Applying machine learning to international drug monitoring: classifying cannabis resin collected in Europe using cannabinoid concentrations.

In Europe, concentrations of ∆9-tetrahydrocannabinol (THC) in cannabis resin (also known as hash) have risen markedly in the past decade, potentially increasing risks of mental health disorders. Current approaches to international drug monitoring cannot distinguish between different types of cannabis resin which may have contrasting health effects due to THC and cannabidiol (CBD) content. Here, we compared concentrations of THC and CBD in different types of cannabis resin collected in Europe (either Moroccan-type, or Dutch-type). We then tested the ability of machine learning algorithms to classify the type of cannabis resin (either Moroccan-type, or Dutch-type) using routinely collected monitoring data on THC and CBD. Finally, we applied the optimal algorithm to new samples collected in countries where the type of cannabis resin was unknown, the UK and Denmark. Results showed that overall, Dutch-type samples had higher THC (Hedges' g = 2.39) and lower CBD (Hedges' g = 0.81) than Moroccan-type samples. A Support Vector Machine algorithm achieved classification accuracy exceeding 95%, with little variation in this estimate, good interpretability, and plausibility. It made contrasting predictions about the type of cannabis resin collected in the UK (94% Moroccan-type; 6% Dutch-type) and Denmark (36% Moroccan-type; 64% Dutch-type). In conclusion, we provide proof-of-concept evidence for the potential of machine learning to inform international drug monitoring. Our findings should not be interpreted as objective confirmatory evidence but suggest that Dutch-type cannabis resin has higher THC concentrations than Moroccan-type cannabis resin, which may contribute to variation in drug markets and health outcomes for people who use cannabis in Europe.

Awareness and knowledge of drug decriminalization among people who use drugs in British Columbia: a multi-method pre-implementation study.

BACKGROUND: In January 2023, British Columbia implemented a three-year exemption to Controlled Drugs and Substances Act, as granted by the federal government of Canada, to decriminalize the personal possession of small amounts of certain illegal drugs. This decriminalization policy, the first in Canada, was announced in response to the overdose emergency in British Columbia as a public health intervention that could help curb overdose deaths by reducing the impact of criminalization and increasing access to health and social services through stigma reduction. METHODS: The current multi-method study examines people who use drugs' awareness and knowledge of British Columbia's decriminalization model through cross-sectional quantitative surveys and qualitative interviews among people who use drugs from September-November 2022, immediately prior to the implementation of decriminalization. RESULTS: Quantitative findings show that two-thirds (63%) of people who use drugs were aware of the policy, but substantial knowledge gaps existed about the legal protections afforded (threshold amount, substances included, drug trafficking, confiscation). The qualitative findings suggest that people who use drugs misunderstood the details of the provincial decriminalization model and often conflated it with regulation. Results suggest that information sharing about decriminalization were minimal pre-implementation, highlighting areas for knowledge dissemination about people who use drugs' rights under this policy. CONCLUSIONS: Given that decriminalization in British Columbia is a new and landmark reform, and that the success of decriminalization and its benefits may be undermined by poor awareness and knowledge of it, efforts to share information, increase understanding, and empower the community, may be required to promote its implementation and benefits for the community.

Mapping new psychoactive substances: Leveraging GIS technology for advanced global surveillance and policy support.

The escalating challenge of New Psychoactive Substances (NPS) necessitates enhanced global monitoring and analysis capabilities. This study introduces an advanced interactive visualization tool that employs Geographic Information System (GIS) technologies to improve the functionality of the UNODC's Early Warning Advisory. The tool enables dynamic observation and analysis of NPS's geographical and temporal distribution, thereby facilitating a comprehensive understanding of their public health impacts. By incorporating detailed choropleth maps and annual and cumulative bar charts, the tool allows policymakers and researchers to visually track and analyze trends in NPS usage and control efforts across different regions. The results demonstrate the tool's effectiveness in providing actionable insights, which support the strategic development of public health policies and interventions to curb the global rise in NPS usage. This initiative illustrates the essential role of digital tools in enhancing public health strategies and responses to emerging drug trends. This rising challenge underscores the urgent need for innovative solutions in monitoring drug trends, a theme explored in this paper. The web tool is available at https://nps-vis.cmdm.tw, and the code is available at https://github.com/CMDM-Lab/nps-vis.

