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.

Racial disparities in use of syringe service programs in King County, WA: a comparison of two cross-sectional surveys.

BACKGROUND: Syringe service programs (SSPs) provide tools to people who inject drugs (PWID) to prevent overdose, reduce the risk of HIV and HCV infection, and reduce injection frequency. While effective, previous research suggests that SSPs may not adequately reach some marginalized or particularly vulnerable subpopulations of PWID. METHODS: To identify disparities in SSP use, data from two cross-sectional surveys conducted in King County, Washington were compared: a survey of SSP clients and a community survey of PWID in King County. It was hypothesized that Black PWID, women, and gender minorities would be underrepresented in the SSP survey relative to the general population of PWID. RESULTS: SSP clients identified as White at a significantly higher rate than the community sample of PWID (p = 0.030). Black (p < 0.001), American Indian/Alaska Native (p < 0.001), Latinx/Hispanic (p = 0.009), and Native Hawaiian/ Pacific Islander PWID (p = 0.034) were underrepresented in the SSP client survey. The gender of SSP clients was similar to the distribution seen in the community sample of PWID (p = 0.483). CONCLUSIONS: Black PWID are underrepresented in Seattle-area SSPs, consistent with studies in other large US cities. Both nationally and in Seattle, overdose deaths have been increasing among Black PWID, and harm reduction strategies are vital to reversing this trend. SSPs should explore and test ways to be more accessible to minority populations.

Perspectives on Medication Treatment for Opioid Use Disorder in Adolescents: Results from a Provider Learning Series.

Background: Adolescent opioid use and associated opioid poisoning rates have risen dramatically in the United States, yet this group has disproportionally poorer access to evidence-based medication treatment for opioid use disorder (MOUD). Methods: A transdisciplinary cohort (N = 77) who attended a learning series focused on MOUD for adolescents were surveyed with the purpose of understanding the landscape of current adolescent MOUD practices in Washington State; and needs and barriers to providing care. Results: Results indicated that a higher percentage of prescriber participants endorsed support for MOUD for adolescents than nonprescriber participants. Lack of adjunctive support services (i.e., social work; mental health) were cited as the highest barriers to providing this care. Conclusions: We discuss the importance of continued transdisciplinary training and collaboration, as well as funding ancillary services to address barriers to providing adolescent MOUD.

Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington.

Background: Clinic-imposed barriers can impede access to medication for opioid use disorder (MOUD). We evaluated a low-barrier buprenorphine program that is co-located with a syringe services program (SSP) in Seattle, Washington, USA. Methods: We analyzed medical record data corresponding to patients who enrolled into the buprenorphine program in its first year of operation. We used descriptive statistics and tests of association to longitudinally evaluate retention, cumulative number of days buprenorphine was prescribed, and toxicology results. Results: Demand for buprenorphine among SSP clients initially surpassed programmatic capacity. Of the 146 enrolled patients, the majority (82%) were unstably housed. Patients were prescribed buprenorphine for a median of 47 days (interquartile range [IQR] = 8-147) in the 180 days following enrollment. Between the first and sixth visits, the percentage of toxicology tests that was positive for buprenorphine significantly increased (33% to 96%, P < .0001) and other opioids significantly decreased (90% to 41%, P < .0001) and plateaued thereafter. Toxicology test results for stimulants, benzodiazepines, and barbiturates did not significantly change. Conclusions: SSP served as an effective point of entry for a low-barrier MOUD program. A large proportion of enrolled patients demonstrated sustained retention and reductions in opioid use, despite housing instability and polysubstance use.

Impacts of an opioid overdose prevention intervention delivered subsequent to acute care.

BACKGROUND: Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons. METHODS: Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk. RESULTS: During the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40). DISCUSSION: These null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings. TRIAL REGISTRATION NUMBER: NCT0178830; Results.

Development of a targeted educational intervention to increase pre-exposure prophylaxis uptake among cisgender men and transgender individuals who have sex with men and use methamphetamine in Seattle (WA, USA).

