The relationship between felt stigma and non-fatal overdose among rural people who use drugs.

BACKGROUND: Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs. METHODS: Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose. RESULTS: 6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14). CONCLUSIONS: Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry.

BACKGROUND: In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS: We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS: We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION: In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder.

Importance: Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. Objective: To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. Design, Setting, and Participants: This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. Main Outcomes and Measures: Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. Results: In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. Conclusions and Relevance: In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis.

BACKGROUND AND AIMS: Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs. METHODS: This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised. RESULTS: Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits. CONCLUSIONS: Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits.

BACKGROUND: Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year. METHODS: This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region. RESULTS: Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020. CONCLUSIONS: Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose.

Importance: Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking. Objective: To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization. Design, Setting, and Participants: This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023. Exposure: Hospital OORP implementation. Main Outcomes and Measures: The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access. Results: A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities. Conclusions and Relevance: In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Trends in non-fatal and fatal opioid overdoses during the first two years of the coronavirus disease-2019 pandemic.

PURPOSE: This study assessed opioid-involved overdose rates by age, sex, and race-ethnicity across strict pandemic mitigation phases and how this varied across data systems. METHODS: We examined opioid-involved overdoses using medical examiner and hospital data for Cook County, Illinois between 2016-2021. Multivariable segmented regression was used to assess weekly overdose rates across subgroups of age, sex and race/ethnicity and strict pandemic mitigation phases. RESULTS: The overall rate of weekly opioid-involved overdoses increased when assessing the medical examiner (ß = 0.01; 95% CI = 0.01,0.02; P ≤ .001) and emergency department visits data sources (ß = 0.15; 95% CI = 0.09,0.20; P ≤ .001) but not for the hospital admissions data source. We found differences in overdose rates across subgroups and phases of pandemic mandates. Fatal overdoses increased during lockdown-1 while admissions and emergency department (ED) visits for opioid-involved overdoses generally decreased across all phases of pandemic mitigation mandates except for the period following lockdown-1. Across pandemic mitigation phases, Hispanics and individuals under 25 years did not demonstrate any change in admissions and ED visits for overdoses. CONCLUSIONS: We underscore the importance of utilizing multiple sources of surveillance to better characterize opioid-involved overdoses and for public health planning.

Using death investigation data to better understand the overdose crisis. / Utiliser les données d'enquête sur les décès pour mieux comprendre la crise des surdoses.

INTRODUCTION: The collection of articles in this theme series of the journal presents results from a national chart review study of the death investigation files of people who died of acute toxicity in Canada between 2016 and 2017. This study endeavoured to better understand the characteristics of the people who died, the circumstances of their deaths and the substances involved. While information about the study and some of its findings have previously been published, we would like to share more about how the study came to be, the people involved and the value of collaborative efforts between coroners, medical examiners and public health practitioners.

Timely and comparable data are essential to the development of a robust evidence base that public health professionals can use to address the evolving national overdose crisis and its drivers. Key to developing this evidence base is fostering collaborative relationships between multidisciplinary teams, including the public health sector and the coroner and medical examiner community.

Il est essentiel de disposer de données comparables et à jour pour constituer une base de données probantes solide dont les professionnels de la santé publique pourront se servir pour lutter contre la crise nationale des surdoses à mesure qu'elle évolue et contre les facteurs qui en sont à l'origine. Le développement de cette base de données probantes repose sur la collaboration d'équipes multidisciplinaires, composées notamment de membres du secteur de la santé publique et des coroners et des médecins légistes.

Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities.

BACKGROUND: Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities. METHODS: PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals. RESULTS: Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23). CONCLUSIONS: The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

The dynamics of heroin and illicit opioid use disorder, casual use, treatment, and recovery: A mathematical modeling analysis.

A leading crisis in the United States is the opioid use disorder (OUD) epidemic. Opioid overdose deaths have been increasing, with over 100,000 deaths due to overdose from April 2020 to April 2021. This paper presents a mathematical model to address illicit OUD (IOUD), initiation, casual use, treatment, relapse, recovery, and opioid overdose deaths within an epidemiological framework. Within this model, individuals remain in the recovery class unless they relapse back to use and due to the limited availability of specialty treatment facilities for individuals with OUD, a saturation treatment function was incorporated. Additionally, a casual user class and its corresponding specialty treatment class were incorporated. We use both heroin and all-illicit opioids datasets to find parameter estimates for our models. Bistability of equilibrium solutions was found for realistic parameter values for the heroin-only dataset. This result implies that it would be beneficial to increase the availability of treatment. An alarming effect was discovered about the high overdose death rate: by 2046, the disorder-free equilibrium would be the only stable equilibrium. This consequence is concerning because it means the epidemic would end due to high overdose death rates. The IOUD model with a casual user class, its sensitivity results, and the comparison of parameters for both datasets, showed the importance of not overlooking the influence that casual users have in driving the all-illicit opioid epidemic. Casual users stay in the casual user class longer and are not going to treatment as quickly as the users of the heroin epidemic. Another result was that the users of the all-illicit opioids were going to the recovered class by means other than specialty treatment. However, the change in the relapse rate has more of an influence for those individuals than in the heroin-only epidemic. The results above from analyzing this model may inform health and policy officials, leading to more effective treatment options and prevention efforts.