The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews.

BACKGROUND: Access to anaesthesia and surgical care is a major problem for people living in Sub-Saharan Africa. In this region, ketamine is critical for the provision of anaesthesia care. However, efforts to control ketamine internationally as a controlled substance may significantly impact its accessibility. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in Sub-Saharan Africa and assess the potential impact on access to ketamine if it were to be scheduled. METHODS: This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in Sub-Saharan Africa. Data on availability of four anaesthetic agents were collected from hospitals (n = 54) in Rwanda. Semi-structured interviews with 10 key informants were conducted, collecting information on the importance of ketamine, the potential impact of scheduling ketamine internationally, and opinions on misuse of ketamine. Interviews were transcribed verbatim and analysed using a thematic analysis approach. RESULTS: The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents were available at only about half of the hospitals. Significant barriers impeding access to anaesthesia care were identified, including a general lack of attention given to the specialty by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers. Misuse of ketamine was not believed to be an issue by the informants. CONCLUSION: Ketamine is critical for the provision of anaesthesia care in Sub-Saharan Africa, and its scheduling would have a significantly negative impact on its availability for anaesthesia care.

Working in a relational way is everything: Perceptions of power and value in a drug policy-making network.

BACKGROUND: The development of drug policies has been a major focus for policy-makers across North America in light of the ongoing public health emergency caused by the overdose crisis. In this context, the current study examined stakeholders' experiences and perceptions of power and value in a drug policy-making process in a North American city using qualitative, questionnaire, and social network data. METHODS: We interviewed 18 people who participated in the development of a drug policy proposal between October 2021 and March 2022. They represented different groups and organizations, including government (n = 3), people who use drugs-led advocacy organizations (n = 5), other drug policy advocacy organizations (n = 5), research (n = 3) and police (n = 2). Most of them identified as men (n = 8) and white (n = 16), and their ages ranged between 30 and 80 years old (median = 50). Social network analysis questionnaires and semi-structured qualitative interviews were administered via Zoom. Social network data were analysed using igraph in R, and qualitative data were analysed using thematic analysis. The analyses explored perceptions of value and power within a drug policy-making network. RESULTS: The policy-making network showed that connections could be found across participants from different groups, with government officials being the most central. Qualitative data showed that inclusion in the network and centrality did not necessarily translate into feeling powerful or valued. Many participants were dissatisfied with the process despite having structurally advantageous positions or self-reporting moderately high quantitative value scores. Participants who viewed themselves as more valued acknowledged many process shortcomings, but they also saw it as more balanced or fair than those who felt undervalued. CONCLUSIONS: While participation can make stakeholders and communities feel valued and empowered, our findings highlight that inclusion, position and diversity of connections in a drug policy-making network do not, in and of itself, guarantee these outcomes. Instead, policy-makers must provide transparent terms of reference guidelines and include highly skilled facilitators in policy discussions. This is particularly important in policy processes that involve historical power imbalances in the context of a pressing public health emergency.

"In Sweden you are worthless. In Denmark you get an identity again" - on being perceived and received as a person who uses drugs in different drug policy settings.

