Monitoring illicit pentobarbital availability in the United States: A National Drug Early Warning System briefing.

BACKGROUND: Pentobarbital is a Schedule II/III short-acting barbiturate with limited medical use in humans. Veterinary professionals use pentobarbital to euthanize dogs, cats, and other companion animals. Pentobarbital is also utilized in capital punishment and small amounts are illegally shipped or diverted to assist in suicides. However, five kilograms of pentobarbital smuggled in from Mexico was recently seized by an organized crime drug enforcement task force (along with fentanyl, heroin, and cocaine), which may suggest a shift in illicit supply. We investigated potential indicators of illicit pentobarbital use or availability in the US to help determine whether this drug is becoming an emerging public health concern. METHODS: The National Drug Early Warning System requested information on pentobarbital from its sentinel surveillance sites and collaborators and conducted a search of current literature. RESULTS: In early 2024, multiple batches of counterfeit pills (e.g., pressed as "M30s" to represent oxycodone) confiscated near the Southwest border tested positive for pentobarbital plus combinations of fentanyl, fentanyl analogs, and xylazine. Other indicators suggest pentobarbital is being smuggled in powder form and possibly sold as another drug such as heroin. One national drug analysis program detected pentobarbital in 217 drug submissions from 2020 to 2023, and there were at least 12 fatal exposures linked to use from 2020 to 2022. CONCLUSION: Continued monitoring of illicit use and availability is needed as pentobarbital may continue to appear on the illicit market. Unknown exposure can occur if the drug is mixed into counterfeit pills or sold in powder form represented to be another drug.

A content analysis of legal policy responses to xylazine in the illicit drug supply in the United States.

BACKGROUND: Xylazine is a veterinary sedative that is quickly spreading in the U.S. illicit drug supply and is increasingly associated with fatal overdoses and severe wounds. In response, xylazine has been deemed an emerging public health threat and several policy initiatives have been introduced to combat its spread and negative broad health impact. We aimed to synthesize trends in all-time U.S. policy responses to xylazine in the drug supply. METHODS: In April 2024, we systematically identified and categorized proposed and enacted policy initiatives that related to human xylazine consumption by searching LexisNexis and Thomas Reuters Westlaw legal databases. RESULTS: Of 58 unique policy initiatives, most were introduced in 2023 (n = 37/58, 64 %) and concentrated in Northeastern states. Penalties for xylazine possession, often tied to state drug scheduling changes, were the most common provision (n = 34/58; 59 %) and Schedule III was the most frequently proposed scheduling level (n = 17/30; 57 %). Other provisions included proposals to enhance: test strip access (n = 11/58; 19 %), public awareness and education (n = 3/58; 5 %), xylazine-specific research (n = 4/58; 7 %), and surveillance (n = 8/58; 14 %). CONCLUSION: U.S. state and federal policy responses to xylazine grew rapidly in 2023, were most concentrated in states affected most by xylazine, and scheduling was the most commonly proposed policy approach. Research measuring policy effects should be prioritized as policies are implemented.

"If it wasn't for them, I don't think I would be here": experiences of the first year of a safer supply program during the dual public health emergencies of COVID-19 and the drug toxicity crisis.

BACKGROUND: In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model. METHODS: This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study. RESULTS: Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability. CONCLUSIONS: Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets.

Broad evidence of xylazine in the UK illicit drug market beyond heroin supplies: Triangulating from toxicology, drug-testing and law enforcement.

BACKGROUND AND AIMS: Xylazine is a non-opioid sedative which has spread rapidly throughout the US illicit drug supply. This study aimed to describe the spread of xylazine throughout the UK illicit drug supply. METHODS: Xylazine detections in human biological samples were collated from toxicology laboratories operating in the United Kingdom with the date, location, case type, xylazine concentration and co-detected drugs (with quantifications where performed) detailed, where permitted, by the corresponding coroner. Drug-testing cases positive for xylazine were collated from the Welsh Emerging Drugs and Identification of Novel Substances (WEDINOS) drug-testing postal service with the date, location, purchase intent and co-detected drugs detailed. Drug seizures made by UK law enforcement were communicated by the Office for Health Improvement and Disparities with the date and location detailed. RESULTS: By the end of August 2023, xylazine was detected in 35 cases from throughout toxicology, drug-testing and drug seizure sources covering England, Scotland and Wales. There were no cases reported from Northern Ireland. Xylazine was detected in biological samples from 16 people. In most cases where full toxicology results were provided, xylazine was detected with heroin and/or a strong opioid (n = nine of 11), but this polydrug use pattern was not evident in all cases (n = two of 11), suggesting a wider circulation of xylazine in the UK illicit drug market beyond heroin supplies. Evidence from WEDINOS supports this claim, as all 14 drug samples (100%) submitted from across the UK contained xylazine; however, in none of these cases was heroin the purchase intent but rather counterfeit prescription medication tablets (n = 11 of 14), tetrahydrocannabinol (THC) vapes (n = two of 14) or white powder (n = one of 14). Additional evidence for the spread of illicit xylazine comes from five drug seizures made by law enforcement. CONCLUSIONS: Xylazine has penetrated the UK illicit drug market and is not limited to heroin supplies.

