, are at an increased risk of fatal opioid overdose. Alternative dosing strategies for the treatment of opioid use disorder must be considered in high-risk patients to prevent opioid overdose. Case: One patient with opioid use disorder at high risk for overdose was treated with extended-release (XR) intramuscular (IM) naltrexone initially every 28 days, but was frequently reporting increased cravings during the week prior to the next injection being due. This patient's dose of XR IM naltrexone was then given at an increased dosing frequency of every 21-24 days for three months. Opioid craving suppression was achieved without clinical or laboratory evidence of side effects or hepatotoxicity. Discussion: In patients with especially high risk of opioid overdose, consideration of novel dosing strategies for continuation of opioid abstinence is necessary. This is the first report demonstrating the short-term safety and efficacy of more frequent dosing of XR IM naltrexone. This case demonstrates that in select high-risk patients, more frequent dosing of XR IM naltrexone may be an effective strategy to reduce opioid cravings. Informed Consent: The case was reviewed with the Intuition's Privacy Officer who informed the authors that informed consent could not be obtained by the patient's family members due to 38 U.S.C 7332 restrictions on protected information. This manuscript was de-identified and approved by the institution's local privacy officer for publication in accordance with institution policy.

Harm Reduction for Adolescents and Young Adults During the COVID-19 Pandemic: A Case Study of Community Care in Reach

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19-June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms.

A review of performance assessment tools for rescuer response in opioid overdose simulations and training programs

Since the 1990s, more than 600 overdose response training and education programs have been implemented to train participants to respond to an opioid overdose in the United States. Given this substantial investment in overdose response training, valid assessment of a potential rescuers' proficiency in responding to an opioid overdose is important. The aim of this article is to review the current state of the literature on outcome measures utilized in opioid overdose response training. Thirty-one articles published between 2014 and 2020 met inclusion criteria. The reviewed articles targeted laypersons, healthcare providers, and first responders. The assessment tools included five validated questionnaires, fifteen non-validated questionnaires, and nine non-validated simulation-based checklists (e.g., completion of critical tasks and time to completion). Validated multiple choice knowledge assessment tools were commonly used to assess the outcomes of training programs. It is unknown how scores on these assessment tools may correlate with actual rescuer performance responding to an overdose. Seven studies reported ceiling effects most likely attributed to participants' background medical knowledge or experience. The inclusion of simulation-based outcome measures of performance, including the commission of critical errors and the time to naloxone administration, provides better insight into rescuer skill proficiency.

Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment

BACKGROUND

New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis.

METHODS

Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data.

RESULTS

Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs.

CONCLUSIONS

A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

Investigation of Fragmentation Pathways of Fentanyl Analogues and Novel Synthetic Opioids by Electron Ionization High-Resolution Mass Spectrometry and Electrospray Ionization High-Resolution Tandem Mass Spectrometry

The global drug market is characterized by the fast development of new psychoactive substances such as fentanyl analogues and novel synthetic opioids, the detection of which is complicated by the lack of appropriate quality control procedures and references. Herein, we analyze the fragmentation pathways and characteristic ions of 25 novel fentanyl analogues and 5 novel synthetic opioids by electron ionization (EI) and electrospray ionization (ESI) high-resolution mass spectrometry to provide a reference for the identification of these species. In the ESI mode, fentanyl analogues mainly undergo piperidine ring degradation, phenethyl and piperidine ring dissociation, and piperidine ring and amide moiety cleavage, while piperidine ring degradation and phenethyl and piperidine ring dissociation are the major pathways in the EI mode. The five novel synthetic opioids largely undergo amide group dissociation and N-cyclohexyl bond cleavage in the ESI mode. Thus, this work facilitates the detection and quantitation of fentanyl analogues and novel synthetic opioids or other substances with similar structures in forensic laboratories.

Known fentanyl use among clients of harm reduction sites in British Columbia, Canada

BACKGROUND

North America is in the midst of an opioid overdose epidemic and it is commonly suggested that exposure to fentanyl is unknown. Using a provincial survey of harm reduction site clients, we aimed to characterize known and unknown fentanyl use and their correlates among people who use drugs in British Columbia, Canada.