BACKGROUND: Policies to address substance use differ greatly between settings, where goals may range from zero-tolerance to harm reduction. Different approaches impact formats of care, policing, and even interpersonal interactions, and may play a role in the labelling and stigmatization of people who use drugs (PWUD). Where Sweden has a more restrictive policy, aiming to have a society free from drugs, Denmark has embraced harm reduction principles. The aim of this study was to explore PWUDs' experiences of interpersonal interactions, policing, and service formats in the two countries. METHODS: The data consists of 17 qualitative semi-structured interviews with Swedish PWUD who have been in both Sweden and Denmark. Recruitment took place at harm reduction sites in both countries, and through snowball sampling. RESULTS: Participants reflected on how they were perceived by those in public spaces, and received by care systems and personnel. In public settings in Sweden, participants felt they were ignored, rendered invisible, and lost their humanity. In Denmark, they were perceived and acknowledged, valued as people. This was simultaneously linked to being embodied by the availability of differing service offerings and policing practices, which solidified their "right to be out" in public. Reflecting on their reception in the treatment system, strict formatting in Sweden caused participants to feel that an identity was projected upon them, limiting their opportunities or growth of new facets of identity. Care relations in Denmark fostered more opportunity for autonomy and trust. CONCLUSION: A zero-tolerance policy and associated public discourses could solidify and universalize stigmatizing categorizations as a central feature of PWUD identity and reception from those around them, exacerbating social exclusion. Conversely, harm reduction-centered policies fostered positive interactions between individuals with care providers, public, and police, which may promote inclusion, empowerment, and wellbeing.

Reframing Dutch drug policies: a new era for harm reduction.

In this article the authors offer their perspective on the changes in the Dutch harm reduction field. From the 1970s to the 1990s, the Netherlands emerged as a leader in harm reduction services, driven by grassroots movements like the Medisch-sociale Dienst Heroïne Gebruikers (MDHG) (Medisch-sociale Dienst Heroïne Gebruikers (MDHG) translates to Medical-Social Service Heroin Users in English) in Amsterdam and Junkiebond in Rotterdam. These organisations advocated for health-centred policies, initiated needle exchange programmes, and created safe consumption spaces. Their efforts led to significant public health improvements and policy shifts towards harm reduction, reducing HIV and hepatitis rates among people who use drugs. By the 1980s, harm reduction became institutionalised within local health and social care systems, leading to notable declines in drug-related harm and crime. However, from the 2000s, a shift towards security and crime prevention emerged, influenced by socio-political changes. Increased criminal justice measures and budget cuts for harm reduction services strained the system, making it harder to address emerging drug trends and the complex needs of people who use drugs. Despite challenges, there is renewed momentum for reform, particularly at the local level, advocating for the responsible regulation of psychoactive substances. Amsterdam Mayor Femke Halsema's 2024 conference on drug regulation exemplifies this shift, calling for policies that address prohibition failures and centre harm reduction. International bodies like the UN High Commissioner for Human Rights support this approach, emphasising a health and rights-based framework. As the Netherlands navigates these evolving dynamics, there is a pressing need to reinvest in harm reduction infrastructure, ensuring it meets diverse community needs and reaffirms its foundational rights-affirming principles.

The war on drugs is a war on us: young people who use drugs and the fight for harm reduction in the Global South.

In the Global South, young people who use drugs (YPWUD) are exposed to multiple interconnected social and health harms, with many low- and middle-income countries enforcing racist, prohibitionist-based drug policies that generate physical and structural violence. While harm reduction coverage for YPWUD is suboptimal globally, in low- and middle-income countries youth-focused harm reduction programs are particularly lacking. Those that do exist are often powerfully shaped by global health funding regimes that restrict progressive approaches and reach. In this commentary we highlight the efforts of young people, activists, allies, and organisations across some Global South settings to enact programs such as those focused on peer-to-peer information sharing and advocacy, overdose monitoring and response, and drug checking. We draw on our experiential knowledge and expertise to identify and discuss key challenges, opportunities, and recommendations for youth harm reduction movements, programs and practices in low- to middle-income countries and beyond, focusing on the need for youth-driven interventions. We conclude this commentary with several calls to action to advance harm reduction for YPWUD within and across Global South settings.

Illicit drug use in Limerick City: A stakeholder and policy analysis using multiple streams model.

