High willingness to use rapid fentanyl test strips among young adults who use drugs

A simple heuristic for allocating opioid settlement funding to reduce overdose mortality in the United States

As resolution for opioid-related claims and litigation against pharmaceutical manufacturers and other stakeholders, state and local governments are newly eligible for millions of dollars of settlement funding to address the overdose crisis in the United States. To inform effective use of opioid settlement funds, we propose a simple framework that highlights the principal determinants of overdose mortality: the number of people at risk of overdose each year, the average annual number of overdoses per person at risk, and the average probability of death per overdose event. We assert that the annual number of overdose deaths is a function of these three determinants, all of which can be modified through public health intervention. Our proposed heuristic depicts how each of these drivers of drug-related mortality - and the corresponding interventions designed to address each term - operate both in isolation and in conjunction. We intend for this framework to be used by policymakers as a tool for identifying and evaluating public health interventions and funding priorities that will most effectively address the structural forces shaping the overdose crisis and reduce overdose deaths.

Fentanyl Test Strips for Harm Reduction: A Scoping Review

BACKGROUND

High potency synthetic opioids like fentanyl have continued to replace or contaminate the supply of illicit drugs in North America, with fentanyl test strips (FTSs) often used as a harm reduction tool for overdose prevention. The available evidence to support FTS for harm reduction has yet to be summarized.

METHODS

A search of PubMed, Ovid Embase, and Web of Science was conducted in March 2023. A 2-stage review was conducted to screen by title and abstract and then by full text by 2 reviewers. Data were extracted from each study using a standardized template.

RESULTS

A total of 91 articles were included, mostly from North America, predominantly reporting on FTS along with other harm reduction tools, and all conducted after 2016. No randomized controlled trials are reported. Robust evidence exists supporting the sensitivity and specificity of FTS, along with their acceptability and feasibility of use for people who use drugs and as a public health intervention. However, limited research is available on the efficacy of FTS as a harm reduction tool for behavior change, engagement in care, or overdose prevention.

CONCLUSIONS

Though FTSs are highly sensitive and specific for point of care testing, further research is needed to assess the association of FTS use with overdose prevention. Differences in FTS efficacy likely exist between people who use opioids and nonopioid drugs, with additional investigation strongly needed. As drug testing with point-of-care immunoassays is embraced for nonfentanyl contaminants such as xylazine and benzodiazepines, increased investment in examining overdose prevention is necessary.

How do we understand the value of drug checking as a component of harm reduction services? A qualitative exploration of client and provider perspectives

BACKGROUND

Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered.

METHODS

We conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis.

RESULTS

We found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels.

CONCLUSION

This study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study

BACKGROUND

In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges.

METHODS

We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants' emphasis that knowing the composition of one's drugs is a "right to know", particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men.

CONCLUSIONS

The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions.

A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA

BACKGROUND

Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the illicit drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who use drugs (PWUD). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida.

CASE PRESENTATION

A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at a Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits were informed by best clinical judgement due to lack of formal guidelines at the time. Wound outcomes are unknown as the patient has not returned to clinic.

CONCLUSIONS

Many PWUD at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system due to stigma. There is an urgent need for access to XTS for PWUD and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.

Understanding Regional Patterns of Overdose Deaths Related to Opioids and Psychostimulants

BACKGROUND

As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures.

METHODS

A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile.

RESULTS

There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region.

CONCLUSION

Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

COVID-19 vaccination among young people who use drugs in Vancouver, Canada

OBJECTIVES

SARS-CoV-2 vaccines provide significant protection against severe illness and death from COVID-19, in addition to reducing community transmission. Emerging research has identified factors associated with vaccine uptake among adults who use drugs; however, less is known about youth and young adults who use drugs (YWUD). To address this gap, we sought to characterize factors associated with vaccine uptake and explore vaccine hesitancy among YWUD.

METHODS

Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved YWUD in Vancouver, Canada. Using multivariable logistic regression, we characterized factors associated with SARS-CoV-2 vaccine uptake between June and November 2021. Data on vaccine hesitancy were also collected.

RESULTS

Among 301 participants enrolled in this study (median age: 29 [min and max: 20-40]), 151 (50.2%) self-reported receipt of at least one dose of a SARS-CoV-2 vaccine. In multivariable analysis, vaccine uptake was significantly associated with recent addiction treatment engagement (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI]: 1.47-4.14) and receiving prescribed safer supply (e.g., opioids, stimulants) (AOR = 2.33, 95% CI: 1.03-5.62). Those who reported at least weekly crack use were significantly less likely to be vaccinated (AOR = 0.35, 95% CI: 0.12-0.92). The most reported reason for vaccine hesitancy was safety concerns, specifically regarding long-term side effects (27.4%).

CONCLUSION

Vaccine uptake was significantly lower among YWUD than adults who use drugs in Vancouver and the general population in British Columbia, among whom 75% and 93% received at least one dose during the same period. Study findings suggest connecting YWUD to healthcare and novel harm reduction interventions may increase vaccine uptake. Responses to vaccine hesitancy questions revealed complex perspectives of vaccines that were aligned with sources of vaccine hesitancy among the general population. Broader strategies combatting misinformation and promoting evidence-based vaccine information could be tailored to address the unique needs and barriers experienced by YWUD.

Making Harm Reduction More Accessible: Fentanyl Test Strip Awareness and Attitudes among Emergency Department Patients Who Use Drugs

BACKGROUND

Fentanyl test strips (FTS) are a harm reduction method for people to test their drugs for fentanyl. Ideal points for FTS distribution have not been identified. Many people who use drugs have frequent contact with the Emergency Department (ED). We piloted FTS distribution in two urban hospital EDs.

METHODS

Between June-December 2021 in Philadelphia, PA, patients with past 30-day drug use completed a survey about drug use, fentanyl attitudes, and FTS; then offered FTS and a brief training. Survey data were analyzed using SPSS for bivariate statistics.

RESULTS

Patients (n = 135) were primarily White (68.1%) and male (72.6%). Participants regularly interacted with substance use (57.8%) and benefits coordination (49.6%) services. The most common drugs used were heroin/fentanyl (68.9%), crack cocaine (45.2%) and cannabis (40.0%). Most (98.5%) had heard of fentanyl though few (18.5%) had ever used FTS. Across most drug types, participants were concerned about fentanyl. All accepted FTS training and distribution. Few (9.6%) were somewhat or very concerned about having FTS if stopped by police and this number varied by race (7.6% of White people were somewhat or very concerned, compared to 12.8% of Black people). Most participants were already engaged in risk reduction practices.

DISCUSSION

FTS are a widely desired harm reduction tool to facilitate informed decision-making, and non-harm reduction locations are potentially feasible and acceptable distribution sites. Given regular contact with EDs and social services across the sample, FTS should be offered at non-harm reduction locations that come into frequent contact with people who use drugs.

Testing the test strips: laboratory performance of fentanyl test strips

BACKGROUND

The overdose crisis driven by synthetic opioids continues to escalate in the USA. We evaluated the efficacy of multiple manufacturing lots of a fentanyl test strip (FTS) to detect fentanyl and fentanyl analogs and assessed cross-reactivity with possible interferences.