METHODS

We recruited 486 clients who were >18 years old and 316 agreed to provide a urine sample for substance use testing. Reported known fentanyl use was defined as a three-level categorical variable assessing recent (i.e., in the previous three days) fentanyl exposure: (i) known exposure; (ii) unknown exposure; and (iii) no exposure. We also assessed any exposure to fentanyl (Yes vs. No) confirmed by urinalysis. Survey data were summarized using descriptive statistics. Multinomial logistic regression and modified Poisson regression models were built to examine different correlates of exposure to fentanyl.

RESULTS

Median age of the participants was 40 (IQR: 32-49). Out of the 303 eligible participants, 38.7% (117) reported known fentanyl use, 21.7% (66) had unknown fentanyl use, and 39.6% (120) had no recent fentanyl use. In the adjusted multinomial logistic regression model and in comparison with unknown fentanyl use, recent known fentanyl use was significantly associated with self-report of methadone use (aRRR = 3.18), heroin/morphine use (aRRR = 4.40), and crystal meth use (aRRR = 2.95). Moreover, any recent exposure to fentanyl (i.e., positive urine test for fentanyl) was significantly associated with living in urban settings (aPR = 1.49), and self-reporting recent cannabis use (aPR = 0.73), crystal meth (aPR = 1.45), and heroin/morphine use (aPR = 2.48).

CONCLUSION

The landscape of illicit opioid use is changing in BC and more people are using fentanyl knowingly. The increasing prevalence of known fentanyl use is concerning and calls for further investments in public awareness and public policy efforts regarding fentanyl exposure and risks.

The rising crisis of illicit fentanyl use, overdose, and potential therapeutic strategies

Fentanyl is a powerful opioid anesthetic and analgesic, the use of which has caused an increasing public health threat in the United States and elsewhere. Fentanyl was initially approved and used for the treatment of moderate to severe pain, especially cancer pain. However, recent years have seen a growing concern that fentanyl and its analogs are widely synthesized in laboratories and adulterated with illicit supplies of heroin, cocaine, methamphetamine, and counterfeit pills, contributing to the exponential growth in the number of drug-related overdose deaths. This review summarizes the recent epidemic and evolution of illicit fentanyl use, its pharmacological mechanisms and side effects, and the potential clinical management and prevention of fentanyl-related overdoses. Because social, economic, and health problems that are related to the use of fentanyl and its analogs are growing, there is an urgent need to implement large-scale safe and effective harm reduction strategies to prevent fentanyl-related overdoses.

More than just availability: Who has access and who administers take-home naloxone in Baltimore, MD

Background

Fatal opioid overdose is a pressing public health concern in the United States. Addressing barriers and augmenting facilitators to take-home naloxone (THN) access and administration could expand program reach in preventing fatal overdoses.

Methods

THN access (i.e., being prescribed or receiving THN) was assessed in a Baltimore, Maryland-based sample of 577 people who use opioids (PWUO) and had a history of injecting drugs. A sub-analysis examined correlates of THN administration among those with THN access and who witnessed an overdose (N = 345). Logistic generalized estimating equations with robust standard errors were used to identify facilitators and barriers to accessing and using THN.

Results

The majority of PWUO (66%) reported THN access. In the multivariable model, decreased THN access was associated with the fear that a person may become aggressive after being revived with THN (aOR: 0.55, 95% CI: 0.35–0.85), police threaten people at an overdose event (aOR: 0.68, 95% CI: 0.36–1.00), and insufficient overdose training (aOR: 0.43, 95% CI: 0.28–0.68). Enrollment in medication-assisted treatment, personally experiencing an overdose, and graduating from high school were associated with higher access. About half (49%) of PWUO with THN access and who had witnessed an overdose reported having administered THN. THN use was positively associated with “often” or “always” carrying THN (aOR: 3.47, 95% CI: 1.99–6.06), witnessing more overdoses (aOR:5.18, 95% CI: 2.22–12.07), experiencing recent homelessness, and injecting in the past year. THN use was reduced among participants who did not feel that they had sufficient overdose training (aOR: 0.56, 95% CI: 0.32–0.96).

Conclusion

THN programs must bolster confidence in administering THN and address barriers to use, such as fear of a THN recipient becoming aggressive. Normative change around carrying THN is an important component in an overdose prevention strategy.