The Emerging Role of Toxic Adulterants in Street Drugs in the US Illicit Opioid Crisis

Performance Evaluation of 2 FDA-Approved Fentanyl Immunoassays against LC-MS/MS Reference

BACKGROUND

Fentanyl, a synthetic opioid, has caused many recent overdose deaths. Diagnosis of fentanyl abuse is not served by traditional opiate assays due to differences in chemical structure between synthetics and natural opioids. To our knowledge, this is the first study that uses liquid chromatography-tandem mass spectrometry (LC-MS/MS) as the reference method to evaluate and compare the ARK Fentanyl II Assay (ARK II) and the Fentanyl II Enzyme Immunoassay by Roche (FEN2). The ARK II is designed to detect fentanyl in urine samples, whereas the FEN2 is designed to detect norfentanyl, which is the major metabolite.

METHODS

Two hundred patient urine samples including 100 positive and 100 negative samples according to an in-house LC-MS/MS assay were selected for the study. These samples were tested using the ARK II and the FEN2 to determine their performances relative to LC-MS/MS results.

RESULTS

The FEN2 showed a positive and negative predictive value of 100% and 97% and a concordance with LC-MS/MS of 98.5% (kappa 0.97). The ARK II showed a positive and negative predictive value of 100% and 95% and a concordance with LC-MS/MS of 97.5% (kappa 0.95). Additionally, the FEN2 accurately identified 9 positive samples with a range of fentanyl concentrations from 0 to 18 ng/mL for which norfentanyl levels were less than the cutoff of 5 ng/mL, indicating potentially greater sensitivity than otherwise stated.

CONCLUSIONS

The FEN2 and the ARK II were evaluated to be similar in terms of positive and negative predictive value during the analysis of 200 patient samples, as well as equally concordant with the LC-MS/MS reference, despite differences in design.

"If everyone knew about this, how many lives could we save?": Do drug suppliers have a role in reducing overdose risk?

Introduction

An unpredictable illicit drug supply is driving high levels of overdose death in North America. Prior research has demonstrated the importance of involving people who use drugs in harm reduction intervention design and implementation. The inclusion of people who supply drugs in these efforts has been scant. We explore this possibility by interviewing persons targeted by a harm reduction educational program designed specifically for people who supply drugs.

Methods

In-person interviews with people who use drugs were conducted in 2022 in Indianapolis, Indiana. We conducted a thematic analysis of data from six interviews with people who were either primarily or secondarily trained through this harm reduction training for people who supply drugs.

Results

Participants described a diverse array of harm reduction strategies, some gained through the targeted education program, which they regularly practiced as they consumed and/or supplied drugs to others. People who supply drugs were regularly identified as key actors capable of widely reducing risk across drug networks. Participants described being motivated by a moral imperative to protect community members, tying the previous loss of friends and loved ones to overdose to their commitments to the safety of others.

Conclusion

This article contributes to the scholarship on the role of people who supply drugs in implementing harm reduction interventions and reducing overdose risk. Better enabling grassroots harm reduction organizations to provide people who supply drugs with harm reduction training and access to harm reduction resources may help to reduce drug-related harms.

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Housing and Displacement as Risk Factors for Negative Health Outcomes Among People Who Inject Drugs in Los Angeles, CA, and Denver, CO, USA

Background

The United States is currently experiencing a housing and homelessness crisis. In response, many cities have adopted policies of displacement that move unhoused people from place to place. Recent research indicates that these policies may have negative health impacts on unhoused people who use drugs. We sought to examine health risks associated with government-enforced displacement among unhoused people who inject drugs (PWID).

Methods

We interviewed a community-recruited sample of opioid-using PWID in Los Angeles, CA and Denver, CO between April 2021 and November 2022 (N = 472) about their demographic/socioeconomic characteristics, drug use patterns, housing status, government-enforced displacement including items discarded during displacements, and health risks. We constructed binomial generalized linear regression to examine the risk ratio of non-fatal overdose, and syringe and cooker/cotton sharing between four groups of participants: housed, unhoused and not displaced, unhoused and relocated voluntarily, and unhoused and displaced in the last three months.

Results

In the last 3 months, 52% of participants were unhoused and displaced by the government. Among those who were displaced, median number of government-enforced displacements was 3 with 69% reporting loss of syringes, 56% loss of naloxone, and 22% loss of buprenorphine medicine. In multivariate models, risk ratios for unhoused and displaced participants were higher for nonfatal overdose and cooker/cotton sharing as compared to housed participants. Risk ratios for syringe sharing amongst unhoused participants did not differ significantly.

Conclusions

Unhoused and displaced PWID experience elevated health risks. Ending the use of government-enforced displacement of unhoused PWID is essential to reducing health risk in this population.

Evaluation of the Psychiatric Disorders among Amphetamine Addicts in Rehabilitation Centers: A Cross-Sectional Analysis

Background

People who are addicted to amphetamines have a much greater chance of developing psychosis compared to those who are not. It is essential to study the behavioral and psychological effects of amphetamines. Therefore, this research aimed to examine conditions such as depression, anxiety, mood, cognitive abilities at the workplace, and social responsibilities by using sociodemographic factors as useful tools in determining effective strategies for preventing, managing, and treating amphetamine addiction.

Methods

A cross-sectional study among addicts hospitalized at two rehabilitation centers across Saudi Arabia between May and October 2023. A validated questionnaire consisting of psychiatric disorders assessment tools was distributed to healthcare professionals to start an interview with addicts to assess the abnormalities. The results were compared with healthy people (control). The assessment tools used are Hamilton Anxiety and Depression Rating Scale, Young Mania Rating Scale, and Work and Social Adjustment Scale. The data were analyzed using SPSS version 22.0. Pearson correlation coefficients (r) were employed.

Results

A total of 60 subjects participated in this study. The participants were divided into two groups (n = 60): group I was control (n = 25) healthy volunteers and group II was amphetamine abusers (n = 35), who were hospitalized for detoxification. The ages ranged from 18 to 60 years old with mean ages of 38.68 (±8.14) and 37.77 (±10.95) years in the control and amphetamine groups, respectively. Among the addicts, the mean severity dependence scale value was 10.46 (±1.82), which denotes high dependency on the illicit drug. The prevalence of high levels of anxiety, depression, and bipolar disorder was significantly higher among addicts when they were compared to healthy people (control). The assessment of the Work and Social Adjustment Scale (WSAS) reflected a higher impairment that minimized their ability to perform the work requirements, home management, social leisure, and relationships.

Conclusions

The addiction to amphetamines was associated with high impairment of work performance and social obligations and a negative impact on the addict's mental health. The risk of suffering anxiety, depression, and bipolar is higher than in nonaddict people. These effects are attributed to brain damage, neurotoxicity, and neuronal inflammation, particularly when these substances are abused over extended periods and at higher doses.