METHODS

Drug standards were dissolved in water in a laboratory setting and serially diluted. Drug dilutions were tested using five different manufacturing lots of BTNX Rapid Response (20 ng/mL cutoff) lateral flow chromatographic immunoassay strips to assess lot-to-lot variability for FTS sensitivity and cross-reactivity for the analytes of interest.

RESULTS

All five manufacturing lots cross-reacted with fentanyl and eleven fentanyl analogs. Diphenhydramine, lidocaine, MDMA, and methamphetamine were found to cause false positives with the strips. There was notable lot-to-lot variability in the sensitivity of the strips for fentanyl, fentanyl analogs, and known interferences.

DISCUSSION

FTS remains an important overdose prevention tool, but lot-to-lot variability in performance complicates robust instructions that balance the prevention of false positives and false negatives. Continued lot-to-lot performance assessment is recommended to ensure health education for FTS remains accurate. More sophisticated drug checking technologies and services are needed in the community landscape to augment personal FTS use to facilitate informed consumption and overdose risk mitigation.

Fentanyl Concentration in Drug Checking Samples and Risk of Overdose Death in Vancouver, Canada

INTRODUCTION

The proliferation of fentanyl and its analogs in illegal, unregulated drug markets remains a major driver of the overdose crisis in North America. Drug checking services have been implemented as a harm reduction strategy to address the crisis. However, little is known about their potential utility as a mechanism for monitoring population-level risk of overdose stemming from changing fentanyl concentration in unregulated drugs over time. Therefore, this study assessed the relationship between median fentanyl concentration in expected opioid drug checking samples and the death rate due to illicit drug toxicity over time in Vancouver, Canada.

METHODS

Monthly population-based rates of death due to illicit drug toxicity were drawn from provincial coroner records. Monthly median percent fentanyl concentration was calculated using a validated quantification model from point-of-care Fourier-transform infrared spectra among expected opioid samples that tested positive for fentanyl at community drug checking services. A time-series analysis using generalized additive modeling was conducted to examine the association between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, controlling for calendar month. Analyses were conducted in 2021-2022.

RESULTS

Between January 2019 and October 2020, 577 deaths due to illicit drug toxicity occurred in Vancouver, and the observed monthly rate ranged from 1.75 to 7.65 deaths per 100,000 population. A significant, positive association was observed between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, adjusting for calendar month (chi-square=52.21, p<0.001).

CONCLUSIONS

Findings suggest a role for point-of-care drug checking as a tool for monitoring evolving overdose risk at the population level.

The Drug Overdose Epidemic in the U.S.-Mexico Border Region: Shifts, Progression, and Community Characteristics

OBJECTIVE

Previous studies show the reach of the current drug overdose epidemic into the U.S.-Mexico border region, albeit with a unique border-specific wave pattern compared to national waves and a delayed onset of fentanyl involvement (Wave I: 2002-2011, Wave II: 2012-2016, and Wave III: since 2017). The objective of this study is to examine the community predictors and the progression of overdose deaths across the U.S-Mexico border-specific epidemic waves.

METHOD

Descriptive epidemiological profile of border communities across the unfolding of the opioid epidemic, integrated data from the CDC-WONDER multiple causes of death data set, the CDC SVI, Uniform Crime Report, and the Behavioral Risk Factor Surveillance System. Using spatially adjusted Bayes rates by border-specific epidemic waves, we provide a descriptive profile of the spatial unfolding of the drug overdose epidemic. Negative binomial regression models assessed community predictors of overdose deaths across waves.

RESULTS

Spatial analysis identified moderate to steep increases in drug overdose deaths over the three waves along the border. The impact and unfolding of the epidemic in the U.S.-Mexico border region were not uniform and affecting communities with differing severity and timing. Our study also finds support for social vulnerability and community violence as predictors of overdose deaths over the current wave of the epidemic.

CONCLUSION

Findings suggest that more disadvantaged U.S.-Mexico border communities may encounter increasing rates of overdose death over the coming years. Interventions need to target not only the supply side but also the underlying social root causes for sustainable overdose prevention.

Medications for Alcohol Use Disorder and Retention in Care in Medicaid-Enrolled Youth, 2014-2019

PURPOSE

Alcohol use disorder (AUD) is a pediatric-onset condition needing timely, effective treatment. Medications for AUD are part of nationally recommended treatments for youth. This study measured receipt of medications and behavioral health services for AUD and subsequent retention in care.

METHODS

This retrospective cohort study used claims data from > 4.7 million publicly insured youth aged 13-22 years in 15 states from 2014-2019. Timely treatment was defined as receipt of medication (naltrexone, acamprosate, or disulfiram) and/or behavioral health services within 30 days of incident AUD diagnosis. Associations of age and other characteristics with timely treatment were identified using modified Poisson regression. Retention in care (i.e., no period ≥ 60 days without claims) was studied using Cox regression.

RESULTS

Among 14,194 youth with AUD, 10,851 (76.4%) received timely treatment. Only 2.1% of youth received medication (alone or in combination); nearly all (97.9%) received behavioral health services only. Older (aged 16-17 years) and younger adolescents (aged 13-15 years) were 0.13 (95% confidence interval [CI], 0.07-0.26) and 0.24 (95% CI, 0.11-0.51) times as likely, respectively, to receive medications than young adults aged ≥ 21 years. Median retention in care for youth receiving medications was 119 days (interquartile range, 54-321) compared with 108 days (interquartile range, 43-243) for behavioral health services alone (p = .126). Young adults aged ≥ 18 years were 1.12 (95% CI, 1.06-1.18) times as likely to discontinue treatment compared with adolescents aged < 18 years.

DISCUSSION

This study found that more than seven in 10 youth received AUD treatment but only two in 100 received medications. Future studies should further characterize the effectiveness of medications and determine whether low rates of receipt represent underuse.

A Confirmed Case of Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Miami, Florida, USA

Background

Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the street drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who inject drugs (PWID). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida.

Case Presentation

A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at the IDEA Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits are discussed below. Wound outcomes are unknown as the patient has not returned to clinic.

Conclusions

Many PWID at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system. There is an urgent need for access to XTS for PWID and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.

Evaluating Technologies to Identify Fentanyl and Adulterants in Street Drug Paraphernalia: Qualitative Perspectives of Service Providers and Their Clientele

Background: Opioid overdose deaths continue to present major public health challenges in the U.S. Harm reduction agencies have begun using drug checking technologies to identify adulterants in the local drug supply and reduce overdose risk among people who use drugs (PWUD). Through qualitative and ethnographic methods, we assess the use of portable mass spectrometers at a harm reduction agency in a Northeastern U.S. city. Methods: We conducted participant observation, and on-the-spot qualitative interviews with harm-reduction staff members (n = 10) and their clientele (n = 17) between May 2019 and December 2020. Interviews explored emic views on drug checking (process, logistics, technology), and perceived benefits and challenges. We used thematic content analysis techniques to code and analyze interview transcriptions. Results: Implementation and use of drug checking devices were not free of challenges and malfunctions, often delaying drug checking opportunities and increasing suspicions and distrust among clients. Yet, staff members perceived that when working properly, or in conjunction with an additional device, they offered information about purchased drugs that could empower clients and potentially lead to positive behavior change. Use of these devices also enhanced engagement between harm reduction staff and PWUD, facilitating meaningful conversations around self-advocacy and harm reduction engagement. Conclusion: We report qualitative findings on the experiences and perceptions of drug checking devices among harm reduction staff and PWUD. Our findings indicate that use of this technology has the potential to decrease risk behaviors, expand health promotion services, and help reduce high rates of fentanyl-related overdose.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Monitoring for fentanyl within Australian supervised injecting facilities: Findings from feasibility testing of novel methods and collaborative workshops

BACKGROUND

Australia is yet to see widespread fentanyl-contaminated heroin, despite the established presence of fentanyl in other countries. International mortality trends alongside a local cluster of fentanyl-related deaths prompted interest in developing methods to monitor for fentanyl and other potentially harmful novel psychoactive substances (NPS) in Australia.