The Overdose Crisis in the 2024 Election-Political Fights and Practical Problems.

This Viewpoint discusses the 2024 presidential election in the context of the addiction and overdose crisis in the US, which has been a unifying challenge and a source of major ideological division in US politics.

"It gets you high as a kite but not unsick": Characterizations of and responses to a changing local drug supply by people who use drugs in Rhode Island.

BACKGROUND: The North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths occurring in the United States (US) in 2022. Overdose deaths have increasingly been polysubstance-involved, with novel substances (e.g., xylazine) complicating overdose risk and health outcomes. Understanding the effects of-and responses to-a changing drug supply among people who use drugs is critical to modifying harm reduction strategies to be more responsive to people's needs. METHODS: This qualitative study draws on data collected from May to December 2022 in Rhode Island. Data include in-depth interviews with 50 people who use drugs and observational fieldwork in spaces frequented by participants (e.g., encampments, drop-in centers). Qualitative data were analyzed thematically drawing on concepts of situated rationality. RESULTS: Participants described significant changes in the drug supply, with many attributing these transitions to COVID-19. Most participants characterized the local supply as "synthetic" with textures, color, and taste evolving. Notably, participants emphasized adverse outcomes related to available supplies, including during use (e.g., intense burning sensations) and post-consumption (e.g., heavy sedation, ongoing withdrawal, necrosis). Given the complex supply, participants highlighted the increased risk of overdose and shared how they altered their use practices to manage evolving health risks. CONCLUSION: Our results underscore how people who use drugs characterized the local drug supply, including perceived changes to supply contents. Implementing and scaling up harm reduction interventions that reduce risk and reinforce the agency of people who use drugs are urgently needed to effectively address the overdose crisis.

Individual differences in legal and illicit cannabis purchasing behaviour in British Columbia, Canada: Findings from a 2021 cross-sectional survey.

BACKGROUND: Despite thousands of licensed cannabis retail stores operating across Canada, there remains a significant illicit cannabis market. Some cannabis users continue to buy cannabis from dealers, illicit stores, and/or illicit online retailers. METHODS: Data are from the 2021 British Columbia Cannabis Use Survey. Respondents (n = 8473) were 19 years or older, lived in British Columbia at the time of the survey, and reported using cannabis in the past 12 months. RESULTS: Buying cannabis from all types of illicit sources was more common among younger cannabis users, those who use cannabis more frequently and started using cannabis before the age of 17 (vs. 19 or older), and among those who co-use cannabis with other drugs. Specifically, buying cannabis from a dealer was more common among men, those with lower educational attainment, and those who seek the lowest prices when buying cannabis. In contrast, those using cannabis for medical (vs. non-medical) purposes were more likely to report getting cannabis from illicit retail stores, while buying cannabis from illicit websites was more common among people who use edible cannabis products. CONCLUSION: Consistent with other studies, younger and more frequent cannabis users were more likely to report buying cannabis from illicit sources. However, these findings suggest there is significant heterogeneity among those who buy cannabis from different types of illicit sources, which should be carefully considered when developing policies and strategies aimed at encouraging consumers to transition to legal sources.

Real or fake? Sourcing and marketing of non-prescribed benzodiazepines amongst two samples of people who regularly use illicit drugs in Australia.

