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

Drug overdose deaths among homeless veterans in the United States Department of Veterans Affairs healthcare system

BACKGROUND AND AIMS

With an epidemic of drug overdoses, contemporary research is needed to examine drug overdose deaths among homeless populations. This study measured rates, types and correlates of drug overdose deaths occurring over a 5-year study period among veterans experiencing homelessness (VEH) and non-homeless veterans (NHV) in the US Department of Veterans Affairs (VA) healthcare system.

DESIGN

Retrospective cohort study.

SETTING

USA.

PARTICIPANTS

A total of 6 128 921 veterans. We followed 399 125 VEH and 5 729 796 NHV between 2017 and 2021 using linked administrative VA and National Death Index data.

MEASUREMENTS

Multivariable Cox regression models were constructed to estimate hazard ratios (HRs) for homelessness as a predictor of time-to-occurrence of overdose deaths with 95% confidence interval (CIs), sequentially controlling for demographic, medical, substance use and mental health characteristics.

FINDINGS

Among overdose deaths, 8653 [93.7%, 95% confidence interval (CI) = 93.2-94.2%] were unintentional and 5378 (57.8%, 95% CI = 56.8-58.8%) involved opioids. The overdose-specific mortality rate (per 100 000 person-years) was 227.3 among VEH and 23.2 among NHV (HR = 9.76, 95% CI = 9.36, 10.16), with rates 7-14 times higher among VEH than NHV, depending on the drug involved. In fully adjusted models, homelessness was associated with greater risk of drug overdose death (HR = 3.33, 95% CI = 3.18, 3.49), with the greatest risk involving psychostimulants (HR = 4.19), followed by antiepileptic/sedative/hypnotic drugs (HR = 3.69), synthetic opioids (HR = 3.50) and natural and semi-synthetic opioids (HR = 2.79).

CONCLUSIONS

US veterans experiencing homelessness appear to have three times the risk for drug overdose deaths than non-homeless veterans. There may be specific risks associated with psychostimulant, antiepileptic, sedative and hypnotic drugs in this population that deserve greater attention.

Smartphone-based drug testing in the hands of patients with substance-use disorder-a usability study

Aim

A clinical study was performed to test the usability of a smartphone eye-scanning app at a needle exchange facility to detect drug use to support therapy.

Methods

The study recruited 24 subjects who visited the facility one to three times, making a total of 40 visits. During each visit the subjects underwent testing for non-convergence (NC), nystagmus (NY), and pupillary light reflex (PLR) using a smartphone-based eHealth system. The collected eye data were transformed into key features that represent eye characteristics. During each visit, a time-line follow-back interview on recent drug use and a usability questionnaire were completed.

Results

Technical usability of the smartphone eye-scanning app was good for PLR and NC, where key features were generated in 82%-91% of the cases. For NY, only 60% succeeded due to cognitive problems to follow instructions. In most cases, subjects were under the influence of drugs when participating in the tests, with an average of 2.4 different drugs ingested within the last 24 h. The key features from PLR could distinguish use of opioids from central stimulants. The usability questionnaire results indicate that 23 of the 24 subjects could perform the eye-scanning by themselves after a short training, even when under severe influence of drugs. The caregiver assessed that 20 out of the 24 challenging subjects could potentially perform these tests in an indoors, home-like environment.

Conclusions

Smartphone-based eye-scanning is functional in a patient population with heavy drug use, also when under the influence of drugs. The use of central stimulants can be distinguished from the use of opioids.

Effect of Risk Mitigation Guidance opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study

OBJECTIVE

To determine the effect of opioid and stimulant Risk Mitigation Guidance (RMG) dispensations on mortality and acute care visits during the dual public health emergencies of overdose and covid-19.

DESIGN

Population based retrospective cohort study.

SETTING

British Columbia, Canada.

PARTICIPANTS

5882 people with opioid or stimulant use disorder who received RMG prescriptions for opioids (n=5356) and/or stimulants (n=1061) (535 received both) from 27 March 2020 to 31 August 2021.

MAIN OUTCOME MEASURES

All cause and overdose specific mortality and acute care visits in the week after RMG opioid or stimulant dispensation. RMG recipients were matched 1:1 with controls through use of high dimensional propensity score matching. Marginal structural models, executed on weekly time steps, were used to measure the effect of dispensations on outcomes.