METHODS

We tested novel methods to monitor for fentanyl and other NPS. From 2017-2021, clients from supervised injecting facilities (SIFs) in Melbourne and Sydney, Australia, contributed urine screens (UDS) with BTNX Rapid Response™ fentanyl test strips (FTS) paired with surveys, and injecting equipment associated with opioid overdoses for laboratory analysis. A single site piloted drug checking using FTS with laboratory confirmation. Two workshops were conducted with SIF staff, content experts and people with lived experience to determine how results can inform practices within SIFs.

RESULTS

Of the 911 UDS with FTS conducted, less than 1% (n=8) yielded positive results that were not explained by self-reported pharmaceutical fentanyl use, with two laboratory confirmed fentanyl positive results. Injecting equipment from 59 overdoses was tested and neither fentanyl nor other NPS were identified. Drug checking with FTS (n=34) indicated the presence of fentanyl on three tests. Two specimens were subsequently sent for laboratory testing and classified as false positives as the presence of fentanyl was not confirmed. Workshop participants (n=21) felt routine monitoring with FTS currently had limited value. A process for using pre-defined signals to trigger surveillance was developed.

CONCLUSION

The high false positive rates with FTS, relative to the small number of positive results and potential for them to undermine confidence in FTS emphasised the need for confirmatory testing. The role of routine surveillance was unclear within the current low-fentanyl context, however, a process was developed to upscale testing should signals of increased fentanyl prevalence in the Australian heroin market emerge.

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

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

Differences in drug use behaviors that impact overdose risk among individuals who do and do not use fentanyl test strips for drug checking

Background

Opioid-involved overdose continues to rise, largely explained by fentanyl adulteration of the illicit opioid supply. Fentanyl test strips are a novel drug checking tool that can be used by people who use drugs to detect the presence of fentanyl in drug products. However, it is unclear whether fentanyl test strip use can prompt behavior changes that impact risk of overdose.

Methods

In this mixed-methods study involving a structured survey (n = 341) of syringe service program clients in southern Wisconsin, we examined the association between fentanyl test strip use and overdose risk behaviors in scenarios where the presence of fentanyl is confirmed and unknown. Individual items were transformed into summary scales representing the performance of riskier and safer behaviors. Linear regression examined the association of behaviors with FTS use. Models are adjusted for study site, race/ethnicity, age, gender, drug of choice, indicator of polysubstance use, times used per day, and lifetime overdose count.

Results

In response to survey questions before prompting about fentanyl risk, people who used fentanyl test strips reported an increased number of safer (p = 0.001) as well as riskier behaviors (p = 0.018) relative to people who did not use fentanyl test strips. The same held true in situations when fentanyl adulteration was suspected, though fentanyl test strip use lost significance in the fully adjusted model examining safer behaviors (safer: p = 0.143; riskier: p = 0.004). Among people who use fentanyl test strips, in unadjusted models, a positive test result was associated with more safer behaviors and fewer riskier behaviors, but these associations became nonsignificant in fully adjusted models (safer: p = 0.998; riskier: p = 0.171). Loss of significance was largely due to the addition of either polysubstance use or age to the model.

Conclusions

Fentanyl test strip use is associated with behaviors that may impact overdose risk, including safer and riskier behaviors. Specifically, a positive test result may promote more risk reducing behaviors and fewer risk enhancing behaviors than a negative test result. Results suggest that while FTS may promote safer drug use behaviors, outreach and education should emphasize the need for multiple harm reduction techniques in all scenarios.

A pilot study assessing client understanding and use of fentanyl test strips for harm reduction

BACKGROUND

The Centers for Disease Control and Prevention reported a sharp increase in overdose deaths from illicitly manufactured fentanyls (IMFs) occurring between 2020 and 2021 in the United States. Approximately 4 in 10 drug overdose deaths involved opioids and stimulants. Fentanyl test strips (FTS), used to test drug product before use, can be a powerful harm reduction tool to promote safer use behaviors.

OBJECTIVES

This pilot study assessed treatment-seeking service users' knowledge and understanding of IMFs and motivation to use FTS to prevent overdose.

METHODS

Clients receiving residential-based or office-based substance use treatment services were recruited from a community mental health center in the midwestern United States to complete a harm reduction-focused survey. Eligibility criteria included clients aged 18-89 years with self-reported drug use in the past year. A 20-question survey was administered verbally, both in person and via phone to assess knowledge of IMFs and FTS.

RESULTS

Of respondents (N = 30), 80% agreed that IMFs cause more overdoses than heroin. Most (73%) indicated concern about a friend overdosing owing to IMFs, and half (53%) expressed concern about personal risk of overdose. Most (73%) would like to be able to detect whether there is fentanyl in their drug before use, but only 17% indicated that they feel confident in their ability to use FTS.

CONCLUSION

Many respondents who were receiving services for past-year substance use lacked understanding of how to use FTS for harm reduction. Clients who primarily use nonopioid (stimulant) drug products are at even greater risk of IMF overdose and would benefit the most from increased access and education surrounding the use of FTS. Our health care system must rapidly continue to explore and expand on overdose prevention efforts, including access to FTS, given that urgent action is needed to reduce the continued rise in overdose deaths in the United States.

Estimating the impact of the COVID-19 pandemic on rising trends in drug overdose mortality in the United States, 2018-2021

PURPOSE

During the COVID-19 pandemic, social and economic disruption such as social isolation, job and income losses, and increased psychological distress, may have contributed to the increase in drug-overdose mortality. This study aims to measure the impact of the pandemic on monthly trends in drug-overdose mortality in the United States.

METHODS

We used the 2018-2020 final and 2021 provisional monthly deaths from the National Vital Statistics System and monthly population estimates from the Census Bureau to compute monthly mortality rates by age, sex, and race/ethnicity. We use log-linear regression models to estimate monthly percent increases in mortality rates from January 2018 through November 2021.

RESULTS

The age-adjusted drug-overdose mortality rate among individuals aged older than or equal to 15 years increased by 30% between 2019 (70,459 deaths) and 2020 (91,536 deaths). During January 2018-November 2021, the monthly drug-overdose mortality rate increased by 2.05% per month for Blacks, 2.25% for American Indians/Alaska Natives, 1.96% for Hispanics, 1.33% for Asian/Pacific Islanders, and 0.96% for non-Hispanic Whites. Average monthly increases in mortality were most marked among those aged 15-24 and 35-44 years.

CONCLUSIONS

The COVID-19 pandemic had a substantial impact on the rising trends in drug-overdose mortality during the peak months in 2020 and 2021.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Music festival drug checking: evaluation of an Australian pilot program

BACKGROUND

This paper explores the feasibility of delivering a music festival-based drug checking service in Australia, evaluating service design and stakeholder acceptability.