INTRODUCTION: There is concern around non-prescribed benzodiazepine use, particularly with increasing detections of counterfeit products containing high-risk novel compounds. The aims of this study were to investigate how and which non-prescribed benzodiazepines are being sourced; forms, appearance and packaging; and awareness of risks associated with non-prescribed benzodiazepines. METHODS: Data were collected from a sample of Australians who inject drugs or use ecstasy and/or other illicit stimulants on a monthly or more frequent basis, and who reported past 6-month use of non-prescribed benzodiazepines (n = 235 and n = 250, respectively). Data were collected on source, diversion from a known/trusted prescription, product name and aesthetic characteristics for the last non-prescribed benzodiazepine obtained. RESULTS: Amongst participants who injected drugs, 71% reported that their last non-prescribed benzodiazepines were diverted from a known/trusted prescription, compared to 59% of participants who used ecstasy/other stimulants. Sourcing via cryptomarkets was rare. Across both samples, the majority reported last obtaining substances sold/marketed as diazepam or alprazolam. Participants sourcing via non-diverted means were twice as likely to obtain alprazolam. Known sourcing of novel compounds was rare. Amongst participants who used ecstasy/other stimulants, 36% reported confidence in the content/dose of non-prescribed benzodiazepines even when the source is unknown. DISCUSSION AND CONCLUSIONS: Most participants obtained substances sold as classic/registered benzodiazepines, mostly via diverted prescriptions, with a substantial minority potentially unaware of counterfeits circulating. While diverted use undeniably presents risks, tightening of prescriptions in Australia could inadvertently lead to greater supply of novel benzodiazepines as seen internationally, reinforcing prioritisation of demand and harm reduction strategies.

What's in Stock? Drug drought anticipation during COVID-19 among people who use drugs and service providers.

BACKGROUND: As with other areas of life, drug markets have been impacted by the COVID-19 pandemic and related restrictions. This article examines how structurally vulnerable people who use drugs (PWUD) experienced and adapted to changes in street drug markets caused by lockdown measures. METHODS: The article builds on ethnographic fieldwork in two Danish cities in 2020, including in-depth interviews with 22 PWUD, and interviews with 20 service providers, including low-threshold service providers and outreach workers. RESULTS: The most consistently reported effect of lockdown measures on local drug markets related to increases in cannabis prices. Accounts of changes in drug availability varied greatly, with some participants reporting changing availability while others described the situation as similar to pre-lockdown conditions. Rather than a long-term drug shortage, changes reported by participants related to the anticipated disruption of local markets and drug scarcity, restrictions in access to cash and sellers seeking to capitalize on the crisis. CONCLUSION: Although no long-term drug scarcity was seen, the anticipation of a shortage was sufficient to impact on local drug market dynamics. Heterogeneity in PWUDs' experiences of access to drug markets during lockdown can to some degree be explained in terms of their varied embeddedness in social networks. While local markets proved resilient to lockdown measures, PWUD less embedded in social networks were more vulnerable to shifts in drug availability and to sellers' over-pricing of drugs.

The impact of the COVID-19 pandemic on illicit drug supply, drug-related behaviour of people who use drugs and provision of drug related services in Georgia: results of a mixed methods prospective cohort study.

BACKGROUND: This study examines the effects of COVID-19 related restrictions on the supply of illicit drugs, drug-use behaviour among people who use drugs (PWUD) regularly (at least weekly), and drug-related service provision in Tbilisi, Georgia. METHODOLOGY: In this mixed methods study, a cohort of 50 Georgian PWUD recruited through a snow-ball sampling participated in a bi-weekly online survey in April-September, 2020. They also took part in the qualitative telephone interviews at 12- and 24-week follow-up time points. In addition, four key informants (field experts) were interviewed monthly to assess their perceptions of changes in the illicit drug market and drug service delivery. RESULTS: Mean age in the sample was 36 (range 18-60); 39 (78%) were males. Perceived availability of drugs was reduced during the lockdown, and many PWUD switched to alternative substances when preferred drugs were not available. On average, participants used significantly fewer substances over the course of the study, from 3.5 substances in the preceding 14 days to 2.1 (aOR 0.92; 95% CI 0.90-0.94). Consumption of cannabis products declined significantly (aOR 0.89; 95% CI 0.84-0.95), likewise alcohol (aOR 0.94; 95% CI 0.88-1.0), diverted medicinal methadone (aOR 0.85; 95% CI 0.8-0.9) and diverted medicinal buprenorphine (aOR 0.91; 95% CI 0.84-0.99). PWUD cited fewer contacts with drug dealers, the lack of transportation, and the lack of conventional recreational environment as the main reasons for these changes. When access to sterile injection equipment was limited, PWUD exercised risk-containing injection behaviours, such as buying drugs in pre-filled syringes (aOR 0.88; 95% CI 0.80-0.96). Harm reduction and treatment programs managed to adopt flexible strategies to recover services that were affected during the initial stage of the pandemic. CONCLUSIONS: COVID-19-related restrictive measures mediated specific changes in supply models and drug-use behaviours. While adjusting to the new environment, many PWUD would engage in activities that put them under increased risk of overdose and blood-borne infections. Harm reduction and treatment services need to develop and implement protocols for ensuring uninterrupted service delivery during lockdowns, in anticipation of the similar epidemics or other emergency situations.

