Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency

Use of harm reduction strategies by individuals with a history of incarceration: A short report using baseline data collected from the STAMINA clinical trial

BACKGROUND

Due to the considerably heightened risk of overdose immediately following jail or prison release, expansion of harm reduction interventions for citizens returning to the community after an incarceration episode should be of utmost concern. However, there are no studies examining the adoption and use of harm reduction among this population. This short report examines the use of individual-level harm reduction strategies (HRS) among people who use drugs, comparing those who have lifetime histories of incarceration with those who do not.

METHODS

This study included baseline data (N = 274) from a larger clinical trial, which recruited participants at two syringe service programs. Fisher's exact tests examine correlations between HRS and lifetime incarceration.

RESULTS

Significant variation in HRS use were observed by demographic characteristics. Those with lifetime incarceration histories were less likely to report ensuring naloxone was available when using, using when others were present, using fentanyl test strips, using a trusted drug supplier, and using some other HRS compared to those without lifetime incarceration histories. Similarly, those with lifetime incarceration histories were also less likely to report using non-prescribed buprenorphine and methadone, which could potentially reduce overdose risk even if not explicitly used as an HRS.

CONCLUSION

The results suggest that one of the populations at highest risk of overdose is least likely to use strategies that may reduce overdose risk. Targeted efforts to increase exposure to HRS learning opportunities and access to these resources could help reduce overdose disparities for people returning to the community after incarceration.

Safety strategies and harm reduction for methamphetamine users in the era of fentanyl contamination: A qualitative analysis

INTRODUCTION

In the United States, methamphetamine use is increasing and the context of its use has changed, with reports of illicitly manufactured fentanyl being mixed with methamphetamine (either deliberately or inadvertently). We explore risk-mitigating actions taken by people who use drugs to protect their health when using methamphetamine in that context.

METHODS

We conducted qualitative interviews with 48 adults (18+) who used methamphetamine in the past three months at two sites in Nevada, USA and two sites in New Mexico, USA. Interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Respondents described two rationales for employing harm reduction strategies. First, to prevent harm from methamphetamine containing illicit fentanyl, and second, to maintain their general wellbeing while using methamphetamine. Regarding methamphetamine containing illicit fentanyl, our findings highlight how respondents employ primary strategies like buying from trusted sources and secondary strategies such as spotting and selective use of harm reduction tools (i.e., fentanyl test strips) to reduce risks. To maintain their general wellbeing, participants reduced their use of methamphetamine as reasonably as possible, and used other substances like marijuana and alcohol alongside methamphetamine to counter the unwanted side effects of methamphetamine (i.e., hallucinations and paranoia). Use of these harm reduction strategies varied within situational and social contexts, and respondents usually developed these strategies based on their lived experiences.

CONCLUSION

Our findings uniquely demonstrate that people who use methamphetamine prioritize community driven, trust-based strategies within their social networks to mitigate risks in a fentanyl-contaminated drug environment. Additionally, our results indicate that harm reduction behaviors are influenced by multilevel risk environments, which include social, physical, economic, and political factors. Overall, these results highlight the potential for targeted interventions at the network level, which are responsive to complexities and shifts in drug market dynamics- such as illicit fentanyl in methamphetamine.

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.

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

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

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.

Consumer expectations, drug effects, price and purity of heroin and cocaine purchased at drug consumption rooms

BACKGROUND

Drug consumption rooms offer heroin and cocaine consumers a secure and hygienic environment including medical and social guidance. Despite the support and mentoring, only sparse information is available about how drug quality, drug prices and user expectations match at these locations. The present study reports analysis of these three parameters in two drug consumption rooms in Luxembourg.

METHODS

Drug users were invited to participate in the project by handing in a few milligrams of the product they planned to consume for chemical analysis and filling out a short questionnaire about the price and their expectations. After consumption, they were asked to report the experienced effects. Drug quality was accessed using LC-Q-ToF and HPLC-UV, and a statistical analysis was carried out of the questionnaires that were correctly filled out.

RESULTS

A total of 513 drug samples have been analyzed. Most consumers were looking for the relaxing/calming effects of heroin and the stimulating effects of cocaine, but they generally overestimated heroin potency and underestimated cocaine potency. No strong correlation based on Spearman's ρ between drug user estimations, drug prices and drug quality was found.

CONCLUSION

To the best of our knowledge, this study is the first to combine drug analysis with heroin and cocaine user feedback about expectation, drug prices and drug effects. The analytical results were of great interest for users and the staff working at the drug consumption rooms. They may be a strong supplementary communication tool for health care workers when discussing effects and risks of highly toxic substance consumption.

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.

A mixed-methods analysis of risk-reduction strategies adopted by syringe services program participants and non-syringe services program participants in New York City

BACKGROUND

Since the emergence of fentanyl in the drug market, syringe services programs (SSPs) have been at the forefront of providing life-saving tools such as naloxone and fentanyl test strips to people who use drugs (PWUD). It is still unclear, however, how the adoption of risk-reduction practices has differed among PWUD in the context of increasing presence of non-pharmaceutical fentanyl in the drug supply. This study aims to assess the adoption of risk-reduction tools (e.g., naloxone) among those engaged with SSP services and those not engaged with SSP services.

METHODS

We conducted a mixed-methods study following a convergent parallel design integrating both quantitative and qualitative data. Interviews were conducted with 80 people who used street opioids (i.e., heroin or opioid pills not prescribed), 32 of whom were not engaged in SSP services. Quantitative differences between those engaged and those not engaged in SSPs were assessed using independent samples t tests and Fisher's exact tests. A thematic analytic approach was employed to compare qualitative responses between the two groups.

RESULTS

Three main themes emerged in our analysis: (1) Both groups expressed an interest in fentanyl test strips (FTS), but those engaged in SSP services found them to be more accessible; (2) there was greater adoption of and enthusiasm for naloxone among SSP participants; and (3) SSP participants were more likely to have or be interested in having someone check in on them when using alone, but stigma and perceived personal risk of overdose prevented widespread adoption of this practice among all participants.

CONCLUSION

SSPs provide a vital function by facilitating naloxone and FTS distribution to participants who often have little control over their exposure to fentanyl. However, stigma and misconceptions regarding drug use are barriers to people adopting risk-reduction practices, particularly among those not engaged with SSPs.