METHODS

Questionnaire and interview data were collected from adult service users and key stakeholders. A mixed methods approach was used to analyse the data on implementation, impact and acceptability.

RESULTS

The trial service tested 170 substances with more than 230 patrons (including individuals who attended in groups). Adult service users had an average age of 21 years. Voluntary participation in the evaluation resulted in 158 participants completing the pre-service questionnaire, most of whom also completed the post-service (147 participants). Eleven in-depth qualitative interviews were conducted with patrons in the weeks following the drug checking. Concordance between what the patron expected the drug to be and drug checking results occurred in 88 per cent (n = 139) of the sample. Evaluation results show that the experience of testing and the accompanying harm reduction brief interventions positively impacted on patrons' self-reported drug harm reduction knowledge, trust of health providers and stated drug use intentions. The service was received positively by service users.

CONCLUSION

This is the first independent evaluation of a pilot drug checking service in Australia. Consideration of operational feasibility and self-reported behavioural change suggests that the program was successful, although communication about the interpretation of drug checking results could be improved. Future studies should develop strategies for follow-up and consider the applicability of behavioural change theory.

Pilot testing fentanyl test strip distribution in an emergency department setting: Experiences, lessons learned, and suggestions from staff

OBJECTIVES

Fentanyl test strips (FTSs) are increasingly used to address fentanyl contamination of the illicit drug supply by testing a drug for the presence of fentanyl, allowing people who use drugs (PWUD) to engage in overdose prevention. While emergency departments (EDs) have implemented various harm reduction strategies for PWUD, to date distribution of FTSs in EDs is limited and not evaluated. Thus, we sought to explore ED staff experiences distributing FTSs.

METHODS

Twenty-one staff serving different roles (e.g., physician, nurse, technician, social worker, certified recovery specialist) within two urban EDs in a major metropolitan area were enrolled in a pilot study to distribute FTS to patients who use drugs. Participants were interviewed about their experience at 3 weeks and again at 3 months. Interviews were recorded, transcribed verbatim, and coded using a conventional content analysis approach.

RESULTS

All participants endorsed the utility of FTS distribution in the ED. Across 42 interviews, participants discussed evolving strategies to approach patients about FTS, primarily favorable patient reactions to FTSs, improved dynamics between participants and patients, mixed intervention support from other staff, and named challenges of FTS distribution and recommendations to make FTS distribution in the ED widespread. Recommendations included medical records prompts to offer FTS, offering via different types of staff, and offering FTS during triage.

CONCLUSIONS

Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTSs within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTSs and how to identify and train patients and explore mechanisms to routinize distribution in the ED environment.

Law Enforcement and Community Provision of Fentanyl Test Strips to People Who Use Drugs for Engagement and Referral to Services

Use of fentanyl test strips (FTS) to test illicit drugs has been shown to be an effective harm-reduction tool for raising awareness of fentanyl risks, increased self-efficacy to prevent overdose, and safer use behavior changes. From March to June 2020, a total of 6 Massachusetts municipal police departments piloted FTS kit distribution during post-overdose outreach visits, community outreach, and related programming. The Police Assisted Addiction and Recovery Initiative developed the kits, trained departments, and oversaw implementation. The pilot evaluation involved site observations, process measures, and interviews with staff and kit recipients. For every kit distributed, there was approximately 1 health or support service or referral provided; 320 kits were distributed. Key themes from interviews were conceptualizing FTS as a tool, collaborations, and adaptations. Police departments that partnered with community programs amplified project reach. FTS distribution is a simple yet powerful tool that community providers and police can offer alongside linkage to care services and engagement with people who use drugs and their family and friends.

Implementation and Uptake of the Massachusetts Drug Supply Data Stream: A Statewide Public Health-Public Safety Partnership Drug Checking Program

CONTEXT

The illicit drug supply is rapidly evolving. Equally important to gathering drug supply data for monitoring is timely sharing of information with people who use drugs, the providers who care for them, law enforcement partners, and public health stakeholders so that efforts to avoid harmful substances, take preventive actions, and better target interventions can occur.

PROGRAM

The Massachusetts Drug Supply Data Stream (MADDS) is the country's first statewide community drug checking program. Founded on public health-public safety partnerships, MADDS collects remnant drug packaging and paraphernalia with residue from people who use drugs and noncriminal samples from partnering police departments. MADDS tests samples using simultaneous immunoassay fentanyl test strips, Fourier-transform infrared spectrometry (FTIR), and off-site laboratory testing by gas chromatography-mass spectrometry (GC/MS). Results are accessible to community programs and municipalities, while trend analyses inform public health for cross-site alerts and informational bulletins.

IMPLEMENTATION

MADDS was launched statewide in 2020 and rapidly expanded to a multisite program. Program staff approached communities and met with municipal police and community partners to secure written agreements to host drug checking. Community partners designed sample collection consistent with their pandemic era workflows. Consultations with stakeholders gathered feedback on design and deliverables.

EVALUATION

The program tests sample donations on-site from community agencies and police departments, incorporates review by a medical toxicologist for health and safety concerns, crafts stakeholder-specific communications, and disseminates English, Spanish, and Portuguese language materials. For 2020, a total of 427 samples were tested, of which 47.1% were positive for fentanyl. By early 2021, MADDS detected shifts in cocaine purity, alerted communities of a new toxic fentanyl analogue and a synthetic cannabinoid contaminant, and confirmed the increase of xylazine (a veterinary sedative) in Massachusetts.

DISCUSSION

Community drug checking programs can be collaboratively designed with public health and public safety to generate critical health and safety information for people who use drugs and the communities where they live.

Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada

BACKGROUND

Drug checking is a harm reduction strategy used to identify components of illicitly obtained drugs, including adulterants, to prevent overdose. This study evaluated the distribution of take-home fentanyl test strips to people who use drugs (PWUD) in British Columbia, Canada. The primary aim was to assess if the detection of fentanyl in opioid samples was concordant between a take-home model and testing by trained drug checking staff.

METHODS

Take-home fentanyl test strips were distributed at ten sites providing drug checking services from April to July 2019. The fentanyl positivity of the aggregate take-home and on-site drug checking groups were compared by class of substance tested. An administered survey assessed acceptability and behaviour change.

RESULTS

1680 take-home results were obtained from 218 unique participants; 68% of samples (n=1142) were identified as opioids and 23% (n=382) were stimulant samples. During this period, 852 samples were tested using on-site drug checking. The fentanyl positivity of opioid samples was 90.0% for take-home samples and 89.1% for on-site samples (Difference 0.8% (95% CI -2.3% to 3.9%)). These results were not affected by previous experience with test strips. Fentanyl positivity of stimulants in the take-home group was higher than on-site (24.7% vs. 3.2%), but the study was underpowered to conduct statistical analysis on this sub-group. When fentanyl was detected, 27% of individuals reported behaviour change that was considered safer/positive. Greater than 95% of participants stated they would use fentanyl test strips again.

CONCLUSIONS

Take-home fentanyl test strips used by PWUD on opioid samples can provide similar results to formal drug checking services and are a viable addition to existing overdose prevention strategies. Use of this strategy for detection of fentanyl in stimulant samples requires further evaluation. This intervention was well accepted and in some participants was associated with positive behaviour change.