Towards cross-Canada monitoring of the unregulated street drug supply.

BACKGROUND: The well-being of people who use drugs (PWUD) continues to be threatened by substances of unknown type or quantity in the unregulated street drug supply. Current efforts to monitor the drug supply are limited in population reach and comparability. This restricts capacity to identify and develop measures that safeguard the health of PWUD. This study describes the development of a low-barrier system for monitoring the contents of drugs in the unregulated street supply. Early results for pilot sites are presented and compared across regions. METHODS: The drug content monitoring system integrates a low-barrier survey and broad spectrum urine toxicology screening to compare substances expected to be consumed and those actually in the drug supply. The system prototype was developed by harm reduction pilot projects in British Columbia (BC) and Montreal with participation of PWUD. Data were collected from harm reduction supply distribution site clients in BC, Edmonton and Montreal between May 2018-March 2019. Survey and urine toxicology data were linked via anonymous codes and analyzed descriptively by region for trends in self-reported and detected use. RESULTS: The sample consisted of 878 participants from 40 sites across 3 regions. Reported use of substances, their detection, and concordance between the two varied across regions. Methamphetamine use was reported and detected most frequently in BC (reported: 62.8%; detected: 72.2%) and Edmonton (58.3%; 68.8%). In Montreal, high concordance was also observed between reported (74.5%) and detected (86.5%) cocaine/crack use. Among those with fentanyl detected, the percentage of participants who used fentanyl unintentionally ranged from 36.1% in BC, 78.6% in Edmonton and 90.9% in Montreal. CONCLUSIONS: This study is the first to describe a feasible, scalable monitoring system for the unregulated drug supply that can contrast expected and actual drug use and compare trends across regions. The system used principles of flexibility, capacity-building and community participation in its design. Results are well-suited to meet the needs of PWUD and inform the local harm reduction services they rely on. Further standardization of the survey tool and knowledge mobilization is needed to expand the system to new jurisdictions.

Shifts in drug seizures in the United States during the COVID-19 pandemic.

BACKGROUND: Little is known regarding how the COVID-19 pandemic has affected patterns of drug use in the United States. Because drug seizures can serve as a proxy for drug availability, we examined shifts in drug seizures in the US during the pandemic. METHODS: We examined trends in seizures of marijuana, cocaine, methamphetamine, heroin, and fentanyl within five High Intensity Drug Trafficking Areas-Washington/Baltimore, Chicago, Ohio, New Mexico, and North Florida. Trends were examined for number and total weight of seizures from March 2019 through September 2020 using Joinpoint regression. RESULTS: Significant decreases in seizures involving marijuana (ß = -0.03, P = 0.005) and methamphetamine (ß = -0.02, P = 0.026) were detected through April 2020, and then seizures of marijuana (ß = 0.10, P = 0.028) and methamphetamine (ß = 0.11, P = 0.010) significantly increased through September 2020. The number of seizures involving marijuana and methamphetamine peaked in August 2020, exceeding the highest pre-COVID-19 number of seizures. Fentanyl seizures increased overall (ß = 0.05, P < .001), but did not significantly drop during the start of COVID-19, and significant changes were not detected for cocaine or heroin. We also detected a significant increase in weight of marijuana seized from April through September 2020 (ß = 0.40, P = .001). The weight of marijuana seized in August 2020 exceeded the highest pre-COVID-19 weight. CONCLUSION: The COVID-19 pandemic was associated with an immediate decrease in marijuana and methamphetamine seizures, and then increases throughout 2020 with some months exceeding the number (and weights) of seizures from the previous year. More research is warranted to determine the extent to which these seizures reflect changes in drug use.

Illicit drugs seizures in 2013-2018 and characteristics of the illicit market within the Neapolitan area.