Strategies for assessing the limit of detection in voltammetric methods: comparison and evaluation of approaches

The realm of analytical chemistry continues to struggle with defining and evaluating the limit of detection in analytical methods in the sense that a multitude of definitions, criteria, caveats, and methods have been proposed, developed, and adopted across disciplines. The last decade has seen a surge in the growth of electrochemical methods and studies in the field of forensic science and forensic chemistry. While many disciplines within forensic science have established method validation guidelines, the historical and current lack of electrochemical methods within forensic laboratories throughout the United States has left a major gap in knowledge, inhibiting the adoption and utilization of electrochemistry, which may serve as a powerful tool in many subdisciplines of forensics. As such, this work begins this discussion by focusing first on the limit of detection (LOD), with application toward both qualitative and quantitative methods. Both inorganic (ferrocyanide and lead) and organic (diphenylamine, naltrexone, and acetaminophen) target analytes were analyzed via two common voltammetry methods: cyclic voltammetry and square-wave voltammetry. The LOD for each analyte was estimated and/or calculated following a variety of literature-described methods and compared. The accuracy and reliability of these LOD characteristics based on the experimental data is described herein along with suggestions and recommendations. This manuscript is intended to compare the resulting LOD values from various methods and provide a starting point for the incorporation of electrochemistry into the forensic science laboratory, beginning a focused discussion on the development of validation guidelines and parameters needed for the adoption of this technology in forensic laboratories in order to meet the standards required by the criminal justice system.

How Social Workers Can Be Deployed to Assist with the Ongoing Opioid Crisis

The opioid epidemic has claimed more than 1 million lives in the United States over the past two decades. The persistent increase in deaths indicates that current strategies intended to decrease the negative consequences of opioid use are inadequate. Harm reduction strategies are designed to promote safer substance usage and reduce overdose mortality rates, yet the implementation of harm reduction programs is inhibited by community- and provider-level stigma against people who use opioids, coupled with limited understanding and insufficient education about harm reduction approaches. Despite ongoing research, engagement in opioid treatment programs remains a challenge, and the opioid crisis continues to disproportionately harm marginalized populations. This article describes how social workers are prepared to play a larger role in opioid use treatment because they are trained with the skill set and values necessary to facilitate access to harm reduction programs, promote engagement in substance use treatment, and create and advocate for interventions to address problematic substance use, especially in high-need communities.

Harm Reduction and Treatment Among People at High Risk of Overdose

Importance

Rates of overdose deaths involving synthetic opioids remain high, increasingly involve stimulants combined with opioids, and are increasing rapidly in racially and ethnically minoritized communities, yet little is known about access to harm reduction and treatment services in these groups.

Objective

To characterize access and barriers to harm reduction and treatment in a racially and ethnically diverse population of people who use drugs.

Design, Setting, and Participants

A cross-sectional telephone survey of people recruited from 39 treatment, harm reduction, and social service organizations in Milwaukee County, Wisconsin; Flint and Detroit, Michigan; and statewide in New Jersey was conducted from January 30 to July 28, 2023. Adults who used cocaine, methamphetamine, or opioids in the past 30 days called a study hotline and completed an interview in English or Spanish.

Exposures

Overdose experience, drug types used (opioids only, stimulants only, and polysubstance), and social risk factors (eg, financial instability and criminal legal involvement).

Main Outcomes and Measures

Recent use of any harm reduction services, fentanyl test strips, naloxone possession, treatment, and self-reported barriers to services.

Results

Of the total sample of 1240 adults, 486 (39.2%) were Black non-Hispanic, 183 (14.8%) were Hispanic, and 464 (37.4%) were White non-Hispanic. In the past 30 days, 826 individuals (66.6%) were polysubstance users, 135 (10.9%) used only opioids, and 279 (22.5%) used only stimulants. A total of 349 respondents (28.1%) experienced a prior-year overdose. Compared with those without a prior-year overdose, people with overdose were more likely to possess naloxone (80.7% vs 68.2%; P < .001), possess fentanyl test strips (36.8% vs 23.5%; P < .001), and use harm reduction services (63.4% vs 53.0%; P = .003), while differences in treatment use were nonsignificant (52.0% vs 46.6%; P = .24). Among stimulant-only users, 51.4% possessed naloxone compared with 77.3% of opioid-only users (P < .001) and 77.6% of polysubstance users (P < .001), with similar disparities in fentanyl test strip possession.

Conclusions and Relevance

In this cross-sectional study of people who used drugs in the past 30 days, findings highlighted low use of harm reduction and treatment services among people who use stimulants. Additional communication regarding their importance may help increase the use of the services amidst a rapidly changing drug supply.

On the pathway to health equity: Creating a harm reduction strategy for a large academic acute care hospital

An urban centre in southwestern Ontario continues to be faced with the extensive impacts of high rates of substance use. To more effectively meet the quintuple aim, in a way that authentically considers patients who use substances, the need for a cohesive, comprehensive organizational harm reduction strategy at the large academic acute care hospital providing community and regional healthcare services was clear. Community-based harm reduction expertise was leveraged to support the development work. Information gathered through literature review and interviews with patients, internal staff and leaders, partner healthcare agencies, and Canadian hospitals leading in harm reduction work provided key insights and supported the formulation of emerging recommendations that will be used to shape the acute care hospital's formal organizational harm reduction strategy.

Rapid and Sensitive Detection of Fentanyl and Its Analogs by a Novel Chemiluminescence Immunoassay

BACKGROUND

Abuse of fentanyl and its analogs is a major contributor to the opioid overdose epidemic in the United States, but detecting and quantifying trace amounts of such drugs remains a challenge without resorting to sophisticated mass spectrometry-based methods.

METHODS

A sensitive immunoassay with a sub-picogram limit of detection for fentanyl and a wide range of fentanyl analogs has been developed, using a novel high-affinity antibody fused with NanoLuc, a small-size luciferase that can emit strong and stable luminescence. When used with human urine samples, the assay has a sub-picogram limit of detection for fentanyl, with results fully concordant with LC-MS.

RESULTS

When applied to clinical samples, the novel chemiluminescence immunoassay can detect low positive fentanyl missed by routine screening immunoassays, with a limit of detection of 0.8 pg/mL in human urine. When applied to environmental samples, the assay can detect levels as low as 0.25 pg fentanyl per inch2 of environment surface. Assay turnaround time is less than 1 h, with inexpensive equipment and the potential for high-throughput automation or in-field screening.

CONCLUSIONS

We have established a novel assay that may have broad applications in clinical, environmental, occupational, and forensic scenarios for detection of trace amounts of fentanyl and its analogs.

Reinforcing effects of fentanyl analogs found in illicit drug markets

RATIONALE

The potent synthetic opioid fentanyl, and its analogs, continue to drive opioid-related overdoses. Although the pharmacology of fentanyl is well characterized, there is little information about the reinforcing effects of clandestine fentanyl analogs (FAs).

OBJECTIVES

Here, we compared the effects of fentanyl and the FAs acetylfentanyl, butyrylfentanyl, and cyclopropylfentanyl on drug self-administration in male and female rats. These FAs feature chemical modifications at the carbonyl moiety of the fentanyl scaffold.