Point-of-care community drug checking technologies: an insider look at the scientific principles and practical considerations

Drug checking is increasingly being explored outside of festivals and events to be an ongoing service within communities, frequently integrated within responses to illicit drug overdose. The choice of instrumentation is a common question, and the demands on these chemical analytical instruments can be challenging as illicit substances may be more complex and include highly potent ingredients at trace levels. The answer remains nuanced as the instruments themselves are not directly comparable nor are the local demands on the service, meaning implementation factors heavily influence the assessment and effectiveness of instruments. In this perspective, we provide a technical but accessible introduction to the background of a few common drug checking methods aimed at current and potential drug checking service providers. We discuss the following tools that have been used as part of the Vancouver Island Drug Checking Project in Victoria, Canada: immunoassay test strips, attenuated total reflection IR-absorption spectroscopy, Raman spectroscopy from powder samples, surface-enhanced Raman scattering in a solution of colloidal gold nanoparticles, and gas chromatography-mass spectrometry. Using four different drug mixtures received and tested at the service, we illustrate the strengths, limitations, and capabilities of such instruments, and expose the scientific theory to give further insight into their analytical results. Each case study provides a walk-through-style analysis for a practical comparison between data from several different instruments acquired on the same sample. Ideally, a single instrument would be able to achieve all of the objectives of drug checking. However, there is no clear instrument that ticks every box; low cost, portable, rapid, easy-to-use and provides highly sensitive identification and accurate quantification. Multi-instrument approaches to drug checking may be required to effectively respond to increasingly complex and highly potent substances demanding trace level detection and the potential for quantification.

Harm reduction behaviors are associated with carrying naloxone among patients on methadone treatment

BACKGROUND

Despite the widespread availability of naloxone, US opioid overdose rates continue to rise. The "Cascade of Care" (CoC) is a public health approach that identifies steps in achieving specific outcomes and has been used to identify gaps in naloxone carriage among individuals with opioid use disorder (OUD). We sought to apply this framework to a treatment-seeking population with OUD that may be more inclined to engage in harm reduction behaviors.

METHODS

Patients were recruited from an urban methadone program to complete a survey. We assessed naloxone familiarity, availability, obtainability, training, and possession, as well as naloxone carriage rates, demographics, and harm reduction behaviors. A multivariable logistic regression examined associations between naloxone carriage and individual-level factors.

RESULTS

Participants (n = 97) were majority male (59%), with a mean age of 48 (SD = 12), 27% had college education or higher, 64% indicated injection drug use, and 84% reported past naloxone training. All participants endorsed familiarity with naloxone, but only 42% regularly carried naloxone. The following variables were associated with carrying naloxone: White race (aOR = 2.94, 95% CI 1.02-8.52), college education (aOR = 8.11, 95% CI 1.76-37.47), and total number of self-reported harm reduction behaviors (aOR = 1.45, 95% CI 1.00-2.11).

CONCLUSION

We found low rates of naloxone carriage among methadone-treated patients. Methadone programs provide opportunities for naloxone interventions and should target racial/ethnic minorities and individuals with lower education. The spectrum of harm reduction behaviors should be encouraged among these populations to enhance naloxone carriage.

I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois

BACKGROUND

Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths.

METHODS

Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods.

RESULTS

Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal.

CONCLUSIONS

People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

Characteristics and correlates of fentanyl preferences among people with opioid use disorder

OBJECTIVES

Fentanyl has come to dominate the U.S. illicit opioid supply. We aimed to characterize and examine correlates of preferences for fentanyl vs. other opioids among individuals starting OUD treatment.

METHODS

We interviewed 250 adults initiating buprenorphine treatment with positive fentanyl toxicology at intake. We characterized opioid preferences and examined bivariate associations between opioid preference (preference for heroin, fentanyl, heroin-fentanyl mix, or other opioid) and sociodemographic characteristics, psychosocial factors, and substance use behaviors. We then used multinomial logistic regression to examine factors independently associated with fentanyl preferences.

RESULTS

Over half (52.0 %) of participants preferred fentanyl (21.2 % fentanyl alone, 30.8 % heroin-fentanyl mix). In bivariate comparisons, participants who preferred fentanyl were a higher acuity group with respect to risks and problems in general. In the multinomial logistic regression, people who preferred fentanyl, either alone or mixed with heroin, used non-prescribed buprenorphine less in the 30 days preceding treatment entry compared to people who preferred heroin or other opioids (RRRalone= 0.88 [0.78, 0.99]; P = 0.037 and RRRmixed= 0.91 [0.84, 0.99]; P = 0.046). People who preferred fentanyl alone were also younger (RRR= 0.93 [0.90, 0.97]; P < 0.001) and more likely to have severe mental illness (RRR= 2.5 [1.1, 5.6]; P = 0.027) than people who prefer heroin or other opioids.

CONCLUSIONS

Many people with OUD report preferring fentanyl. People who express preference for fentanyl differ substantively from those with other opioid preferences, and may be at elevated risk for poor health outcomes. Understanding preferences surrounding fentanyl could inform treatment and harm reduction interventions.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting

Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD. This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the "microinduction" method). Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.

Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis

Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.

Variability in the unregulated opioid market in the context of extreme rates of overdose

BACKGROUND

Drug checking uses analytical chemistry technologies to report on the composition of drugs from the unregulated market to reduce substance use-related risks, while additionally allowing for monitoring and reporting of the supply. In the context of an overdose crisis linked to fentanyl, we used drug checking data to examine variability within the illicit opioid supply.

METHODS

In this time-series analysis, data was collected from a drug checking service in Victoria, Canada from November 2020 to July 2021. Drugs reported as opioids by participants of the service (N = 454) were analyzed to determine sample composition and paper spray mass spectroscopy was used to quantify low-concentration actives. Interquartile and statistical process control (SPC) analysis, namely standard deviation control charts, were used to examine the degree of variability among samples.

RESULTS

Fentanyl was found in 96% of samples reported to be opioids, with a median concentration of 9%. Concentrations varied significantly, with a standard deviation of 7% for fentanyl and where nearly 20% of data points fell outside the control limits. Over half of the samples contained an additional and unexpected active, most commonly etizolam (43% of samples). Etizolam also showed a large level of variability, uncorrelated to that of fentanyl.