Background Cisgender men and transgender individuals who have sex with men (MSM/TG) and use methamphetamine are at elevated risk for HIV and have had limited pre-exposure prophylaxis (PrEP) uptake. The aim of this study was to quantify the knowledge and use of PrEP, identify barriers to PrEP use, and develop a targeted educational campaign to promote PrEP among MSM/TG who use methamphetamine. METHODS: We conducted three consultations with peer educators of Project Needle and Sex Education Outreach Network (NEON) to develop and disseminate educational materials. We surveyed the peers' HIV-negative contacts before and after this work to explore knowledge and opinions about PrEP and to assess the effect of our materials. RESULTS: There were 221 respondents at baseline (August 2016) and 100 at follow-up (April-May 2017). At baseline, nearly all participants had 'heard of PrEP' (96%) and were insured (97%). However, only 3% had ever used PrEP. Peers suggested educational cards that included a definition of PrEP, adherence tips and that PrEP does not prevent other sexually transmissible infections. Peers distributed approximately 2560 educational cards. At follow-up, approximately half the respondents (53%) had seen the cards, and those who did reported significantly more agreement with the majority of the card messages about PrEP. Significantly more participants reported ever receiving PrEP at follow-up (21%; P<0.001). There was a trend between seeing the cards and PrEP use (P=0.053). CONCLUSIONS: Although we cannot be certain that the effect was due to our intervention, a greater number of the peers' contacts reported receiving PrEP at follow-up, and those who saw our materials were more likely to agree with factual statements about PrEP. There is continued need for PrEP education for MSM/TG who use methamphetamine.

Opioid use disorder and misuse: A review of the epidemiology and medical implications for pediatric anesthesiologists.

This educational review presents an overview of opioid use disorder, misuse and overdose among adolescents, and the clinical implications for anesthesiologists. It provides definitions, discusses the epidemiology worldwide, (focusing on North America), and emphasizes the clinical implications of patients with chronic opioid exposure, including perioperative pain management, as well as opioid overdose and prolonged use of opioids after acute exposure. In the USA, opioid use disorder and negative outcomes related to opioids rose dramatically from 1999-2010; concomitantly heroin use and fatal overdoses have increased as heroin use is associated with the disordered use of licit opioids. Among adolescents and young adults, opioid use disorder is significant, with continued increases in disordered use specifically among young adults. Acute opioid intoxication may have multiple medical implications in addition to respiratory depression, and children are susceptible to acute intoxication via accidental ingestion of prescription opioids. Novel opioid formulations, such as acetyl fentanyl, with unpredictable pharmacology may also be present in acute intoxication. Chronically, opioid use presents challenges for safe and adequate pain management, in the presence of opioid-induced hyperalgesia and differential tolerance as well as mental health issues including depression and anxiety. Predictors of prolonged opioid use in adolescents and adults after surgery is an area of ongoing research. Young patients encountered by pediatric anesthesiologists may be involved in diversion and disordered use of opioids. Increased awareness among anesthesiologists is important, as perioperative discussions often provide an opportunity to detect at risk patients.

An Initial Evaluation of Web-Based Opioid Overdose Education.

BACKGROUND: Fatal opioid overdose is a significant public health concern in the United States. One approach to reducing fatalities is expanding overdose response education to broader audiences. This study examined responses to a web-based overdose education tool. METHODS: The results of 422 anonymous surveys submitted on www.stopoverdose.org were analyzed for participant demographics, knowledge of opioid overdose recognition and response, and knowledge of Washington's Good Samaritan overdose law. Characteristics, knowledge, and planned behavior of respondents with professional versus personal interest in overdose education were compared. RESULTS: Most respondents were age 35 or older (57%) and female (65%). The mean score on the knowledge quiz for overdose recognition and response items was 16.2 out of 18, and 1.5 out of 2 possible points for items concerning the law. Respondents indicating professional interest were significantly more likely to be 35 or older (p = .001) and to have received prior overdose education (p < .001), but less likely to know someone at risk for opioid overdose (p < .001) or report planning to obtain take-home naloxone (p < .001). No significant differences were found in overdose knowledge scores between groups. CONCLUSIONS: Online training may be effective among individuals with professional and personal interest in overdose, as general knowledge scores of overdose response were high among both groups. Lower scores reflecting knowledge of the law suggest that the web-based training may not have adequately presented this information. Overall, results suggest that a web-based platform may be a promising approach to basic overdose education.

A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned.

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

Working upstream: how far can you go with sewage-based drug epidemiology?