"They say it's fentanyl, but they honestly look like Perc 30s": Initiation and use of counterfeit fentanyl pills

BACKGROUND

Worsening of the overdose crisis in the USA has been linked to the continuing proliferation of non-pharmaceutical fentanyl (NPF). The recent wave of NPF spread in the USA has been fueled by an increased presence of counterfeit pills that contain NPF. This qualitative study aims to characterize the motivation and practices of counterfeit NPF pill initiation and use among individuals using illicit opioids in Arizona.

METHODS

Between October 2020 and May 2021, semi-structured interviews were conducted with 22 individuals meeting the following eligibility criteria: (1) 18 years or older; (2) residence in Arizona; and (3) use of illicit opioids in the past 30 days and/or opioid use disorder treatment in the past 12 months. Participants were recruited through referrals by a harm reduction organization, craigslist ads, and referrals by other participants. Interviews were conducted virtually via Zoom. Qualitative interviews were transcribed and analyzed thematically using NVivo.

RESULTS

Out of 22 participants, 64% were male, and 45% were ethnic minorities. Age ranged between 25 and 51 years old. Participants noted significant recent increases in the availability of counterfeit NPF pills ("blues," "dirty oxys") that were most commonly used by smoking. The majority indicated first trying NPF pills in the past year, and the first use often occurred in situations of reduced access to heroin or pharmaceutical opioids. Participant decisions to switch over to more frequent NPF pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with NPF effects. They were also influenced by conflicting views of social acceptability of pharmaceutical-like drugs, perceived harms of NPF in terms of overdose risks and increased difficulty of quitting, and perceived benefits of switching to the non-injection route of opioid administration (e.g., from injecting heroin to smoking NPF pills).

CONCLUSION

Our findings highlight the need for the implementation of novel policy, treatment, and harm reduction approaches to address the growing unpredictability of drug supply and NPF pill-specific risks, attitudes, and behaviors.

Time-Series Analysis of Fentanyl Concentration in the Unregulated Opioid Drug Supply in a Canadian Setting

North America has been contending with an unregulated street drug supply in which opioids are often adulterated with illicitly manufactured fentanyl. The unpredictability of composition may result in an increased risk of overdose due to unexpected elevated concentrations of the high-potency drug. Using data from a community-based drug-checking project, we evaluated trends in fentanyl concentration of illicit opioids in the context of an overdose epidemic. Using a quantification model for fentanyl hydrochloride, historical Fourier-transform infrared spectra from opioid drug-checking samples were analyzed to determine fentanyl concentrations. Median monthly fentanyl concentrations were plotted, and polynomial and autoregressive time-series analyses were performed to examine trends over time. A total of 3,621 fentanyl-positive samples were included in the study, spanning November 2017 to December 2019. Monthly median fentanyl concentrations ranged from 4.5% to 10.4%. Time-series analyses indicated that a third-degree polynomial model fit the data well (R2 = 0.639), suggesting a cyclical pattern in median concentration over time. Notably, absolute variance in fentanyl concentration decreased by an average 0.1% per month (P < 0.001). Future research should explore the relationship between fentanyl concentration and overdose to identify potential targeted harm-reduction interventions that can respond to changes in observed fentanyl concentration.

"It's called overamping": experiences of overdose among people who use methamphetamine

BACKGROUND

The USA is experiencing increases in methamphetamine use and methamphetamine-related or attributed deaths. In the current study, we explore qualitative narratives of methamphetamine overdose and strategies used by people who use drugs to reduce the undesirable effects associated with methamphetamine use.

METHODS

We conducted 21 qualitative interviews with people over the age of 18 who reported using methamphetamine in the previous 3 months in Nevada and New Mexico. Interviews were recorded, transcribed, and analyzed using qualitative thematic analysis.

RESULTS

Respondents described a constellation of psychological and physical symptoms that they characterized as "overamping," experienced on a continuum from less to more severe. Reports of acute, fatal methamphetamine overdose were rare. Few reported seeking medical attention for undesirable effects (usually related to psychological effects). General self-care strategies such as sleeping and staying hydrated were discussed.

CONCLUSIONS

When asked directly, our respondents claimed that acute, fatal methamphetamine overdose is rare or even impossible. However, they described a number of undesirable symptoms associated with overconsumption of methamphetamine and had few clinical or harm reduction strategies at their disposal. Addressing this current wave of drug-related deaths will require attention to the multiple factors that structure experiences of methamphetamine "overdose," and a collaborative effort with PWUDs to devise effective harm reduction and treatment strategies.

Fentanyl Test Strip Use and Overdose History among Individuals on Medication for Opioid Use Disorder

BACKGROUND

The number of deaths from drug overdose in the United States has more than doubled in the past decade. In particular, drug overdose deaths involving fentanyl have doubled every year since 2013. Rapid fentanyl test strips (FTS) are a useful strategy for detecting traces of fentanyl in substances and have received overwhelming support from individuals with opioid-dependence.

METHODS

We investigated fentanyl use, knowledge of FTS, willingness to use FTS, and overdose history among a sample of 105 individuals currently on medication for opioid use disorder (MOUD).

RESULTS

Results showed that the majority (63%) of the sample had experienced a non-fatal overdose and that 85% of participants were willing to use FTS. The majority of participants reported concern about fentanyl in their drug supply (70%) and 77% reported likelihood of past unintentional fentanyl use. Of note, only about half (47%) of participants knew of FTS prior to being surveyed, and only 17% reported ever using FTS.

CONCLUSION

These results expand on previous literature that documents high levels of willingness, yet low uptake of FTS among individuals on MOUD. Widespread education about FTS, in addition to the implementation of the use of FTS, is a highly promising and critical primary prevention alternative to overdose treatment and/or death due to fentanyl.

Machine learning takes a village: Assessing neighbourhood-level vulnerability for an overdose and infectious disease outbreak

BACKGROUND

Multiple areas in the United States of America (USA) are experiencing high rates of overdose and outbreaks of bloodborne infections, including HIV and hepatitis C virus (HCV), due to non-sterile injection drug use. We aimed to identify neighbourhoods at increased vulnerability for overdose and infectious disease outbreaks in Rhode Island, USA. The primary aim was to pilot machine learning methods to identify which neighbourhood-level factors were important for creating "vulnerability assessment scores" across the state. The secondary aim was to engage stakeholders to pilot an interactive mapping tool and visualize the results.

METHODS

From September 2018 to November 2019, we conducted a neighbourhood-level vulnerability assessment and stakeholder engagement process named The VILLAGE Project (Vulnerability Investigation of underlying Local risk And Geographic Events). We developed a predictive analytics model using machine learning methods (LASSO, Elastic Net, and RIDGE) to identify areas with increased vulnerability to an outbreak of overdose, HIV and HCV, using census tract-level counts of overdose deaths as a proxy for injection drug use patterns and related health outcomes. Stakeholders reviewed mapping tools for face validity and community distribution.

RESULTS

Machine learning prediction models were suitable for estimating relative neighbourhood-level vulnerability to an outbreak. Variables of importance in the model included housing cost burden, prior overdose deaths, housing density, and education level. Eighty-nine census tracts (37%) with no prior overdose fatalities were identified as being vulnerable to such an outbreak, and nine of those were identified as having a vulnerability assessment score in the top 25%. Results were disseminated as a vulnerability stratification map and an online interactive mapping tool.