RESULTS

RMG opioid dispensations of one day or more were associated with reduced all cause mortality (adjusted hazard ratio 0.39, 95% confidence interval 0.25 to 0.60) and overdose related mortality (0.45, 0.27 to 0.75) in the subsequent week. Dispensations of RMG stimulants (≥1 days) were not significantly associated with reduced all cause mortality (adjusted hazard ratio 0.50, 0.20 to 1.23) or overdose related mortality (0.53, 0.18 to 1.56). The protective effect of RMG opioid dispensations increased with the number of days the medications were dispensed in a given week. People who received four or more days of RMG opioid dispensations had reduced all cause mortality (adjusted hazard ratio 0.09, 0.04 to 0.21) and overdose related mortality (0.11, 0.04 to 0.32) compared with the control group. Opioid RMG dispensations did not significantly modify the odds of all cause or overdose related acute care visits. Dispensations of RMG stimulants were associated with a significant decrease in the odds of acute care visits for any cause but did not affect the odds of overdose related acute care visits.

CONCLUSIONS

RMG opioid dispensations were associated with reduced overdose related and all cause mortality among a sample of people with opioid use disorder. Pharmaceutical alternatives to the illegal drug supply are promising interventions to reduce mortality in people with opioid use disorder.

Patterns & Predictors of Telehealth Utilization Among Individuals Who Use Substances: Implications for the Future of Virtual Behavioral Health Services

Telehealth dramatically expanded during the COVID-19 pandemic, but there remains a dearth of literature examining how this service modality is utilized by individuals who use substances. This study examined patterns of telehealth use and individual level sources of variation among clients receiving counseling in an outpatient substance use clinic in early 2021 (n = 370). Univariate statistics described the percentage of counseling visits delivered via telehealth. OLS regression explored individual level demographic and clinical characteristics that predicted greater telehealth utilization. Overall, more than two thirds (86%) of counseling visits were conducted via telehealth. Individuals with unstable housing or with a co-occurring serious mental illness used less telehealth. Findings suggest that while telehealth appears to be an acceptable way to deliver substance use counseling, patterns varied among vulnerable subgroups. As telehealth becomes further integrated into behavioral health services delivery, it is critical to uncover sources of this variation and identify potential solutions.

Incidence of SARS-CoV-2 and all-cause mortality in persons with co-occurring substance use disorder and mental illness during the pandemic: a Norwegian cohort study

PURPOSE

Most people were affected by the COVID-19 pandemic. Persons with co-occurring substance use disorder (SUD) and mental illness (MI) are already a marginalized group, with above average mortality. Thus, the study aim was to investigate SARS-CoV-2 incidence and mortality among persons with SUD/MI during the first two years of the pandemic.

METHODS

This historical cohort study merged data from the Norwegian Patient Register, the Norwegian Surveillance System for Communicable Diseases and census data from Statistics Norway. We calculated crude mortality rates for persons with SUD and mild/moderate vs. severe MI and compared them to persons with physical illnesses or healthy controls. The incidence rate ratios for SARS-CoV-2 infection and mortality were estimated using Poisson regression models.

RESULTS

Compared to healthy controls, the SARS-Cov-2-infection rate was marginally lower in persons with SUD and mild/moderate MI (IRR,1.19 [95%CI,1.09-1.30]) as in persons with physical illness (IRR,1.35 [95%CI, 1.23-1.47]), whereas persons with SUD and severe MI showed a lower rate compared to healthy controls. Crude mortality rates for persons with SUD/MI were substantially higher and increased much more during the pandemic than for persons with physical illnesses or healthy controls. The IRR for mortality in persons with SUD and mild/moderate MI was 10.61 (95%CI,7.19-15.67) and 11.44 (95%CI,7.50-17.45) for SUD and severe MI, compared to 5.03 (3.34-7.57]) for persons with physical illnesses only.

CONCLUSION

The analysis showed excess mortality during COVID-19-pandemic for SUD/MI, but without higher SARS-CoV-2 infection rates in this group. Consequently, excess mortality among persons with SUD/MI was not due to SARS-CoV-2 infection.

COVID-19 control accelerates the decline in illegal drug use in China

This work illustrates the accelerated decline in illegal drug use during the COVID-19 pandemic in China. We first reviewed the global effects of the COVID-19 pandemic on the situation of illegal drugs. We then compared the data of the pre-pandemic (2016-2019) and pandemic period (2020-2022) for drug seizures, individuals identified as using drugs, registered and newly discovered illegal drug users and the number of community-treated drug users to demonstrate the fast decline in the use of illegal drugs in China. We then discussed the possible reasons and additional considerations for these changes. Overall, the COVID-19 controls in China, such as all-staff nucleic acid testing and ID-based dynamic monitoring, substantially reduced illegal drug use. Being wary of a possible rebound in drug use and preventing new types of drug crimes are still essential in post-COVID China.