METHODS

Sprague-Dawley rats fitted with intravenous jugular catheters were placed in chambers containing two nose poke holes. Active nose poke responses resulted in drug delivery (0.2 mL) over 2 s on a fixed-ratio 1 schedule, followed by a 20 s timeout. Acquisition doses were 0.01 mg/kg/inj for fentanyl and cyclopropylfentanyl, and 0.03 mg/kg/inj for acetylfentanyl and butyrylfentanyl. After 10 days of acquisition, dose-effect testing was carried out, followed by 10 days of saline extinction.

RESULTS

Self-administration of fentanyl and FAs was acquired by both male and female rats, with no sex differences in acquisition rate. Fentanyl and FAs showed partial inverted-U dose-effect functions; cyclopropylfentanyl and fentanyl had similar potency, while acetylfentanyl and butyrylfentanyl were less potent. Maximal response rates were similar across drugs, with fentanyl and cyclopropylfentanyl showing maximum responding at 0.001 mg/kg/inj, acetylfentanyl at 0.01 mg/kg/inj, and butyrylfentanyl at 0.003 mg/kg/inj. No sex differences were detected for drug potency, efficacy, or rates of extinction.

CONCLUSIONS

Our work provides new evidence that FAs display significant abuse liability in male and female rats, which suggests the potential for compulsive use in humans.

Target and Nontarget Screening to Support Capacity Scaling for Substance Use Assessment through a Statewide Wastewater Surveillance Network in New York

Wastewater-based epidemiology (WBE) has been widely implemented around the world as a complementary tool to conventional surveillance techniques to inform and improve public health responses. Currently, wastewater surveillance programs in the U.S. are evaluating integrated approaches to address public health challenges across multiple domains, including substance abuse. In this work, we demonstrated the potential of online solid-phase extraction coupled with liquid chromatography-high-resolution mass spectrometry to support targeted quantification and nontargeted analysis of psychoactive and lifestyle substances as a step toward understanding the operational feasibility of a statewide wastewater surveillance program for substance use assessment in New York. Target screening confirmed 39 substances in influent samples collected from 10 wastewater treatment plants with varying sewershed characteristics and is anticipated to meet the throughput demands as the statewide program scales up to full capacity. Nontarget screening prioritized additional compounds for identification at three confidence levels, including psychoactive substances, such as opioid analgesics, phenethylamines, and cathinone derivatives. Consumption rates of 12 target substances detected in over 80% of wastewater samples were similar to those reported by previous U.S.-based WBE studies despite the uncertainty associated with back-calculations. For selected substances, the relative bias in consumption estimates was sensitive to variations in monitoring frequency, and factors beyond human excretion (e.g., as indicated by the parent-to-metabolite ratios) might also contribute to their prevalence at the sewershed scale. Overall, our study marks the initial phase of refining analytical workflows and data interpretation in preparation for the incorporation of substance use assessment into the statewide wastewater surveillance program in New York.

Xylazine: A Drug Adulterant of Clinical Concern

PURPOSE OF REVIEW

The opioid epidemic has been responsible for significant morbidity and mortality in the USA and worldwide. As a result, it is essential to recognize the threat these potent drugs can cause when illicitly used. Specifically, introducing fentanyl as a drug adulterant has been shown to impact overdose rates drastically. In this regard, the Drug Enforcement Agency recently released a public safety alert announcing the new threat of a new adulterant called xylazine. Xylazine is a powerful animal sedative with a different mechanism of action when compared to illicit opioids such as heroin and fentanyl. Xylazine is typically injected intravenously via a syringe, often in combination with multiple other drugs. One of the most common drugs, xylazine, is taken in combination with fentanyl, with users of this drug combination describing xylazine as prolonging the euphoric sensation produced by fentanyl.

RECENT FINDINGS

Xylazine may cause adverse effects such as bradycardia, brief hypertension followed by hypotension, premature ventricular contractions, ataxia, slurred speech, sedation, and respiratory depression. Much of the recent literature on xylazine use in humans comes from case reports and review articles. Related to widespread use in veterinary medicine and increasing circulation in illicit drug markets, there is a critical need for public awareness and additional clinical-based studies to further increase understanding of mediated or modulated pharmacological effects of xylazine in humans. Further research is urgently needed to more clearly understand the implications of unregulated xylazine in the illicit drug market, to formulate public health interventions, and to implement harm reduction strategies.

Wellness Tour for Tribal Communities During the COVID-19 Pandemic: Uniting Sacred Space with Western Medicine to Prevent Substance Use

Substance use disorders (SUD) and overdose deaths worsened further during the Covid-19 pandemic in American Indian and Alaska Native (AIAN) communities. The Native Dad's Network (NDN) delivered the Wellness Tour, offering cultural activities and SUD prevention education, from March 2021 to June 2022, to 11 AIAN tribal communities across California. The in-person program created a "sacred space" through culturally congruent song, dance, and prayer. SUD education included: a lecture about opioids and SUD; group talking circles; an educational skit led by adolescents; and training in naloxone and fentanyl testing strip use along with supplies. After the day-long program, 341 participants agreed strongly on a 5-point Likert type question that it improved their quality of life (mean = 4.7). Among 243 respondents, agreement was strong (mean = 4.8) to two Likert-type questions about cultural relevance and confidence in using naloxone. This AIAN-led program adopted safe practices during the pandemic to deliver culturally congruent SUD prevention education to severely affected AIAN communities.

Adulterants present in the San Diego county fentanyl supply: a laboratory analysis of seized law enforcement samples

BACKGROUND

The opioid overdose crisis is one of the worst public health crises ever to face the US and emerging evidence suggests its effects are compounded by the presence of drug adulterants. Here we report our efforts to characterize the adulterants present within the local fentanyl supply of San Diego County, obtained from undifferentiated drug samples seized by local law enforcement over the calendar year 2021.

METHODS

Thirty-two participating local law enforcement agencies across San Diego submitted 4838 unknown individual illicit drug samples (total of 312 kg) to the San Diego County Sheriff's Department Regional Crime Laboratory for identification.

RESULTS

Qualitative analysis of these samples via FTIR and GC-MS identified methamphetamine (38.7%), fentanyl (20.8%), diacetylmorphine (heroin) (10.2%), codeine (5.8%) and alprazolam (4.3%) as the most common illicit substances and the presence of 52 unique adulterants. The most common adulterants included 4-methylaminoantipyrine (4-MAAP) (10.9%), mannitol (9%), acetaminophen (8.5%), methamphetamine (4.2%), diacetylmorphine (heroin) (3.6%), tramadol (1.9%), and xylazine (1.7%). Several additional pharmacologically active adulterants and contaminants of interest were also identified.

CONCLUSION

This analysis is vital for public health use and harm reduction efforts at the level of the individual consumer. Continued direct surveillance of the drug supply is necessary for the detection of potentially harmful adulterants that may pose serious threats to the public.

Diphenhydramine-involved Fatal and Nonfatal Drug Overdoses in Tennessee, 2019-2022

BACKGROUND

Diphenhydramine (DPH), known as the brand name Benadryl, is an over-the-counter medication associated with accidental ingestion leading to nonfatal overdoses. Additionally, DPH has been used in tandem with illicit substances leading to fatal drug overdoses.