CONCLUSION

Machine learning methods are well suited to predict neighborhoods at higher vulnerability to an outbreak. These methods show promise as a tool to assess structural vulnerabilities and work to prevent outbreaks at the local level.

Comparison of Characteristics of Deaths From Drug Overdose Before vs During the COVID-19 Pandemic in Rhode Island

Importance

The rate of deaths from overdose has increased during the COVID-19 pandemic, and recent US overdose mortality rates have been markedly high. However, scant data are available on the causes of this increase or subpopulations at elevated risk.

Objective

To evaluate the rates and characteristics of deaths from drug overdose before vs during the COVID-19 pandemic.

Design, Setting, and Participants

This retrospective, population-based cohort study used data from 4 statewide databases linked at the person level via the Rhode Island Data Ecosystem on adults with deaths due to overdose in Rhode Island from January 1 to August 31, 2019, and January 1 to August 31, 2020.

Main Outcomes and Measures

The rates of unintentional deaths from drug-related overdose during the 2019 and 2020 observation periods overall and by sociodemographic characteristics, drugs contributing to the cause of death, location of death, and socioeconomic factors were evaluated. In subgroup analyses restricted to Medicaid beneficiaries (n = 271), the proportions of deaths from overdose by behavioral health treatment and diagnosis claims in the year before death were also examined.

Results

A total of 470 adults who died of drug overdose were included in the analysis (353 men [75%]; mean [SD] age, 43.5 [12.1] years). The rate of deaths from overdose in Rhode Island increased 28.1%, from 29.2 per 100 000 person-years in 2019 to 37.4 per 100 000 person-years in 2020 (P = .009). Compared with 2019, rates of deaths due to overdose during 2020 were higher among men (43.2 vs 59.2 per 100 000 person-years; P = .003), non-Hispanic White individuals (31.0 vs 42.0 per 100 000 person-years; P = .005), single individuals (54.8 vs 70.4 per 100 000 person-years; P = .04), deaths involving synthetic opioids (20.8 vs 28.3 per 100 000 person-years; P = .005), and deaths occurring in a personal residence (13.2 vs 19.7 per 100 000 person-years; P = .003). A decrease in the proportion of deaths from overdose involving heroin (11 of 206 [5%] vs <2% [exact value suppressed]; P = .02) and an increase among persons experiencing job loss (16 of 206 [8%] vs 41 of 264 [16%]; P = .01) from 2019 to 2020 were observed. Among individuals who died of overdose and were Medicaid beneficiaries, the proportions of those aged 50 to 59 years with anxiety (11 of 121 [9%] vs 29 of 150 [19%]; P = .03), men with depression (27 of 121 [22%] vs 57 of 150 [38%]; P = .008), and men with anxiety (28 of 121 [23%] vs 55 of 150 [37%]; P = .02) increased during 2020 compared with 2019.

Conclusions and Relevance

In this cohort study, during the first 8 months of 2020, the rate of deaths from overdose increased in Rhode Island compared with the same period in 2019, and several emerging characteristics of deaths from drug overdose during the first year of the COVID-19 pandemic were identified. These findings may inform interventions that address macroenvironmental changes associated with the pandemic.

Predictors of intentional fentanyl use: Market availability vs consumer demand

BACKGROUND

Attempts to reduce opioid overdoses have been complicated by the dramatic rise in fentanyl use. While market forces contributing to fentanyl proliferation in the illicit drug supply have increased inadvertent exposure to the drug, rising fentanyl use may also be driven by growing consumer demand. Interventions to reduce the spread of fentanyl must be based on an understanding of the motivations underlying its use.

METHODS

Data for this cross-sectional study were derived from a computerized self-administered survey completed by a convenience sample of 432 people who use illicit opioids (PWUO) recruited from methadone and detoxification programs in NJ. The anonymous survey was based on a prior qualitative study of attitudes and behaviors surrounding opioid use. Multivariate analysis identified correlates of intentional fentanyl use in the full sample and among sub-populations of white and non-white PWUO.

RESULTS

In the full sample, intentional fentanyl use was associated with white race/ethnicity, younger age, polydrug use, and a preference for the drug effects of fentanyl, which more than tripled the probability of intentional use (AOR=3.02; 95% CI=1.86-4.89; p=.000). Among whites, a preference for the fentanyl drug effects was also the strongest predictor of intentional use (AOR=5.34; 95% CI=2.78-10.28; p=.000). Among non-whites, however, exposure, not preference, was the primary driver of use, with intentional use more than doubling (AOR=2.48; 95% CI=1.04-5.91; p<.05) among those living in high fentanyl dispersion counties.

CONCLUSION

The motivations underlying fentanyl use are multifactorial and vary across populations of PWUO, indicating a need for targeted interventions to counter the increasing spread and adverse consequences of fentanyl use. In order to counteract the increasing spread and adverse consequences of fentanyl use, these findings indicate a need for harm-reduction interventions, like drug testing or supervised injection sites, that address the differing motivations for fentanyl use among PWUO.

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.

The discounting of death: Probability discounting of heroin use by fatal overdose likelihood and drug purity

As fatal overdoses from synthetic opioids continue to rise, we need to understand decision-making processes underlying heroin and synthetic opioid use. This study evaluated the influence of sample impurity and fatal overdose risk on hypothetical heroin use. Individuals who currently use heroin (n = 69) were recruited online. Participants completed two probability-discounting tasks evaluating the likelihood of using a sample of heroin based on the likelihood of sample impurity and likelihood of fatal overdose, where greater discounting represented reduced use likelihood. Prior to completing the probability-discounting tasks, participants were randomized to read one of four prompts varying by the presence of information on heroin effects and active (e.g., fentanyl) or inert impurities. Influence of prompts on discounting processes and associations among probability-discounting measures, opioid use behaviors, and dependence severity were evaluated. Heroin use likelihood decreased with increased impurity or overdose risk and in a generally orderly fashion. Discounting was greater (i.e., reduced heroin use likelihood) when overdose risk, compared to sample impurity, was manipulated. Less discounting was associated with more severe opioid dependence. Discounting did not differ among prompts for either task. Individuals might adjust their heroin-use behavior to reduce harm with risk-related information. Greater discounting elicited by overdose relative to impurity risk suggests that equating adulteration and overdose risk is essential for harm reduction. Expanded access to drug checking services, which inform impurity and overdose risk, can reduce fatal overdoses. Due to fear of legal sanctions for these services, legislation and judicial decisions should explicitly protect these services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

New and Emerging Opioid Overdose Risk Factors

Purpose of Review

The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis.

Recent Findings

Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose.

Summary

The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.