CONCLUSIONS

Based on our chemical quantification and SPC analysis, a high degree of variability was found in opioid samples from the unregulated market in both the drugs detected and the concentrations of those drugs. This demonstrated the opioid crisis to be less attributable to a bad batch of drugs but rather the general variability found in the unregulated market.

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.

Increasing preference for fentanyl among a cohort of people who use opioids in Vancouver, Canada, 2017-2018

Background: Despite increasing prevalence of illicit fentanyl use in the US and Canada, preference for fentanyl over other illicit opioids has not been fully characterized. Therefore, we sought to describe changes in illicit opioid preferences over time among people who inject drugs (PWID). Methods: Data were obtained from two prospective cohort studies between 2017 and 2018. Trends in opioid preference over time were examined using bivariable generalized estimating equation (GEE) analysis. Multivariable models were used to identify factors associated with fentanyl preference. Results: Among 732 eligible participants, including 425 (58%) males, the prevalence of preference for fentanyl increased from 4.4% in 2017 to 6.6% in 2018 (Odds Ratio [OR] = 1.27, 95% Confidence Interval [CI]: 1.05-1.52). In a multivariable analysis, younger age (Adjusted Odds Ratio [AOR] = 0.94, 95% CI: 0.92-0.96) and daily crystal methamphetamine injection (AOR = 1.68, 95% CI: 1.01-2.78) were independently associated with preference for fentanyl. The most common reasons for preferring fentanyl included "better high than other opioids" (45%), and "lasts longer than heroin" (27%). Conclusions: The current study has demonstrated that preference for fentanyl has been increasing over time among our sample of PWID who use opioids. Further work is needed to clarify risk factors surrounding transitions to illicit fentanyl.

Changes in the development of opioid tolerance on re-exposure among people who use heroin: A qualitative study

BACKGROUND AND AIMS

This qualitative study aimed to explore how the development of tolerance to both the psychoactive and respiratory depressant effects of heroin on re-exposure are experienced by people who use heroin.

METHODS

Semi-structured one-to-one interviews were conducted with 20 adults who currently or previously used heroin (for at least 6 months), with any type of administration (injected, smoked) and experience of abstinence (at least 2 weeks) and relapse. Topic guides explored the participants understanding of tolerance, their experience of developing tolerance to heroin and of tolerance following relapse. Interviews were audio-recorded and transcribed. Thematic analysis was used to generate salient themes.

RESULTS

The analysis produced three broad themes: lay understanding of tolerance; tolerating tolerance; and rapid tolerance development following relapse. Tolerance was defined as the body adapting to regular drug use, so that the drug no longer produced the same level of effect. Tolerance was experienced as interacting and co-developing with physical dependence and the symptoms of withdrawal. Indeed, several participants did not differentiate between tolerance and dependence. Most participants did not notice tolerance to respiratory depression. Tolerance levels fluctuated-increasing over periods of regular use and reducing when abstinent. Using more drug was the most common response to increasing tolerance to the desired effects. On re-use following abstinence, tolerance was experienced as developing more quickly in the most recent relapse compared to the first. Tolerance was also perceived to return more quickly with each abstinence-relapse cycle.

CONCLUSIONS

Qualitative accounts of tolerance report that tolerance returns more quickly with each relapse episode. By elucidating the mechanism(s) involved and potentially discovering how they could be switched on prior to relapse occurring we might be able to develop a beneficial harm reduction treatment for people in abstinence that would protect against overdose occurring on subsequent relapse.

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

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

Consuming illicit opioids during a drug overdose epidemic: Illicit fentanyls, drug discernment, and the radical transformation of the illicit opioid market

BACKGROUND

North America continues to face an opioid overdose epidemic, driven by persistent increases in illicit fentanyls and fluctuations in potency leading to uncertainty for consumers. This qualitative study was conducted to better understand how people who inject drugs (PWID) came to recognize fentanyl as a growing adulterant of heroin and the subsequent sensory discernment strategies they employed to continue injecting. Our main objective was to investigate how observations and knowledge are combined as homegrown techniques for detecting fentanyl and minimizing risk. Secondary objectives were to examine the impact of growing fentanyl adulteration on individual drug use behavior.

METHODS

Between April and May 2019, 28 PWID (18 men, 10 women; average age = 38.43 years, SD = 9.26) were purposely recruited from a needle services program in Greensboro, North Carolina. Study participants were interviewed in-person using a qualitative, semi-structured instrument. Interviews were analyzed with a general inductive approach using NVivo12.

RESULTS

Participants described methods for detecting fentanyl in illicit opioids. Sudden increases in the potency of the 'rush' and sharp decreases in the length of the 'high' were chief indicators along with changes in drug color and texture. Heavy sedation was associated with fentanyl use and histamine-releasing effects characterized as 'pins and needles' were ascribed to injecting fentanyl as a component of the rush. Fentanyl's short high helped explain higher injection frequency and heavy sedation was the leading reason for co-using fentanyl with cocaine/crack or methamphetamine.

CONCLUSION

PWID have the capacity to recognize changes to the illicit opioid supply. Study participants navigated unpredictable fluctuations in the illicit opioid market by employing homegrown discernment techniques, modifying drug use behavior, and co-using non-opioid drugs. Researchers and policymakers should involve PWID as subject matter experts to help modernize harm reduction for the fentanyl age with practical strategies to boost resiliency and save lives.

Lay knowledge and practices of methamphetamine use to manage opioid-related overdose risks

AIM

Methamphetamine use has increased among individuals with opioid use disorder. The key aims of this study are to detail and contextualise lay knowledge, attitudes, and behaviours related to methamphetamine use in relation to opioid overdose risks in an area dominated by non-pharmaceutical fentanyl-type drugs (NPF).

METHODS

The study recruited 41 individuals in Dayton, Ohio, who reported past 30-day use of methamphetamine and heroin/fentanyl. Interviews included structured and qualitative questions. Urine toxicology analysis was conducted to identify NPFs and other drugs. Open-ended interview sections were audio-recorded, transcribed, and analysed qualitatively using NVivo.

