Shifting drug markets in North America - a global crisis in the making?

Impacts of the COVID-19 pandemic on the availability and retail price of unregulated drugs in Vancouver, Canada: An interrupted time-series analysis, 2018-2022

BACKGROUND

Impacts of the COVID-19 pandemic on unregulated drug markets in North America have not been well characterized. We sought to estimate potential changes in the availability and retail price of unregulated drugs in Vancouver, Canada pre- vs. post-emergence of the COVID-19 pandemic.

METHODS

We used self-report data from two prospective cohorts of people who use drugs in Vancouver. We employed interrupted time series analyses to identify changes in the monthly prevalence of immediate availability (i.e., within 10 minutes vs. any longer) and median retail price of crystal methamphetamine, powder cocaine, crack cocaine, and 'down' (the local term for unregulated opioids, e.g., heroin, fentanyl, etc), post-pandemic emergence (i.e. post-July 2020).

RESULTS

Between 2018 and 2022 among 739 participants, the monthly prevalence of immediate availability significantly decreased for all drugs immediately post- emergence of the pandemic (all p<0.05). The monthly prevalence of immediate availability of cocaine declined most (-18.1%, 95% confidence interval [CI]: -25.9, -10.4) and the immediate availability of 'down' declined least (-13.0%, 95% CI:-18.8, -7.3). In analyses of median price, the only significant change was in the price of cocaine, which increased by $3.46 per 0.5 grams (95% CI:1.0, 5.9) immediately post-emergence of the pandemic.

CONCLUSION

While more research is needed to investigate reasons for the observed trends, the stagnant price amidst decreased availability for all drugs examined in this study (save cocaine) may reflect decreased purity/increased contamination of unregulated drugs following the beginning of the pandemic in our study setting. These findings may have implications for drug policy and practice approaches, particularly in regions where synthetic psychoactive substances are increasingly dominating the unregulated drug supply.

Four-year evaluation of drug-impaired driving drug concentrations

Drug-impaired driving is a significant public health and safety concern in the USA. To help assess current patterns of drug use in drivers, we evaluated 4 years of drug positivity in a large cohort of suspected impaired drivers. Samples collected between January 2017 and December 2020 were tested via a method compliant with the National Safety Council's Alcohol, Drugs, and Impairment Division's Tier I scope of recommended drugs. In 2017, NMS Labs received 17 346 driving under the influence of drugs cases, 17 471 in 2018, 19 050 in 2019, and 16 539 in 2020. The most common drug class detected was cannabinoids in ∼50% of the cases each year. The most common drugs detected over the 4 years were delta-9 tetrahydrocannabinol (delta-9 THC), ethanol, amphetamine/methamphetamine, fentanyl, and alprazolam. Delta-9 THC increased in positivity over the study, having been identified in 45% of cases in 2017, 46% in 2018, 46% in 2019, and 49% in 2020. Ethanol was found in 59% of cases in 2017, 59% in 2018, 61% in 2019, and 53% in 2020. Delta-9 THC and ethanol were the most common drug combination, found together in ∼19% of the cases every year of the study. Statistically significant increases in the average concentration of the following drugs were observed: fentanyl (5.7 ng/mL in 2017 to 9.6 ng/mL in 2020), methamphetamine (301 ng/mL in 2017 to 381 ng/mL in 2020), and delta-9-THC (6.4 ng/mL in 2017 to 7.3 ng/mL in 2020). Other findings included increases in the maximum reported concentrations between 2017 and 2020 for amphetamine (1400 to 2700 ng/mL), methamphetamine (5550 to 13 000 ng/mL), and fentanyl (56 to 310 ng/mL). Statistically significant concentration decreases were noted for several central nervous system depressants, notably prescription benzodiazepines, and several prescription narcotic analgesics.

Opportunities and challenges for implementing drug checking services in British Columbia, Canada: A qualitative study

BACKGROUND

Amidst the ongoing drug poisoning crisis across North America, drug checking services (DCS) are increasingly being implemented as an intervention intended to reduce drug-related harms. This study sought to identify key opportunities and challenges influencing the implementation of DCS in British Columbia (BC), Canada.

METHODS

Between January 2020 and July 2021, semi-structured, in-depth interviews were conducted with 21 individuals involved in the implementation of DCS across BC (i.e., policymakers, health authority personnel, community organization representatives and service providers). The Consolidated Framework for Implementation Research (CFIR) was used to guide coding and analysis of the interviews.

RESULTS

By bringing in a wealth of knowledge about community needs and concerns, in addition to a passion and energy for social justice and health equity, community members and organizations with a dedication for harm reduction played a critical role in the successful implementation of DCS in BC. Other significant facilitators to implementation included the preventive benefits of DCS that made the intervention compelling to policy influencers and decision makers, the provincial public health emergency regarding overdose that shifted the regulatory environment of DCS, the adaptability of DCS to meet concerns and needs in various contexts, including via ongoing processes of reflection and evaluation. Barriers to implementation included criminalization and stigmatization of drug use and people who use drugs and lack of funding for community-led implementation actions.