OBJECTIVE

In response to DPH being seized with illicit drugs as an adulterant, as well as its growing intentional misuse, we sought to explore its recent involvement in fatal and nonfatal drug overdoses in the state of Tennessee.

METHODS

We conducted a statewide cross-sectional study to determine the characteristics of DPH-involved fatal and nonfatal overdoses in Tennessee during 2019-2022 using data from the State Unintentional Drug Overdose Reporting System, the Electronic Surveillance System for the Early Notification of Community-based Epidemics, and the National Forensic Laboratory Information System Public Data Query System. Frequencies were generated to compare demographic characteristics, circumstances, and toxicology between fatal and nonfatal DPH-involved overdoses.

RESULTS

We identified 143 suspected nonfatal DPH and 409 fatal DPH-involved overdoses in Tennessee from 2019 to 2022. Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021. Most nonfatal overdoses were under 18 (63.4%), while most fatal overdoses were between 18 and 64 years of age (95.7%). For fatal overdoses, fentanyl was the most prevalent substance on toxicology followed by prescription opioids.

CONCLUSION

Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021 in Tennessee. Use of DPH among other illicit substances lends to evidence suggesting its use as an adulterant. Monitoring of DPH-involved fatal and nonfatal overdoses is critical to inform harm reduction initiatives.

Physiologic Effects of Substance Use

Physiologic and psychological effects of substance use are common occurrences. They may be the proximate purpose of the exposure or related to an unintended complication. Acute short-term exposure effects may not be the same as long-term effects. These effects are mediated by different receptors they act on and the homeostatic changes that occur due to repeat exposure. We review in this article the physiologic and psychological effects from exposure to commonly encountered drugs, ethanol, sedative hypnotics, cocaine, amphetamines, marijuana, opioids, nicotine, hydrocarbons (halogenated and non-halogenated), and nitrous oxide.

Screening Incarcerated Women for Opioid Use Disorder

The overall aim of the present study is to examine the utility of the DSM OUD Checklist and the NM-ASSIST screening tools to identify symptoms consistent with OUD among incarcerated women in county jails. This study contributes to the existing literature because research on screening and assessment approaches for incarcerated women has been limited. The focus of the current study is to describe the screening procedures and study recruitment for a larger parent study focused on increasing treatment linkages. Study findings indicate a positive correlation between indicators of OUD using the two screening tools, as well as a high degree of correlation between street opioid misuse and other high-risk drug indicators (overdose and injection practices). These findings underscore the importance of outreach, screening, and intervention in real-world settings, including jails, in order to increase access to OUD treatment among this vulnerable sample of women.

Comprehensive Urine Drug Screen by Liquid Chromatography-Quadrupole Time of Flight Mass Spectrometry

Current trends in drug use include polydrug use as well as an ever-changing landscape of novel psychoactive substances. Immunoassay-based urine drug screens limited to classic drugs of abuse do not have the scope necessary to identify patients with drug intoxications or drug misuse. Mass spectrometry is an alternative method that is both sensitive and specific. In this chapter, we present a liquid chromatography-quadrupole mass spectrometry-based method for qualitative comprehensive urine drug screening. The method runs in positive mode and encompasses over 1000 basic compounds, including pharmaceutical, illicit, and novel drugs. Retention time, MS and MS/MS spectra, mass error, and isotope confidence are parameters used for compound identification. New compounds are readily added as new recreational drugs emerge.

Postmortem toxicology findings from the Camden Opioid Research Initiative

The United States continues to be impacted by decades of an opioid misuse epidemic, worsened by the COVID-19 pandemic and by the growing prevalence of highly potent synthetic opioids (HPSO) such as fentanyl. In instances of a toxicity event, first-response administration of reversal medications such as naloxone can be insufficient to fully counteract the effects of HPSO, particularly when there is co-occurring substance use. In an effort to characterize and study this multi-faceted problem, the Camden Opioid Research Initiative (CORI) has been formed. The CORI study has collected and analyzed post-mortem toxicology data from 42 cases of decedents who expired from opioid-related toxicity in the South New Jersey region to characterize substance use profiles. Co-occurring substance use, whether by intent or through possible contamination of the illicit opioid supply, is pervasive among deaths due to opioid toxicity, and evidence of medication-assisted treatment is scarce. Nearly all (98%) of the toxicology cases show the presence of the HPSO, fentanyl, and very few (7%) results detected evidence of medication-assisted treatment for opioid use disorder, such as buprenorphine or methadone, at the time of death. The opioid toxicity reversal drug, naloxone, was detected in 19% of cases, but 100% of cases expressed one or more stimulants, and sedatives including xylazine were detected in 48% of cases. These results showing complex substance use profiles indicate that efforts at mitigating the opioid misuse epidemic must address the complications presented by co-occurring stimulant and other substance use, and reduce barriers to and stigmas of seeking effective medication-assisted treatments.

Xylazine Use in Pregnancy: The Effects of the Fentanyl Adulterant Xylazine on Pregnant Patients and the Developing Fetus

Objective

A literature review was completed to outline the effects of xylazine on the pregnant patient while raising awareness of the increasing prevalence of opioid use disorder in pregnancy and the increase in adulterants in non-prescribed controlled substances.

Data Sources

PubMed and Google Scholar were searched using the key words "xylazine, adulterant," "xylazine, humans," "xylazine, pregnancy," and "xylazine, placenta" to identify the studies evaluating xylazine's effects on humans and the pregnant patient.

Study Selection

Studies were included if they provided information on symptoms of xylazine exposure, the prevalence of xylazine in pregnant humans and the hemodynamic effects of xylazine on both human and animal pregnant populations. Animal studies were included given the limited data on xylazine in pregnant humans. Four studies were utilized for background data and five studies were included in the final review of the effects of xylazine on pregnancy.

Results

Studies involving humans show that xylazine toxicity can cause respiratory depression, bradycardia, and central nervous system depression. There is evidence of xylazine in human umbilical cord tissue, showing that the fetus is exposed to xylazine. Animal studies show decreased uterine blood flow, increased uterine vascular resistance, and decreased fetal growth in response to xylazine.

Conclusions

Due to the limited studies on the effects of xylazine on pregnant populations, providers rely on animal studies for knowledge on xylazine's effects throughout pregnancy. Animal studies suggest an increased risk of adverse effects during pregnancy in response to xylazine. Future studies should focus on the pregnancy outcomes in patients exposed to xylazine to create more robust recommendations for treatment and pregnancy surveillance.

A qualitative assessment of key considerations for drug checking service implementation

BACKGROUND

With many drug-related deaths driven by potent synthetic opioids tainting the illicit drug supply, drug checking services are becoming a key harm reduction strategy. Many drug checking technologies are available, ranging from fentanyl test strips to mass spectrometry. This study aimed to identify key considerations when implementing drug checking technologies and services to support harm reduction initiatives.

METHODS

Key informant interviews were conducted with harm reduction stakeholders throughout Illinois. Participants included members of existing drug checking services and recovery centers. Interviews were recorded, transcribed, and coded by two researchers using the framework method. Findings were contextualized according to micro (client)-, meso (organization)-, and macro (policy)-level themes.