The study presents results of toxicological analysis performed on seized material in Neapolitan area in the period from 2013 to 2018. A constancy in THC and heroin percentages is evidenced (%THC ~10% and ~11.5% for marijuana and hashish; heroine: 20-24%), with mean values exceeding the European data. Data on cocaine revealed a constant increment of active principle percentage over the studied period (from 40% in 2013 to ~65% in 2018), with peak of 70% in 2017; also, number of samples exceeding the mean value increased over years. Active principles contents resulted higher than the ones reported in other Italian area ever the same period; marijuana was prevalent on hashish, confirming an Italian trend different from other European countries. A map of the Campania region evidenced two main "storage" districts, one corresponding to the city center and the second located in the northern part. If compared with literature data on the presence of local mafia, these areas are perfectly superimposable to those with the highest risk of homicides, thus confirming the degree of radicalization of local organizations and the relative weight of proceeds from drugs sale. Moreover, such radicalization within the territory seems to be the main reason of the absence of new psychoactive substances among the seized material.

The occurrence of non-anatomical therapeutic chemical-international nonproprietary name molecules in suspected illegal or illegally traded health products in Europe: A retrospective and prospective study.

The General European Official Medicines Control Laboratory (OMCL) Network (GEON), co-ordinated by the European Directorate for the Quality of Medicines & HealthCare (EDQM), regularly organises market surveillance studies on specific categories of suspected illegal or illegally traded products. These studies are generally based on a combination of retrospective and prospective data collection over a defined period of time. This paper reports the results of the most recent study in this context with the focus on health products containing non-Anatomical Therapeutic Chemical-International Nonproprietary Name (ATC-INN) molecules. In total 1104 cases were reported by 16 countries for the period between January 2017 and the end of September 2019. The vast majority of these samples (83%) were collected from the illegal market, while only 3% originated from a legal source. For the rest of the samples, categorisation was not possible. Moreover, 69% of all the reported samples were presented as medicines, including sexual performance enhancers, sports performance enhancers, physical performance enhancers and cognitive enhancers or nootropic molecules that act on the central nervous system (CNS). Although the popularity of anabolics, PDE-5 inhibitors and CNS drugs in illegal products has already been reported, the study showed some new trends and challenges. Indeed, 11% of the samples contained molecules of biological origin, that is, research peptides, representing the second most reported category in this study. Furthermore, the study also clearly shows the increasing popularity of Selective Androgen Receptor Modulators and nootropics, two categories that need attention and should be further monitored.

A transnational perspective on the evolution of the synthetic cannabinoid receptor agonists market: Comparing prison and general populations.

The synthetic cannabinoid receptor agonist (SCRA) market is transnational, and the availability of individual SCRAs changes regularly in response to national and international legislative controls. This generates a cyclic pattern and near constant evolution of SCRA compounds. This study reports toxicology-based and/or seized sample-based prevalence data relating to SCRA use in prisons from Germany, the United Kingdom (UK; Scotland and Wales), and the United States (US), representing 4427 individual test results. The study examines SCRA detections in prisons from July 2018 to September 2020, and where possible, prison-based data are compared with SCRA prevalence data in the wider population. The relative influence of Chinese, other international, and national drug legislation on the prevalence of individual SCRAs in prisons is also considered. tert-Leucinate- and valinate-indole- and indazole-3-carboxamides were the most common SCRA detections, and MDMB-4en-PINACA was one of the most commonly detected SCRAs in all jurisdictions by September 2020. However, despite there being a global production and supply market, there were notable regional differences. Analog controls in German and US legislation may have led to increased compound diversity that is not reflected in the UK which has both analog controls and a blanket ban on psychoactive substances. While there were regional differences, SCRA prevalence in prisons closely aligned with the SCRAs detected on the local market, demonstrating that SCRA (and possibly other NPS) monitoring programs in prisons can act as early warning systems for the wider population in that given jurisdiction.

New psychoactive substances on dark web markets: From deal solicitation to forensic analysis of purchased substances.

