LatinX harm reduction capital, medication for opioid use disorder, and nonfatal overdose: A structural equation model analysis among people who use drugs in Massachusetts.

BACKGROUND: We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we hypothesize to predict MOUD use and opioid overdose. In this study, we explored the interrelationships between ethnicity, HRCap, nonfatal overdose, and MOUD use among PWUD. METHODS: Between 2017 and 2019, people who currently or in the past used opioids and who lived in Massachusetts completed a one-time survey on substance use history, treatment experiences, and use of harm reduction services. We fit first-order measurement constructs for positive and negative HRCap (facilitators and barriers). We used generalized structural equation models to examine the inter-relationships of the latent constructs with LatinX self-identification, past year overdose, and current use of MOUD. RESULTS: HRCap barriers were positively associated with past-year overdose (b=2.6, p<0.05), and LatinX self-identification was inversely associated with HRCap facilitators (b=-0.49, p<0.05). There was no association between overdose in the past year and the current use of MOUD. LatinX self-identification was positively associated with last year methadone treatment (b=0.89, p<0.05) but negatively associated with last year buprenorphine treatment (b=-0.68, p<0.07). Latinx PWUD reported lower positive HRCap than white non-LatinX PWUD and had differential utilization of MOUD. CONCLUSION: Our findings indicate that a recent overdose was not associated with the current use of MOUD, highlighting a severe gap in treatment utilization among individuals at the highest risk. The concept of HRCap and its use in the model highlight substance use treatment differences, opportunities for intervention, and empowerment.

Changes to opioid overdose deaths and community naloxone access among Black, Hispanic and White people from 2016 to 2021 with the onset of the COVID-19 pandemic: An interrupted time-series analysis in Massachusetts, USA.

BACKGROUND AND AIMS: The onset of the coronavirus disease 2019 (COVID-19) pandemic was associated with a surge in opioid overdose deaths in Massachusetts, particularly affecting racial and ethnic minority communities. We aimed to compare the impact of the pandemic on opioid overdose fatalities and naloxone distribution from community-based programs across racial and ethnic groups in Massachusetts. DESIGN: Interrupted time-series. SETTING AND CASES: Opioid overdose deaths (OODs) among non-Hispanic White, non-Hispanic Black, Hispanic and non-Hispanic other race people in Massachusetts, USA (January 2016 to June 2021). MEASUREMENTS: Rate of OODs per 100 000 people, rate of naloxone kits distributed per 100 000 people and ratio of naloxone kits per opioid overdose death as a measure of naloxone availability. We applied five imputation strategies using complete data in different periods to account for missingness of race and ethnicity for naloxone data. FINDINGS: Before COVID-19 (January 2016 to February 2020), the rate of OODs declined among non-Hispanic White people [0.2% monthly reduction (95% confidence interval = 0.0-0.4%)], yet was relatively constant among all other population groups. The rate of naloxone kits increased across all groups (0.8-1.2% monthly increase) and the ratio of naloxone kits per OOD death among non-Hispanic White was 1.1% (0.8-1.4%) and among Hispanic people was 1.0% (0.2-1.8%). After the onset of the pandemic (March 2020+), non-Hispanic Black people experienced an immediate increase in the rate of OODs [63.6% (16.4-130%)], whereas rates among other groups remained similar. Trends in naloxone rescue kit distribution did not substantively change among any groups, and the ratio of naloxone kits per OOD death for non-Hispanic Black people did not compensate for the surge in OODs deaths in this group. CONCLUSIONS: With the onset of the COVID-19 pandemic, there was a surge in opioid overdose deaths among non-Hispanic Black people in Massachusetts, USA with no compensatory increase in naloxone rescue kit distribution. For non-Hispanic White and Hispanic people, opioid overdose deaths remained stable and naloxone kit distribution continued to increase.

Protocol for the implementation of a statewide mobile addiction program.

With overdose deaths increasing, improving access to harm reduction and low barrier substance use disorder treatment is more important than ever. The Community Care in Reach® model uses a mobile unit to bring both harm reduction and clinical care for addiction to people experiencing barriers to office-based care. These mobile units provide many resources and services to people who use drugs, including safer consumption supplies, naloxone, medication for substance use disorder treatment, and a wide range of primary and preventative care. This protocol outlines the evaluation plan for the Community in Care® model in MA, USA. Using the RE-AIM framework, this evaluation will assess how mobile services engage new and underserved communities in addiction services and primary and preventative care.

The Massachusetts Department of Public Health Post Overdose Support Team Initiative: A Public Health-Centered Co-Response Model for Post-Overdose Outreach.