The field of drug epidemiology based upon sewer sampling has only emerged in the last 10 years and has great potential to aid in drug epidemiological studies. This rapidly expanding field can provide an unbiased look into the illicit drug habits of large populations as well as specific, smaller groups. How far the field has evolved is discussed as well as where the future for these types of monitoring studies could go.

Beyond Fentanyl Test Strips: Investigating Other Urine Drug Test Strips for Drug Checking Applications.

Use of immunoassay test strips for the detection of fentanyl in drug samples has become commonplace in harm reduction, law enforcement, public health, customs, and forensic science settings for testing drug product. With the increase of xylazine in the drug supply in recent years, use of xylazine test strips has also increased. As use of test strips expands, a desire to implement them for other drugs may emerge. However, since these strips are designed for urine testing, it is important to understand their applicability to testing drug product. In this work, we investigate the utility of seven types of urine immunoassay test strips - amphetamine, benzodiazepine, cocaine, methamphetamine, nitazene, opiate, and xylazine - for drug checking applications. Reproducibility, sensitivity, cross-reactivity, and the effect of prolonged exposure to elevated temperatures were studied. Generally, the tests were found to be reproducible, able to detect trace (µg/mL) levels of the analyte of interest, and minimally affected by prolonged storage at elevated temperatures. Nearly all tests showed cross-reactivity with compounds other than the analyte of interest, highlighting the need to better understand these limitations prior to implementation in a drug checking scenario. The viability of expired cocaine, fentanyl, and methamphetamine test strips was also interrogated, and little to no change in sensitivity was found even though the tests were multiple years expired.

Community-Based Medications First for Opioid Use Disorder - Care Utilization and Mortality Outcomes.

Purpose: A large treatment gap exists for people who could benefit from medications for opioid use disorder (MOUD). People OUD accessing services in harm reduction and community-based organizations often have difficulty engaging in MOUD at opioid treatment programs and traditional health care settings. We conducted a study to test the impacts of a community-based medications first model of care in six Washington (WA) State communities that provided drop-in MOUD access. Participants and Methods: Participants included people newly prescribed MOUD. Settings included harm reduction and homeless services programs. A prospective cohort analysis tested the impacts of the intervention on MOUD and care utilization. Intervention impacts on mortality were tested via a synthetic comparison group analysis matching on demographics, MOUD history, and geography using WA State agency administrative data. Results: 825 people were enrolled in the study of whom 813 were matched to state records for care utilization and outcomes. Cohort analyses indicated significant increases for days' supply of buprenorphine, months with any MOUD, and months with any buprenorphine for people previously on buprenorphine (all results p<0.05). Months with an emergency department overdose did not change. Months with an inpatient hospital stay increased (p<0.05). The annual death rate in the first year for the intervention group was 0.45% (3 out of 664) versus 2.2% (222 out of 9893) in the comparison group in the 12 months; a relative risk of 0.323 (95% CI 0.11-0.94). Conclusion: Findings indicated a significant increase in MOUD for the intervention group and a lower mortality rate relative to the comparison group. The COVID-19 epidemic and rapid increase in non-pharmaceutical-fentanyl may have lessened the intervention impact as measured in the cohort analysis. Study findings support expanding access to a third model of low barrier MOUD care alongside opioid treatment programs and traditional health care settings.

Acceptability and anticipated effectiveness of a safe supply of opioids, among people who inject opioids in King County, WA.

BACKGROUND: Opioid overdose mortality in the US has exceeded one million deaths over the last two decades. A regulated opioid supply may help prevent future overdose deaths by reducing exposure to the unregulated opioid supply. We examined the acceptability, delivery model preference, and anticipated effectiveness of different regulated opioid models among people in the Seattle area who inject opioids. METHODS: We enrolled people who inject drugs in the 2022 Seattle-area National HIV Behavior Surveillance (NHBS) survey. Participants were recruited between July and December 2022 using respondent-driven sampling. Participants who reported injecting opioids (N = 453) were asked whether regulated opioids would be acceptable, their preferred model of receiving regulated opioids, and the anticipated change in individual overdose risk from accessing a regulated opioid supply. RESULTS: In total, 369 (81 %) participants who injected opioids reported that a regulated opioid supply would be acceptable to them. Of the 369 who found a regulated opioid supply to be acceptable, the plurality preferred a take-home model where drugs are prescribed (35 %), followed closely by a dispensary model that required no prescription (28 %), and a prescribed model where drugs need to be consumed on site (13 %), a model where no prescription is required and drugs can be accessed in a community setting with a one-time upfront payment was the least preferred model (5 %). Most participants (69 %) indicated that receiving a regulated opioid supply would be "a lot less risky" than their current supply, 20 % said, "a little less risky", 10 % said no difference, and 1 % said a little or a lot more risky. CONCLUSION: A regulated opioid supply would be acceptable to most participants, and participants reported it would greatly reduce their risk of overdose. As overdose deaths continue to increase in Washington state pragmatic and effective solutions that reduce exposure to unregulated drugs are needed.