The dark web scene has been drawing the attention of law enforcement agencies and researchers alike. To date, most of the published works on the dark web are based on data gained by passive observation. To gain a more contextualized perspective, a study was conducted in which three vendors were selected on the "Dream Market" dark web marketplace, from whom subsequently several new psychoactive substances (NPS) were ordered. All transactions were documented from the initial drug deal solicitation to the final qualitative analysis of all received samples. From the selected vendors, a total of nine NPS samples was obtained, all of which were analyzed by NMR, HRMS, LC-UV, and two also by x-ray diffraction. According to our analyses, four of the five substances offered under already known NPS names contained a different NPS. The selected vendors therefore either did not know about their product, or deliberately deceived the buyers. Furthermore, two of three obtained samples of purportedly novel NPS were identified as already documented substances sold under a different name. However, the third characterized substance sold as "MPF-47700" was a novel, yet uncharacterized, NPS. Finally, we received a single undeclared substance, later identified as 5F-ADB. In addition to chemical analysis of the nine obtained NPS samples, the methodology used also yielded contextual information about the accessibility of NPS on the dark web, the associated purchase process, and the modus operandi of three NPS vendors. Direct participation in dark web marketplaces seems to provide additional layers of information useful for forensic studies.

Harm Reduction Policies Where Drugs Constitute a Security Issue.

There is strong evidence suggesting that harm reduction policies are able to reduce the adverse health and social consequences of drug use. However, in this article I will compare two different countries to demonstrate that some social aspects lead to the adoption or rejection of harm reduction policies. In this case, countries where drugs are seen as a security concern are less likely to adopt these harm reduction policies. For that purpose, I will compare Colombia and Uruguay's political, normative, and social aspects, which are considered drivers in the adoption of harm reduction policies, as well as how those factors influence the treatments available for substance abuse disorders.

COVID-19 and overdose prevention: Challenges and opportunities for clinical practice in housing settings.

The global coronavirus disease 2019 (COVID-19) will exacerbate the negative health outcomes associated with the concurrent opioid overdose crisis in North America. COVID-19 brings unique challenges for practitioners who provide opioid use disorder (OUD) care. The majority of overdose deaths in the Canadian province of British Columbia occur in housing environments. Some supportive housing environments in Vancouver, British Columbia, have on-site primary care and substance use disorder treatment clinics. Some of these housing environments also include supervised consumption services. These housing environments needed to make adjustments to their care to adhere to COVID-19 physical distancing measures. Such adjustments included a pandemic withdrawal management program to provide patients with a pharmaceutical grade alternative to the toxic illicit drug supply, which allow patients to avoid the heightened overdose risk while using illicit drugs alone or potentially exposing themselves to COVID-19 while using drugs in a group setting. Other modifications to the OUD care continuum included modified supervised injection spaces to adhere to physical distancing, the use of personal protective equipment for overdose response, virtual platforms for clinical encounters, writing longer prescriptions, and providing take-home doses to promote opioid agonist treatment retention. These strategies aim to mitigate indoor overdose risk while also addressing COVID-19 risks.

The responsiveness of criminal networks to intentional attacks: Disrupting darknet drug trade.

Physical, technological, and social networks are often at risk of intentional attack. Despite the wide-spanning importance of network vulnerability, very little is known about how criminal networks respond to attacks or whether intentional attacks affect criminal activity in the long-run. To assess criminal network responsiveness, we designed an empirically-grounded agent-based simulation using population-level network data on 16,847 illicit drug exchanges between 7,295 users of an active darknet drug market and statistical methods for simulation analysis. We consider three attack strategies: targeted attacks that delete structurally integral vertices, weak link attacks that delete large numbers of weakly connected vertices, and signal attacks that saturate the network with noisy signals. Results reveal that, while targeted attacks are effective when conducted at a large-scale, weak link and signal attacks deter more potential drug transactions and buyers when only a small portion of the network is attacked. We also find that intentional attacks affect network behavior. When networks are attacked, actors grow more cautious about forging ties, connecting less frequently and only to trustworthy alters. Operating in tandem, these two processes undermine long-term network robustness and increase network vulnerability to future attacks.

Social Capital and Social Networks of Hidden Drug Abuse in Hong Kong.

Owing to the increasing prevalence of hidden drug abuse in Hong Kong, yet scarce relevant current local research, this study seeks to carry out an in-depth investigation into the experience of hidden drug abusers, paying particular attention to their relevance to social capital and social networks. Seventy-three abusers attending drug treatment programs were interviewed, and a thematic analysis was performed. The results indicate hidden drug abuse is popular in Hong Kong. Apart from the decline of public, large-scale discos and the change of the types of drugs abused to date, one important contributing factor is the drug supply and transaction networks, which are extensive and multilocused, but secretive, with high closure levels. This kind of network is supported by bonding, bridging, and linking social capital as well as by providing convenient supply modes and offering drug abusers psychological comfort and safety. These factors encourage the hidden drug abuse to prevail and allow drug abusers to remain unidentifiable.