BACKGROUND: The changing drug situation in Ireland has led to the development of various drug policies. This paper aims to use Limerick City as a case study to examine approaches to policy development. METHODOLOGY: The study is qualitative and uses a hybrid technique that combines document, content, and stakeholder analysis. Kingdon's multiple streams model underpins this study. In addition, guidelines for the systematic search for grey literature were adopted as the search strategy. RESULTS: Problem Stream: Illicit drug use and its related problems have changed. The increasing availability of drugs, increasing usage and changes in the types of drugs being used have led to increased drug-related crimes, adverse health outcomes and elevated demand for treatment services. Local drug policies and initiatives emerge by recognising drug-related problems in the region. Policy Stream: The current national drug strategy 2017-2025 which informs action plans in Limerick is the first to focus on a unified health approach. Some national policies have evolved to ensure that guidelines meet current service needs. However, these changes have occurred in some cases with no clear actions. Political Stream: Statutory, voluntary and community stakeholders provide drug addiction and drug addiction-related services, which have evolved rapidly since their first introduction. The Mid-West Regional Drug Task Force was identified as essential in coordinating stakeholders locally. One area for improvement is limited evidence of the voices of persons who take drugs included in service/policy development. This regional analysis also suggests that local implementation of policies concerning dual diagnosis and supervised injection facilities can be further expanded. Despite the challenges experienced by stakeholders in Limerick, a hands-on approach has been adopted in the creation of strategies to tackle the drug problem. CONCLUSION: The approaches to drug policy development have delivered continuous development of services. However, services remain underdeveloped in areas removed from the capital city of Dublin. Navigating the complex drug landscape reveals that inclusivity, adaptation, and ongoing research are critical components of successful and long-lasting drug policies.

Traceability and control as levers to prevent leakage from legal circulation when legalizing medical cannabis.

OBJECTIVE: Aim: To reveal traceability and control as levers to prevent leakage from legal circulation when legalizing medical cannabis. PATIENTS AND METHODS: Materials and Methods: The methodological basis of this research work is based on a systematic approach. Methods of structural and logical analysis, bibliosemantic, abstraction and generalization were used in this article. RESULTS: Results: The analysis of the regulatory framework and regulatory initiatives in the field of circulation of narcotic drugs, in particular, cannabis (in total 56 documents) demonstrated repeated attempts to reform it in Ukraine in order to increase the availability and efficiency of medical and pharmaceutical services. Recently adopted law on the legalization of medical cannabis pays special attention to the traceability of the circulation of medical cannabis and cannabis-based medicines (CbMs) by digitalization and creation of the appropriate electronic information system. CONCLUSION: Conclusions: With the adoption of the law on the legalization of medical cannabis Ukraine became the 57th country in the world to legalize such cannabis. The study and analysis of the regulatory framework of Ukraine, taking into account the best world practices, showed that the legalization of medical cannabis will allow for providing more effective care to many patients including wounded defenders.

Using Multiple Authorized Generics to Maintain High Prices: The Example of Entacapone.

OBJECTIVES: Brand-name drug manufacturers can market or license authorized generics (AGs), which are the same product sold under a generic name. By contrast, independent generics (IGs) are made by other manufacturers. The brand-name manufacturer of entacapone, a treatment for Parkinson's disease, established 4 AGs before IGs emerged. We used this case study to understand how AGs can affect the length of brand-name exclusivity and robustness of generic competition. METHODS: Using public Food and Drug Administration and court records, we identified the regulatory and legal history for generic entacapone products marketed through 2021. We used Medicare Part D data to estimate trends in use, prices, and spending on entacapone products from 2011 to 2020, comparing actual spending with projected spending if IG competition had begun after expiration of the key patent protecting entacapone (October 2013) and prices had fallen consistent with levels observed for other generic drugs. RESULTS: From 2012 to 2014, 3 potential entacapone IG manufacturers instead launched AG versions after settlement agreements with the brand-name manufacturer; the brand-name manufacturer additionally introduced its own AG. Four different IG versions were marketed beginning in 2015. From 2011 to 2020, average Medicare prices declined by 62%, less than the projected 74% to 92% price decline expected for a drug with 8 generics. Over this period, Medicare spent $1.1 billion on entacapone products, which could have been reduced by an estimated $137 to $449 million through typical IG competition. CONCLUSIONS: The case of entacapone demonstrates how licensing multiple AGs in place of IG competition can increase spending. Government regulators should more rigorously monitor AGs to prevent such strategies.