Police officers' and paramedics' experiences with overdose and their knowledge and opinions of Washington State's drug overdose-naloxone-Good Samaritan law.

Opioid overdoses are an important public health concern. Concerns about police involvement at overdose events may decrease calls to 911 for emergency medical care thereby increasing the chances than an overdose becomes fatal. To address this concern, Washington State passed a law that provides immunity from drug possession charges and facilitates the availability of take-home-naloxone (the opioid overdose antidote) to bystanders in 2010. To examine the knowledge and opinions regarding opioid overdoses and this new law, police (n = 251) and paramedics (n = 28) in Seattle, WA were surveyed. The majority of police (64 %) and paramedics (89 %) had been at an opioid overdose in the prior year. Few officers (16 %) or paramedics (7 %) were aware of the new law. While arrests at overdose scenes were rare, drugs or paraphernalia were confiscated at 25 % of the most recent overdoses police responded to. Three quarters of officers felt it was important they were at the scene of an overdose to protect medical personnel, and a minority, 34 %, indicated it was important they were present for the purpose of enforcing laws. Police opinions about the immunity and naloxone provisions of the law were split, and we present a summary of the reasons for their opinions. The results of this survey were utilized in public health efforts by the police department which developed a roll call training video shown to all patrol officers. Knowledge of the law was low, and opinions of it were mixed; however, police were concerned about the issue of opioid overdose and willing to implement agency-wide training.

"That Line Just Kept Moving": Motivations and Experiences of People Who Use Methamphetamine.

INTRODUCTION: Methamphetamine use is on the rise with increasing emergency department (ED) visits, behavioral health crises, and deaths associated with use and overdose. Emergency clinicians describe methamphetamine use as a significant problem with high resource utilization and violence against staff, but little is known about the patient's perspective. In this study our objective was to identify the motivations for initiation and continued methamphetamine use among people who use methamphetamine and their experiences in the ED to guide future ED-based approaches. METHODS: This was a qualitative study of adults residing in the state of Washington in 2020, who used methamphetamine in the prior 30 days, met criteria for moderate- to high-risk use, reported recently receiving care in the ED, and had phone access. Twenty individuals were recruited to complete a brief survey and semi-structured interview, which was recorded and transcribed prior to being coded. Modified grounded theory guided the analysis, and the interview guide and codebook were iteratively refined. Three investigators coded the interviews until consensus was reached. Data was collected until thematic saturation. RESULTS: Participants described a shifting line that separates the positive attributes from the negative consequences of using methamphetamine. Many initially used methamphetamine to enhance social interactions, combat boredom, and escape difficult circumstances by numbing the senses. However, continued use regularly led to isolation, ED visits for the medical and psychological sequelae of methamphetamine use, and engagement in increasingly risky behaviors. Because of their overwhelmingly frustrating experiences in the past, interviewees anticipated difficult interactions with healthcare clinicians, leading to combativeness in the ED, avoidance of the ED at all costs, and downstream medical complications. Participants desired a non-judgmental conversation and linkage to outpatient social resources and addiction treatment. CONCLUSION: Methamphetamine use can lead patients to seek care in the ED, where they often feel stigmatized and are provided little assistance. Emergency clinicians should acknowledge addiction as a chronic condition, address acute medical and psychiatric symptoms adequately, and provide positive connections to addiction and medical resources. Future work should incorporate the perspectives of people who use methamphetamine into ED-based programs and interventions.

Trends and correlates of naloxone possession and use among people who inject drugs in Seattle, Washington.