RESULTS

Seven interviews were conducted with ten participants. Fourier transform infrared spectroscopy was consistently identified as a technology of choice given its accuracy, range of substance detection, portability, and usability. Recommendations included the use of confirmatory testing, which can help address the limitations of technologies and provide a mechanism to train technicians. Locations of drug checking services should maximize public health outreach and leverage existing harm reduction agencies and staff with lived experience, who are critical to developing trust and rapport with clients. Criminalization and loss of privacy were major concerns for clients using drug checking services. Additional issues included the need to raise awareness of the legitimacy of services through public support from governing bodies, and funding to ensure the sustainability of drug checking services.

CONCLUSIONS

This research facilitated the identification of issues and recommendations from stakeholders around key considerations for the adoption of drug checking technologies, which not only included the cost and technical specifications of instrumentation, but also broader issues such as accessibility, privacy, and well-trained personnel trusted by clients of the service. Successful implementation of drug checking services requires knowledge of local needs and capacity and an in-depth understanding of the target population.

Guidance for Handling the Increasing Prevalence of Drugs Adulterated or Laced With Fentanyl

The use of fentanyl and its analogs is the primary driver of deaths related to the opioid overdose crisis. In fall 2021, the U.S. Drug Enforcement Administration issued its first public safety alert in 6 years to raise awareness of the escalating prevalence of fentanyl in counterfeit pills and in other opioids, such as heroin, and nonopioids, such as methamphetamine. In addition to increased public awareness, specific actions are needed to remediate the risk for fentanyl overdose. The authors endorse four principles to address the opioid overdose crisis and provide guidance for remediating its impacts: an incremental approach to behavior change or harm reduction; engagement strategies for individuals with substance use disorder; an integrated care approach to ensure better access to treatment programs and effective interventions; and vigilance among clinicians, program staff, and patients to the threat of fentanyl-adulterated drugs. The authors offer specific recommendations on how to apply these principles effectively within health care systems, communities, and law enforcement agencies across the United States.

Trends and correlates of abscess history among people who inject drugs in Massachusetts: A mixed methods exploration of experiences amidst a rapidly evolving drug supply

Background

Injection drug use poses significant risk for skin and soft tissue infections, such as abscesses. In places with endemic fentanyl and an increasingly contaminated drug supply, injecting and injection-related harms may be increasing, yet are understudied. We aimed to explore abscess prevalence, experiences, and themes among people who inject drugs (PWID) in the context of an evolving drug supply.

Methods

Between 2019 and 2022, we surveyed and interviewed Massachusetts- based PWID about current drug use behaviors and abscess experiences. Chi-square tests explored correlates of abscess history and trends for past-year abscess percentages over time. Transcribed interview data were analyzed to identify themes related to abscess risk and opportunities for intervention.

Results

Of the 297 PWID surveyed, 65.3% reported having an abscess at the injection site in their lifetime; 67.5% of these instances occurred within the last year. Reported past-year abscesses increased from 36.7% to 75.6% between 2019 and 2022. Correlates of past-year abscesses included frequent injection; methamphetamine, crack, or fentanyl use; and injection into the neck or calf. Methadone treatment was associated with significantly fewer recent abscesses. Interview data (n=151) confirmed the identified abscess risks, including syringe sharing and lack of hygienic supplies. Qualitative interviews provided additional data regarding healthcare provider stigma contributing to healthcare avoidance and the self-treatment of abscesses with adverse results.

Conclusions

Abscesses are an increasing concern among PWID residing in areas of high fentanyl prevalence and a contaminated drug supply. Community drug checking, overdose prevention sites, injection hygiene interventions, and improved access to care are indicated.

Identifying early intervention opportunities for illicit stimulant use: A cross-sectional study of factors associated with illicit stimulant use among young people accessing integrated youth services in British Columbia, Canada

INTRODUCTION

Illicit stimulant (cocaine and/or amphetamine) use among young people aged 12-24 is a public health priority given that substance use initiation tends to peak in this developmental period and significant associated immediate and long-term harms are associated with its use. Young people using stimulants must be engaged in services as early as possible to reduce these harms. To inform early intervention opportunities, this study aimed to identify the risk/protective factors associated with illicit stimulant use among young people.

METHODS

We conducted a cross-sectional study on routinely collected self-reported data among young people accessing integrated youth services in British Columbia (Canada) between April 2018 and January 2022. Data were collected on young peoples' socio-demographic characteristics, and social, behavioral, and health profiles. Variable selection was guided by established risk/protective factors for substance use among young people. The study used multivariable logistic regression to identify risk/protective factors that were independently associated with past 30-day illicit stimulant use.

RESULTS

The analytic sample included n = 5620 young people aged 12-24 and a total of 163 (2.9 %) reported past 30-day illicit cocaine and/or amphetamine use. Demographic characteristics that were independently associated with illicit stimulant use included older age (aOR = 1.27, 95 % CI = 1.17-1.38) and gender identity as man vs woman (aOR = 1.71, 95 % CI = 1.10-2.70). Social and environmental risk factors included recently witnessing or experiencing violence (aOR = 2.32, 95 % CI = 1.47-3.68) and higher past-year crime/violent behaviors score (aOR = 1.39, 95 % CI = 1.13-1.69). Finally, regular alcohol (aOR = 6.90, 95 % CI = 2.36-25.42), regular (aOR = 3.74, 95 % CI = 1.95-7.54) or social (aOR = 3.06, 95 % CI = 1.44-6.60) tobacco use, and lifetime hallucinogen (aOR = 3.24, 95 % CI = 1.8-5.91) and ecstasy/MDMA (aOR = 2.53, 95 % CI = 1.48-4.39) use were also statistically significant risk factors.

CONCLUSIONS

These risk/protective factors support identification of young people who may benefit from further screening, assessment, and treatment for illicit stimulant use. This study also underscores the need to expand early intervention and harm reduction programs that can comprehensively respond to young peoples' stimulant use, health, and social needs.

Fentanyl, etizolam, and beyond: A feasibility study of a community partnership using handheld Raman spectrometry to identify substances in the local illicit drug supply

Background:

The United States is currently experiencing an unprecedented rise in fatal drug overdoses, which is in part due to the arrival of fentanyl, fentanyl analogs, and other synthetic drugs into the illicit drug supply. Traditional urine drug testing is often unable to detect fentanyl analogs and other novel synthetic drugs, which places physicians and first responders in the difficult position of treating patients who are intoxicated with or overdosing on unknown substances.

Design and methods:

We report, as a feasibility study, the development of a novel program to use a handheld Raman spectrometry device in our hospital’s Emergency Department to surveil our local illicit drug supply in terms of what substances are being sold and used.

Results:

Using our novel program, we were able to detect 27 substances in our illicit drug supply over a 10 month period, including fentanyl analogues. We shared, through our local opioid safety coalition, real-time information to first responders, substance use treatment programs, and physicians about the novel substances we detected using the handheld Raman spectrometer.

Conclusions:

A community partnership of using handheld Raman spectrometry in our hospital’s Emergency Department was successful in providing information to health care providers about novel substances in our illicit drug market. Additionally, the implementation of this program improved collaboration between local health care providers and local law enforcement.