RESULTS

The mean age was 38.3 years, 51% were female, and 100% non-Hispanic white. Participants described an exceedingly unpredictable local opioid market that became saturated with NPFs. The sample tested positive for 10 NPFs, including fentanyl (100%), acetyl fentanyl (61%), tetrahydrofuran fentanyl (29%), and carfentanil (12%). Most participants believed that methamphetamine could help prevent and/or reverse an opioid-related overdose. Nearly half had personally used it to help manage overdose risks related to NPF. These beliefs were embedded in a lay understanding of how methamphetamine works to stimulate the cardiovascular system. They were acted upon in the context of last resort situations that were determined by a lack of immediate access to naloxone, ambiguities surrounding overdose symptomatology, and easy access to plentiful and inexpensive methamphetamine.

CONCLUSION

Lay efforts to rely on methamphetamine to manage NPF-related overdose risks highlight the need for a continuing expansion of take-home-naloxone programs and implementation of other novel harm reduction approaches in communities affected by NPFs.

Transition from injecting opioids to smoking fentanyl in San Francisco, California

BACKGROUND

The introduction of illicitly made fentanyl in the United States has slowly replaced heroin. New illicit drugs are often associated with changes in frequency and modes of administration. We assessed changes in injection frequency and smoking fentanyl in the new era of fentanyl availability in San Francisco.

METHODS

We used targeted sampling to recruit 395 people who inject drugs (PWID) into an observational cohort study in San Francisco 2018-2020. We assessed changes in injection frequency, opioid injection frequency and fentanyl smoking frequency in four six-month periods. We also conducted qualitative interviews with PWID asking about motivations for injecting and smoking opioids.

RESULTS

The median number of past-month injections steadily decreased by semi-annual calendar year from 92 injections in July to December 2018 to 17 injections in January to June 2020. The rate of opioid injections reduced by half (Adjusted Incidence Rate Ratio = 0.41; 95 % Confidence Interval = 0.25, 0.70; p < 0.01). The number of days smoking fentanyl was associated with fewer number of injections (X2(2) = 11.0; p < 0.01). Qualitative interviews revealed that PWID's motivation for switching from injecting tar heroin to smoking fentanyl was related to difficulties accessing veins. After switching to smoking fentanyl, they noticed many benefits including how the drug felt, improved health, fewer financial constraints, and reduced stigma.

CONCLUSION

Between 2018 and 2020, there was a shift from injecting tar heroin to smoking fentanyl in San Francisco. Reductions in injection of illicit drugs may offer public health benefit if it reduces risk of blood-borne viruses, abscesses and soft-tissue infections, and infective endocarditis.

Rapid situational assessment of people who inject drugs (PWID) in Nairobi and coastal regions of Kenya: a respondent driven sampling survey

BACKGROUND

A Cross-sectional Rapid Situational Assessment of People Who Inject Drug (PWIDs) applying Respondent Driven sampling techniques (RDS) was used to recruit subjects/participants in a study aimed at assessing HIV prevalence and risk behaviors among injecting drug users in Nairobi and Coastal regions of Kenya. There is paucity of data and information on injecting drug use in sub-Saharan Africa and there is sufficient evidence of existence of the environment for development and growth of injecting drug use. Past studies on PWID and its association to HIV and AIDS that have been conducted in Kenya do not provide sufficient information to support effective planning and comprehensive national response to the HIV and AIDS epidemic.

METHODS

A cross-sectional study design was adopted in which a set of initial subjects referred to as 'seeds' were first identified from which an expanding chain of referrals were obtained, with subjects from each wave referring subjects of subsequent waves. The seeds were drawn randomly from the population and interviewed to pick the one with the largest network and other unique characteristics. A maximum of twelve seeds were recruited. The second stage involved conducting assessment visits to the sites to identify potential collaborators that included non-governmental organizations (NGOs), drug treatment centres, health facilities, community based organizations (CBO's) among others. Three NGOs located in the coast region and one in Nairobi region were identified to assist in identifying drug injection locations and potential participants. Key informant interviews (KIIs) and Focus Group Discussions (FGDs) were also conducted using interview guides.

RESULTS

A total of 646 individuals (344 in Nairobi and 302 at the coast) were recruited for the study between January and March 2010. Of these 590 (91%) were male and 56 (9%) were female. Findings showed that most PWIDs initiated injecting drug use between the ages of 20-29 years, with the youngest age of initiation being 11 years and oldest age being 53 years. Most commonly injected drug was heroin (98%), with a small (2%) percentage injecting cocaine. Other non-injecting methods such as smoking or combining these two drugs with other drugs such as cannabis or Rohypnol were also common. Most PWIDs used other substances (cigarettes, alcohol, and cannabis) before initiating injecting drug use. The adjusted national HIV prevalence of PWIDs was 18.3% (19.62% unadjusted) with PWIDs in Nairobi region registering 18.33% (20.58% unadjusted) compared PWIDs for Coastal region indicating 18.27% (18.59% - unadjusted). The gender based HIV prevalence showed that women were more at risk of acquiring HIV (44.51%-adjusted) compared to men (15.97%-adjusted). The age specific HIV prevalence showed that PWIDs who initiated injecting at 11-19 years (44.7% adjusted) were most at risk in Nairobi compared to those who initiated injecting at age 20-24 years (23.2% - adjusted) in the coastal region. While all PWIDs continue to be at risk in the two regions, those from the Western parts of Nairobi, Kenya were at a relatively higher risk given their increased propensity for sharing injecting equipment and solutions.

CONCLUSIONS

Compared to the national HIV prevalence of (4.9%), the results show that People Who Inject Drugs (PWIDs) are at particularly high risk of infection in Kenya and there is urgent need for intervention (KenPHIA, 2018). This study also showed clear evidence that 70% of PWIDs are primary school educated, engage in high risk injecting and sexual behaviors comprising sharing of injecting equipment, unprotected heterosexual and homosexual sex. Given that initiation of injecting drug use begins early and peaks after formal school years (20-29 years), prevention programmes should be targeted at primary and secondary school students, college and out of school youth. Further, to protect People who inject drugs (PWIDs) from HIV infection, the country should introduce free Needle Syringe Programs (NSP) with provision of condoms and Methadone Assisted Therapy (MAT) as a substitute for drug use.

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.