Engagement in Harm Reduction Strategies After Suspected Fentanyl Contamination Among Opioid-Dependent Individuals

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially (Centers for Disease Control and Prevention in Opioid overdose, 2020c, https://www.cdc.gov/drugoverdose/data/otherdrugs.html#:~:text=Polysubstance%20drug%20use%20occurs%20with,or%20other%20non%2Dopioid%20substances ). Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates (Centers for Disease Control and Prevention in Drug overdose deaths involving fentanyl, 2011-2016, 2019a, https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf ). Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations (Kennedy et al. in Drug Alcohol Depend 185:248-252, 2018, https://doi.org/10.1016/j.drugalcdep.2017.12.026 ; Laing et al. in Int J Drug Policy 62:59-66, 2018, https://doi.org/10.1016/j.drugpo.2018.10.001 ). Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID's engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

Implementing an integrated multi-technology platform for drug checking: Social, scientific, and technological considerations

The illicit drug overdose crisis in North America continues to devastate communities with fentanyl detected in the majority of illicit drug overdose deaths. The COVID-19 pandemic has heightened concerns of even greater unpredictability in the drug supplies and unprecedented rates of overdoses. Portable drug-checking technologies are increasingly being integrated within overdose prevention strategies. These emerging responses are raising new questions about which technologies to pursue and what service models can respond to the current risks and contexts. In what has been referred to as the epicenter of the overdose crisis in Canada, a multi-technology platform for drug checking is being piloted in community settings using a suite of chemical analytical methods to provide real-time harm reduction. These include infrared absorption, Raman scattering, gas chromatography with mass spectrometry, and antibody-based test strips. In this Perspective, we illustrate some advantages and challenges of using multiple techniques for the analysis of the same sample, and provide an example of a data analysis and visualization platform that can unify the presentation of the results and enable deeper analysis of the results. We also highlight the implementation of a various service models that co-exist in a research setting, with particular emphasis on the way that drug checking technicians and harm reduction workers interact with service users. Finally, we provide a description of the challenges associated with data interpretation and the communication of results to a diverse audience.

Detection of 30 Fentanyl Analogs by Commercial Immunoassay Kits

Health-care workers, laboratorians and overdose prevention centers rely on commercial immunoassays to detect the presence of fentanyl; however, the cross-reactivity of fentanyl analogs with these kits is largely unknown. To address this, we conducted a pilot study evaluating the detection of 30 fentanyl analogs and metabolites by 19 commercially available kits (9 lateral flow assays, 7 heterogeneous immunoassays and 3 homogenous immunoassays). The analogs selected for analysis were compiled from the Drug Enforcement Administration and National Forensic Laboratory Information System reports from 2015 to 2018. In general, the immunoassays tested were able to detect their intended fentanyl analog and some closely related analogs, but more structurally diverse analogs, including 4-methoxy-butyryl fentanyl and 3-methylfentanyl, were not well detected. Carfentanil was only detected by kits specifically designed for its recognition. In general, analogs with group additions to the piperidine, or bulky rings or long alkyl chain modifications in the N-aryl or alkyl amide regions, were poorly detected compared to other types of modifications. This preliminary information is useful for screening diagnostic, forensic and unknown powder samples for the presence of fentanyl analogs and guiding future testing improvements.

The utility of visual appearance in predicting the composition of street opioids

Background: With the emergence of unregulated fentanyl, people who use unregulated opioids are increasingly relying on appearance in an effort to ascertain the presence of fentanyl and level of drug potency. However, the utility of visual inspection to identify drug composition in the fentanyl era has not been assessed. Methods: We assessed client expectation, appearance, and composition of street drug samples being presented for drug checking. Results of a visual screening test were compared to fentanyl immunoassay strip testing. We calculated sensitivity, specificity and likelihood ratios (LR) to assess the accuracy of the common assumption that samples with a "pebbles" appearance contain fentanyl. Results: In total, of the 2502 unregulated opioid samples tested, 1820 (73.5%) appeared as "pebbles", of which 1729 (95.0%) tested positive for fentanyl for a sensitivity of 75.9% (95% Confidence Interval [CI]: 74.2-77.6) and specificity of 59.4% (95%CI: 57.5-61.3). Although, the odds of samples containing fentanyl was 4.60 (95%CI: 3.47-6.11) times higher among pebbles samples compared to non-pebble samples, the positive LR for pebbles to contain fentanyl was only 1.87 (CI: 1.59-2.19). The negative LR was more useful at 0.41 (95% CI: 0.36-0.46). Conclusions: A positive screening test for pebbles is not strongly enough associated to be used as a proxy for detecting fentanyl. While the absence of the appearance of pebbles does somewhat reduce the likelihood of fentanyl being present in a given sample, the high prevalence of fentanyl and fentanyl analogues in the drug supply and the risks of consumption are such that public health providers should routinely advise people who use unregulated opioids against solely relying on visual characteristics of drugs as a harm reduction strategy.

Purposeful Fentanyl Use and Associated Factors among Opioid-Dependent People Who Inject Drugs

Introduction: In recent years, opioid-related mortality has increased steadily in the United States. Fentanyl, a synthetic opioid, has been a primary driver of the current wave of overdose-related deaths. Little is known, however, about fentanyl use among opioid-dependent people who inject drugs (PWID). We, therefore, sought to characterize purposeful fentanyl use among PWID. Methods: A cross-sectional survey was administrated to 104 opioid-dependent PWID on methadone who self-reported drug- or sex-related risk behaviors. Participants were recruited between July 2018 and October 2019 from a methadone clinic in New Haven, Connecticut. Multivariable logistic regressions were used to identify independent correlates of purposeful fentanyl use. Results: Overall, 43.2% and 22.1% of the participants reported any (lifetime) or recent (past 30 days) purposeful fentanyl use, respectively. Independent correlates of any purposeful fentanyl use were younger age (aOR= 0.94; p = 0.021), recent daily injection (aOR= 3.52; p = 0.047), recent cocaine use (aOR= 3.54; p = 0.041), and moderate/severe depression (aOR= 3.82; p = 0.028). Independent correlates of recent purposeful fentanyl use were moderate/severe depression (aOR= 10.94; p = 0.031), recently sharing injection equipment (aOR= 2.96; p = 0.044), and recently engaging in transactional sex (aOR= 3.60; p = 0.026). Conclusions: These findings indicate that opioid-dependent PWID on methadone remain at increased risk for overdose given the high prevalence of ongoing purposeful fentanyl exposure. Interventions to reduce the harms associated with fentanyl use should target young PWID and active fentanyl users, with an emphasis on achieving adequate methadone dosage and screening and treating depression in methadone-maintained patients who preferentially seek fentanyl.

A randomized clinical trial of a theory-based fentanyl overdose education and fentanyl test strip distribution intervention to reduce rates of opioid overdose: study protocol for a randomized controlled trial

Background

Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs.

Methods

Residents of Rhode Island aged 18–65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses.

Discussion

If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose.

Trial registration

ClinicalTrials.gov NCT04372238. Registered on 01 May 2020

A fentanyl test strip intervention to reduce overdose risk among female sex workers who use drugs in Baltimore: Results from a pilot study

BACKGROUND

In 2018, there were over 67,000 drug overdose deaths in the United States, with almost half involving illicit fentanyl and other synthetic opioids. While overall age-adjusted drug overdose deaths decreased by 4.6% from 2017 to 2018, synthetic opioid deaths increased 10.0%. This pilot study evaluates the impact of a brief fentanyl test strip (FTS) intervention to increase fentanyl awareness and reduce overdose risk.

METHODS

Female sex workers (FSW) reporting past month illicit opioid use were recruited between April 2018 through February 2019 in Baltimore City, Maryland. At baseline, they completed a baseline survey, and received tailored harm reduction messaging, 5 FTS and training, and a naloxone kit, then completed a survey after one month. McNemar's test was used to compare repeated measures.