COVID-19-Related Changes to Drug-Selling Networks and Their Effects on People Who Use Illicit Opioids

OBJECTIVE

The COVID-19 pandemic has significantly affected people's ability to buy, sell, and obtain items that they use in their daily lives. It may have had a particularly negative effect on the ability of people who use illicit opioids to obtain them because the networks they relied on are illicit and not part of the formal economy. Our objective in this research was to examine if, and how, disruptions related to COVID-19 of illicit opioid markets have affected people who use illicit opioids.

METHOD

We collected 300 posts--including replies to posts--related to the intersection of COVID-19 and opioid use from Reddit.com, a forum that has several discussion threads (i.e., subreddits) dedicated to opioids. We then coded posts from the two most popular opioid subreddits during the early pandemic period (March 5, 2020-May 13, 2020) using an inductive/deductive approach.

RESULTS

We found two themes related to active opioid use during the early pandemic: (a) changes in drug supply and difficulty obtaining opioids, and (b) buying less-trustworthy drugs from lesser-known sources.

CONCLUSIONS

Our findings suggest that COVID-19 has created market conditions that place people who use opioids at risk of adverse outcomes, such as fatal overdose.

Amphetamines modulate fentanyl-depressed respiration in a bidirectional manner

BACKGROUND

The opioid epidemic remains one of the most pressing public health crises facing the United States. Fentanyl and related synthetic opioid agonists have largely driven the rising rates of associated overdose deaths, in part, because of their surreptitious use as substitutes for other opioids and as adulterants in psychostimulants. Deaths involving opioids typically result from lethal respiratory depression, and it is currently unknown how co-use of psychostimulants with opioids affects respiratory toxicity. Considering psychostimulant overdoses have increased over 3-fold since 2013, and half of those co-involved opioids, this is a cardinal question.

METHODS

Naloxone, d-amphetamine (AMPH), and (±)-methamphetamine (METH) were evaluated for their effects on basal and fentanyl-depressed respiration. Minute volume (MVb) was measured in awake, freely moving mice via whole-body plethysmography to quantify fentanyl-induced respiratory depression and its modulation by dose ranges of each test drug.

RESULTS

Naloxone immediately reversed respiratory depression induced by fentanyl only at the highest dose tested (10 mg/kg). Both AMPH and METH exhibited bidirectional effects on MVb under basal conditions, producing significant (p ≤ 0.05) depressions then elevations of respiration as dose increased. Under depressed conditions the bidirectional effects of AMPH and METH on respiration were exaggerated, exacerbating and then reversing fentanyl-induced depression as dose increased.

CONCLUSIONS

These results indicate that co-use of amphetamines with fentanyl may worsen respiratory depression, but conversely, monoaminergic components of the amphetamines may possibly be exploited to mitigate fentanyl overdose.

Analysis of umbilical cord tissue as an indicator of in utero exposure to toxic adulterating substances

In utero drug exposure is a significant public health threat to the well-being and normal development of the neonate. Recently, testing of umbilical cord tissue (UCT) has been employed to measure illicit drug exposure, as drugs used by the mother during the third trimester may be retained in the UCT. Focus has also been given to potential adverse health effects among drug users, resulting from exposure to pharmacologically active adulterants and cutting agents in the street drug supply. The in utero effects of these substances have not been well studied in humans, nor has their presence been demonstrated as a means for assessing adverse health effects in the neonate. Here, we describe the application of a novel test method to analyze UCT for the presence of more than 20 common adulterating/cutting substances via LC/Q-TOF. In total, 300 de-identified UCT samples were analyzed-all had previously tested positive for cocaine or opiates. Generally, the positivity rates of individual compounds were similar between the Cocaine and Opiates Subgroups, apart from levamisole, xylazine, dipyrone (metabolites), and promethazine. Many of the adulterants used in the street drug supply do have legitimate medicinal/therapeutic uses, including several of the compounds most frequently detected in this study. Caffeine and lidocaine were the most frequently identified compounds both individually (>70% each) and in combination with each other. Alternatively, levamisole, an adulterant with no legitimate therapeutic use, was present in 12% of cases. Importantly, this data demonstrates that the detection of traditional drugs of abuse may serve as indicators of potential in utero exposure to toxic adulterating substances during gestation. While there is cause for concern with respect to any unintentional drug exposure, illicit drug use during pregnancy, including uncontrolled dosing, poly-adulterant consumption, and the interactions of these drug mixtures, produces a significant public health threat to the neonate which warrants further study.

The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions

The overdose crisis in Canada has continuously evolved and is increasingly challenging to contain, while efforts from governments and policymakers to address it have often fallen short and resulted in unintended consequences. One of the main repercussions has been an unprecedented rise in adulterants in the illegal drug supply, including a wide array of pharmacological and psychoactive compounds and chemicals, which has resulted in a progressively toxic drug supply. Most recently, there has been a stark increase in synthetic benzodiazepine-laced opioids (i.e., 'benzodope') in some Canadian jurisdictions. This unique combination carries distinct and amplified risks for people who use drugs including fatal and non-fatal overdoses, increased dependence and withdrawal symptoms, and places them in extremely vulnerable positions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug-related morbidity and mortality in Canada, and has further complicated current public health initiatives and overdose prevention efforts. This reality underscores the need for effective and sustainable policy solutions to address the evolving overdose epidemic including increased knowledge and education on the specific harms of opioid and benzodiazepine co-use (especially in regards to the complexity of opioid/benzodiazepine overdoses), scaling-up harm reduction measures, and eliminating the toxic drug supply altogether.

Co-administration of morphine and levamisole increases death risk, produces neutropenia and modifies antinociception in mice

Levamisole is a veterinary anthelmintic drug and a common adulterant of misused drugs. This study analyses the lethal, antinociceptive and haematological effects produced by acute or repeated levamisole administration by itself or combined with morphine. Independent groups of male Swiss Webster mice were i.p. injected with 100 mg/kg morphine, 31.6 mg/kg levamisole (lethal doses at 10%, LD₁₀ ) or the same doses combined. Naloxone pretreatment (10 mg/kg, i.p.) prevented morphine-induced death, as did 2.5 mg/kg, i.p. mecamylamine with levamisole. Co-administration of levamisole and morphine (Lvm + Mor) increased lethality from 10% to 80%. This augmented effect was prevented by 30 mg/kg, i.p. naloxone and reduced with 10 mg/kg naloxone plus 2.5 mg/kg, i.p. mecamylamine. In independent groups of mice, 17.7 mg/kg, i.p. levamisole antagonized the acute morphine's antinociceptive effect evaluated in the tail-flick test. Repeated 17.7 mg/kg levamisole administration (2×/day/3 weeks) did not affect tolerance development to morphine (10 mg/kg, 3×/day/1 week). Blood samples obtained from mice repeatedly treated with levamisole showed leukopenia and neutropenia. Morphine also produced neutropenia, increased erythrocyte count and other related parameters (e.g. haemoglobin). Lvm + Mor had similar effects on leukocyte and neutrophil counts to those seen with levamisole only, but no erythrocyte-related alterations were evident. Blood chemistry analysis did not indicate liver damage but suggested some degree of electrolyte balance impairment. In conclusion, Lvm + Mor increased death risk, altered morphine-induced antinociceptive effects and produced haematologic abnormalities. The importance of studying combinations of drugs of abuse lies in the fact that drug users frequently combine drugs, which are commonly adulterated.