The uptake of foil from needle and syringe provision services and its role in smoking or snorting heroin among people who inject drugs in Scotland

BACKGROUND

In the UK, legislation was implemented in 2014 allowing needle and syringe provision (NSP) services to offer foil to people who inject drugs (PWID) to encourage smoking rather than injecting. This paper aims to examine the association between foil uptake and smoking or snorting heroin among PWID. This is the first large scale national study to examine foil uptake and smoking or snorting heroin among PWID post legislative change.

METHOD

Data from 1453 PWID interviewed via Scotland's Needle Exchange Surveillance Initiative in 2017-2018 were analysed using multivariate logistic regression.

RESULTS

Overall, 36% of PWID had obtained foil from NSP services in the past six months. The odds of smoking or snorting heroin were higher among those who had obtained foil (Adjusted Odds Ratio (AOR) 3.79 (95% CI 2.98-4.82) p<0.001) compared to those who had not. Smoking or snorting heroin was associated with lower odds of injecting four or more times daily (AOR 0.60 (95% CI 0.40-0.90) p = 0.012) and injecting into the groin or neck (AOR 0.57 (95% CI 0.46-0.71) p<0.001) but increased odds of having had a skin and soft tissue infection (SSTI) (AOR 1.49 (95% CI 1.17-1.89) p = 0.001) and having experienced an overdose (AOR 1.58 (95% CI 1.18-2.10) p = 0.002) both in the past year.

CONCLUSION

The promotion of smoking drugs via foil provision from NSP services may contribute to the package of harm reduction measures for PWID alongside the provision of injecting equipment. We found that those in receipt of foil were more likely to smoke or snort heroin, and that smoking or snorting heroin was associated with a lower likelihood of some risky injecting behaviours, namely frequent injecting and injecting into the groin or neck. But it remains uncertain if the provision of foil can lead to a reduction in health harms, such as SSTI and overdose. Future research is needed to understand PWID motivations for smoking drugs, obtaining foil from NSP services, and its uses particularly among polydrug users.

Injecting drug use, the skin and vasculature

Damage to the skin, subcutaneous tissues and blood vessels are among the most common health harms related to injecting drug use. From a limited range of early reports of injecting-related skin and soft tissue damage there is now an increasing literature relating to new drugs, new contaminants and problems associated with unsafe injection practices. Clinical issues range from ubiquitous problems associated with repeated minor localised injection trauma to skin and soft tissue and infections around injection sites, to systemic blood infections and chronic vascular disease. The interplay of limited availability and access to sterile injecting equipment, poor injecting technique, compromised drug purity, drug toxicity and difficult personal and environmental conditions give rise to injection-related health harms. This review of injecting-related skin, soft tissue and vascular damage focuses on epidemiology and causation, clinical examination and investigation, treatment and prevention.

Consumer discernment of fentanyl in illicit opioids confirmed by fentanyl test strips: Lessons from a syringe services program in North Carolina

BACKGROUND

The United States (U.S.) continues to witness an unprecedented increase in opioid overdose deaths driven by precipitous growth in the supply and use of illicitly-manufactured fentanyls (IMF). Fentanyl's growing market share of the illicit opioid supply in the U.S. has led to seismic shifts in the composition of the country's heroin supply. The growth in fentanyl supply has transformed illicit opioid markets once offering heroin with fairly consistent purity and potency to a supply overpopulated with fentanyl(s) of inconsistent and unpredictable potency. In response, people who inject drugs (PWID) have developed a number of sensory strategies to detect fentanyl in illicit opioids. The current study examined the accuracy of sensory discernment strategies by measuring study participants' descriptions of the last opioid injected and checked with a fentanyl test strip (FTS) by that test's positive/negative result. The primary objective was to determine associations between FTS results and descriptions of the illicit opioid's physical appearance and physiological effects.

METHODS

Between September-October 2017, a total of 129 PWID were recruited from a syringe services program in Greensboro, North Carolina and completed an online survey about their most recent use of FTS. Participants were instructed to describe the appearance and effects associated with the most recent opioid they injected and tested with FTS. We conducted bivariate and multivariate analyses to determine differences in positive vs negative FTS results and the physical characteristics and physiological experiences reported. An exploratory analysis was also conducted to describe the types and bodily locations of unusual sensations experienced by PWID reporting positive FTS results.

RESULTS

For physical characteristics, 32% reported that the drug was white before adding water and 38% reported the solution was clear after adding water. For physiological effects compared to heroin, 42% reported a stronger rush, 30% a shorter high, 30% a shorter time to the onset of withdrawal symptoms, and 42% experienced unusual sensations. In the multivariable model adjusting for demographics and polydrug correlates, white color of drug before adding water, stronger rush, shorter time to withdrawal, and unusual sensations were significantly associated with a positive FTS result. The most common unusual sensations were pins and needles (51%), warming of the head and face (35%), and lightheadedness (30%), and the most common locations where sensations occurred were face and neck (61%), arms/legs (54%), and chest (37%).

CONCLUSION

We found positive FTS results were significantly associated with the physical characteristics and physiological effects described by PWID. Descriptions concerning physical appearance were consistent with law enforcement profiles of illicitly-manufactured fentanyl and physiological effects were concomitant with scientific and clinical medical literature on iatrogenic fentanyl use. Taken together, these findings suggest sensory strategies for detecting fentanyl in illicit opioids may be an effective risk reduction tool to help consumers navigate unpredictable markets more safely.

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.

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.

"It's Crazy What Meth Can Help You Do": Lay Beliefs, Practices, and Experiences of Using Methamphetamine to Self-Treat Symptoms of Opioid Withdrawal

BACKGROUND

Across the U.S., methamphetamine use is expanding among people who use illicit opioids (PWUIO). Motives for methamphetamine use must be contextualized within the experiences of PWUIO, who may use methamphetamine not only to achieve euphoria, but also as a tactic of self-management. The overall aim of this study is to contextualize lay beliefs, practices, and experiences of methamphetamine use as a form of self-treatment of symptoms related to chronic opioid use among PWUIO in the Dayton Metro Area of Southwest Ohio, an epicenter of the ongoing opioid crisis.

METHODS

This paper draws on two phases of interviews conducted with 38 individuals who use both heroin/fentanyl and methamphetamine. This paper primarily analyzes qualitative data but includes supplementary information from the structured interview component. Qualitative interview sections were transcribed in their entirety and thematically analyzed.