BACKGROUND: Naloxone distribution has been implemented as an essential opioid overdose prevention measure for people who inject drugs (PWID), and many jurisdictions in the United States have implemented policy change to increase naloxone access. This project describes temporal trends in and correlates of naloxone possession and use among PWID in the Seattle area of Washington State. METHODS: Using a repeat cross-sectional design, we utilized two sets of serial cross-sectional surveys of PWID, which included biennial surveys of Seattle area syringe service program (SSP) clients and community-based National HIV Behavioral Surveillance surveys of PWID (NHBS-PWID) conducted from 2012-2019. Survey participant characteristics were descriptively compared between participants reporting naloxone possession to those not reporting naloxone possession. Multivariable Poisson regression was used to calculate prevalence ratios for naloxone possession comparing later to earlier survey years, adjusting for age, gender, race/ethnicity, primary drug, and experiencing and witnessing an overdose in the past 12 months. RESULTS: Naloxone possession and use increased in both survey populations. The prevalence of possessing naloxone was 2.8 times greater [2019 vs. 2013= 95% CI: 2.40-3.33] among SSP participants and 2.8 times greater [2018 vs. 2012=95% CI: 2.41-3.16] among NHBS-PWID participants for the most recent time period. The prevalence of naloxone use was 1.3 times greater [2019 vs. 2017= 95% CI: 1.13-1.58] and 2.1 times greater [2015 vs. 2012=95% CI:1.62-2.73] among SSP and NHBS-PWID participants, respectively, for the most recent time period. CONCLUSION: Naloxone possession and use increased in PWID in the Seattle area from 2012-2019, and is, at least in part, likely the result of numerous policy and programmatic efforts to facilitate easier naloxone accessibility in the wake of dramatic increases in overdose mortality. Further research on disparities in naloxone possession are needed to ensure equitable access.

Normalized diurnal and between-day trends in illicit and legal drug loads that account for changes in population.

Drug concentrations in composite municipal wastewater samples and census-based estimates of population are used to derive daily loads of illicit substances that are indexed to population. However, such estimates do not provide information on the diurnal trends of substance excretion nor can they account for changes in population. To address these limitations, a series of 1 h composites created by sampling wastewater influent at 6 min intervals was collected over four consecutive days at a single wastewater treatment plant. Creatinine (a urinary indicator), caffeine, methamphetamine, benzoylecgonine (BZE), and cocaine were analyzed by liquid chromatography/tandem mass spectrometry (LC-MS/MS). Diurnal trends and between-day trends were substance specific and related to the number of estimated doses and excretory half-life. Normalization to creatinine yielded trends in substances that differed significantly from non-normalized trends by accounting for changes in population within the municipality studied. Increases in normalized substance excretion observed during early morning hours originate from individuals among the resident population of the municipality due to the absence of commuters.

Substance use, treatment admissions, and recovery trends in diverse Washington State tribal communities.

BACKGROUND: Qualitative and quantitative data and participatory research approaches might be most valid and effective for assessing substance use/abuse and related trends in American Indian and Alaska Native (AIAN) communities. METHOD: Twenty-nine federally recognized AIAN tribes in Washington (WA) State were invited to participate in Health Directors (HD) interviews and State treatment admissions data analyses. Ten Tribal HD (or designees) from across WA participated in 30-60-minute qualitative interviews. State treatment admissions data from 2002 to 2008 were analyzed for those who identified with one of 11 participating AIAN communities to explore admission rates by primary drug compared to non-AIANs. Those who entered treatment and belonged to one of the 11 participating tribes (n = 4851) represented 16% of admissions for those who reported a tribal affiliation. RESULTS: Interviewees reported that prescription drugs, alcohol, and marijuana are primary community concerns, each presenting similar and distinct challenges. Additionally, community health is tied to access to resources, services, and culturally appropriate and effective interventions. Treatment data results were consistent with interviewee-reported substance use/abuse trends, with alcohol as the primary drug for 56% of AIAN adults compared to 46% of non-AIAN, and other opiates as second most common for AIAN adults in 2008 with 15% of admissions. LIMITATIONS: Findings are limited to those tribal communities/community members who agreed to participate. CONCLUSION: Analyses suggest that some diverse AIAN communities in WA State share similar substance use/abuse, treatment, and recovery trends and continuing needs. SCIENTIFIC SIGNIFICANCE: Appropriate and effective research with AIAN communities requires respectful and flexible approaches.