The Potential of Methocinnamox as a Future Treatment for Opioid Use Disorder: A Narrative Review

The opioid epidemic is an ongoing public health crisis, and the United States health system is overwhelmed with increasing numbers of opioid-related overdoses. Methocinnamox (MCAM) is a novel mu opioid receptor antagonist with an extended duration of action. MCAM has potential to reduce the burden of the opioid epidemic by being used as an overdose rescue treatment and a long-term treatment for opioid use disorder (OUD). The currently available treatments for OUD include naloxone, naltrexone, and methadone. These treatments have certain limitations, which include short duration of action, patient non-compliance, and diversion. A narrative review was conducted using PubMed and Google Scholar databases covering the history of the opioid epidemic, pain receptors, current OUD treatments and the novel drug MCAM. MCAM could potentially be used as both a rescue and long-term treatment for opioid misuse. This is due to its pseudo-irreversible antagonism of the mu opioid receptor, abnormally long duration of action of nearly two weeks, and the possibility of using kappa or delta opioid receptor agonists for pain management during OUD treatment. MCAM’s novel pharmacokinetic and pharmacodynamic properties open a new avenue for treating opioid misuse.

Deviant Peer Association as a Predictor of Development of Risk for Selling Illicit Drugs: Are Effects Age-Graded?

Illicit drug sales present a public health issue that results in proliferation of drug use–related problems, like overdose deaths, stemming from use of illicit drugs. However, there remain gaps in understanding of psychosocial and developmental processes involved with predicting drug sales. Deviant peer association presents one potential risk factor for selling drugs and this relationship may be age-graded. This study examined deviant peer association as a predictor of risk for selling drugs and investigated whether salience of this relationship depended on when exposure to deviant peers occurred. The Pathways to Desistance data were analyzed. Mixed effects logistic regression models were utilized to examine the effects of deviant peer association on odds of selling illicit drugs and cross-level interactions with age variables. Findings indicated that association with deviant peers increased odds of selling illicit drugs. This relationship diminished as participants aged through adolescence, but later increased in magnitude as participants aged.

Analysis of drug residue in needle-exchange syringes in Washington, D.C

For the first time in Washington, D.C., an analysis of drug residue from used needle-exchange syringes has been performed. This analysis is part of a larger initiative to understand the District of Columbia's illicit drug supply and its intravenous (IV) user's consumption trends as our nation faces the opioid epidemic. The goal of this study is to develop a more comprehensive monitoring program that provides real-time analysis necessary for public health organizations, in addition to providing initial observations of drugs detected. A total of 1187 syringes were analyzed over a period of nine months. Of these, 732 syringes (61.7%) were confirmed to contain a controlled dangerous substance (CDS). Fentanyl was detected in 490 syringes, the most observed CDS in all syringes analyzed. Heroin was the second most detected CDS, observed in 192 syringes. The third most detected CDS was cocaine, which was observed in 132 syringes, followed by the fourth most detected CDS, methamphetamine, observed in 82 syringes. Novel findings of this study include the first reported detections of methamphetamine, synthetic cathinones, and synthetic cannabinoids in used syringes in D.C. Ninety-seven syringes that contained no CDS contained a non-controlled substance of interest, such as diphenhydramine, xylazine, and etizolam. One limitation of this study is that this method cannot determine whether mixtures present in syringes stem from mixtures present prior to injection, back-to-back usage, or sharing of needles. This preliminary study illustrates the strength of surveillance to monitor drug trends and can be used to detect emerging novel dangerous substances in the future.

Biosurveillance of Drug Overdoses and Substance Misuse Treated in Selected Emergency Departments in Minnesota, 2017-2020

OBJECTIVES

Increasing knowledge about the toxicology of drug overdose and substance misuse (DOSM) is important in improving our understanding of the epidemic. We describe the Minnesota Drug Overdose and Substance Use Pilot Surveillance Activity, which started collecting data on emergency department (ED) visits attributable to DOSM in 2017, with a focus on the toxicology results of a subset of clinical encounters.

METHODS

From November 1, 2017, through January 30, 2020, we collected near-real-time data on DOSM-related ED encounters. The Minnesota Department of Health Public Health Laboratory tested leftover clinical specimens (blood and/or urine) for the presence of various substances for patients who died, were hospitalized, had an atypical clinical presentation, or were part of a local drug overdose cluster. Testing looked for >250 drugs or their metabolites, including those commonly misused (eg, methamphetamine, cocaine), prescription medications, synthetic cannabinoids and cathinones, and opioids. We describe characteristics of the overall group and a subgroup of clinical encounters with toxicology results.

RESULTS

Specimens submitted from 6 EDs during the study period represented 239 clinical encounters. Methamphetamine was the most frequently detected substance (67.4%) but was suspected in only 45.6% of encounters. At least 1 opioid was detected in 42.5% of encounters but suspected in only 29.7%. Testing also detected potential adulterants and additives (eg, fentanyl, fentanyl analogues, levamisole) and showed frequent patient exposure to substances not reported by patients or suspected by clinicians. Nearly half (44.4%) of clinical encounters had >1 substance detected.

CONCLUSIONS

ED surveillance for DOSM encounters, enhanced by toxicology testing, can provide local situational awareness on overdoses, prevent potential mischaracterization of the true drug overdose epidemic, and inform harm reduction and drug overdose prevention efforts.

Xylazine detected in unregulated opioids and drug administration equipment in Toronto, Canada: clinical and social implications

BACKGROUND

The North American opioid overdose crisis is driven in large part by the presence of unknown psychoactive adulterants in the dynamic, unregulated drug supply. We herein report the first detection of the psychoactive veterinary compound xylazine in Toronto, the largest urban center in Canada, by the city's drug checking service.

METHODS

Toronto's Drug Checking Service launched in October 2019. Between then and February 2021, 2263 samples were submitted for analysis. The service is offered voluntarily at harm reduction agencies that include supervised consumption services. Samples were analyzed using gas chromatography-mass spectrometry or liquid chromatography-high resolution mass spectrometry. Targeted and/or untargeted screens for psychoactive substances were undertaken.

RESULTS

In September 2020, xylazine was first detected by Toronto's Drug Checking Service. Among samples analyzed from September 2020 to February 2021 expected to contain fentanyl in isolation (610) or in combination with methamphetamine (16), xylazine was detected in 46 samples (7.2% and 12.5% of samples, respectively). Samples were predominantly drawn from used drug equipment. Three of the samples containing xylazine (6.5%) were associated with an overdose.