RESULTS

Participants described learning about methamphetamine as a tactic to treat opioid withdrawal symptoms through social networks and through personal experimentation. Many participants suggested that methamphetamine was helpful in relieving exhaustion, alleviating some acute physical symptoms of opioid withdrawal, and providing a psychological distraction, although some admitted that methamphetamine use could incur additional health risks. To effectively use methamphetamine as a tactic of self-treatment, participants emphasized the importance of timing and dosing.

DISCUSSION

Among PWUIO in the Dayton area, methamphetamine use as a tactic to self-manage opioid withdrawal must be studied in relation to historical and evolving patterns of illicit opioid use and associated risks. More research is needed to understand the long-term health impacts of this emergent practice of polydrug use.

Fentanyl and fentanyl analogs in the illicit stimulant supply: Results from U.S. drug seizure data, 2011-2016

BACKGROUND

U.S. research examining the illicit drug supply remains rare even though the information could help reduce overdoses. Relatively little is known regarding how often opioids are found in stimulants and whether temporal and geographic trends exist. We examined trends in fentanyl-cocaine and fentanyl-methamphetamine combinations in the national illicit drug supply.

METHODS

We analysed serial cross-sectional data from the National Forensic Laboratory Information System (NFLIS) collected between January 2011 and December 2016. We restricted the analysis to cocaine (N = 1,389,968) and methamphetamine (n = 1,407,474) samples and calculated proportions containing fentanyl (including 23 related analogs) over time.

RESULTS

The combined presence of fentanyl and cocaine steadily increased nationally between 2012-2016 (p = 0.01), and the number of such samples tripled from 2015 to 2016 (n = 423 to n = 1,325). Similarly, the combined presence of fentanyl and methamphetamine increased 179 % from 2015 to 2016 (n = 82-n = 272). Patterns varied widely by state; in 2016, fentanyl-cocaine samples were most common in New Hampshire (7.2 %), Connecticut (5.4 %), Ohio (2.6 %) and Massachusetts (2.1 %), whereas fentanyl-methamphetamine samples were most often in New Hampshire (6.1 %), Massachusetts (5.6 %), Vermont (2.4 %) and Maine (1.2 %).

CONCLUSIONS

Although relatively uncommon, the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occuring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast. Given these trends, strengthening community-based drug checking programs and surveillance within the public health infrastructure could help promote timely responses to novel threats posed by rapid shifts in the drug supply that may lead to inadvertent exposures.

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

Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency

Background

West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state’s drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston’s needle and syringe program was forced to close. This paper considers the risk environment in which the state’s drug-related loss of life, and those attempting to prevent it, exist.

Methods

This rapid ethnographic study involved semi-structured interviews (n = 21), observation and video recordings of injection sequences (n = 5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n = 2) with individuals involved in service provision were also carried out.

Results

PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH.

Conclusions

Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs

OBJECTIVE

Opioid withdrawal symptoms are widely understood to contribute to health risk but have rarely been measured in community samples of opioid using people who inject drugs (PWID).

METHODS

Using targeted sampling methods, 814 PWID who reported regular opioid use (at least 12 uses in the last 30 days) were recruited and interviewed about demographics, drug use, health risk, and withdrawal symptoms, frequency, and pain. Multivariable regression models were developed to examine factors associated with any opioid withdrawal, withdrawal frequency, pain severity, and two important health risks (receptive syringe sharing and non-fatal overdose).

RESULTS

Opioid withdrawal symptoms were reported by 85 % of participants in the last 6 months, with 29 % reporting at least monthly withdrawal symptoms and 35 % reporting at least weekly withdrawal symptoms. Very or extremely painful symptoms were reported by 57 %. In separate models, we found any opioid withdrawal (adjusted odds ratio [AOR] = 2.75, 95 % confidence interval [CI] = 1.52, 5.00) and weekly or more opioid withdrawal frequency (AOR = 1.94; 95 % CI = 1.26, 3.00) (as compared to less than monthly) to be independently associated with receptive syringe sharing while controlling for confounders. Any opioid withdrawal (AOR = 1.71; 95 % CI = 1.04, 2.81) was independently associated with nonfatal overdose while controlling for confounders. In a separate model, weekly or more withdrawal frequency (AOR = 1.69; 95 % CI = 1.12, 2.55) and extreme or very painful withdrawal symptoms (AOR = 1.53; 95 % CI = 1.08, 2.16) were associated with nonfatal overdose as well.

CONCLUSIONS

Withdrawal symptoms among PWID increase health risk. Treatment of withdrawal symptoms is urgently needed and should include buprenorphine dispensing.

Hospital admissions among people who inject opioids following syringe services program implementation

Background

Syringe services programs (SSPs) are an evidence-based harm reduction strategy that reduces dangerous sequelae of injection drug use among people who inject drugs (PWID) such as overdose. SSP services include safer injection education and community-based naloxone distribution programs. This study evaluates differences in overdose-associated hospital admissions following the implementation of the first legal SSP in Florida, based in Miami-Dade County.

Methods

We performed a retrospective analysis of hospitalizations for injection drug-related sequelae at a county hospital before and after the implementation of the SSP. An algorithm utilizing ICD-10 codes for opioid use and sequelae was used to identify people who inject opioids (PWIO). Florida Department of Law Enforcement Medical Examiners Commission Report data was used to analyze concurrent overdose death trends in Florida counties.

Results

Over the 25-month study period, 302 PWIO admissions were identified: 146 in the pre-index period vs. 156 in the post-index period. A total of 26 admissions with PWIO overdose were found: 20 pre-index and 6 post-index (p = 0.0034).

Conclusions

Declining overdose-associated admissions among PWIO suggests early impacts following SSP implementation. These results indicate a potential early benefit of SSP that should be further explored for its effects on future hospital admission and mortality.

Practices of care among people who buy, use, and sell drugs in community settings

BACKGROUND

Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.

METHODS

Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.

RESULTS

Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.

CONCLUSION

Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"Am I gonna get in trouble for acknowledging my will to be safe?": Identifying the experiences of young sexual minority men and substance use in the context of an opioid overdose crisis

BACKGROUND

North America and other parts of the globe are in the midst of a public health emergency related to opioid overdoses and a highly contaminated illicit drug supply. Unfortunately, there is a substantial gap in our understandings about how this crisis affects key populations not conventionally identified within overdose-related surveillance data. This gap is particularly pronounced for gay, bisexual, and other men who have sex with men (sexual minority men)-a population that experiences substance use-related inequities across adolescence and young adulthood.