RESULTS

Among N = 103, 54% were <40 years, 59% were white, and 24% had overdosed in the past year. Among 68 who completed follow-up, most (84%) used ≥1 FTS to test their drugs, 86% had ≥1 fentanyl-positive result, 57% were surprised by the result, and 69% engaged in harm reduction behaviors following the result (e.g., asked someone to check on them, did a tester shot, used a smaller amount). Significant pretest-posttest reductions in daily illicit opioid use (77% to 56%; p = 0.003), injection frequency (40% to 25%; p = 0.004), benzodiazepine use (22% to 7%; p = 0.008), and solitary drug use (96% vs. 68%; p < 0.001) were observed. No change in preferring drugs containing fentanyl was found. Some (18%) gave their FTS to others. All but three (96%) reported being likely to use FTS in the future.

CONCLUSIONS

We found high FTS acceptability and reductions in drug use frequency and solitary drug use following FTS use among FSW who use drugs in Baltimore. These findings demonstrate that FTS-based interventions hold potential in reducing overdose risk.

A mixed-methods approach to understanding overdose risk-management strategies among a nationwide convenience sample

BACKGROUND

This mixed-methods study compared drug use histories between individuals who had a reported non-fatal overdose to individuals who did not and described the overdose risk-management strategies as they were experienced by a sample of people who use drugs (PWUD). Shifts from non-medical prescription opioid use (NMPOU) to the use of heroin and synthetic opioids have been implicated in national increases in overdose incidences in the United States. However, relatively limited data exists regarding the narrative experiences of the evolving overdose risk management strategies among a nationwide sample of PWUD.

METHODS

Data recruitment was conducted via Amazon's mTurk crowdsourcing technology and was collected through semi-structured interviews that occurred in 2019. Participants (N = 60) with a history of NMPOU with transition to heroin or fentanyl use were recruited.

RESULTS

Participants reporting a previous non-fatal overdose were more likely to report a history of injection drug use, a history of heroin injection, greater overdose risk knowledge, and current medication for opioid use disorder (MOUD) use. Qualitative analysis revealed that participants attempted to mitigate overdose risk in primarily three ways: 1) self-regulation; 2) harm reduction; and 3) passive approach. Self-regulatory measures included administering small or incremental dosing, being mindful of personal tolerance limits, and avoiding the initiation of injection drug use. Harm reduction measures used to protect from overdose included carrying Narcan and relying on trusted drug-suppliers as references to drug purity. A passive approach indicated that participants relied on "luck" or divine support systems where religiosity and faith were endorsed as factors that mitigated personal overdose risk.

CONCLUSION

Participants reported successful overdose mitigation via self-regulation, which may suggest that PWUDs were capable at managing their drug use amid the overdose crisis. The importance of the drug-supplier relationship was critical to many in reducing their overdose risk as formal harm reduction services (e.g., safe injection sites) remain inaccessible in the U.S. Implications for drug policy and harm reduction interventions are discussed.

Elevated prevalence of self-reported unintentional exposure to fentanyl among women who use drugs in a Canadian setting: A cross-sectional analysis

BACKGROUND

The United States and Canada are in the midst of an overdose epidemic, fueled by illicitly manufactured fentanyl. While marked differences in vulnerability to drug-related harm between men and women who use drugs is well characterized, the extent to which gender differences manifest in the present overdose crisis remains understudied. We examined differences in self-reported unintentional exposure to fentanyl between men and women who use drugs.

METHODOLOGY

Data were derived from three prospective cohorts of people who use drugs in Vancouver, Canada. Survey data were extracted on individuals who self-reported having used drugs known or believed to contain fentanyl in the past 30 days between December 2016 and November 2017. We used multivariable logistic regression (MLR) to examine the relationship between self-identified gender (woman vs. man) and self-reported unintentional exposure to fentanyl. As a sub-analysis, correlates of self-reported unintentional exposure to fentanyl were identified using MLR, stratified by gender.

RESULTS

Of 578 eligible participants, including 219 (37.9%) women, 200 (33.2%) perceived their exposure to fentanyl as unintentional (40.2% among women and 29.0% among men). In the MLR, being a woman was positively associated with self-reported unintentional fentanyl exposure (adjusted odds ratio = 2.11; 95% confidence interval: 1.45-3.09). Among women at least daily heroin use was negatively associated with self-reported unintentional fentanyl exposure, while perceiving a high or moderate risk of overdosing on fentanyl was positively associated with outcome. Among men older age was positively associated with self-reported unintentional fentanyl exposure, while injection drug use and at least daily heroin use was negatively associated with the outcome (all p<0.05).

CONCLUSIONS

Women were more than two times as likely to self-report they were unintentionally exposed to fentanyl compared to men. These findings highlight the urgent need to further understand experiences of gender-based risk differences and develop gender-focused interventions and policies aimed at preventing drug-related harm.

Effect of witnessing an overdose on the use of drug checking services among people who use illicit drugs in Vancouver, Canada

BACKGROUND

Since 2013, fentanyl-contaminated drugs have been driving North America's opioid-overdose epidemic. Drug checking, which enables people who use illicit drugs (PWUD) to test and receive feedback regarding the contents of their drugs, is being considered as a potential tool to address the toxic drug supply. While some PWUD witness overdoses, little is known about the impact of these experiences on subsequent risk reduction practices.

OBJECTIVE

The purpose of this study was to examine the effect of witnessing an overdose on drug checking service use.

METHODS

Data were derived from prospective cohorts of PWUD in Vancouver, Canada, a setting with a community-wide fentanyl overdose crisis, between June 1, 2018 and December 1, 2018. Multivariable logistic regression was used to estimate the effect of witnessing an overdose on drug checking service use.

RESULTS

1,426 participants were eligible for the study, including 530 females; 767 (53.8%) participants reported witnessing an overdose and 196 (13.7%) reported using drug checking services in the last 6 months. In multivariable analyses, after adjusting for a range of confounders including the use of fentanyl, witnessing an overdose was positively associated with drug checking service use (adjusted odds ratio = 2.32; 95% confidence interval: 1.57-3.49).

CONCLUSION

Our findings suggest that witnessing an overdose may motivate PWUD to use drug checking services. Given that only a small proportion of PWUD in the study reported using drug checking services, our findings highlight the need to continue to scale-up a range of overdose prevention interventions.

The effect of injecting alone on the use of drug checking services among people who inject drugs

OBJECTIVES

Drug checking services aim to provide people who use drugs with information on the content and purity of their substances as a harm reduction intervention. The objective of this study was to determine the relationship between injecting alone and use of drug checking services in Vancouver, Canada.

METHODS

Data were derived from three prospective cohort studies of people who inject drugs (PWID). We conducted bivariable and multivariable logistic regression analysis to estimate the effect of injecting alone on use of drug checking services.

RESULTS

Between May 2018 and December 2018, a total of 793 people who inject drugs were included in the study: 579 (73.0%) reported injecting alone and 177 (22.3%) reported use of drug checking services. In a multivariable model adjusted for various confounders (including various sociodemographic variables, drug use patterns, and whether participants had suffered physical attacks/violence), injecting alone was negatively associated with use of drug checking services (Adjusted Odds Ratio = 0.65; 95% Confidence Interval: 0.44-0.97).

CONCLUSIONS

We observed a negative association between injecting drugs alone and use of drug checking services, which may be due in part to a number of exogenous factors that prevent people who inject alone from accessing drug checking services (e.g., stigma, location of services). As these individuals are at heightened risk of experiencing overdoses, there is a need to pursue other strategies to reach this group of people who use drugs.