CONCLUSION

We present the first detection of xylazine in Toronto, North America's fourth-largest metropolitan area. The increased risk of overdose associated with use of xylazine and its detection within our setting highlights the importance of drug checking services in supporting rapid responses to the emergence of potentially harmful adulterants. These data also highlight the clinical challenges presented by the dynamic nature of unregulated drug markets and the concomitant need to establish regulatory structures to reduce their contribution to overdose morbidity and mortality.

Qualitative LC/Q-TOF Analysis of Umbilical Cord Tissue via Data-Dependent Acquisition as an Indicator of In Utero Exposure to Toxic Adulterating Substances

Toxic adulterants are drug or chemical agents used to add bulk volume to traditional drugs of abuse such as cocaine, and heroin. These cutting agents include levamisole, metamizole, noxiptillin, phenacetin, and xylazine as well as common legal drugs such as acetaminophen, caffeine, diphenhydramine, lidocaine, quinine, quetiapine, and tramadol. Because they possess pharmacological activity they result in exposure of the user, but also in the case of pregnant women, the developing fetus, to potential drug toxicity. We describe the development, validation, and implementation of a rapid (48 second sample-to-sample) test based on a qualitative data-dependent liquid chromatography-quadrupole time of flight mass spectrometry (LC/Q-TOF) method for the analysis of toxic adulterating substances in umbilical cord tissue (UCT) samples. The method provides a means of studying potential in utero exposure to these agents. Library spectra comparison at 3 different collision energies was used in conjunction with retention time and accurate mass to identify these substances in UCT. Analytically based reporting limits were established to determine positivity rates of adulterants in UCT utilizing a standard addition approach. The method was applied to authentic cocaine and opioid positive UCT's to screen for toxic adulterants. There were a total of 82 potential adulterant positives found in a 30-sample cohort of authentic UCT samples, with an average of 2.7 substances per case. Lidocaine was the predominant finding followed by caffeine, and diphenhydramine all of which could result from non-illicit drug exposure, however, there were positives for levamisole, phenacetin, noxiptillin, and xylazine none of which are approved in the United States for human therapeutic use. This initial set of data established a preliminary positivity rate of potentially toxic adulterants in UCT samples positive for cocaine or opioid use.

Towards cross-Canada monitoring of the unregulated street drug supply

Background

The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions.

Methods

The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018–March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use.

Results

The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal.

Conclusions

This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.

Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse

Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.

Increasing Substance Use Disorder Treatment Professionals Knowledge: The Child Intervention for Living Drug-free (CHILD) Curriculum

BACKGROUND

A worldwide and ever-growing population of children are using psychoactive substances. To slow this problem, the Child Intervention for Living Drug-Free (CHILD) Curriculum was created to train treatment providers on how to screen, assess, and treat children between the ages of 4-12 years of age exposed to or actively using psychoactive substances. The purpose of the present project was to evaluate the extent to which completion of a six-session training of the six courses of the CHILD Curriculum met the objective of increasing the participants' knowledge of the Curriculum's approach to treating children for substance use problems.

METHODS

71 participants from Africa, Asia, and South America were invited for training and 100% accepted the invitation. Trainees completed an in-person small-group course, occurring over 32 days and comprising 256 total hours. During the CHILD Curriculum training, they completed six separate, 20-item, multiple choice knowledge assessment measures, one for each of the six courses comprising the Curriculum.

RESULTS

Significant (ps<.001) improvement in knowledge in each course was associated with a multivariate measure of strength of the relationship that indicated the change was substantial for five courses (R²s>.5) and moderate for a sixth course. Percentage change from baseline varied from a low of 17% to a high of 63%.

CONCLUSION

The CHILD Curriculum provides a useful educational framework to ensure knowledge gains by trainees. This curriculum content and evaluation provides a framework for future training of providers to pre-adolescent children who use psychoactive substances or are at risk for such use.

Recent Increase in Methamphetamine Use in a Cohort of Rural People Who Use Drugs: Further Evidence for the Emergence of Twin Epidemics

Appalachian Kentucky was at the epicenter of the prescription opioid epidemic in the early 2000's. As we enter the third decade of the epidemic, patterns have begun to emerge as people who use drugs (PWUD) transition from use of opioids to other drugs. The purpose of this analysis was to examine longitudinal changes in methamphetamine use in an ongoing cohort of rural people who use drugs (PWUD) in Appalachian Kentucky. All but five of the cohort participants (N = 503) reported nonmedical prescription opioid use (NMPOU) at baseline and those 498 are included in this longitudinal analysis encompassing eight waves of data (2008-2020). Past 6-month use of methamphetamine was the dependent variable. Given the correlated nature of the data, mixed effects logistic regression was utilized to examine changes in methamphetamine use over time. Significant increases in methamphetamine use were observed over the past decade in this cohort of PWUD, especially in recent years (2017-2020). Prevalence of recent use at baseline and each of the follow-up visits was as follows: 9.4, 5.6, 5.0, 5.4, 8.1, 6.8, 6.9, and 33.1%, respectively (p < 0.001). On the contrary, significant reductions in NMPO and heroin use were observed in the same time period. The odds of methamphetamine use at the most recent visit were 25.8 times greater than at baseline (95% CI: 14.9, 44.6) and 52.6% of those reporting methamphetamine use reported injecting the drug. These results provide further evidence of "twin epidemics" of methamphetamine use among NMPOU. While problematic on several fronts, of particular concern is the lack of effective treatment options for methamphetamine use disorder. As policies around the opioid epidemic continue to evolve, particular attention should be paid to the surge in stimulant use in opioid-endemic areas.

Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors

BACKGROUND

Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors.

METHODS

In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion.

RESULTS

Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses.

CONCLUSION

Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.

High-Throughput Qualitative and Quantitative Drug Checking by MALDI HRMS

Illicit drugs are a global health problem, since both their acute and chronic consumption have negative impacts on the drug user's health. Drug checking facilities are receiving growing interest as they allow drug users to chemically analyze their product prior to consumption to assess the presence of adulterants or other non-expected substances. Such harm reduction programs allow the reduction of the risks associated with drug consumption without encouraging it. In particular, the emergence of new psychoactive substances (NPS) emphasizes the risk for the population increasing the diversity and the lability of illicit drugs on the market. Analytical developments are required to catch up with this rapid evolution and reduce the potential harm caused by such consumption. In this study, we developed a matrix-assisted laser desorption/ionization (MALDI) high-resolution mass spectrometry (HRMS) strategy for the high-throughput qualitative and quantitative analysis of drug checking samples. The use of online-based m/z cloud library for untargeted compound search improved the ability to identify unknown compounds. Sixty-seven drug checking samples were analyzed using this analytical strategy, allowing the detection of 10 designer drugs and several classical drugs of abuse (mainly cocaine and MDMA) as well as adulterants and contaminants. The results were then compared with routine analyses of the same samples using conventional approaches showing similar performance while removing the use of chromatographic separation thus resulting in a significant reduction of the time required for sample preparation and analysis. This study enlightens the potential of MALDI-HRMS as a high-throughput approach allowing to speed-up up to six times the identification and quantification of substances enabling to catch the fast changes on the drug of abuse market. This strategy could be an interesting alternative analytical approach, allowing better prevention and harm reduction for drug users.