METHODS

We draw on in-depth semi-structured interviews conducted in 2018 with a diverse sample (N = 50) of sexual minority men ages 15-30 who use substances and live in Vancouver, Canada, to identify how patterns and contexts of substance use are occurring in the context of the opioid overdose crisis.

RESULTS

Our analysis revealed three themes: awareness, perceptions, and experiences of risk; strategies to mitigate risk; and barriers to safer substance use. First, participants described how they are deeply impacted by the contaminated illicit drug supply, and how there is growing apprehension that fatal and non-fatal overdose risk is high and rising. Second, participants described how procuring substances from "trustworthy" drug suppliers and other harm reduction strategies (e.g., drug checking technologies, Naloxone kits, not using alone) could reduce overdose risk. Third, participants described how interpersonal, service-related, and socio-structural barriers (e.g., drug criminalization and the lack of a regulated drug supply) limit opportunities for safer substance use.

CONCLUSIONS

Equity-oriented policies and programming that can facilitate opportunities for safer substance use among young sexual minority men are critically needed, including community- and peer-led initiatives, access to low-barrier harm reduction services within commonly frequented social spaces (e.g., Pride, night clubs, bathhouses), nonjudgmental and inclusive substance use-related health services, the decriminalization of drug use, and the provision of a safe drug supply.

The Rapidly Changing US Illicit Drug Market and the Potential for an Improved Early Warning System: Evidence from Ohio Drug Crime Labs

BACKGROUND

The US has seen a rapid increase in synthetic opioid-related overdose deaths. We investigate Ohio, a state with one of the highest overdose death rates in 2017 and substantial numbers of deaths related to fentanyl, carfentanil, and other fentanyl analogs, to provide detailed evidence about the relationship between changes in the illicit drug market and overdose deaths.

METHODS

We investigate the illicit drug market using Ohio's Bureau of Criminal Investigation's (BCI) crime lab data from 2009 to 2018 that shows the content of drugs seized by law enforcement. We use Poisson regression analysis to estimate the relationship between monthly crime lab data and monthly unintentional drug overdose death data at the county level.

RESULTS

During this time period there has been a rapid change in the composition of drugs analyzed by the BCI labs, with a rapid fall in heroin observations, simultaneous rise in synthetic opioids, and an increase in the number of different fentanyl analogs. We find that the increased presence of fentanyl, carfentanil, and other fentanyl analogs have a strong correlation with an increase in overdose deaths. The types of opioids most associated with deaths varies by the population size of the county.

CONCLUSIONS

Crime lab data has the potential to be used as an early warning system to alert persons who inject drugs, harm reduction services, first responders, and law enforcement about changes in the illicit opioid risk environment.

When and how do individuals transition from regular drug use to injection drug use in Uganda? Findings from a rapid assessment

Background

In Uganda, injection drug use is a growing but less studied problem. Preventing the transition to injection drug use may help prevent blood-borne viral transmission, but little is known about when and how people transition to injection drug use. A greater understanding of this transition process may aid in the country’s efforts to prevent the continued growth of injection drug use, HIV, and hepatitis C Virus (HCV) infection among people who inject drugs (PWID).

Methods

Using a rapid situation assessment framework, we conducted semi-structured interviews among 125 PWID (102 males and 23 females)—recruited through outreach and snow-ball sampling. Participants were interviewed about their experiences on when and how they transitioned into injection drug use and these issues were also discussed in 12 focus groups held with the participants.

Results

All the study participants started their drug use career with non-injecting forms including chewing, smoking, and sniffing before transitioning to injecting. Transitioning was generally described as a peer-driven and socially learnt behavior. The participants’ social networks and accessibility to injectable drugs on the market and among close friends influenced the time lag between first regular drug use and first injecting—which took an average of 4.5 years. By the age of 24, at least 81.6% (95.7% for females and 78.4% for males) had transitioned into injecting. Over 84.8% shared injecting equipment during their first injection, 47.2% started injecting because a close friend was already injecting, 26.4% desired to achieve a greater “high” (26.4%) which could reflect drug-tolerance, and 12% out of curiosity.

Conclusions

Over 81% non-injecting drug users in Kampala and Mbale districts transitioned into injecting by the age of 24; a process that reproduces a population of PWID but also puts them at increased risk of HIV and HCV infection. As Uganda makes efforts to introduce and/or strengthen harm reduction services, interventions targeting non-injecting drug users before they transition into injecting should be considered as a key component for HIV/HCV epidemic control efforts, and their evaluation considered in future researches.

Polysubstance use patterns and novel synthetics: A cluster analysis from three U.S. cities

The rapid emergence of novel psychoactive substances within the past decade has raised new concerns about the harms associated with unregulated drug use. Synthetic analogues-chemically related to established psychoactive substances like cannabis sativa and catha edulis-in particular have proliferated rapidly, allowing little opportunity for scientific research or the establishment of informal guidelines for safe use among consumers. To explore how synthetic substance use relates to other forms of use, this paper presents an analysis of polysubstance use among a sample of 676 people who use illicit substances in the United States. Participants were sampled from three greater metropolitan areas (Houston/Galveston, Texas; New York City; and New Orleans, Louisiana). Study researchers used cluster-type analyses to develop dendrogram visualizations of the interrelationships between substance types. Results suggest a considerable variation in substance and polysubstance use patterns across states in the U.S. Polysubstance use clustered around well-observed combinations like MDMA/cannabis and cocaine/heroin. Synthetic cannabinoids and cathinones showed no strong clustering with other substances. High rates of binge drinking among users of other substances further support the importance of interventions sensitive to the clinical challenges of polysubstance use.

Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs

BACKGROUND

Over the last several years, fentanyl has been introduced into the illicit drug supply in the United States. While the impact of fentanyl on overdose fatalities is clear, the increase in fentanyl use may also be affecting drug use practices with implications for infectious disease transmission. We conducted a cross-sectional survey to explore associations of perceived illicit fentanyl use with opioid use frequency, injection frequency and syringe sharing among people who inject drugs in two California cities.