Ups and downs of addiction harm reduction in Iran: key insights and implications for harm reduction policy and policing.

Drug use is a critical behavioral disorder or a delinquency behavior (in the judiciary system's words) that comes with a burden at multiple levels: individual, community, public, and global. These social structures apply different interventions to reduce this burden in their field. Given the society as a whole, these structures must be harmonious and synergistic to optimize these endeavors in terms of cost-benefit. In practice, however, reducing the burden of addiction is followed by conflicting approaches by different organizations, in terms such as "eradicating drugs," "eliminating drug users," "obliterating addiction," and ultimately, drug use harm reduction. In the harm reduction philosophy, drug use is recognized as an inescapable fact in human societies, and tries to control its personal and public consequences in different dimensions (health, economic, and social). Therefore, this approach includes broad measures such as: changing the pattern of consumption (from high-risk substances to less dangerous substances) through modification of the laws and law enforcement measures, distributing disposable syringes to prevent HIV transmission, providing basic life needs such as shelter for street-based drug users to reduce the social consequences like homelessness, prescribing substitute agonists to reduce the committing crime to obtain the needed drugs, and even the drug court program, which prevents the exacerbation of complications in a person with a chronic and relapsing disorder, due to the imposition of inappropriate sentences (like incarceration in unacceptable conditions). It is contrary to the approaches that aim to reduce the drug supply rate and drug use incidence and prevalence to zero. As a result of the conflict of interests, goals discrepancies, and differences in organizational culture, these approaches may contrast with each other. We see this in the harm reduction between the health system and law enforcement. Different factors affect the harmony or conflict between these two structures. This article addresses the impact of ideology, social conditions, and bureaucratic administration on the relationship between the health system and the police in drug use harm reduction in Iran.

Exploring the subjective experience of rave party participants in Israel who consume psychedelic drugs: a qualitative inquiry.

BACKGROUND: Rave music parties (RMP) are a world-wide socio-cultural phenomenon, where people listen to rave music while frequently consuming psychedelic drugs. Epidemiological studies have emphasized the hazardous consequences following the consumption of psychedelic drugs at RMP, and qualitative studies have shown social and psycho-spiritual experiences. Yet, phenomenological inquiry into subjective experiences of attendees is scant. This study aimed to examine physical, emotional, perceptual and social experiences of RMP participants in Israel, and their view on Israel's policy toward rave events. In addition, the study aimed to contribute useful information for policymakers and society on rave music and psychedelic drugs experiences at RMP. METHOD: Interpretative phenomenological analysis was used to analyze transcriptions of semi-structured interviews with 27 individuals attending RMP regularly and consume psychedelic drugs. RESULTS: Analysis revealed four significant themes: the first theme, the impact of Israel's drug policy on participants' sense of safety, relates to participants' sense of insecurity and anxiety at Israeli RMP due to government drug ban policy. The second theme, the stigma on rave culture, relates to participants' perception regarding the stigma on rave culture in law enforcement agencies and in society in general. The third theme, negative experiences, describes short-term experiences after consuming psychedelics at RMP, including hallucinations and disorientation. The fourth theme, positive experiences, describes positive sensory, emotional and self/world attitudinal aspects after consuming psychedelics at RMP. Sensory experiences included intensified auditory, visual and tactile experiences; emotional experiences included positive feelings toward others, reduced stress and ability to vent difficult emotions; self/world attitudinal aspects included self-acceptance, higher appreciation of life and connectedness to nature. CONCLUSIONS: The study highlights RMP participants' sense of insecurity due to Israel's strict drug policy and absence of harm reduction strategies at rave scenes. The study also notes participants' experience of stigmatization as drug addicts by society and law enforcement agencies. Reducing police presence and adopting harm reduction policies at rave scenes in Israel may increase participants' sense of security, reduce stigmatization and decrease overdose risk. Hence, the findings may contribute to new knowledge useful for policymakers and society concerning RMP and the use of psychedelics.

Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review.

BACKGROUND: Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access. METHODS: To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S. RESULTS: In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD. CONCLUSIONS: Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.

Health care administration and drug policy.

The American healthcare system faces a potential reorganization of the way in which services are provided and financed. We argue that healthcare administrators need to be increasingly aware of the ways in which our nation's illicit drug policy, commonly referred to as the 'War on Drugs', affects the provision of health services. A large and growing portion of the US population uses one or more of the currently illegal drugs and some of these persons suffer from an addiction or other substance use disorder. This is clearly demonstrated by the current opioid epidemic which is not yet being adequately controlled. Providing specialty treatment for drug abuse disorders will be increasingly important for healthcare administrators thanks to recent mental health parity legislation. At the same time, drug users and abusers will be increasingly encountered while providing care not specifically tied to drug use or abuse. The character of our current national drug policy has an important impact on how drug abuse disorders are treated and how the health delivery system responds to drug users who are increasingly often encountered in primary care, emergency care, specialty care, and long-term care settings.

Decriminalisation and smart regulation of psychoactive substances: a modern alternative to prohibition.

Prohibition has been the globally dominant concept for the regulation and control of psychoactive substances for nearly 70 years. Its effectiveness and legitimacy as a sustainable solution to the problems associated with the existence of psychoactive substances in society has been repeatedly questioned. It is based on the normative assumption that the use of psychoactive substances for other than therapeutic purposes is not allowed, and non-medical supply should be severely punished. This precludes the use of the full range of regulatory, public health, prevention, and harm reduction strategies, reduces well-being, and increases harms for the human-rights, health, and social cohesion. It is time to replace the prohibitionist paradigm with modern regulation that considers the different harms and risks of psychoactive substances, but also the benefits of psychoactive substances for mental health and well-being, lifestyle, and socialisation. This new paradigm (the so-called 'smart regulation') should accept non-medical use of psychoactive substances, apply criminal law as an exceptional tool to regulate human behaviour, regulate the availability of substances according to their harmfulness, regulate the risk profile of the product, strictly regulate marketing and advertising, protect minors and 'others' from the use and supply of psychoactive substances, protect the legal market from the supply of substances from the illegal market, and use economic instruments to regulate demand and to subsidise prevention and treatment.

Racial resentment and support for decriminalization of drug possession in the United States.

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.

International trends in prescription opioid sales among developed and developing economies, and the impact of the COVID-19 pandemic: A cross-sectional analysis of 66 countries.

PURPOSE: We sought to compare trends in opioid purchasing between developed and developing economies to understand patterns of opioid consumption, and how they were impacted by the COVID-19 pandemic. METHODS: We conducted a retrospective cross-sectional study of retail pharmacy opioid sales from 66 jurisdictions between July 2014 and August 2020. We measured monthly population-adjusted rate of opioid units purchased, stratified by development group and country, and used interventional time series analysis to assess the impact of the COVID-19 pandemic on rates of opioid purchasing among developed and developing economies separately. RESULTS: Rates of opioid purchasing were generally higher among developed economies, although trends differed considerably by development group. Rates of opioid purchasing declined 23.8% (95% confidence interval [CI] -34.7% to 3.6%) in the 5 years prior to the pandemic in developed economies, but rose 15.2% (95% CI 4.6%-35.6%) among developing economies. In March 2020 there was a short-term increase in the rate of opioid purchases in both developing (10.9 units/1000 population increase; p < 0.0001) and developed (145.5 units/1000 population; p < 0.0001) economies, which was followed immediately by reduced opioid purchasing of a similar scale in April-May 2020 (-14.8 and -171.8 units/1000 population in developing and developed economies, respectively; p < 0.0001). CONCLUSION: The COVID-19 pandemic led to disruptions in opioid purchasing around the world; although the specific impacts varied both between and among developed and developing economies. With global variation in opioid use, there is a need to monitor these trajectories to ensure the safety of opioid use, and adequate access to pain management globally.