CONCLUSIONS

Alongside structural reforms that address the underlying contextual factors that influence implementation (e.g., decriminalization of drugs, increased funding for DCS), centering community expertise throughout implementation is critical to the success of DCS. Our findings provide important insights into how BC can successfully implement systems-level harm reduction interventions and offer insights for other jurisdictions in their implementation of DCS.

Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit

Importance

Hospitalizations related to opioid use disorder (OUD) represent an opportunity to initiate medication for OUD (MOUD).

Objective

To assess whether starting MOUD after a hospitalization or emergency department (ED) visit is associated with the odds of fatal and nonfatal opioid overdose at 6 and 12 months.

Design, Setting, and Participants

This population-based cohort study used data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other administrative health datasets, for individuals aged 18 years or older who had diagnosis codes related to OUD recorded at an index ED visit or hospitalization from January 2017 to December 2019. Data were analyzed between May 2023 and January 2024.

Exposures

Receipt of MOUD within the 7 days after an OUD-related hospital visit.

Main Outcomes and Measures

The primary outcome was fatal or nonfatal overdose at 6 and 12 months after discharge. Sample characteristics, including age, sex, insurance plan, number of comorbidities, and opioid-related overdose events, were stratified by receipt or nonreceipt of MOUD within 7 days after an OUD-related hospital visit. A logistic regression model was used to investigate the association between receipt of MOUD and having an opioid overdose event.

Results

The study included 22 235 patients (53.1% female; 25.0% aged 25-39 years) who had an OUD-related hospital visit during the study period. Overall, 1184 patients (5.3%) received MOUD within 7 days of their ED visit or hospitalization. Of these patients, 683 (57.7%) received buprenorphine, 463 (39.1%) received methadone, and 46 (3.9%) received long-acting injectable naltrexone. Patients who received MOUD within 7 days after discharge had lower adjusted odds of fatal or nonfatal overdose at 6 months compared with those who did not (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.97). At 12 months, there was no difference in adjusted odds of fatal or nonfatal overdose between these groups (AOR, 0.79; 95% CI, 0.58-1.08). Patients had a lower risk of fatal or nonfatal overdose at 6 months associated with buprenorphine use (AOR, 0.50; 95% CI, 0.27-0.95) but not with methadone use (AOR, 0.57; 95% CI, 0.28-1.17).

Conclusions and Relevance

In this cohort study of individuals with an OUD-related hospital visit, initiation of MOUD was associated with reduced odds of opioid-related overdose at 6 months. Hospitals should consider implementing programs and protocols to offer initiation of MOUD to patients with OUD who present for care.

Associations among drug acquisition and use behaviors, psychosocial attributes, and opioid-involved overdoses

AIMS

This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses.

DESIGN

We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose.

SETTING AND PARTICIPANTS

We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe services program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270).

MEASUREMENTS

Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any.

FINDINGS

The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (β = .234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (β = .683, p < .001) and drug use (β = .567, p = .001). Drug use behaviors (β = .287, p = .04) but not drug acquisition (β = .105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors.

CONCLUSIONS

Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. Further research is needed to replicate these findings with populations at high-risk of an opioid-related overdose to assess generalizability and refine the metrics used to assess psychosocial characteristics.

Xylazine and Adulterants in the Evolving Drug Supply: Urgent Call for Responsive Education Models

Novel adulterants and synthetic substances are rapidly infiltrating the US drug supply causing new clinical harms. There is an urgent need for responsive education and training to address these evolving harms and mitigate new risks. Since 2020, xylazine, a veterinary tranquilizer, has become increasingly common in the illicit opioid supply, especially alongside fentanyl. Training and technical assistance (TTA) programs employing an adaptive model can quickly disseminate emerging information and provide the tools to respond effectively. We describe our TTA program's experience developing and delivering virtual instructor-led xylazine training to a diverse group of addiction care professionals. The training objectives included the following: (1) introducing epidemiologic trends, pharmacology, and existing literature related to xylazine; (2) reviewing xylazine-associated harms and management; and (3) discussing harm reduction strategies related to xylazine use. We conducted 14 training sessions between October 2022 and July 2023, which were attended by over 2000 individuals across 49 states. We review our experience developing innovative training content and managing flexible training logistics and highlight our lessons learned, including targeting multidisciplinary professionals, leveraging online synchronous delivery methods, and a need for sustainable funding for TTA programs.

Associations among Drug Acquisition and Use Behaviors, Psychosocial Attributes, and Opioid-Involved Overdoses: A SEM Analysis

Aims

This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses.

Methods

We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe service program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any.

Results

The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (β=.234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (β=.683, p < .001) and drug use (β=.567, p = .001). Drug use behaviors (β=.287, p = .04) but not drug acquisition (β=.105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors.

Conclusions

Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. To increase effectiveness, prevention efforts might address the interacting overdose risks that span multiple functional domains.