Opioid Use Disorder in Missouri: An Evidence-Based, Public Health-Oriented Approach.

Opioid use disorder (OUD) represents a growing public health crisis in Missouri and nationwide. Reversing the trend of rising OUD-associated morbidity and mortality will require implementing evidence-based approaches grounded in public health principles. Key evidence-based interventions include medications for opioid use disorder, naloxone distribution, overdose education, and syringe services programs. The increasing presence of fentanyl and xylazine in the drug supply represent new challenges to the OUD crisis in Missouri. Optimal implementation of evidence-based interventions will require action at the individual physician, community, and state policy level.

Income inequality and deaths of despair risk in Canada, identifying possible mechanisms.

BACKGROUND: Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services). METHODS: We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion, and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death. RESULTS: Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HRadj. = 1.28; 95 CI = 1.05, 1.55), suicide (HRadj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HRadj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HRadj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes. CONCLUSION: Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada.

Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties.

BACKGROUND: The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties. METHODS: Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios. RESULTS: Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county. CONCLUSIONS: Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.

People who use drugs' prioritization of regulation amid decriminalization reforms in British Columbia, Canada: A qualitative study.

BACKGROUND: North America and the province of British Columbia (BC), Canada, is experiencing an unprecedented number of overdose deaths. In BC, overdose has become the leading cause of death for people between the ages of 10-59 years old. In January 2023, BC decriminalized personal possession of a number of illegal substances with one aim being to address overdose deaths through stigma reduction and promoting access to substance use services. METHODS: We conducted a qualitative study to understand people who use drugs' (PWUD) perceptions of the new decriminalization policy, immediately prior to its' implementation (October-December 2022). To contextualize decriminalization within broader drug policy, we also asked PWUD what they perceived as the priority issues drug policy ought to address and the necessary solutions. Our final sample included 38 participants who used illegal drugs in the past month. RESULTS: We identified four themes: 1) The illicit drug supply as the main driver of drug toxicity deaths 2) Concerns about the impact of decriminalization on drug toxicity deaths 3) Views towards decriminalization as a policy response in the context of the drug toxicity crisis 4) Regulation as a symbol of hope for reducing drug toxicity deaths. CONCLUSION: From our data it became clear that many anticipated that decriminalization would have minimal or no impact on the overdose crisis. Regulation was perceived as the necessary policy approach for effectively and candidly addressing the drivers of the ongoing overdose crisis. These findings are important as jurisdictions consider different approaches to moving away from prohibition-based drug policy.

Emergency Room Utilization and Methamphetamine Overdose Symptoms Among Syringe Services Program Participants in Washington State.

BACKGROUND: Methamphetamine overdose can cause severe psychological and physical health issues including psychosis, heart attack, and death. People who use methamphetamine (PWUM) who experience methamphetamine overdose symptoms (MOS) are advised to seek emergency healthcare; however, factors related to seeking care are not well characterized. METHODS: This study used data from the 2021 Washington State Syringe Services Program (SSP) Health Survey, a cross-sectional survey administered to participants at 21 SSPs in Washington (N = 955). Participants answered questions related to substance use including emergency department/room (ER) utilization for methamphetamine use and whether they experienced psychological and physical MOS. Using Poisson regression, we assessed the association between ER utilization for methamphetamine use, non-fatal opioid overdose, and other key covariates among PWUM who experienced MOS. RESULTS: Methamphetamine use in the last three months was reported by 86% of participants. Among PWUM, 31% reported psychological MOS, 19% reported physical MOS, and 37% reported ≥1 MOS in the prior three months. Non-fatal opioid overdose (adjusted prevalence ratio [APR] = 2.04, 95% CI = 1.38-3.03), main drug of goofball (heroin and methamphetamine combined) (APR = 1.98, 95% CI = 1.34-2.92) and recent blood infection/sepsis (APR = 2.07, 95% CI = 1.24-3.46) were associated with ER utilization for MOS. CONCLUSION: Among people who use SSPs in Washington State, methamphetamine use remains high, and MOS are common. Recent non-fatal opioid overdose was positively associated with ER utilization for methamphetamine use among PWUM who experienced MOS. Patients in the ER for MOS should be screened for opioid use disorder and linked with harm reduction supplies like naloxone and medications for opioid use disorder.