High Prevalence and Early Onsets: Legal and Illegal Substance Use in an Urban Cohort of Young Adults in Switzerland.

INTRODUCTION: Debates about the legalization of illegal substances (e.g., cannabis) continue around the globe. A key consideration in these debates is the adequate protection of young people, which could be informed by current prevalence and age-of-onset patterns. For Switzerland, such information is limited, which is particularly true for women, despite advanced political efforts to legalize cannabis. The objective of the current study was to investigate substance use prevalence rates and ages of onset in a community-representative sample of female and male young adults in Switzerland. METHODS: Data came from the Zurich Project on the Social Development from Childhood to Adulthood (z-proso). In 2018, participants (N = 1,180, 50.8% females) were ∼20 years old. Lifetime and past-year use of alcohol, tobacco, cannabinoids, stimulants, hallucinogens, opioids, and benzodiazepines were assessed with an extensive substance use questionnaire. Additionally, ages of onsets of the respective substances were estimated by averaging participants' self-reported ages of onsets from ages 13 to 20 (max. 4 assessments). RESULTS: 57% of 20-year-olds had used cannabinoids, 16% stimulants, 15% opioids (mostly codeine), and 8% hallucinogens in the past year. Males had higher prevalence than females for most drugs; nevertheless, females' prevalence rates were notably high. Legal substance use was typically initiated 1.3-2.7 years before legal selling age. Thus, almost half of the sample had consumed alcohol and tobacco by age 14. More than 40% of the total sample had smoked cannabis by age 16. Males initiated use of legal substances and cannabis earlier than females. DISCUSSION: Our recent community-representative data suggested unexpectedly high levels and early onsets of substance use compared to a previous Swiss surveys and also the European average. Drug policy debates should consider urban substance use patterns when considering legalization efforts.

Modeling cocaine traffickers and counterdrug interdiction forces as a complex adaptive system.

Counterdrug interdiction efforts designed to seize or disrupt cocaine shipments between South American source zones and US markets remain a core US "supply side" drug policy and national security strategy. However, despite a long history of US-led interdiction efforts in the Western Hemisphere, cocaine movements to the United States through Central America, or "narco-trafficking," continue to rise. Here, we developed a spatially explicit agent-based model (ABM), called "NarcoLogic," of narco-trafficker operational decision making in response to interdiction forces to investigate the root causes of interdiction ineffectiveness across space and time. The central premise tested was that spatial proliferation and resiliency of narco-trafficking are not a consequence of ineffective interdiction, but rather part and natural consequence of interdiction itself. Model development relied on multiple theoretical perspectives, empirical studies, media reports, and the authors' own years of field research in the region. Parameterization and validation used the best available, authoritative data source for illicit cocaine flows. Despite inherently biased, unreliable, and/or incomplete data of a clandestine phenomenon, the model compellingly reproduced the "cat-and-mouse" dynamic between narco-traffickers and interdiction forces others have qualitatively described. The model produced qualitatively accurate and quantitatively realistic spatial and temporal patterns of cocaine trafficking in response to interdiction events. The NarcoLogic model offers a much-needed, evidence-based tool for the robust assessment of different drug policy scenarios, and their likely impact on trafficker behavior and the many collateral damages associated with the militarized war on drugs.