CONTEXT: Post-overdose outreach programs have emerged in response to surging overdose deaths amid fentanyl contamination of the illicit opioid supply. Predominantly centered in police departments in collaboration with public health providers, these programs conduct home-based outreach with survivors and their social networks following an overdose. APPROACH: We describe implementation of the Post Overdose Support Team (POST) initiative, an ongoing public health funded and centered approach. Post Overdose Support Team is a person-centered model led by harm reductionists in health and human services agencies in collaboration with municipal first responders. The goal of POST is to engage overdose survivors and their social network to improve general health, connect people to services (including access to treatment, if desired), and reduce risk of subsequent overdose. IMPLEMENTATION: Nine agencies in Massachusetts that are part of the state's overdose education and naloxone distribution network implemented POST programs, covering 28 municipalities. The POST teams conduct home-based outreach with individuals who experienced an opioid-related overdose to provide a menu of services, including naloxone rescue kits, overdose response and risk reduction planning, referral to treatment for substance use disorders, including medication for opioid use disorder, and referral to recovery and family supports. EVALUATION: From October 2017 to October 2021, the POST teams attempted to reach 5634 overdose survivors via 10 536 outreach visits. Teams successfully engaged 3014 survivors, either directly or through contact with their social network (53.5% success rate). Using data from a real-time encounter-level database, monthly peer-sharing calls with program sites, and annual site visits, we describe the implementation of the POST initiative and provide practice-based recommendations and lessons learned. DISCUSSION: Early evidence suggests that the POST initiative is meeting its goal to engage overdose survivors, improve general health, and reduce subsequent overdose risk. Future evaluations should examine long-term outcomes among participants, including service linkages and incremental behavior change.

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

CONTEXT: The illicit drug supply is rapidly evolving. Equally important to gathering drug supply data for monitoring is timely sharing of information with people who use drugs, the providers who care for them, law enforcement partners, and public health stakeholders so that efforts to avoid harmful substances, take preventive actions, and better target interventions can occur. PROGRAM: The Massachusetts Drug Supply Data Stream (MADDS) is the country's first statewide community drug checking program. Founded on public health-public safety partnerships, MADDS collects remnant drug packaging and paraphernalia with residue from people who use drugs and noncriminal samples from partnering police departments. MADDS tests samples using simultaneous immunoassay fentanyl test strips, Fourier-transform infrared spectrometry (FTIR), and off-site laboratory testing by gas chromatography-mass spectrometry (GC/MS). Results are accessible to community programs and municipalities, while trend analyses inform public health for cross-site alerts and informational bulletins. IMPLEMENTATION: MADDS was launched statewide in 2020 and rapidly expanded to a multisite program. Program staff approached communities and met with municipal police and community partners to secure written agreements to host drug checking. Community partners designed sample collection consistent with their pandemic era workflows. Consultations with stakeholders gathered feedback on design and deliverables. EVALUATION: The program tests sample donations on-site from community agencies and police departments, incorporates review by a medical toxicologist for health and safety concerns, crafts stakeholder-specific communications, and disseminates English, Spanish, and Portuguese language materials. For 2020, a total of 427 samples were tested, of which 47.1% were positive for fentanyl. By early 2021, MADDS detected shifts in cocaine purity, alerted communities of a new toxic fentanyl analogue and a synthetic cannabinoid contaminant, and confirmed the increase of xylazine (a veterinary sedative) in Massachusetts. DISCUSSION: Community drug checking programs can be collaboratively designed with public health and public safety to generate critical health and safety information for people who use drugs and the communities where they live.

Caring for People Who Use Drugs: Best Practices for EMS Providers.

People who use drugs (PWUD) face stigmatizing treatment and substandard care during all stages of their health care journey, including in the prehospital setting by Emergency Medical Services (EMS) providers. Drawing on the professional and lived experience of the authors, we have developed a training with an intended audience of Emergency Medical Technicians (EMTs) and Paramedics in Massachusetts that will orient them to harm reduction philosophy. The training is delivered online through an asynchronous platform housed at Boston University School of Public Health and centers around several themes including the impact of fentanyl on the drug supply, the role of harm reduction in mitigating the impacts of drug criminalization, and ensuring that EMS providers have access to tools and best practices for improving overdose response, pain management, documentation, and respectful language. The training has been approved for Massachusetts Office of Emergency Medical Services (OEMS) continuing education credit and will be offered for free. We plan to evaluate changes in participant knowledge and attitudes and overall acceptability of the training among EMS providers in Massachusetts.

Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019.

BACKGROUND: People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. METHODS: We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. RESULTS: The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05). CONCLUSION: We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.

Post opioid overdose outreach by public health and public safety agencies: Exploration of emerging programs in Massachusetts.

BACKGROUND: Opioid overdose is a significant public health problem. Collaborative programs between local public health and public safety agencies have emerged to connect overdose survivors and their personal networks with harm reduction and addiction treatment services following a non-fatal overdose event. This study explored the prevalence of these programs in Massachusetts and the different ways they have been structured and function. METHODS: We sent an online screening questionnaire to police and fire departments in all 351 communities in Massachusetts to find instances in which they collaborated with a community-based public health agency to implement a post-overdose outreach and support program. We conducted telephone interviews with communities that implemented this type of program and categorized programs based on their structure, outreach approach, and other key characteristics. RESULTS: Police and fire personnel from 110 of the 351 communities in Massachusetts (31% response rate) completed the screening survey. Among respondents, 21% (23/110) had implemented a collaborative, community-based, post-overdose program with a well-defined process to connect overdose survivors and their personal networks with support services or addiction treatment services. Using data from the interviews, we identified four types of programs: (1) Multi-Disciplinary Team Visit, (2) Police Visit with Referrals, (3) Clinician Outreach, and (4) Location-Based Outreach. CONCLUSIONS: This study represents the first attempt to systematically document an emerging approach intended to connect opioid overdose survivors and their personal networks with harm reduction and addiction treatment services soon after a non-fatal overdose event. These programs have the potential to increase engagement with the social service and addiction treatment systems by those who are at elevated risk for experiencing a fatal opioid overdose.