METHODS

People who inject drugs (PWID) were recruited from community settings in Los Angeles and San Francisco, CA from June 2017 to September 2018. Multivariable logistic regression was used to explore adjusted associations between perceived illicit fentanyl use and high frequency opioid use, high frequency injection and syringe sharing.

RESULTS

Among the 395 study participants, the median age of participants was 44 years; 74% of participants were cisgender male; 73% reported to be homeless; 61% lived in San Francisco and 39% in Los Angeles. The prevalence of perceived illicit fentanyl use in the past six months was 50.4% (95% confidence interval (CI): 45.4%-55.3%) among PWID. Findings from our adjusted logistic regression models suggested that people reporting perceived illicit fentanyl use had a greater odds of high frequency opioid use (adjusted odds ratio (aOR) = 2.36; 95% CI: 1.43-3.91; p = 0.001), high frequency injection (aOR = 1.84; 95% CI: 1.08-3.13; p = 0.03) and receptive syringe sharing (aOR = 2.16; 95% CI: 1.06-4.36; p = 0.03), as compared to people using heroin and other street drugs but not fentanyl.

CONCLUSION

People reporting perceived illicit fentanyl use were at increased risk for injection-related infectious disease risks. Actions must be taken to reduce these risks, including improved access to syringe service programs and opioid treatment and consideration of innovative approaches, such as supervised consumption services.

Fentanyl exposure and preferences among individuals starting treatment for opioid use disorder

BACKGROUND

Fentanyl has become widespread in the illicit opioid supply, and is a major driver of overdose mortality.

METHODS

This study used a medical records review at a community opioid use disorder treatment program to examine patient-level correlates of fentanyl exposure as measured by urine testing at admission (N= 1,174). Additionally, an anonymous survey was conducted with 114 patients about their experiences and preferences regarding fentanyl.

RESULTS

Overall, 39% of patients entering treatment tested positive for fentanyl. Prevalence of fentanyl exposure differed based on other drug test results (fentanyl-positive = 81.1% vs. 15.4% among participants positive vs. negative for heroin/opioids, p < .001; 59.0% vs. 38.3% among participants positive vs. negative for methadone, p = .001; 53.8% vs. 24.9% among participants positive vs. negative for cocaine, p < .001), prior addiction treatment (40.6% vs. 32.0% among participants with vs. without prior treatment, p < .05), and mental health (36.7% vs. 43.1% among participants with vs. without co-occurring psychiatric diagnosis, p < .05). Most participants reported knowingly using fentanyl (56.1%) and knowing people who prefer fentanyl as a drug of choice (65.8%). Preference for fentanyl (alone or mixed with heroin) was expressed by 44.7% of participants. Participants thought fentanyl withdrawal had faster onset (53.5%), greater severity (74.8%), and longer duration (62.0%) than heroin withdrawal.

CONCLUSIONS

Recent opioid and cocaine use were strongly associated with fentanyl exposure in this sample. Although fentanyl exposure is often unintentional, there may be a subgroup of individuals who come to prefer fentanyl. Future research should examine the relationship between fentanyl use, patient preferences for fentanyl, and treatment outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs

Background: From 2011 to 2016, the United States has experienced a 55% increase in overall overdose deaths and a 260% increase in fatal fentanyl-related overdoses. Increasing engagement in harm reduction practices is essential to reducing the rate of fentanyl-related overdoses. This study sought to examine the uptake of harm reduction practices among young adults who reported recent drug use and who were recruited for a study to assess the utility and acceptability of rapid fentanyl test strips. Methods: Between May and October 2017, 93 young adults who reported drug use in the past 30 days were recruited through word of mouth, Internet advertising, and public canvasing. Participants completed an interviewer-administered survey that assessed participants' sociodemographic and behavioral characteristics, suspected fentanyl exposure, and overdose history. We assessed harm reduction practices and other correlates associated with experiencing a suspected fentanyl-related overdose. Results: Of 93 eligible participants, 36% (n = 34) reported ever having experienced an overdose, among whom 53% (n = 18) suspected having experienced a fentanyl-related overdose. Participants who had ever experienced a fentanyl-related overdose were more likely to keep naloxone nearby when using drugs compared with those who had never experienced an overdose and those who had experienced an overdose that they did not suspect was related to fentanyl (P < .001). Additionally, experiencing a suspected fentanyl-related overdose was associated with having previously administered naloxone to someone else experiencing an overdose (P < .001). Conclusion: Those who had experienced a suspected fentanyl-related overdose were more likely to carry and administer naloxone. Future overdose prevention interventions should involve persons who have experienced a suspected fentanyl overdose and/or responded to an overdose in order to develop harm reduction programs that meet the needs of those at risk of an overdose.

Willingness to Use Safe Consumption Spaces among Opioid Users at High Risk of Fentanyl Overdose in Baltimore, Providence, and Boston

Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system.

Being "hooked up" during a sharp increase in the availability of illicitly manufactured fentanyl: Adaptations of drug using practices among people who use drugs (PWUD) in New York City

Illicitly manufactured fentanyl (IMF), a category of synthetic opioids 50-100 times more potent than morphine, is increasingly being added to heroin and other drugs in the United States (US). Persons who use drugs (PWUD) are frequently unaware of the presence of fentanyl in drugs. Use of heroin and other drugs containing fentanyl has been linked to sharp increases in opioid mortality. In New York City (NYC), opioid-related mortality increased from 8.2 per 100,000 residents in 2010 to 19.9 per 100,000 residents in 2016; and, in 2016, fentanyl accounted for 44% of NYC overdose deaths. Little is known about how PWUD are adapting to the increase in fentanyl and overdose mortality. This study explores PWUDs' adaptations to drug using practices due to fentanyl. In-depth qualitative interviews were conducted with 55 PWUD at three NYC syringe services programs (SSP) about perceptions of fentanyl, overdose experiences and adaptations of drug using practices. PWUD utilized test shots, a consistent drug dealer, fentanyl test strips, naloxone, getting high with or near others and reducing drug use to protect from overdose. Consistent application of these methods was often negated by structural level factors such as stigma, poverty and homelessness. To address these, multi-level overdose prevention approaches should be implemented in order to reduce the continuing increase in opioid mortality.